GASTROINTESTINAL GASTROINTESTINAL BLEEDINGBLEEDING

Ajay Jain, MD, FACG, FRCPCAjay Jain, MD, FACG, FRCPCGastroenterologistGastroenterologist

Meridian Medical GroupMeridian Medical Group

INSGNAINSGNAMarch 5, 2011March 5, 2011

ObjectivesObjectives IntroductionIntroduction

Lower Gastrointestinal Bleeding (LGIB)Lower Gastrointestinal Bleeding (LGIB) etiologyetiology presentationpresentation diagnostic testingdiagnostic testing managementmanagement

Upper Gastrointestinal Bleeding (UGIB)Upper Gastrointestinal Bleeding (UGIB) etiologyetiology evaluationevaluation endoscopyendoscopy managementmanagement

IntroductionIntroduction gastrointestinal bleeding (GIB) common clinical gastrointestinal bleeding (GIB) common clinical

problemproblem

source of GIB traditionally divided into either source of GIB traditionally divided into either upper or lowerupper or lower

upperupper gastrointestinal bleeding (UGIB): gastrointestinal bleeding (UGIB): bleeding from any source bleeding from any source proximalproximal to ligament of to ligament of

TreitzTreitz

lowerlower gastrointestinal bleeding (LGIB): gastrointestinal bleeding (LGIB): bleeding from any source bleeding from any source distaldistal to ligament of Treitz to ligament of Treitz

Lower Gastrointestinal Lower Gastrointestinal BleedingBleeding

one-fifth to one-third as common as UGIBone-fifth to one-third as common as UGIB less severe course compared with UGIBless severe course compared with UGIB annual incidence rate:annual incidence rate:

25 cases per 100,000 adult population at risk 25 cases per 100,000 adult population at risk (UGIB rate : 150 cases per 100,000)(UGIB rate : 150 cases per 100,000)

incidence increases with ageincidence increases with age greater than 200-fold increase from 20s to 80sgreater than 200-fold increase from 20s to 80s

mean age of patients with LGIB: 63 - 77mean age of patients with LGIB: 63 - 77 mortality rate 2 - 4%mortality rate 2 - 4%

LGIB - EtiologyLGIB - EtiologyStudyStudy MeaMea

n n AgeAge

(yrs(yrs))

MortalMortalityity

(%)(%)

DivertiDivertic-c-

ulosisulosis

(%)(%)

Angio-Angio-

dysplasdysplasiaia

(%)(%)

CancerCancer//

PolypPolyp

(%)(%)

Colitis/Colitis/

Ulcer*Ulcer*

(%)(%)

Ano-Ano-

rectalrectal

(%)(%)

OtherOther

(%)(%)

Boley Boley (1979)(1979)

n = 183n = 183

>65>65 22 4040 1111 1414 1212 NANA NANA

Jensen Jensen (1988)(1988)

n = 80n = 80

6565 NANA 2020 3737 1414 1111 55 55

Leitman Leitman (1989)(1989)

n = 65n = 65

6363 22 2727 2424 1515 1010 NANA NANA

Richter Richter (1995)(1995)

n = 107n = 107

7070 22 4848 1212 1111 66 33 66

Jensen Jensen (2003)(2003)ΨΨ

n = 291n = 291

7777 66 3030 66 66 2121 2323 1515

NA Not availableNA Not available* Includes Inflammatory bowel disease, infectious colitis, radiation colitis, * Includes Inflammatory bowel disease, infectious colitis, radiation colitis, vasculitis and inflammation ofvasculitis and inflammation of unknown originunknown originΨΨ Expressed as % of colonic causes of bleeding Expressed as % of colonic causes of bleeding

Age, Mortality Rates, and Causes of Acute Lower Gastrointestinal Bleeding in the ElderlyAge, Mortality Rates, and Causes of Acute Lower Gastrointestinal Bleeding in the Elderly

LGIB - PresentationLGIB - Presentation Chief complaint may varyChief complaint may vary

passage of occasional bright red blood per passage of occasional bright red blood per rectum associated with formed, brown stoolrectum associated with formed, brown stool

patient usually hemodynamically patient usually hemodynamically stablestable

passage of relatively higher volumes of passage of relatively higher volumes of bright red blood (“hematochezia”)bright red blood (“hematochezia”)

patient may be hemodynamically patient may be hemodynamically unstableunstable

passage of black, tarry stools (“melena”)passage of black, tarry stools (“melena”) first evaluate for UGIBfirst evaluate for UGIB if evaluation shows no upper GI source then if evaluation shows no upper GI source then

consider bleeding from right colon or small bowelconsider bleeding from right colon or small bowel patient may be hemodynamically patient may be hemodynamically unstableunstable

