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Justin CY Wu Professor, Department of Medicine & Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong Updates in Management.

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Presentation on theme: "Justin CY Wu Professor, Department of Medicine & Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong Updates in Management."— Presentation transcript:

1 Justin CY Wu Professor, Department of Medicine & Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong Updates in Management of Non-Variceal Bleeding

2 Cook et al. Gastroenterology 1992 Acute upper GI bleeding Bleeding peptic ulcers Primary Endoscopic Hemostasis Primary Surgical Hemostasis ’s1990’s 2

3 Bleeding stigmata Spurting (Ia) Adherent clot (IIb) Visible vessel (IIa) Oozing (Ib)Clean base (III)

4 Endoscopic stigmataForrestPrevalenceRisks of rebleeding w/o therapy Acute SpurterIa18%~ 100% Acute oozingIb Non-bleeding visible vessel IIa17%Up to 50% Non-bleeding adherent clot IIb17%30-35% Flat spotIIc20%5-8% Clean baseIII42%< 3% Johnson et al. GIE 1990; Laine et al. NEJM

5 Tamponade effect and vasoconstriction with epinephrine

6  Heater probe  3.2mm [need 2T scope]  2.8mm  Pressure + Heat  Coaptive effect – compress until sealing of vessel 6

7 7 Hemoclip

8 Hemospray (Nanopowder) Sung et al. Endoscopy 2011

9 9 Clip vs Injection Clip + injection vs Injection Clip vs Thermal Sung JJ et al Gut 2007

10 STUDY BALANZO 1990 LOIZOU 1991 SOLLANO 1991 CHUNG 1993 VILLANUEVA1993 LIN1993 CHOUDARI 1994 KUBBA1996 CHUNG1996 VILLANUEVA1996 LEE1997 CHUNG1997 LIN1999 CHUNG1999 GAQRRIDO2002 PESCATORE2002 TOATL WEIGHT (%)PETO OR Favors combined therapy Favors epinephrine alone Calvet et al. Gastro

11  30 day mortality: a: Bleeding; b: Perforation BleedingPerforation Lau JY, Sung JJ et al Digestion 2011

12 12 Causes of mortality in peptic ulcer bleeding Mortality cases N = 577 / SubcategoriesNPercentage Bleeding relatedUncontrolled bleeding / rebleeding3129.2% N = 106 (18.4%)Within 48h after endoscopy2725.5% During surgery for uncontrolled bleeding32.8 Surgical complications or within 1 month after surgery % Endoscopy related complication1413.2% Non-bleeding relatedCardiac diseases (ACS, Heart failure)6223.5% N = 460 (79.7%)Pulmonary diseases (COPD, Pneumonia) % Multi-organ failure % Neurological diseases (Stroke)255.4% Terminal malignancy % Unclassified111.9% Sung JJ et al AJG 2009

13  Identification of predictors to adverse events (including rebleeding & mortality)  Intensive monitoring and pre-emptive management  Prevention of rebleeding  Improvement in post-endoscopy management  Improve the success rate of primary endoscopic hemostasis 13

14 Combining ALL predictive factors for the derivation cohort (AUC 0.842) 14 CUHK Outcome Prediction Score Chiu et al. Clin Gastroenterol Hepatol 2009

15 15

16 Time (minutes) ADP, adenosine diphosphate. Green et al 1978 Aggregation (%) pH=6.0 Disaggregation=77% pH=6.4 Disaggregation=16% pH=7.3 Disaggregation=0% Buffer ADP 16

17 Berstad Maximum pepsin activity (%) Gastric juice pH

18 18  240 patients with bleeding peptic ulcers  Forrest Ia, Ib, IIa  Treated by injection + Heater probe  IV Omeprazole infusion vs placebo  80mg bolus dose  8mg / hour for 72 hours  Total dose = 656 mg

19 Lau JYW et al NEJM

20 p = 0.14; p = 0.13 Lau et al. NEJM

21  Randomised, double-blind, placebo- controlled study at 91 centres in 16 countries R R esomeprazole 40 mg qd i.v. treatment (72 hours) Oral treatment (27 days) Endoscopic Haemostasis 1.Single 2.Combo Endoscopic Haemostasis 1.Single 2.Combo esomeprazole i.v. 80 mg over 30 min followed by esomeprazole i.v. 8 mg/h for 71.5 hours placebo i.v. for 30 min followed by placebo for 71.5 hours Intravenous Esomeprazole for Prevention of Peptic Ulcer Re- bleeding: A Multinational, Randomised, Placebo-Controlled Study Joseph J.Y. Sung 1, Alan Barkun 2, Ernst J. Kuipers 3, Joachim Mössner 4, Dennis Jensen 5, Robert Stuart 6, James Y. Lau 1, Henrik Ahlbom 7, Jan Kilhamn 7, Tore Lind 7

