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Presentation on theme: "Merhaba."— Presentation transcript:

1 Merhaba

2 Endoscopic Management of Ulcer Bleeding
Dr Redha Lajam, MD Consultant gastroenterologist UST Hospital

3 Outline Epidemiology and natural history
Risk assessment and pre-endoscopic management Endoscopic therapy Post endoscopic management

4 Bleeding Peptic Ulcer -Epidemiology-
More than 300,000 hospital admissions annually in the US1 Incidence: 103 cases/100,000 adults/year2 Mortality: 5~14%3, unchanged for the past two decades, exclusively among elderly patients with significant co morbidities 1Yavorski RT et al. Am J Gastroenterol 1995; 90:568-73 2Longstreth GF. Am J Gastroenterol 1995; 90:206-10 3Rockall TA et al. BMJ 1995; 38:222-6

5 Bleeding Peptic Ulcer -Natural History-
Approximately 80-85% bleeding stops spontaneously Remaining 15-20% recurrent or continuous bleeding Re-bleeding increase mortality by 10 times

6 Pre-Endoscopic Resuscitation
Assess hemodynamic status Tachycardia (pulse, ≥100 beats per minute) Hypotension (systolic blood pressure, <100 mm Hg), postural changes (an increase in the pulse of ≥20 beats per minute or a drop in systolic blood pressure of ≥20 mm Hg on standing) Mucous membranes, neck veins, urine output Obtain CBC, electrolytes, BUN/Cr, PT INR/ APTT, blood type, and cross-match

7 Pre-Endoscopic Resuscitation
Initiate resuscitation with crystalloid intravenous fluids with the use of large-bore IV-access catheters PRBC If tachycardia or hypotension is present If the hemoglobin level is less than 10 g per deciliter. Patients who received transfusion within 12 h of presentation had a twofold increased rate of re-bleeding (OR 2.26; 95% CI 1.76–2.90) and a 28% increase in mortality (OR 1.28; 95% CI 0.94–1.74) compared to those not early transfused. Oxygen correction of coagulopathy Hearnshaw SA, Logan RF, Palmer KR, Card TR, Travis SP, Murphy MF.Aliment Pharmacol Ther Jul;32(2):

8 Active bleeding by endoscopy
NG tube aspirate Active bleeding by endoscopy Requires Surgery Death Clear 16 % 10 % 6 % Coffee ground 30 % 13 % Red blood 48 % 23 % 18 % American Society For Gastrointestinal Endoscopy

9 Mortality according NGT aspirate
Stool color NGT aspirate Black Red Clear 5 % 7 % Coffee ground 9 % 20 % 12 % 30 %

10 Pharmacotherapy Prior to Endoscopy
Consider initiating treatment with an IV PPI (80-mg bolus dose plus continuous infusion at 8 mg/hr) while awaiting early endoscopy down-staging of endoscopic lesions by stabilizing clot with decrease need for endoscopic therapy (19 % vs. 28% p value 0.007) not have an effect on outcomes (mortality , re-bleeding , transfusion requirement ) The cost- effectiveness remains controversial No role for H2 blocker Consider octeriotide infusion may be beneficial Lau JY, N Engl J Med Apr 19;356(16):

11 Risk assessment Clinical Predictors of Poor Outcomes
Older age (>60years) Severe comorbidity Active bleeding Hypotension or shock RBC transfusion6 unit Inpatient bleeding Severe coagulopathy Adler DG et al. Gastrointest Endosc 2004; 60:

12 Risk-Stratification Tools for Upper Gastrointestinal Hemorrhage
The Rockall score : Used clinical and endoscopic criteria The scale ranges from 0 to 11 points, with higher scores indicating higher risk. Blatchford scores from 0 to 23, with higher scores indicating higher risk

13 Timing of endoscopy Should be performed within 24 hours for high risk patients Improve certain outcomes the number of units of blood transfused the length of the hospital stay Treatment recommendations have focused on the first 72 hours after presentation and endoscopic evaluation and therapy, since this is the period when the risk of rebleeding is greatest (90 %)

14 Am J Emerg Med 2007; 25,

15 Outcomes of total cases
Total, n (%) EE, n (%) UE, n (%) P 189 88 101 Transfusion requirements Total (%) Total (U) 144 (76) 3.54.3 65 (74) 3.5.8 79 (78) 3.43.9 0.499 0.765 Need for 2nd modality Angiography (%) Surgery (%) 6 (3) 0 (0) 2 (2) 4 (4) 0.687 Days in hospital (d) 6.110.1 6.312.4 6.07.7 0.440 Days in hospitala (d) 5.66.6 5.15.0 0.522 Inhosptial mortality (%) 7 (4) 1 (1) 6 (6) 0.124 a One patient in the emergency group with hospitalization for 112 days was excluded No difference in outcome between emergent vs. urgent endoscopy

16 Role of Endoscopy Diagnosis : 90-95% sensitive at locating
bleeding site Prognosis : likelihood of persistent or recurrent bleeding can be predicted Therapy : provide therapeutic options ( inject , burn ,clip )

17 Forrest classification
Forrest grade Ia Forrest grade Ib Forrest grade IIa

18 Forrest classification
Forrest grade IIb Forrest grade IIc Forrest grade III

19 Endoscopic Risk Stratification
Endoscopic Finding Rebleed Mortality Active bleeding 55% 11% Visible vessels 43% 11% Adherent dot 22% 7% Flat spots 10% 3% CLEAN UCLER BASE 5% 2% Laine et al. NEJM 1994; 331:717

20 Endoscopic predictors stigmata of recent bleeding
Percent Johnston JH. Endoscopic risk factors for bleeding peptic ulcer. Gastrointest Endosc 1990;36:S16.