LGIBLGIB

MonitoringMonitoring patients may be critically ill at presentationpatients may be critically ill at presentation not only at risk for direct consequences of GI tract not only at risk for direct consequences of GI tract

pathology, but also for cardiac, pulmonary, renal pathology, but also for cardiac, pulmonary, renal and neurologic complications of acute blood lossand neurologic complications of acute blood loss

identify symptoms of hemodynamic compromise:identify symptoms of hemodynamic compromise: postural symptoms/fatigue/palpitations/chest pain/dyspneapostural symptoms/fatigue/palpitations/chest pain/dyspnea

monitor vital signs (including postural vitals)monitor vital signs (including postural vitals) increase of > 10 beats/min or drop in BPs > 10mmHg increase of > 10 beats/min or drop in BPs > 10mmHg

indicative of at least a 15% acute blood loss volumeindicative of at least a 15% acute blood loss volume

Ebert et al, Arch Int Med 1941; Am Coll Surg 1993Ebert et al, Arch Int Med 1941; Am Coll Surg 1993

LGIBLGIB Initial resuscitationInitial resuscitation

restore euvolemia, prevent complications of acute restore euvolemia, prevent complications of acute blood lossblood loss

MI, CHF, CVA, etc.MI, CHF, CVA, etc. transfuse packed red blood cells as necessarytransfuse packed red blood cells as necessary correct coagulopathycorrect coagulopathy

fresh frozen plasma & vitamin Kfresh frozen plasma & vitamin K obtain relevant history while resuscitation is underwayobtain relevant history while resuscitation is underway

duration of bleeding/presence or absence of abdominal duration of bleeding/presence or absence of abdominal pain/chest pain /feverpain/chest pain /fever

history of ulcer disease/IBD/radiation therapy to abdomen or history of ulcer disease/IBD/radiation therapy to abdomen or pelvispelvis

cardiopulmonary, renal, hepatic diseasecardiopulmonary, renal, hepatic disease current medications (ASA, NSAIDS, anticoagulants)current medications (ASA, NSAIDS, anticoagulants)

LGIBLGIB

Initial resuscitation (cont’d)Initial resuscitation (cont’d) Physical examinationPhysical examination

cardiac/pulmonary/abdominal and rectal cardiac/pulmonary/abdominal and rectal examinationsexaminations

Laboratory studiesLaboratory studies CBC/electrolytes/BUN/CR/PT/PTTCBC/electrolytes/BUN/CR/PT/PTT type and crosstype and cross EKGEKG

LGIBLGIB

Not All Hematochezia is Due to a Colonic Not All Hematochezia is Due to a Colonic SourceSource

first think of a colonic source of bleeding but first think of a colonic source of bleeding but remember that UGIB source may present with remember that UGIB source may present with hematochezia, if the bleeding is briskhematochezia, if the bleeding is brisk

in one series 11% of patients with hematochezia and in one series 11% of patients with hematochezia and hemodynamic compromise had an UGI sourcehemodynamic compromise had an UGI source

Jensen et al, Gastroenterology 1988Jensen et al, Gastroenterology 1988

LGIBLGIB

Not All Hematochezia is Due to a Colonic Not All Hematochezia is Due to a Colonic Source (cont’d)Source (cont’d) nasogastric (NG) tube is reasonable to use to nasogastric (NG) tube is reasonable to use to

evaluate for possible UGIBevaluate for possible UGIB note presence or absence of both blood and bilenote presence or absence of both blood and bile if significant blood seen on NG tube, consider performing if significant blood seen on NG tube, consider performing

upper endoscopyupper endoscopy presence of bile confirms that duodenal contents sampled; presence of bile confirms that duodenal contents sampled;

if bile absent an upper GI endoscopy should be consideredif bile absent an upper GI endoscopy should be considered NG tube has been shown to be useful test in this regard NG tube has been shown to be useful test in this regard

with accuracy of 94-98%with accuracy of 94-98% no role for upper GI barium x-rayno role for upper GI barium x-ray

Luk et al, JAMA 1979; Cuellar et al, Arch Intern Med, 1990Luk et al, JAMA 1979; Cuellar et al, Arch Intern Med, 1990

