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

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Presentation on theme: "Merhaba. Endoscopic Management of Ulcer Bleeding Dr Redha Lajam, MD Consultant gastroenterologist UST Hospital UST Hospital."— Presentation transcript:

1 Merhaba

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

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

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

5 Bleeding Peptic Ulcer - Natural History - Approximately 80-85% bleeding stops spontaneously Approximately 80-85% bleeding stops spontaneously Remaining 15-20% recurrent or continuous bleeding Remaining 15-20% recurrent or continuous bleeding Re-bleeding increase mortality by 10 times 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 – 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. –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 NG tube aspirate Active bleeding by endoscopy Requires Surgery Death Clear 16 % 10 % 6 % Coffee ground 30 % 13 % 10 % Red blood 48 % 23 % 18 % American Society For Gastrointestinal Endoscopy

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

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 JYLau JY, N Engl J Med Apr 19;356(16): N Engl J Med.

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

12 Risk-Stratification Tools for Upper Gastrointestinal Hemorrhage Blatchford scores from 0 to 23, with higher scores indicating higher risk The Rockall score : -Used clinical and endoscopic criteria -The scale ranges from 0 to 11 points, 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 Transfusion requirements Total (%) Total (%) Total (U) Total (U) 144 (76) 3.5  (74) 3.5 .8 79 (78) 3.4  Need for 2nd modality Angiography (%) Angiography (%) Surgery (%) Surgery (%) 6 (3) 0 (0) 2 (2) 0 (0) 4 (4) 0 (0) - Days in hospital (d) 6.1    Days in hospital a (d) 5.6    Inhosptial mortality (%) 7 (4) 1 (1) 6 (6) 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 Diagnosis : 90-95% sensitive at locating bleeding site bleeding site Prognosis : likelihood of persistent or recurrent bleeding can be predicted Prognosis : likelihood of persistent or recurrent bleeding can be predicted Therapy : provide therapeutic options Therapy : provide therapeutic options ( inject, burn,clip ) ( inject, burn,clip )

17 Forrest grade IaForrest grade Ib Forrest classification Forrest grade IIa

18 Forrest grade IIcForrest grade III Forrest classification Forrest grade IIb

19 Endoscopic Risk Stratification Endoscopic FindingRebleedMortality Active bleeding55%11% Visible vessels43%11% Adherent dot22%7% Flat spots10%3% CLEAN UCLER BASE5%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 Jensen D.Gastroenterlogy 2002;123407Bleau B Gastrointest Endosc 2002;56:1 This is pre PPI data H2RA used in these trials So still controversial

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 Outpatient Care PPI H. Pylori Treatment Endoscopic Therapy Hospital Admission ICU Care based on comorbidity High Risk Stigmata Endoscopic Therapy No High Risk Stigmata Outpatient Therapy

26 Types of endoscopic therapy Injection Injection Ablative Ablative Mechanical Mechanical combination combination Novel techniques Novel techniques

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

28 Endoscopic therapy ablative Contact ablative therapy by Contact ablative therapy by 1. Thermo coagulation heat probe 2. Electro coagulation BICAP, Gold probe Non contact ablative argon plasma cougulation Non contact ablative argon plasma cougulation

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

30 Endoscopic therapy mechanical hemoclips

31 Application of a clip in upper GI bleeding

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

33 Dual vs. Monotherapy in High-risk Bleeding Ulcers: A meta-analysis of Controlled trials GroupComparison# studies# pts AInjection+Mechanical vs. Injection4362 BInjection+Thermal vs.Injection3376 CInjection+Injection vs. Injection D Injection+Mechanical vs. Mechanical 3234 EInjection+Thermal vs. Thermal 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 Dual(n=1069)Mono(n=1068) P value Overall morbidity 38 (3.5%) 35 (3.3%) NS Induced bleeding 1818NS Perforation7*00.03 *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 Injection therapy less effective  No injection alone  ADD SOMETHING ELSE No significant clinical advantage for dual therapy over thermal or mechanical monotherapy (? active bleeder) No significant clinical advantage for dual therapy over thermal or mechanical monotherapy (? active bleeder) Single therapy?  thermal or if applicable, mechanical therapy Single therapy?  thermal or if applicable, mechanical therapy Single therapy is safer than dual therapy Single therapy is safer than dual therapy Barkun A et al. Ann Intern Med 2003; 139: Adler DG et al. Gastrointest Endsoc 2004; 60:

39 Injection- Bicap vs. injection-Hemoclip INJ-CLIPINJ-BICAP 2930Patients with ulcer Re-bleeding(%) Retreatment(%) Failure of hemostasis(%) 3.520Surgery Deaths Jensen DM.Gastrointrst Endosc 2008:67;AB106

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

41 Iv erythromycin 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 Large ulcer defect more than 2cm Visible vessel more than 2 mm Visible vessel more than 2 mm Inaccessible lesions Inaccessible lesions Challenging positions ( posterior wall stomach,lesser curve, posterior bulbar wall) Challenging positions ( posterior wall stomach,lesser curve, posterior bulbar wall) Fibrotic base for hemoclip 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 Meta-analysis of 16 studies: 1673 patients Rebleeding 18.4  10.6% OR 0.53 (0.40~0.69) 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) 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) Mortality 5.1  2.6% OR 0.51 (0.31~0.84) Risk decreased regardless of which second procedure was applied Risk decreased regardless of which second procedure was applied ACG guidelines not recommend routine second look ACG guidelines not recommend routine second look Calvet X et al. Gastroenterology 2004; 126:441-50

44 Outcome of Endoscopic Management Hemostasis>95% Hemostasis>95% Recurrent bleeding<15% Recurrent bleeding<15% Death 6-8% (irrespective of any optimal endoscopic & medical treatment) 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 JJSung JJ Endoscopy Apr;43(4): Epub 2011 Mar 31.Endoscopy.

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

48 Teşekkür ederim


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