1. Do you use a proton pump inhibitor (PPI) infusion in patients with undifferentiated upper GI bleeding (UGIB)?
2. Do you use octreotide in patients with bleeding varices?
3. In which patients with UGIB do you place a nasogastric tube and for what purpose (diagnostic vs. therapeutic)?
4. What is the utility of fecal occult blood test for patients in whom we suspect UGIB?
1. Not of my own volition.
2. Not of my own volition
4. I would argue incredibly low, but don’t know the data.
Our GI colleagues and medicine admitting teams frequently demand the first two ,and on occasion will ask for the third. I still explain to them every time the data (including the harmful aspects of PPI), but they still prefer to do it the way they always do.
I do give Rocephin frequently, as I have a lot of patients with liver disease, from mild to cirrhosis.
I concur with Justin, above.
As a hospitalist, I know that admitting medical housestaff often insist on #1-4 even when they don’t necessarily think the evidence of benefit is strong because they will otherwise get chewed out by the GI fellow, and the argument isn’t worth it for them. (At least that’s been my experience at our own institution.) Regarding Justin’s comment above, although acute PPI data is underwhelming, I’m not sure of any acutely harmful aspects of treatment (though obviously many long-term harmful effects), and I think the data for octreotide in variceal bleeds may be better than implied above (see PMID 24297127 for a good explanation).
Definitely agree with Justin especially for nr 3. Best regards
1. I’ll do a one time dose in the ED, but not a drip
2. Evidence is low, if not non-existent. If they look awful, I’ll consider it.
3. No NGT! ALiEM had a good review on this. Even American college of GI recs against this. It also delays time to endoscopy suite
4. Can’t imagine there’s much data on this. I rarely, if ever, do it for known cirrhotic with hematemesis.
Think best evidence for ED intervention is for early endoscopy and rocephin. And to (not) liberally transfuse. Oh, and evidence for INR in UGIB is bleh.