LGIBLGIB

Sources of Colonic BleedingSources of Colonic Bleeding DiverticulosisDiverticulosis

arterial bleeding, painless, ceases arterial bleeding, painless, ceases spontaneously in most casesspontaneously in most cases

LGIBLGIB

Sources of Colonic BleedingSources of Colonic Bleeding Diverticular BleedingDiverticular Bleeding

87 year-old woman who presented with lower gastrointestinal bleeding. 87 year-old woman who presented with lower gastrointestinal bleeding. The bleeding was finally localized to a single diverticulum, shown hereThe bleeding was finally localized to a single diverticulum, shown here

LGIBLGIB

Sources of Colonic BleedingSources of Colonic Bleeding AngiodysplasiaAngiodysplasia

vascular malformationsvascular malformations frequently involves proximal colonfrequently involves proximal colon

Arrow indicates point of bleedingArrow indicates point of bleeding

LGIBLGIB

Sources of Colonic BleedingSources of Colonic Bleeding Colonic Neoplasia (large adenoma or Colonic Neoplasia (large adenoma or

adenocarcinoma)adenocarcinoma) may present with blood per rectum but more often may present with blood per rectum but more often

present with change in bowel habits, abdominal pain present with change in bowel habits, abdominal pain or other related symptomor other related symptom

Bleeding polypBleeding polypSessile (flat) polypSessile (flat) polyp Colon cancerColon cancer

LGIBLGIB

Sources of Colonic BleedingSources of Colonic Bleeding Inflammatory Colitides/UlcerationInflammatory Colitides/Ulceration

inflammatory bowel disease, infectious colitis, inflammatory bowel disease, infectious colitis, radiation colitis, vasculitisradiation colitis, vasculitis

33 year-old man with Crohn’s colitis involving 33 year-old man with Crohn’s colitis involving the proximal colon, with severe inflammation, the proximal colon, with severe inflammation, edema and ulcersedema and ulcers

NormalNormalvascular patternvascular pattern

NormalNormaltransverse colontransverse colon

LGIBLGIB

Sources of Colonic BleedingSources of Colonic Bleeding AnorectalAnorectal

hemorrhoids, anal fissure, idiopathic rectal hemorrhoids, anal fissure, idiopathic rectal ulcerulcer

LGIBLGIB

Diagnostic TestingDiagnostic Testing ColonoscopyColonoscopy clearly test of choice clearly test of choice

no evidence that colonic purge will increase the rate no evidence that colonic purge will increase the rate of bleeding or cause renewed bleeding if it has of bleeding or cause renewed bleeding if it has ceasedceased

overall diagnostic yield of colonoscopy 70-80%overall diagnostic yield of colonoscopy 70-80% not only allows identification of bleeding source but not only allows identification of bleeding source but

also can apply therapy to stop bleedingalso can apply therapy to stop bleeding endoscopic therapies (discussed in greater detail endoscopic therapies (discussed in greater detail

with UGIB)with UGIB) Thermal (heater probe, argon plasma coagulation)Thermal (heater probe, argon plasma coagulation) Injection (epinephrine, ethanolamine etc.)Injection (epinephrine, ethanolamine etc.) Mechanical (band ligation, hemoclips, endoloops)Mechanical (band ligation, hemoclips, endoloops)

Forde et al, Gastrointest Endosc 1981Forde et al, Gastrointest Endosc 1981

LGIBLGIB Diagnostic Testing (cont’d)Diagnostic Testing (cont’d)

AngiogramAngiogram use if unable to find bleeding siteuse if unable to find bleeding site diagnostic yield: 40-80%diagnostic yield: 40-80% usually need to have a bleeding rate of >0.5mL/min to usually need to have a bleeding rate of >0.5mL/min to

identify extravasation of contrast into bowelidentify extravasation of contrast into bowel risk of complications greater than colonoscopyrisk of complications greater than colonoscopy

contrast-induced renal failure, contrast allergy, bleeding after contrast-induced renal failure, contrast allergy, bleeding after arterial puncture, embolism from dislodged thrombusarterial puncture, embolism from dislodged thrombus

therapy can be applied (embolization or intra-arterial therapy can be applied (embolization or intra-arterial injection)injection)