21 High risk lesions

22 Indication of endoscopic therapy
Stigmata Endoscopic therapy Active bleeding Yes Non-bleeding visible vessel Yes Adherent clot Probable Flat spot No Clean base No

23 Adherent clot

24 Re-bleeding rates in RCT’s of treatment of adherent clots
This is pre PPI data H2RA used in these trials So still controversial Jensen D.Gastroenterlogy 2002;123407 Bleau B Gastrointest Endosc 2002;56:1

25 Potential Triage for UGI Bleeding
UGIB (Non-variceal) Stable Hemodynamics Blatchford score <2 (10%) Blatchford score 2 (90%) Outpatient care Elective Endoscopy PPI Urgent Endoscopy Definitive Care based on endoscopic findings Rockall score<3 (20-30%) Rockall Score3 High Risk Stigmata High Risk Stigmata Endoscopic Therapy No High Risk Stigmata Outpatient Therapy Outpatient Care PPI H. Pylori Treatment Endoscopic Therapy Hospital Admission ICU Care based on comorbidity

26 Types of endoscopic therapy
Injection Ablative Mechanical combination Novel techniques

27 Endoscopic therapy injection
Reduce blood flow by temporary local tamponade Vasoconstricting agents reduce blood flow -Adrenaline 1:10,000 -1:100,000 Sclerosants Ethanolamine Polidocanol Ethanol Tissue adhesive Histoacryl Fibirin glue

28 Endoscopic therapy ablative
Contact ablative therapy by Thermo coagulation heat probe Electro coagulation BICAP, Gold probe Non contact ablative argon plasma cougulation

29 Endoscopic therapy ablative
Coaptive coagulation compress vessel & cougulate watts for 8-12 seconds for 4-6 pulses Larger 10 French more effective than 7 French probes

30 Endoscopic therapy mechanical hemoclips

31 Application of a clip in upper GI bleeding
A vessel in a bleeding ulcer was provided with a clip.

32 Endoscopic therapy combination
Injection combined with thermo-coagulation therapy Inject first 1:10,000 adrenaline Can use combination probe May inject and clip

33 Dual vs. Monotherapy in High-risk Bleeding Ulcers: A meta-analysis of Controlled trials
Group Comparison # studies # pts A Injection+Mechanical vs. Injection 4 362 B Injection+Thermal vs.Injection 3 376 C Injection+Injection vs. Injection 10 1075 D Injection+Mechanical vs. Mechanical 234 E Injection+Thermal vs. Thermal 425 20 2472 Marmo R et al. Am J Gastroenterol 2007; 102:279-89

34 Outcome recurrent bleeding

35 Outcome need of surgery

36 Outcome death

37 Safety of Dual vs. Monotherapy
P value Overall morbidity 38 (3.5%) 35 (3.3%) NS Induced bleeding 18 Perforation 7* 0.03 *5 cases with injection plus thermal & 2 cases with double injection therapy

38 Summary of Endoscopic Therapy
Injection therapy less effectiveNo injection aloneADD SOMETHING ELSE No significant clinical advantage for dual therapy over thermal or mechanical monotherapy (? active bleeder) Single therapy?thermal or if applicable, mechanical therapy Single therapy is safer than dual therapy Barkun A et al. Ann Intern Med 2003; 139:843-57 Adler DG et al. Gastrointest Endsoc 2004; 60:

39 Injection- Bicap vs. injection-Hemoclip
INJ-CLIP INJ-BICAP 29 30 Patients with ulcer 20.7 43.3 Re-bleeding(%) 10.3 Retreatment(%) 3.5 23.3 Failure of hemostasis(%) 20 Surgery 6.7 Deaths Jensen DM.Gastrointrst Endosc 2008:67;AB106

40 Limitation of endoscopic therapy
We can only treat what we see Double or wide channel scope NG tube lavage pre-endoscopy Water pump/jet External large suction device Iv erythromycin

41 Iv erythromycin We can only treat what we can see
Consider giving a single 250-mg IV dose of erythromycin 30 to 60 minutes before endoscopy promote gastric motility and substantially improve visualization of the gastric mucosa on initial endoscopy. not improve the diagnostic yield of endoscopy substantially or to improve the outcome We can only treat what we can see

42 Limitation of endoscopic therapy challenging lesions
Large ulcer defect more than 2cm Visible vessel more than 2 mm Inaccessible lesions Challenging positions ( posterior wall stomach ,lesser curve , posterior bulbar wall) Fibrotic base for hemoclip

43 Addition of a Second Endoscopic Treatment Following Injection: Two is better than one may be?
Meta-analysis of 16 studies: 1673 patients Rebleeding 18.410.6% OR 0.53 (0.40~0.69) Need for surgery 11.37.6% OR 0.64 (0.46~0.90) Mortality 5.12.6% OR 0.51 (0.31~0.84) Risk decreased regardless of which second procedure was applied ACG guidelines not recommend routine second look Calvet X et al. Gastroenterology 2004; 126:441-50

44 Outcome of Endoscopic Management
Hemostasis>95% Recurrent bleeding<15% Death 6-8% (irrespective of any optimal endoscopic & medical treatment) Barkun A et al. Ann Intern Med 2003; 139:843-5, Cipolletta L et al. Endoscopy 2007; 39:7-10 Treat the patient and Not just the source of bleeding

45 Hemospray

46 Hemospray 95% acute hemostasis
Sung JJ Endoscopy Apr;43(4): Epub 2011 Mar 31.

47 Post endoscopic therapy
Surgery when 2nd endoscopic attempt failed or unapplicable Angiography Antisecretory treatment H pylori eradication confirmation

48 Teşekkür ederim

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