Upper GI Bleedcurrent endoscopic management

Dr. B K Jalan, MD

Aditya Diagnostics and Hospitals,Dibrugarh

Evolution of multidisciplinary approach

• From a purely surgical amenable disease entity to

• medically treatable condition with significant role of surgery in large no. of cases

to • purely therapeutic endoscopically manageable entity

with • pre and post endoscopy medications and • limited role for intervention radiology and surgery in

desperate cases only

Major causes

VaricesPeptic ulcerErosionsothers

Other causes include:

Mallory Weiss tearCancer

Dieulafoy’s lesionsPolyp etc.

Asian Institute of Gasteroenterology, Hyderabad,India

The most common causes of upper GI bleeding

• duodenal ulcers(35%) and • Gastric ulcers (20%). • esophageal varices 5-11% (incidence varies

depending on geographic location).

• Other causes for upper GI bleeding are • acute gastric erosions/hemorrhagic gastritis

(18%), • Mallory Weiss tears (10%), • Gastric carcinoma (6%), and • other causes (6%)

Medscape data

Variceal Bleed

• Esophageal• Gastric usual cause is portal hypertension

due toCirrhosis of liverportal thrombosisothers

Variceal bleed - general outlook

• In about 80% of patients, variceal bleeding stops spontaneously.

• mortality is high, often > 50%. • Mortality depends primarily on severity of the associated

liver disease rather than on the bleeding itself. • Surviving patients are at high risk of further variceal

bleeding typically 50 to 75% have recurrence within 1 to 2 yr.

• Ongoing endoscopic or drug therapy significantly lowers this risk,

Endoscopic sclerotherapy successful in controlling acute esophageal variceal

bleeding in up to 90% of patients. Hemorrhagic control should be obtained with 1-2

sessions. Patients continuing to bleed after 2 sessions should be considered for alternative methods to control their bleeding.

sclerosants: sodium tetradecyl sulfate sodium morrhuate polidocanol Ethanolamine Glue (cyanoacrylate) injection may also be used instead, with

immediate hardening of the site and arrest of bleeding

Endoscopic sclerotherapy

Serious complications to sclerotherapy have been reported in 15-20% of patients, with an associated mortality rate of 2%.

Complications of sclerotherapy may include mucosal ulceration, bleeding, oesophageal perforation, mediastinitis, and pulmonary complications. Long-term complications, such as esophageal stricture

formation, may also occur.

Bleeding esophageal varix and sclerosant/ glue injection

Esophageal variceal bleed controlled after sclerosant and glue injection respectively

Endoscopic variceal ligation (banding)

The esophageal mucosa and the submucosa containing varices are ensnared, causing subsequent strangulation, sloughing, and eventual fibrosis, resulting in obliteration of the varices.

Very effective in securing hemostasis from a platelet plug over a recently bled varix

Esophageal varix with platelet plug ligated

Bleeding esophageal varix ligated with immediate control of bleed

Varix being sucked in the cup and ligated

Endoscopic variceal ligation (banding)

endoscopic field of view may be a problem because of the device itself and because of pooling of blood in the cup

Comparison with sclerotherapy:• Initial rate of hemostasis same• Rebleeding rates are less with ligation: 26% vs 45%• Local complications are less, e.g. strictures• Systemic complications like pulmonary infections and

bacterial peritonitis : trend towards less incidence with ligation

Gastric varices

• Glue injection• Banding

Glue injection of bleeding gastric varix

Mr. Sarma 74 yrsPresented with repeated

hematemesis, precipitated by blood transfusions

05 12 2009 18 12 2009

06 01 201022 12 2009

Prognosis of variceal bleeding• The natural course of the disease causing portal hypertension

• The severity of portal hypertension

• The location and number of the bleeding varices

• The functional status of the liver and the severity of liver disease (early rebleeding, within 5 d of admission, occurred in

• 21% of patients classified as Child-Pugh grade A, • 40% of patients classified as grade B, and• 63% of patients classified as grade C)

• Presence of associated systemic disorders

• Continued alcohol abuse

• Response to emergency treatment

Bleeding erosions

• In most cases bleeds due to erosions are minor and amenable to acid suppression therapy

• In cases of significant and generalized ooze, APC (Argon plasma Coagulation) is the usual method employed to cause superficial burns in the mucosa with adequate control of bleeding

Ulcer Bleed – general outlook

• 80% of ulcers stop bleeding spontaneously

• Overall mortality is 10%

• 73.2 % mortality in patients over 60 yrs of age

• Associated co morbid illness in 51% patients

• One or more co-morbid conditions noted in 98% of patients who died

Management of Upper GI Bleed

Resuscitation - ABCs

Assessment – hemodynamic signs

Symptomatic therapy with drugs

Definitive treatment (endoscopy / Surgery)

Prevention of rebleed

• Is early endoscopy necessary ?• Out of the hours procedure

• Who need early endoscopy – high risk patients ?

• Can some non endoscopy treatment buy time?

Patients at High Risk of Increased Mortality

• Age above 60years• Recurrent bleeding• Severe co-morbidity• Active bleeding e.g.

• witnessed hematemesis,• red blood per naso-gastric tube, • RBC transfusion of 6 units or more, • Supine hypotension <100mm of Hg• rebleed in hospital, • severe coagulopathy, • need for endoscopic hemostasis or surgery

Rockall scoreAge in

years

score Evidence Of

shock

score Co-morbidity score

>60 0 none 0 none 0

60 - 79 1 Pulse>100SBP>100

1CCF, IHD or any other

major disease

2

>80 2 SBP<100 2Renal / liver

failure, disseminated malignancy

3

HIGH RISK: ≥4 MODERATE RISK: 2-3 LOW RISK: 0-1

Early endoscopy in high risk patients can

Control bleeding and reduce rebleeding rate

Reduce rate of surgery

Reduce hospital stay

Probably reduce mortality

early endoscopy ?

