Hematemesis secondary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Secondary Prevention

Prophylaxis Against Bleed From Variceal Hemorrhage and Ulceration

• Primary prophylaxis against variceal hemorrhage is indicated because of high rate of bleeding from esophageal varices and the high mortality associated with bleeding. Prophylactic propranolol or nadolol therapy is the only cost-effective therapy in this setting.
• Prophylaxis against stress ulceration maybe also indicated for ICU patients with any of the following characteristics:

1. Coagulopathy
2. Mechanical ventilation for more than 2 days
3. History of GI ulceration or bleeding with the past year
4. Two or more of the following risk factors — sepsis, ICU admission lasting >1 week, occult GI bleeding lasting ≥6 days, and glucocorticoid therapy.

• Effective identification and antibiotic treatment of H.Pylori infections is also crutial in preventing complications including upper GI bleeding.
• In regards to the prevention of NSAID-related peptic ulcer disease and complicating upper GI bleed: patients are at the highest risk for NSAID-induced GI toxicity when they have any of these risk factors:

1. A history of an ulcer or GI hemorrhage
2. Age >60
3. High dosage of a NSAID
4. Concurrent use of glucocorticoids
5. Concurrent use of anticoagulants

In these patients, the use of COX-2 selective inhibitor or a nonselective NSAID in combination with a PPI or misoprostol is indicated. In addition, patients with a history of uncomplicated or complicated peptic ulcers should be tested for H. pylori prior to beginning a NSAID or low dose aspirin. If present, H. pylori should be treated with appropriate therapy, even if it is believed that the prior ulcer was due to NSAIDs.