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Management of Adherent Clots

Outline. Case PresentationIdentify the clinical questionClarify some endoscopic definitionsReview 4 key articles evaluating the management of adherent clotsHow does the literature affect the management of our patientConclusions. Case Presentation. 70 yo WF with COPD, CAD, CHF is admitted with 3

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Management of Adherent Clots

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    1. Management of Adherent Clots To Disturb or Not to Disturb…That is the Question GI Grand Rounds, March 1, 2004 Murat Akdamar

    2. Outline Case Presentation Identify the clinical question Clarify some endoscopic definitions Review 4 key articles evaluating the management of adherent clots How does the literature affect the management of our patient Conclusions

    3. Case Presentation 70 yo WF with COPD, CAD, CHF is admitted with 3 day hx of bright red hematemesis. No hx of anticoagulation, prior PUD, or ETOH abuse Pt was confused and unable to give further history.

    4. Case Presentation PE: Hemodynamically stable – anything else ?? HCT 17, Plts 181, INR 1.1. Pt admitted to a monitored bed on the GI ward Tx- PRBC’s and IV PPI therapy. The following morning, she underwent EGD.

    5. EGD Endoscopic findings: A 2 cm x 3 cm deep ulceration located on the posterior wall of the stomach. There was a large fibrinous clot located in the base of the ulcer. The adherent clot was irrigated but could not be dislodged.

    6. EGD The clot was attempted to be removed with a snare. A large, spurting vessel was uncovered and significant hemorrhage occurred. 1:10,000 dilution of Epinephrine was injected into the base of the bleeding vessel. No hemostasis was achieved. The patient became hypotensive, required ACLS and intubation. Surgery was notified.

    7. Outcome The patient underwent laparotomy and a posterior wall gastric ulcer eroding into the pancreatic bed exposing the splenic artery. Subtotal gastrectomy was performed. She was taken back to the O.R. after further resuscitation for Billroth II gastrojejunostomy.

    11. Outcome Subtotal gastrectomy was performed. She was taken back to the O.R. after further resuscitation for Billroth II gastrojejunostomy. After prolonged hospitalization, she was discharged from rehab 2 months later. Pathology specimens were negative for malignancy.

    12. Question What is the optimal therapy for a peptic ulcer with an adherent clot? What is the associated controversy? What does the evidence support? Should we have “angered” the clot or left well enough alone?

    13. Endoscopic Definitions Discrepancy between various study results and controversy largely arises from interpretation of the endoscopic of vocabulary Can use jensens table Adherent clot: ? Visible vessel: ? The continuum: a visible vessel is actually a small clot on the top of a vessel Some prior studies included flat spots as adherent clots

    17. Background: Rebleeding Rates Clean base ulcer: 3-5% Pigmented spot: 7% Adherent clot: 25-36% Non-bleeding visible vessel: 50-70% Lau (N= 778, 1998): rebleeding rates 5%, 13%, 29%, 39% respectively, with incidence of adherent clots 13% Why early studies suggested clot removal was bad idea

    18. Background: Options Medical Therapy only Injection of Epinephrine Heater Probe coagulation Medical and Endoscopic Therapy

    19. Reviewing the Literature Bleau: “Recurrent bleeding from peptic ulcer associated with adherent clot: A randomized study comparing endoscopic treatment with medical therapy” Gastrointestinal Endoscopy, July 2002. Jensen: “Randomized Trial of Medical or Endoscopic Therapy to Prevent Recurrent Ulcer Hemorrhage in Patients With Adherent Clots” Gastroenterology, Aug. 2002. Sung: “The Effect of Endoscopic Therapy in Patients Receiving Omeprazole for Bleeding Ulcers with Nonbleeding Visible Vessels or Adherent Clots” Annals of Internal Medicine, Aug. 2003. Bini: “Endoscopic treatment compared with medical therapy for the prevention of recurrent ulcer hemorrhage in patients with adherent clots” Gastrointestinal Endoscopy, Nov. 2003.