Endoscopy within 1 to 24 hours

after initial resuscitation and stabilization As first case during usual endoscopy timings

Proper personals, proper equipment and adequate infrastructure - available

What to do in the intervening period ?

0

20

40

60

80

100

120

omeprazoleplacebo

Hongkong study – IV Omeprazole before endoscopy in ulcer bleed

Forrest Classification Rebleeding Incidence

Surgical Requirement

Incidence of

DeathType I: Active Bleed

55-100% 35% 11%

Ia: Spurting Bleed

Ib: Oozing Bleed

Type II: Recent Bleed

40-50% 34% 11%IIa: Non-Bleeding Visible Vessel

(NBVV)

IIb: adherent clot20-30% 10% 7%

Type III: Lesion without Bleeding10% 6% 3%Flat Spot

Clean Base5% 0.5% 2%

Endoscopic therapeutic options

• Injection• Thermal

• Heater probe• Bipolar probe• Nd: YAG laser• Argon Plasma Coagulation

• Mechanical• Hemoclips• Banding

Injection temponade• 1:10000 to 1:20000 adrenalin solution injected round the

bleeding site to produce local compression

• Large volumes up to 30 to 40 cc may be injected

• Up to 90 to 95% cases there is immediate arrest of bleeding

• Bleeding may recur in a large number of cases

• Elderly people and people with portal hypertension, concern is because of systemic effects of adrenaline that is absorbed in the circulation

Bleeding duodenal ulcer

Injection of adrenalin 1:20000

Local blanching with cessation of bleed

Thermal coagulationCo-aptive coagulation

• Usually , a gold probe is used with an ordinary diathermy equipment

• The culprit vessel is compressed to occlude and burned and sealed off completely

• A combination of injection temponade followed by coaptive coagulation is the standard protocol now a days

• Vessels up to 2mm diameter can be handled this way, larger vessels can not be treated.

Combination of methods

• Combination of methods is better.• In a meta-analysis, Calvet showed that

• The rate of re-bleed reduces from 18.4% to 10.6%

• Rate of emergency surgery reduced from 11.3% to 7.6%

• Mortality reduced from 5.1% to 2.6%

Adherent clot

• Best treated or left alone ??

• Cold snare to remove the clot and then treat the underlying vessel in the usual way

• Left alone :: rebleed rate as high as 35%

• Treated :: none of the patients rebleed

Jenson DM et al 2002

clips• Mechanical hemostasis• No tissue destruction• Repeat application safe

• One or more clips can be applied to occlude the bleeding area

• Multi-clip devices are available• Cost is a disadvantage• Sometimes clip can cut through the bleeder with

catastrophic results• Sometimes all three methods may be combined

Clips’ limitations

• Posterior wall duodenal ulcers• High lesser curve ulcers• Fibrotic ulcers

Comparison of clips with thermal methods don’t show superiority of one over other

For large vessels, eagle claw devices are coming which can suture the vessels completely just like surgeons

Forrest Classification Endoscopic treatment modalitiesType I: Active Bleed Injection

Plus thermal method or clipIa: Spurting Bleed

Ib: Oozing Bleed Injection or thermal method or both

Type II: Recent Bleed Clips plus injectionOr

clips plus coagulation or

clips only

IIa: Non-Bleeding Visible Vessel

(NBVV)

IIb: adherent clot Removal of clots plus injection plus thermal methods

Type III: Lesion without Bleeding

No endoscopic treatment requiredFlat Spot

Clean Base

Recurrent bleed

• How likely?

bleeding recurs in 15 to 20%

• How to avoid?

Acid suppression therapy

• For healing ulcers a pH >4.0 is adequate

• High intragastric pH (>6.0) facilitates platelet aggregation and stabilzes the clot

• Acid suppression therapy may decrease re-bleed and need for surgery

• H 2 receptor antagonists are not useful except may be in gastric ulcers.

IV PPI reduce re-bleeding from ulcers after endoscopic therapy

72 hours7 days

30 days

0

5

10

15

20

25

omeprazoleplacebo

Omeprazole 80mg IV followed by 8mg hourly for 72 hours followed by oral omeprazoleLau et al NEJM 2000

Cum

ulati

ve

rebl

eedi

ng

rate

%

Variability in response to PPIs

• Asians respond better than non Asians they are slow metabolizers (20% population) compared to Europeans and Americans (2% population)

• Even among Asians, response to different PPIs is different

• IV ESOMEPRAZOLE is the best- pH rises to 6 in a matter of minutes and remains persistently so for a long time

• oral esomeprazole is as effective as IV at least 40 mg twice a day

summary• Endoscopic therapy is now the mainstay of treatment of

bleeding peptic ulcers

• IV PPI before and after endotherapy facilitate therapy, prevent rebleeding, reduce the emergency surgery rate and hospital stay and probably reduce mortality.

• Patients with significant co- morbid conditions require early endoscopy, are difficult to treat and their overall outlook may not improve despite endotherapy and PPIs

rebleed

• About 2 to 5% patients may still re-bleed• Role of 2nd look endoscopy ?

• Not required in all patients• High risk patients may require

» Ulcer size more than 2 cms» shock

• Endotherapy / surgery ?? • Complication rates and 30 day mortality are still higher with

surgical intervention; • so repeat endotherapy may be attempted. • Very large ulcers probably one should go for surgery instead of

repeat endotherapy

Follow up treatment

• Full four weeks course of PPIs orally followed by

• Anti H pylori treatment in the last one week

My sincere thanks and gratitude

• for the opportunity,

• for your rapt attention and

• for being kind enough to overlook any inadvertent shortcomings

Thank you once again