Nuclear MedicineNuclear Medicine Red Blood Cell Red Blood Cell (RBC) Scan(RBC) Scan can potentially identify slower rate of bleedingcan potentially identify slower rate of bleeding diagnostic yield 26-72%diagnostic yield 26-72%

Gomes et al, AJR 1986; Suzman et al, Ann Surg 1996Gomes et al, AJR 1986; Suzman et al, Ann Surg 1996

LGIBLGIB Role of SurgeryRole of Surgery

if bleeding does not cease, and site of bleeding if bleeding does not cease, and site of bleeding known, directed surgery (ie. limited colonic known, directed surgery (ie. limited colonic resection) can be performed with better resection) can be performed with better outcomes compared with subtotal colectomy outcomes compared with subtotal colectomy or “blind” right hemicolectomyor “blind” right hemicolectomy

Evaluation of Small IntestineEvaluation of Small Intestine LGIB but no colonic source identifiedLGIB but no colonic source identified rule-out UGIB firstrule-out UGIB first if absent upper and lower GI source, exam if absent upper and lower GI source, exam

small intestine:small intestine: video capsule endoscopyvideo capsule endoscopy enteroclysisenteroclysis Meckels scanMeckels scan

ALGORITHALGORITHMM

TO ACUTETO ACUTE

LGIBLGIB

SEE NEXT SLIDESEE NEXT SLIDE

(Part 1)(Part 1)

ALGORITHM TO ACUTE ALGORITHM TO ACUTE LGIBLGIB

Upper Gastrointestinal Upper Gastrointestinal BleedingBleeding

can divide causes intocan divide causes into variceal and non-variceal UGIB (focus on non-variceal and non-variceal UGIB (focus on non-

variceal UGIB)variceal UGIB) Healthcare burden/cost of UGIB from Healthcare burden/cost of UGIB from

peptic ulcer diseasepeptic ulcer disease 250,000 to 300,000 hospital admissions250,000 to 300,000 hospital admissions $2.5 billion in US each year$2.5 billion in US each year

despite advances in diagnosis and despite advances in diagnosis and treatment, mortality of UGIB remains from treatment, mortality of UGIB remains from 5 – 14%5 – 14% mortality higher in patients > 60 yrs and in mortality higher in patients > 60 yrs and in

patients with multiple comorbid conditionspatients with multiple comorbid conditions

Rockall et al, Lancet 1995; Rockall et al, Gut 1996Rockall et al, Lancet 1995; Rockall et al, Gut 1996

UGIBUGIB

Natural HistoryNatural History majority of patients with UGIB will majority of patients with UGIB will

spontaneously ceasespontaneously cease 70-80% will stop within first 48 hrs of onset; of those 70-80% will stop within first 48 hrs of onset; of those

10-20% will have recurrence of UGIB10-20% will have recurrence of UGIB

at initial presentation ~20% will continue to at initial presentation ~20% will continue to bleedbleed

mortality greatest in these patients and also patients mortality greatest in these patients and also patients that have recurrent bleedingthat have recurrent bleeding

UGIB - EtiologyUGIB - Etiology

EtiologyEtiology %%

Peptic ulcer Peptic ulcer diseasedisease

50+50+

Esophageal Esophageal varicesvarices

1010

Mallory-Weiss Mallory-Weiss teartear

5-105-10

EsophagitisEsophagitis 8-108-10

NeoplasmNeoplasm 2-52-5

AngiodysplasiaAngiodysplasia 2-52-5

MiscellaneousMiscellaneous 1010

UGIB - EtiologyUGIB - Etiology

20-30% of patients will have two or more 20-30% of patients will have two or more diagnoses of UGIBdiagnoses of UGIB

no disease entity is found in 10-15% of no disease entity is found in 10-15% of patients (prognosis is excellent)patients (prognosis is excellent)

bleeding peptic ulcer diseasebleeding peptic ulcer disease most common most common etiology and is also the most etiology and is also the most widely studiedwidely studied excellent randomized control trials regarding excellent randomized control trials regarding

best treatment modalities, outcomes, risk of best treatment modalities, outcomes, risk of rebleeding and natural progressionrebleeding and natural progression

UGIBUGIB

Initial evaluationInitial evaluation monitor hemodynamic statusmonitor hemodynamic status IV access; vigorous volume replacementIV access; vigorous volume replacement confirm UGI source of bleeding byconfirm UGI source of bleeding by

history (hematemesis – fresh blood or coffee ground history (hematemesis – fresh blood or coffee ground emesis, melena)emesis, melena)

nasogastric aspiration is 80% sensitive for actively nasogastric aspiration is 80% sensitive for actively bleeding UGI sourcebleeding UGI source

