NON VARICEAL GI BLEEDING

Adolfo Parra-BlancoConsultant Gastroenterologist

NUH9th Nottingham Endoscopy Masterclass 2016

Type of lesion?

• Anamnesis – interview very helpful:

–GD ulcer

–Epigastric pain/dyspepsia

–NSAIDs

–ETOH, signs of Chronic liver failure

–Fresh blood without stool

–Previous episodes of bleeding

–Radiotherapy

FIa FIIa FIIb FIIc FIII

Prediction of rebleeding Endoscopic variables (Forrest)

Active

Visible vessel

Adherent clot

Flat spot

No stigmata

Forrest I-a (spurting)High risk: treat in all cases e.g. Adrenaline + clips or Gold probe

Forrest I-b (oozing)

High risk of re-bleed (~55%) needs endoscopic Rx

Forrest II-a (visible vessel)High risk of re-bleed ~43%, treat in all cases

Forrest II-b (adherent clot)

High risk, re-bleed ~22%

Fresh clot, may wash away with water jet irrigation

Organised (stable) clot, may not wash away with irrigation, leave it alone!

Forrest II-c (haem pigment)Low risk: re-bleed ~10%, leave alone and treat

with PPI

Forrest III (clean base)Low risk of re-bleed ~ 5%, no need for endoscopic

Rx

Choose adequate endoscope

Diagnostic Gastroscope

Pros:

- Less discomfort

- Adequate if stenosis

Therapeutic Gastroscope

Pros:

- Suction power

- Double channel

- Large channel-large devices

Endoscopic therapy: Effect on risks

• Achieves hemostasis >90%

• Reduces rebleeding risk

• Reduces emergency surgery

• Reduces mortality

Perform OGD in adequate setting

• Haemodynamically stable?

• Active bleeding / haematemesis?

• Will tolerate OGD / risk of sedation?

• With GA – airway protection whenever needed

Erythomycin to clean the stomach

• Erythromycin stimulates gi motility

• Residual blood/clots should be removed for endoscopic diagnosis-treatment.

• iv erythromycin (250 mg 30-120 min prior to OGD):

• - empty stomach more frequent (69%vs 37%)

• - reduced need repeat OGD reduced hospital stay

Bai et al. Aliemnt Pharmacol Ther 2011; 34: 166-71.

Tools for OGD - Bleeding

• Water Pump: connected to biopsy valve

Connected to water jet channel

• Syringe

▫ 60ml

Symethicone 100 mg/100 ml

Caps

When should we use a cap?

• Usefulness:

▫ Facilitate observation beyond folds / swollen areas

▫ Facilitate identification of bleeding source if active

▫ Facilitate application of endotherapy (mainatins stability of tip of endoscope)

▫ Facilitate suction of clots

Use if:

- lesion not detected

- difficult approach to lesion (duodenum)

Endoscopic methods to treat

bleeding

• Injection

• Thermal

▫ Non contact

▫ Contact

• Mechanical

• Spray

Injection

• First treatment used for hemostasis (ref)

• Adrenaline, ethanol, sclerosants, cyanoacrylate

• Careful (not to harm channel)

• Not as single agent

Communication

• Needle back / out

• Volume injected real time (ml ) (too deep injection?)

• Feedback about resistance

Types of needles

Use needle we are familiar with21G/23G/25G (no comparative studies)4-6mm

Thermal methods

• Laser probes

• Bipolar probes

• Heater probes

• Argon Plasma Coagulation (APC)

• Coagulation forceps

Bipolar probes

Bipolar probes

www.gastrotraining.com

Settings for GoldProbe

Dr. Dennis Jensen-CURE Group.

Heater probe

APC

• Non contact

• Argon gas passes through probe, ioinised by high voltage discharge: plasma

• Gas flow / power / pulses can be controlled

APC

The 10 commandments of APC in

endoscopy• 1. You shall not confuse Argon Plasma with Argon Laser

• With Argon Laser.

• 2. You shall always test APC ignition and electric arc outside the endoscope befor inserting probe into channel.

• 3. You shall insert at least far enough into working channel for first distal black ring to become visible.

• 4. You shall always carry out APC under visual control

• 5. You shall take care that APC probe does not touch the organ wall during activation: however application shall be near enough to ensure plasma ignition.

Grund, Farin. Endosc Surg 1994; 2:71-7.

• 6. You shall never press activated probe into tissue or against organ wall, since this can lead to emphysema or wall damage.

• 7. You shall not touch metal stents directly with the APC probe; here, too, you shall maintain an adequate distance.

• 8. You shall avoid distension caused by inflowing argon and shall therefore check and vacuum repeatedly and place decompression cathether if necessary.

• 9. You shall set power limit and activation duration adequately in relation to wall thickness in affected organ (maximum upper limit 40W right colon).

• 10. You shall prefer short duration activations to a few long-duration activations.

Grund, Farin. Endosc Surg 1994; 2:71-7.

Communication

• Neutral pad needed (in place before starting procedure)

• Settings set by endoscopist beforehand

• Check adequate function

Coagulation forceps

• Monopolar (Coagrasper, Olympus)

• Bipolar (Hemostat Y, Pentax)

Use of Coagulation forceps

• Identify vessel (washing – push with cap – washing)

• Grasp vessel – washing: persistent bleeding?

• Coagulate (soft coagulation)

Mechanical

• Conventional clips

• Over the scope clips

• Endoloops

Conventional clips

Available Clips for hemostasis

- Size- Rotation

“Over the scope” Clips

Mangiavillano. Endoscopy 2012; 44: E221.

What is Hemospray?

Intended Use: Used for nonvariceal gastrointestinal bleeding

• Disposable

• Preassembled with C02 cartridge

• Available with 7 or 10 FR Catheter

▫ 220 cm catheter length

▫ Packaged with extra catheter

How does Hemospray work? When Hemospray comes in contact with blood, the powder absorbs water, then acts both cohesively and adhesively, forming a mechanical barrier over the bleeding site.

Endoclot

Beg et al. EIO 2015; 03: E605-E609.