Current issues in the upper gastrointestinal tract

Dr. Yu-Xiao Yang reported at the 2013 AGA Spring Postgraduate Course that proton pump inhibitor’ therapy has been associated with a variety of potential side effects. The exact underlying biological mechanism for all side effects remains to be elucidated. For example, literature analysis revealed that PPI use may not be associated with a clinically important increase in community-acquired pneumonia risk. The marked increase in risk of community-acquired pneumonia that has been associated with newly started PPI therapy is likely due to protopathic bias. The latter suggests that use of a drug to treat early signs of an outcome gives the appearance that the drug is associated with the outcome. In the case of PPI therapy and bone health the evidence is retrospective and observational only. Short-term and standard-dose PPI therapy is associated with very modest increased risk, if any. In contrast, long-term and/or high-dose PPI therapy may be associated with clinically important increased risk. Thus far, there are no data to support the benefit of altering existing diagnostic and treatment practices for osteoporosis in patients on long-term treatment with a PPI.

Dr. Doug Corley stated that the availability of effective ablative techniques for Barrett’s esophagus (BE) require us to come up with clear recommendations about who to watch and who to treat. Patients with nondysplastic BE, unifocal low-grade dysplasia on a single examination, low-grade dysplasia not confirmed by a second pathologist, and no intestinal metaplasia without dysplasia should be watched. Patients with high-grade dysplasia and those with true low-grade dysplasia (persistent, multifocal, confirmed by a second pathologist) should be considered for esophageal ablation and, if needed, endoscopic mucosal resection (EMR). Aspirin should be considered in proper patients and all should be treated aggressively for gastroesophageal reflux disease.

Dr. Loren Laine provided tips for the treatment of nonvariceal upper GI bleeding. In patients with ulcer bleeding, endoscopic therapy should be performed for active bleeding, a visible vessel, and considered for an adherent clot. In general, epinephrine should not be used as monotherapy. In contrast, thermal and sclerosant treatment and clips may all be used alone. However, sclerosant and clips may be less effective if there is active bleeding. In patients with non-ulcer bleeding, endoscopic therapy should be done for Dieulafoy lesions and actively bleeding Mallory-Weiss tears. Importantly, epinephrine should not be used as monotherapy.

Dr. Neena Abraham discussed the challenging topic of endoscopy in patients requiring antithrombotics. Dr. Abraham reviewed the currently available literature and provided the following tips; it is safe to perform endoscopy on patients taking aspirin monotherapy, avoid stopping P2Y12 receptor antagonists (clopidogrel, prasugrel, and ticagrelor) in the first 90 days post acute coronary syndrome (ACS) and continue aspirin therapy when stopping a P2Y12 receptor antagonists. In addition, patients with GI bleed leading to ACS should be scoped within 48-72 hours post ACS, which will increase the chance of finding high-risk bleeding stigmata that is treatable by endoscopy and will lead to faster cardiac catheterization in 43% of the patients. Another important tip is that endoscopic therapy is effective in patients with moderately elevated International Normalized Ratios (INRs) (less than 2.7). There is no need to normalize the INR. Warfarin should be resumed within 4-7 days post GI-bleed. The introduction of new oral anticoagulants revealed an increase in GI bleed risk. Dual antiplatelet therapy plus a new oral anticoagulant (triple antithrombotic therapy) is associated with threefold increase risk of GI bleed. In general, dabigatran-related bleeding requires support of patient’s hemodynamics to promote renal excretion of the drug.

Dr. Fass is director, division of gastroenterology and hepatology, and Head, Esophageal and Swallowing Center, MetroHealth Medical Center, Cleveland.

Dr. Yu-Xiao Yang reported at the 2013 AGA Spring Postgraduate Course that proton pump inhibitor’ therapy has been associated with a variety of potential side effects. The exact underlying biological mechanism for all side effects remains to be elucidated. For example, literature analysis revealed that PPI use may not be associated with a clinically important increase in community-acquired pneumonia risk. The marked increase in risk of community-acquired pneumonia that has been associated with newly started PPI therapy is likely due to protopathic bias. The latter suggests that use of a drug to treat early signs of an outcome gives the appearance that the drug is associated with the outcome. In the case of PPI therapy and bone health the evidence is retrospective and observational only. Short-term and standard-dose PPI therapy is associated with very modest increased risk, if any. In contrast, long-term and/or high-dose PPI therapy may be associated with clinically important increased risk. Thus far, there are no data to support the benefit of altering existing diagnostic and treatment practices for osteoporosis in patients on long-term treatment with a PPI.

Dr. Doug Corley stated that the availability of effective ablative techniques for Barrett’s esophagus (BE) require us to come up with clear recommendations about who to watch and who to treat. Patients with nondysplastic BE, unifocal low-grade dysplasia on a single examination, low-grade dysplasia not confirmed by a second pathologist, and no intestinal metaplasia without dysplasia should be watched. Patients with high-grade dysplasia and those with true low-grade dysplasia (persistent, multifocal, confirmed by a second pathologist) should be considered for esophageal ablation and, if needed, endoscopic mucosal resection (EMR). Aspirin should be considered in proper patients and all should be treated aggressively for gastroesophageal reflux disease.