False negative aspirates occur when the tube is False negative aspirates occur when the tube is improperly positioned or when reflux of blood from a improperly positioned or when reflux of blood from a duodenal source prevented by pylorospasm or duodenal source prevented by pylorospasm or obstructionobstruction

Cuellar et al, Arch Intern Med 1990Cuellar et al, Arch Intern Med 1990

UGIBUGIB EndoscopyEndoscopy

when UGIB suspected, test of choice for when UGIB suspected, test of choice for identifyingidentifying and and treating treating the bleeding lesion is the bleeding lesion is upper endoscopyupper endoscopy

no role for barium studies in acute UGIBno role for barium studies in acute UGIB greatest benefit in the ~20% of patients with greatest benefit in the ~20% of patients with

continued or recurrent bleedingcontinued or recurrent bleeding endoscopy can improve morbidity and mortalityendoscopy can improve morbidity and mortality endoscopic therapy with coagulation and/or injection endoscopic therapy with coagulation and/or injection

therapy effective in the setting of actively bleeding therapy effective in the setting of actively bleeding ulcersulcers

active bleeding can be controlled in 85-90% of active bleeding can be controlled in 85-90% of patients, with less than 3% complication ratepatients, with less than 3% complication rate

mortality decreased by nearly one thirdmortality decreased by nearly one third concurrent use of proton pump inhibitors (eg. concurrent use of proton pump inhibitors (eg.

IV prevacid or protonix) of significant benefit in IV prevacid or protonix) of significant benefit in decreasing recurrent bleedingdecreasing recurrent bleeding

Sacks et al, JAMA 1990; Laine et al, Gastro 1990Sacks et al, JAMA 1990; Laine et al, Gastro 1990

UGIBUGIB

EndoscopyEndoscopy management decision for other 80% who will not management decision for other 80% who will not

have further bleeding can be altered by have further bleeding can be altered by aggressive diagnosisaggressive diagnosis

requires ability to separate high-risk patients requires ability to separate high-risk patients from low-risk patientsfrom low-risk patients

clinical indicators of higher mortality from UGIBclinical indicators of higher mortality from UGIB variceal bleedingvariceal bleeding advanced ageadvanced age comorbid illnessescomorbid illnesses large volume bleedinglarge volume bleeding persistent or recurrent bleeding despite medical therapypersistent or recurrent bleeding despite medical therapy

UGIBUGIB EndoscopyEndoscopy

best predictor of recurrent bleeding in peptic ulcer best predictor of recurrent bleeding in peptic ulcer disease is the endoscopic appearance of the ulcerdisease is the endoscopic appearance of the ulcer

Endoscopic Endoscopic FindingFinding

Risk of Risk of Recurrent Recurrent BleedingBleeding

MortalityMortality

Active Active BleedingBleeding

55%55% 11%11%

Visible Visible VesselVessel

43%43% 11%11%

Adherent Adherent ClotClot

22%22% 7%7%

Flat SpotFlat Spot 10%10% 3%3%

Clean BaseClean Base 5%5% 2%2%

Risk of Recurrent Bleeding By Endoscopic CriteriaRisk of Recurrent Bleeding By Endoscopic Criteria

Freeman et al, Gastrointest Endosc 1993Freeman et al, Gastrointest Endosc 1993

UGIBUGIB

EndoscopyEndoscopy

Clean based ulcerClean based ulcer Adherent clotAdherent clot

UGIBUGIB

EndoscopyEndoscopy

Small ulcer with aSmall ulcer with aprominent visible vessel prominent visible vessel

2 cm ulcer with pulsatile,2 cm ulcer with pulsatile,arterial bleed arterial bleed

UGIBUGIB

EndoscopyEndoscopy Laine et al (Gastro 1992) showed that patients Laine et al (Gastro 1992) showed that patients

with a clean based ulcer had only a 2% risk of with a clean based ulcer had only a 2% risk of recurrent bleeding and could be safely fed and recurrent bleeding and could be safely fed and immediately discharged from hospitalimmediately discharged from hospital

reduces hospital stay → reduces healthcare costsreduces hospital stay → reduces healthcare costs