    20. Bleau: GI Endo, Jul. 2002 Randomized, prospective, multicenter trial Endoscopic treatment of adherent clot plus medical therapy vs. medical therapy alone Included N=56, from 12/1993- 10/1996 UGI bleeding underwent EGD within 24 hrs of admit and identified to have adherent clot of G.U. or D.U. Excluded: pt’s with coagulopathy

    21. Bleau: GI Endo, Jul. 2002 Adherent clot: not removed with irrigation via 200cc of H2O by 50 cc syringe Endoscopic treatment (N=21): 1st- Epi 1:10,000 at least 1cc per quadrant, 2nd- clot removal via suction/snare/bx forcep, 3rd- 3.2mm heater probe at 30J min. 3 pulses to area under clot for visible vessel/pigmented protuberance/flat spot Medical therapy (N=35): omeprazole 20mg bid x 1 month (famotidine 20mg IV q12 if NPO) H. pylori not treated until after study

    22. Bleau: GI Endo, Jul. 2002 Primary outcome: Recurrence of bleeding in 1 month (def: HD instability, new hematemesis, new hematochezia, new melena, decreased Hg > 2.0 mg/dL). Confirmed by endoscopy. Secondary outcomes: # units PRBC’s transfused, repeat endoscopy, surgery, length of stay, bleeding specific mortality.

    23. Bleau: GI Endo, Jul. 2002 Patient characteristics all similar- no statistical differences Primary Outcome (Rebleeding within 1 month): Medical Therapy-12/35 (34.3%) vs. Combination Therapy- 1/21 (4.8%) p<0.02, OR 10.45- not cross 1 Secondary Outcome: None statistically significant

    24. Bleau: GI Endo, Jul. 2002 Key points: Mean Epi= 4.5 cc, # heater probe applications= 5.2 74% clots with underlying stigmata: 1 flat spot and 13 visible protuberance. One pt had induced bleeding with clot removal Larger clot size (90mm2 vs 38mm2) was the only factor identified as a predictor of rebleeding. All endoscopist reviewed definitions and pictures of stigmata to ensure similarities

    25. Jensen: Gastro, Aug. 2002 Randomized, prospective, multicenter trial Endoscopic treatment of adherent clot plus medical therapy vs. medical therapy and sham endoscopy Included N=32, from 10/1995- 3/2001 (32/147= 21.8% of UGI Blds) UGI bleeding underwent EGD within 24 hrs of admit and identified to have adherent clot of G.U. or D.U. Excluded: pt’s with coagulopathy or life expectancy < 30 d’s due to other comorbidities

    26. Jensen: Gastro, Aug. 2002 Adherent clot: not removed with “water jet irrigation and suctioning” Endoscopic treatment+ PPI (N=15): 1st- Epi 1:10,000 at least 1cc per quadrant, 2nd- clot removal via snare with shave down cold guillotining technique to a 3-4mm remnant, 3rd- target irrigation with a probe to see stigmata, 4th 3.2mm heater probe at 12-15w for 10s to the clot remnant or stigmata (endpoint: flattened clot, white coagulum, hemostasis). Medical therapy+ Sham endoscopy (N=17): PPI BID. Sham endo= gentle irrigation H. pylori tested and treated

    27. Jensen: Gastro, Aug. 2002 Outcomes: Recurrence of bleeding prior to discharge* (def: HD instability, new hematemesis, new hematochezia, new melena, decreased Hg > 2.0 mg/dL). Confirmed by endoscopy. Other outcomes: # units PRBC’s transfused, repeat endoscopy, surgery, length of stay, bleeding specific mortality.

    28. Jensen: Gastro, Aug. 2002 Result table med 6/17 (35.3%) vs 0/15 (0), p=0.011 Other outcomes no St sig

    29. Jensen: Gastro, Aug. 2002 Key points: The medical tx group was older (70.1 vs 55.8). More musculoskeletal dz and ASA/NSAIDS in medical tx group (64.7% vs. 26.7% and 88.2% vs. 66.7%). Trial stopped early due to difference in rebleeding rates among the two groups (the pretreatment goal was for 27 pts in each group). All endoscopist reviewed definitions and pictures of stigmata to ensure similarities.

    30. Sung: Annals, Aug. 2003 Randomized, prospective, single center trial Endoscopic treatment of adherent clot and visible vessels plus medical therapy vs. medical therapy and sham endoscopy Included N=156, from 1/2001- 7/2002 UGI bleeding underwent EGD within 24 hrs of admit and identified to have adherent clot of G.U. or D.U. Excluded: pt’s in whom irrigation provoked bleeding before treatment

    31. Sung: Annals, Aug. 2003 Adherent clot: not removed with irrigation with 3.2mm heater probe for 5 minutes Visible vessel: a protuberant discoloration (NIH, 1989) Endoscopic treatment+ PPI (N=78): 1st- Epi 1:10,000 to induce blanching and edema (avg 5cc), 2nd- clot removal via snare with “cheese-wiring”, 3rd- 3.2mm heater probe at 30J for 6s (endpoint: flattened or “cavitation” of protuberance). Medical therapy+ Sham endoscopy (N=78): Omeprazole 80mg IV bolus during endoscopy, then 8mg/h x 72 hrs followed 20mg PO QD. Sham endo= gentle irrigation H. pylori tested and treated

    32. Sung: Annals, Aug. 2003 Primary outcome: Recurrence of bleeding in 1 month (def: HD instability, new hematemesis, new hematochezia, new melena, decreased Hg > 2.0 mg/dL). Confirmed by endoscopy. Secondary outcomes: # units PRBC’s transfused, repeat endoscopy, surgery, length of stay, death w/in 30 d’s.