Dr. Loren Laine provided tips for the treatment of nonvariceal upper GI bleeding. In patients with ulcer bleeding, endoscopic therapy should be performed for active bleeding, a visible vessel, and considered for an adherent clot. In general, epinephrine should not be used as monotherapy. In contrast, thermal and sclerosant treatment and clips may all be used alone. However, sclerosant and clips may be less effective if there is active bleeding. In patients with non-ulcer bleeding, endoscopic therapy should be done for Dieulafoy lesions and actively bleeding Mallory-Weiss tears. Importantly, epinephrine should not be used as monotherapy.

Dr. Neena Abraham discussed the challenging topic of endoscopy in patients requiring antithrombotics. Dr. Abraham reviewed the currently available literature and provided the following tips; it is safe to perform endoscopy on patients taking aspirin monotherapy, avoid stopping P2Y12 receptor antagonists (clopidogrel, prasugrel, and ticagrelor) in the first 90 days post acute coronary syndrome (ACS) and continue aspirin therapy when stopping a P2Y12 receptor antagonists. In addition, patients with GI bleed leading to ACS should be scoped within 48-72 hours post ACS, which will increase the chance of finding high-risk bleeding stigmata that is treatable by endoscopy and will lead to faster cardiac catheterization in 43% of the patients. Another important tip is that endoscopic therapy is effective in patients with moderately elevated International Normalized Ratios (INRs) (less than 2.7). There is no need to normalize the INR. Warfarin should be resumed within 4-7 days post GI-bleed. The introduction of new oral anticoagulants revealed an increase in GI bleed risk. Dual antiplatelet therapy plus a new oral anticoagulant (triple antithrombotic therapy) is associated with threefold increase risk of GI bleed. In general, dabigatran-related bleeding requires support of patient’s hemodynamics to promote renal excretion of the drug.

Dr. Fass is director, division of gastroenterology and hepatology, and Head, Esophageal and Swallowing Center, MetroHealth Medical Center, Cleveland.

Dr. Yu-Xiao Yang reported at the 2013 AGA Spring Postgraduate Course that proton pump inhibitor’ therapy has been associated with a variety of potential side effects. The exact underlying biological mechanism for all side effects remains to be elucidated. For example, literature analysis revealed that PPI use may not be associated with a clinically important increase in community-acquired pneumonia risk. The marked increase in risk of community-acquired pneumonia that has been associated with newly started PPI therapy is likely due to protopathic bias. The latter suggests that use of a drug to treat early signs of an outcome gives the appearance that the drug is associated with the outcome. In the case of PPI therapy and bone health the evidence is retrospective and observational only. Short-term and standard-dose PPI therapy is associated with very modest increased risk, if any. In contrast, long-term and/or high-dose PPI therapy may be associated with clinically important increased risk. Thus far, there are no data to support the benefit of altering existing diagnostic and treatment practices for osteoporosis in patients on long-term treatment with a PPI.

Dr. Doug Corley stated that the availability of effective ablative techniques for Barrett’s esophagus (BE) require us to come up with clear recommendations about who to watch and who to treat. Patients with nondysplastic BE, unifocal low-grade dysplasia on a single examination, low-grade dysplasia not confirmed by a second pathologist, and no intestinal metaplasia without dysplasia should be watched. Patients with high-grade dysplasia and those with true low-grade dysplasia (persistent, multifocal, confirmed by a second pathologist) should be considered for esophageal ablation and, if needed, endoscopic mucosal resection (EMR). Aspirin should be considered in proper patients and all should be treated aggressively for gastroesophageal reflux disease.

Dr. Loren Laine provided tips for the treatment of nonvariceal upper GI bleeding. In patients with ulcer bleeding, endoscopic therapy should be performed for active bleeding, a visible vessel, and considered for an adherent clot. In general, epinephrine should not be used as monotherapy. In contrast, thermal and sclerosant treatment and clips may all be used alone. However, sclerosant and clips may be less effective if there is active bleeding. In patients with non-ulcer bleeding, endoscopic therapy should be done for Dieulafoy lesions and actively bleeding Mallory-Weiss tears. Importantly, epinephrine should not be used as monotherapy.

Dr. Neena Abraham discussed the challenging topic of endoscopy in patients requiring antithrombotics. Dr. Abraham reviewed the currently available literature and provided the following tips; it is safe to perform endoscopy on patients taking aspirin monotherapy, avoid stopping P2Y12 receptor antagonists (clopidogrel, prasugrel, and ticagrelor) in the first 90 days post acute coronary syndrome (ACS) and continue aspirin therapy when stopping a P2Y12 receptor antagonists. In addition, patients with GI bleed leading to ACS should be scoped within 48-72 hours post ACS, which will increase the chance of finding high-risk bleeding stigmata that is treatable by endoscopy and will lead to faster cardiac catheterization in 43% of the patients. Another important tip is that endoscopic therapy is effective in patients with moderately elevated International Normalized Ratios (INRs) (less than 2.7). There is no need to normalize the INR. Warfarin should be resumed within 4-7 days post GI-bleed. The introduction of new oral anticoagulants revealed an increase in GI bleed risk. Dual antiplatelet therapy plus a new oral anticoagulant (triple antithrombotic therapy) is associated with threefold increase risk of GI bleed. In general, dabigatran-related bleeding requires support of patient’s hemodynamics to promote renal excretion of the drug.

Dr. Fass is director, division of gastroenterology and hepatology, and Head, Esophageal and Swallowing Center, MetroHealth Medical Center, Cleveland.