Lee et al (Gastrointest Endosc 1999) showed Lee et al (Gastrointest Endosc 1999) showed that “endoscopic triage” significantly decreased that “endoscopic triage” significantly decreased costs and resulted in median savings of $2068costs and resulted in median savings of $2068

UGIBUGIB Endoscopic ManagementEndoscopic Management

several endoscopic therapeutic techniques several endoscopic therapeutic techniques available to attempt hemostasis in patients with available to attempt hemostasis in patients with UGIBUGIB

ThermalThermal Heater ProbeHeater Probe Multipolar electrocautery (MPEC)/bipolar Multipolar electrocautery (MPEC)/bipolar

electrocauteryelectrocautery Argon plasma coagulation Argon plasma coagulation

InjectionInjection EpinephrineEpinephrine AlcoholAlcohol EthanolamineEthanolamine OtherOther

MechanicalMechanical Band LigationBand Ligation HemoclipsHemoclips (Endoclip) (Endoclip) Detachable Snare (Endoloop)Detachable Snare (Endoloop)

UGIBUGIB Endoscopic ManagementEndoscopic Management

several endoscopic therapeutic techniques several endoscopic therapeutic techniques available to attempt hemostasis in patients with available to attempt hemostasis in patients with UGIBUGIB

ThermalThermal Heater ProbeHeater Probe Multipolar electrocautery (MPEC)/bipolar Multipolar electrocautery (MPEC)/bipolar

electrocauteryelectrocautery Argon plasma coagulation (APC)Argon plasma coagulation (APC)

InjectionInjection EpinephrineEpinephrine AlcoholAlcohol EthanolamineEthanolamine OtherOther

MechanicalMechanical Band LigationBand Ligation HemoclipsHemoclips (Endoclip) (Endoclip) Detachable Snare (Endoloop)Detachable Snare (Endoloop)

UGIBUGIB

Endoscopic Management – Endoscopic Management – ThermalThermal all thermal devices generate heatall thermal devices generate heat

directly (heater probe) ordirectly (heater probe) or indirectly by tissue absorption of light energy (laser) orindirectly by tissue absorption of light energy (laser) or passage of electrical current through tissue (multipolar passage of electrical current through tissue (multipolar

probes, APC)probes, APC) heating leads to edema, coagulation of tissue heating leads to edema, coagulation of tissue

protein, contraction of vessels, resulting in protein, contraction of vessels, resulting in hemostatic bondhemostatic bond

multipolar electrocautery (MPEC) has been multipolar electrocautery (MPEC) has been compared with sham treatment in patients with compared with sham treatment in patients with active bleeding or nonbleeding visible vesselactive bleeding or nonbleeding visible vessel

shown to reduce re-bleeding, emergency surgery, mean shown to reduce re-bleeding, emergency surgery, mean hospital stay and cost of hospitalizationhospital stay and cost of hospitalization

ThermalThermal

small ulcer with a prominent visible

vessel

site after eradication of the

vessel using heater probe

UGIBUGIB Endoscopic ManagementEndoscopic Management

several endoscopic therapeutic techniques several endoscopic therapeutic techniques available to attempt hemostasis in patients with available to attempt hemostasis in patients with UGIBUGIB

ThermalThermal Heater ProbeHeater Probe Multipolar electrocautery (MPEC)/bipolar Multipolar electrocautery (MPEC)/bipolar

electrocauteryelectrocautery Argon plasma coagulationArgon plasma coagulation

InjectionInjection EpinephrineEpinephrine AlcoholAlcohol EthanolamineEthanolamine OtherOther

MechanicalMechanical Band LigationBand Ligation HemoclipsHemoclips (Endoclip) (Endoclip) Detachable Snare (Endoloop)Detachable Snare (Endoloop)

UGIBUGIB

Endoscopic Management – Endoscopic Management – InjectionInjection devices passed through working channel of devices passed through working channel of

endoscope that allow injection of liquid agents endoscope that allow injection of liquid agents into target site of interestinto target site of interest

injection of various solutions achieves injection of various solutions achieves hemostasis by mechanical tamponadehemostasis by mechanical tamponade

in sham controlled trials, injection therapy in sham controlled trials, injection therapy reduced rebleeding, transfusion requirement, reduced rebleeding, transfusion requirement, emergency surgery and hospital stayemergency surgery and hospital stay

Nelson et al, Gastointest Endosc 1999; Chung et al, Br Med J 1988Nelson et al, Gastointest Endosc 1999; Chung et al, Br Med J 1988

