Non-variceal Bleeds
PPI:
PPIs, such as omeprazole or pantoprazole, are widely used. Theoretically, they reduce bleeding by increasing the pH of the normally acidic gastric environment, leading to clot stability. They have been shown post-endoscopy to reduce the re-bleeding rate and need for surgery, but have no effect on overall mortality [sreehdaran].
Evidence for their use before endoscopy is conflicting. A Cochrane review in 2010 found that pre-endoscopy PPIs reduced findings of recent serious bleeding and the need for treatment during endoscopy [SREEDHARAN]. However, current guidance from NICE is that PPI therapy should not be commenced pre-endoscopy, as there is no evidence that it improves clinically significant outcomes, such as mortality, re-bleeding rate or need for surgery [NICE].
Learning Bite
Whilst PPIs are commonly used in the management of upper GI bleeds, there is little evidence to support their use in the ED.
Somatostatins
Octreotide is not recommended for routine use in patients with acute non-variceal bleeds, but can be used as an adjunct to therapy where there is a delay in endoscopy. [SALTZMANN]
Antifibrinolytic therapy
The Halt It trial published its results in 2020 and included over 12,000 patients randomised to receive either tranexamic acid (TXA) or placebo. This showed no significant difference in death due to bleeding. Secondary outcomes revealed a slightly higher rate of venous thromboembolic events in the TXA group. This would suggest that TXA does not reduce death from GI bleeding and should not be routinely used as part of the treatment of GI bleeding.[21]