    33. Sung: Annals, Aug. 2003 Characteristics: similar age, small # of adherent clots (39 out of 1000 pts) Primary Outcome (Rebleed at 30d)- Medical Therapy 9 (11.6%) vs. Combination Therapy 1 (1.1%), RR 11.6 CI not cross 1 NonBleeding Visible Vessel: 9/54 (16.7%) vs 0 Adherent clot: Medical 0/24 vs. Combo 1/15 (6.7%) p >0.2 Avg 9ml of epi and 6 pulses Units blood: Medical 2.5 vs. Combo 2 p=0.02

    34. Bini: GI Endo, Nov. 2003 Retrospective, chart review Goal: determine the efficacy of combination therapy for adherent clots in a clinical practice setting (large municipal hospital in New York) Compared outcomes of adherent clot treated with endoscopic therapy vs. medical therapy UGI bleeding underwent EGD within 24 hrs of admit and identified to have adherent clot of G.U. or D.U. (26 endoscopists/fellows) Included N=244, from 1/1992- 12/1999

    35. Bini: GI Endo, Nov. 2003 Adherent clot: an amorphous red clot that is hooked onto an ulcer base by a pedicle and is resistant to target irrigation with water. (CUREHRG). Multipolar probe was used. Endoscopic treatment (N=138): 1st- Epi 1:10,000 in 1cc increments to pedicle, 2nd- clot removal via snare shave down (cold guillotining) 74% vs. other, 3rd- 3.2mm heater probe at 15W in 10s pulses to any underlying stigmata until flattening or white coagulum. Medical therapy (N=106): cimetidine 300mg q 6hr IV or ranitidine 50mg q 6-8hr IV then omeprazole 20-40mg qd or lansoprazole 30-60mg qd. H. pylori tested and treated.

    36. Bini: GI Endo, Nov. 2003 Primary outcome: Recurrence of bleeding in 7 days (def: HD instability, new hematemesis, new hematochezia, new melena, decreased Hg > 2.0 mg/dL). Confirmed by endoscopy. Secondary outcomes: # units PRBC’s transfused, repeat endoscopy, surgery, length of stay, bleeding specific mortality, and complications of endoscopy.

    37. Bini: GI Endo, Nov. 2003 Baseline characteristics: only sign. P was age – 56 in endo vs. 51.3 in med, Of the 1407 pts with UGI bld, adherent clot = 21.9% After removing the clot, stigmata were seen 78.3%

    38. Bini: GI Endo, Nov. 2003 Primary Outcome (Rebleed 7d)- Medical 27.4% vs. Combo 8.7%, p<0.001 OR 0.25, 95% CI RRR 68.2% ARR 18.7% NNT 6

    39. Bini: GI Endo, Nov. 2003 7d rebld based on underlying stigmata= act bld 25%, vv 11.6%, flat spot 3.7%, clean base 0% RF’s for recurrent bld 7d: age > 60, inpt, comorbid, shock, anticoag, hb< 8, > 3u prbc, ucler > 2cm, high risk location, decrease risk =endoscopic therapy or 0.25 Multivariate: agem inpt, shock , antico, ulcer sz, high risk Sec outc: LOS 6vs8, prbc 2vs3, 30d bld 10.1vs28.3%

    40. Bini: GI Endo, Nov. 2003 Spurting or oozing after clot removal occurred in 8.7% and was higher with forceful removal vs. cold guillotining (22.9% vs. 3.9%, OR 7.3)

    41. Review

    43. Conclusions In general, the literature supports irrigation, epinephrine injection, and clot removal to decrease the risk of rebleeding when an adherent clot is identified. The techniques of the above steps is variable, although heater probe irrigation and “cold guillotining” is the most common practice. Method of PPI therapy is variable

    44. Discussion/Opinions What could we have done different for our patient? What should we do the next time we are faced with an adherent clot?

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