UGIBUGIB Endoscopic ManagementEndoscopic Management

several endoscopic therapeutic techniques several endoscopic therapeutic techniques available to attempt hemostasis in patients with available to attempt hemostasis in patients with UGIBUGIB

ThermalThermal Heater ProbeHeater Probe Multipolar electrocautery (MPEC)/bipolar Multipolar electrocautery (MPEC)/bipolar

electrocauteryelectrocautery Argon plasma coagulation Argon plasma coagulation

InjectionInjection EpinephrineEpinephrine AlcoholAlcohol EthanolamineEthanolamine OtherOther

MechanicalMechanical Band LigationBand Ligation HemoclipsHemoclips (Endoclip) (Endoclip) Detachable Snare (Endoloop)Detachable Snare (Endoloop)

UGIBUGIB Endoscopic Management – Endoscopic Management – MechanicalMechanical

Band ligationBand ligation preloaded elastic band(s) with a release mechanism preloaded elastic band(s) with a release mechanism

affixed to tip of endoscopeaffixed to tip of endoscope esophageal variceal band ligation effective in control of esophageal variceal band ligation effective in control of

active hemorrhage in 86 to 91%active hemorrhage in 86 to 91% HemoclipsHemoclips

preloaded metal clips deployed through biopsy channel of preloaded metal clips deployed through biopsy channel of scope (mechanism of hemostasis is mechanical scope (mechanism of hemostasis is mechanical compression)compression)

achieved hemostasis in 84 to 100% of patients with achieved hemostasis in 84 to 100% of patients with variety of UGIB sourcesvariety of UGIB sources

Detachable SnaresDetachable Snares loop placed around target tissue and loop tightened and loop placed around target tissue and loop tightened and

then releasedthen released were developed to prevent and treat post-polypectomy were developed to prevent and treat post-polypectomy

bleedingbleedingLaine et al, Ann Intern Med 1995; Binmoeller et al, Endoscopy 1993Laine et al, Ann Intern Med 1995; Binmoeller et al, Endoscopy 1993

Band ligationBand ligation

Esophageal varices in a 74 year-old

man with alcoholic cirrhosis

Two neighboring esophageal varices which have been

successfully banded

In another day or two the banded areas will

sloughed off

Detachable SnaresDetachable Snares

Detachable SnaresDetachable Snares

HemoclipsHemoclips

Erythematous ulcer Erythematous ulcer basebase

with a visible vesselwith a visible vessel

Two hemostatic clips were Two hemostatic clips were successful applied to the successful applied to the

vessel, andvessel, andthere was no further there was no further

bleedingbleeding

ALGORITHALGORITHMM

TO UGIBTO UGIB

ALGORITHM TO UGIBALGORITHM TO UGIB

SummarySummary LGIBLGIB

resuscitation, hemodynamic stability a priorityresuscitation, hemodynamic stability a priority colonoscopy procedure of choice for colonoscopy procedure of choice for

evaluation of acute LGIBevaluation of acute LGIB upper endoscopy should be performed when upper endoscopy should be performed when

an upper source is suspected or when an upper source is suspected or when evaluation of colon is negativeevaluation of colon is negative

if colonoscopy and upper endoscopy are if colonoscopy and upper endoscopy are negative, evaluation of small bowel should be negative, evaluation of small bowel should be consideredconsidered

angiogram and/or a bleeding scan may be angiogram and/or a bleeding scan may be appropriate in the setting of massive bleedingappropriate in the setting of massive bleeding

pre-operative localization of bleeding pre-operative localization of bleeding attempted prior to surgical interventionattempted prior to surgical intervention

SummarySummary UGIBUGIB

resuscitation, hemodynamic stability a priorityresuscitation, hemodynamic stability a priority determine if (based on available information), determine if (based on available information),

if variceal vs non-variceal UGIBif variceal vs non-variceal UGIB upper endoscopy procedure of choice for upper endoscopy procedure of choice for

evaluation of UGIBevaluation of UGIB ““endoscopic triage”endoscopic triage” endoscopic therapeutic options (thermal, endoscopic therapeutic options (thermal,

injection, mechanical)injection, mechanical) use of IV proton pump inhibitors (eg. Prevacid use of IV proton pump inhibitors (eg. Prevacid

or protonix) in the high risk group of or protonix) in the high risk group of significant benefit in reducing recurrent significant benefit in reducing recurrent bleedingbleeding