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Merhaba

Merhaba. Endoscopic Management of Ulcer Bleeding. Dr Redha Lajam, MD Consultant gastroenterologist UST Hospital. Outline. Epidemiology and natural history Risk assessment and pre-endoscopic management Endoscopic therapy Post endoscopic management.

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Merhaba

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  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. 2010 Jul;32(2):215-24.

  8. NG tube aspirate American Society For Gastrointestinal Endoscopy

  9. Mortality according NGT aspirate 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 JY, N Engl J Med. 2007 Apr 19;356(16):1631-40.

  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; 60:497-504

  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; 25,273-278

  15. Outcomes of total cases 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 IIc Forrest grade III Forrest grade IIb

  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 StigmataEndoscopic 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 (90%) Blatchford score <2 (10%) Urgent Endoscopy Outpatient care Elective Endoscopy PPI Rockall score<3 (20-30%) Definitive Care based on endoscopic findings 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 15-20 watts for 8-12 seconds for 4-6 pulses • Larger 10 French more effective than 7 French probes

  30. Endoscopic therapymechanical hemoclips

  31. Application of a clip in upper GI bleeding

  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 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 *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. GastrointestEndsoc 2004; 60:497-504

  39. Injection- Bicap vs. injection-Hemoclip 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 • 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 JJEndoscopy. 2011 Apr;43(4):291-5. 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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