22 Esomeprazole n=375 Placebo n= hours 353 (94.1) (5.9) 3.7 – 8.8 No rebleed p-value Rebleed 95% CI 349 (89.7) (10.3) 7.5 – Risk reduction: 43% Sung JY et al, AIM 2009

23 Prevention of ulcer rebleeding Scheduled second endoscopy OGD : Bleeding peptic ulcers Primary Endoscopic Hemostasis Rebleeding (10-20%) Scheduled second endoscopy hours Scheduled second endoscopy hours Treat persistent SRH before rebleeding 23

24

25 Acute Upper GI Bleeding [556] Bleeding peptic ulcer [326] Primary therapeutic endoscopy [305] Adjunctive omeprazole infusion [153] Scheduled 2 nd endoscopy [152] Failed hemostasis [11] Forrest I, IIa, IIb Endoscopic Retreatment Forrest I, IIa, IIb Endoscopic Retreatment Rebleeding OGD ± Laparotomy Nov 2003 to May 2008 Carcinoma [9] 25 Chiu et al. DDW 2010

26 p = 0.646; OR 1.23 (95% CI ) 26

27 P =0.51; OR = 0.49 (95% CI 0.12 – 2.01) 27

28 28

29  After primary endoscopic hemostasis, PPI infusion achieved a similar rate of ulcer rebleeding as compared to scheduled second endoscopy  PPI infusion reduced patients’ discomfort and endoscopists’ workload from repeating endoscopy  Second endoscopy may have an advantage of shortening the hospital stay  Second endoscopy should be recommended if PPI infusion is not available 29

30 OGD : Bleeding peptic ulcers Primary Endoscopic Hemostasis Rebleeding (5%) Salvage Surgery Adjunctive PPI infusion / Scheduled second endoscopy 30 Pre-emptive PPI infusion Acute Upper GI Hemorrhage

31 31

32 Lau JY, et al. N Engl J Med Preemptive high-dose PPI reduces need of endoscopic treatment 371 UGIB patients randomized to high dose IVPPI or placebo before endoscopy

33 Omeprazole N=179 Placebo N=190 P value Blood transfusion Mean, SD Median range 1.7, 2.8 0, , , Hospital stay Mean, SD Median, range 4.2, 4.9 3, , 5.6 3, Urgent intervention231 Surgery for hemostasis day rebleeding day mortality45.79 Preemptive high-dose PPI reduces need of endoscopic treatment Lau JY, et al. N Engl J Med. 2007

34  TAE as an alternative to salvage surgery  Can also act to pre-emptive embolization

35 1254 (39.9%) required endoscopic hemostasis 3144 bleeding peptic ulcer from January 2000 to July (97.1%) successful hemostasis 1218 (97.1%) successful hemostasis 36 (2.9%) failed initial hemostasis 36 (2.9%) failed initial hemostasis 166(13.6%) Rebleeding 52 (31.3%) failed 2 nd endoscopic treatment/ 2 nd rebleeding 19 TAE 33 Surgery 13 TAE 23 Surgery Total: TAE n=32 Surgery n=56 Total: TAE n=32 Surgery n=56 Wong TL, Lau JY et al DDW 2010

36 P = <0.005 P = 0.77 Wong TL, Lau JY et al DDW 2010

37 P = 0.09 P = 0.60 P = 0.01 Wong TL, Lau JY et al DDW 2010

38  Pre-emptive Transcatheter Angiographic Embolization in high risk patients  A prospective RCT is ongoing in PWH…

39 39  Peptic ulcer rebleeding remains one of the most important clinical catastrophy with significant mortality  PPI Infusion after endoscopic therapy prevent ulcer rebleeding  Schedule 2 nd endoscopy served as an alternative when PPI infusion is not available  Pre-emptive Transarterial embolization may served as an adjunctive measure to prevent ulcer rebleeding

40 Advanced Technology Multidisciplinary Clinical Exposure 2 Year Master Programme for Medical and Nursing Professionals


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