Turning off the tap: Endoscopy Blood & Guts: Transfusion and bleeding in the medical patient

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1 Turning off the tap: Endoscopy Blood & Guts: Transfusion and bleeding in the medical patient John Greenaway 1

2 Turning off the tap: Endoscopy Answer the questions Benefits and risks of endoscopy Urgency of endoscopy Who needs an Out-of-Hours (OOH) endoscopy? How to do this safely Who needs intervention? What interventions are available? Non-variceal upper GI haemorrhage Post procedure care What are the outcomes? When to repeat the endoscopy or use other options 2

3 Augustine Gibson aka AUGIB 3

4 AUGIB - Current aetiology Endoscopic finding % Oesophagitis 24 Gastritis/ erosions 22 Ulcer 36 Erosive duodenitis 13 Malignancy 4 Mallory- Weiss 4 Varices 11 Portal Gastropathy 5 Vascular malformation 3 None 17 BSG 2007 ( _2007.pdf), 32% SRH 6%

5 AUGIB Mortality Factors Study Mortality All Mortality 1 o Admission Rockall % 11% 33% Mortality In-patient Blatchford % 42% BSG % 7% 26% 7,000 deaths per annum in UK Compared to other major acute killers 5%, 11% On average a 3-fold increase in mortality for AUGIB in patients already admitted with another condition 5

6 Rockall risk scoring system Rockall et al Gut 1996 & BMJ

7 Age AUGIB - Mortality Factors Age Mortality < 60 yoa 3% yoa 11% > 79 yoa 20% Co-morbidity One co-morbidity - OR 1.8 / Malignancy OR 3.8 Liver Disease - doubles mortality, higher risk of interventions (overall mortality for variceal bleeding 14%) Haemodynamic factors - modifiable Shock Mortality OR of 3.8 Continued bleeding up to 50-fold increased mortality BSG 2007 ( _2007.pdf), Blatchford et al. BMJ 1997, Rockall et al. BMJ 1995, Klebl et al. Int J Colorectal Dis 2005, Zimmerman et al. Scand J Gastroenterol 1995, Cameron et al. Eur J Hepatol 2002, Lecleire et al. J Clin Gastroenterol

8 Benefits & Risks of Endoscopy AUGIB OGD deemed safe procedure Mortality < 0.1% (50% cardio-pulmonary) Major complication 0.9% Risk stratification more related to patient factors Elderly frail with multiple co-morbidities Drugs NSAIDs, anti-platelet and anticoagulants In general, huge support for endoscopy unless futile Katon RM: Complications of upper gastrointestinal endoscopy in the gastrointestinal bleeder. Dig Dis Sci 27:47s-54s, 1981, NICE 2012 Acute upper gastrointestinal bleeding management (CG 141) & ESGE

9 Urgency of Endoscopy NICE 2012 (CG 141) - Offer endoscopy to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation NICE 2013 (QS38) - GI bleed and haemodynamic instability should have 24/7access to an OGD within two hours of optimal resuscitation ESGE within 12 hours Offer endoscopy within 24 hours of admission to all other patients with upper gastrointestinal bleeding Units > 330 cases per annum = daily endoscopy lists NICE 2012 Acute upper gastrointestinal bleeding management (CG 141), NICE 2013 (QS38), National Confidential Enquiry into Patient Outcome and Death - Time to Get Control? A review of the care received by patients who had a severe gastrointestinal haemorrhage. ESGE 2015 Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage. Endoscopy;47:a1-a46. 9

10 Who needs out-of-hours endoscopy? 2-tier treatment based on pre-endoscopy clinical scoring system Integrated with clinical acumen and concern occult liver disease (particularly in the young) Rockall score less than 3 30% fall into category where mortality < 0.3% Home after swift endoscopy within 24 hours Rockall score of 3 or more Discuss with endoscopy unit / Gastroenterologist within office hours SpR contacts on-call endoscopist out of hours 10 National Confidential Enquiry into Patient Outcome and Death - Time to Get Control? A review of the care received by patients who had a severe gastrointestinal haemorrhage. NICE 2012 Acute upper gastrointestinal bleeding management (CG 141). ESGE 2015 Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage. Endoscopy;47:a1-a46.

11 Out of Hours Emergency endoscopy Performed in endoscopy unit Gold standard (NCEPOD scoping our practice ) Theatre with untrained staff less appropriate (Varices?) Experienced therapeutic endoscopists and nursing staff Usual environment where feasible medical & nursing help Rapid assessment & management May require critical care input (HDU / ITU) or CCU Patient instability Consider theatre (+/- GA) Suspected variceal bleeds High chance of progression to surgery 11 National Confidential Enquiry into Patient Outcome and Death - Time to Get Control? A review of the care received by patients who had a severe gastrointestinal haemorrhage. NICE 2012 Acute upper gastrointestinal bleeding management (CG 141).

12 Non-variceal bleeding Forrest classification: Stigmata of recent haemorrhage in peptic ulcer bleeding Acute haemorrhage Forrest I a (Spurting haemorrhage) Forrest I b (Oozing haemorrhage) Signs of recent haemorrhage Forrest II a (Visible vessel) Forrest II b (Adherent clot) Forrest II c (Flat pigmented haematin on ulcer base) Lesions without active bleeding Forrest III (Lesions without signs of recent haemorrhage or fibrin-covered clean ulcer base) Forrest, JA.; Finlayson, ND.; Shearman, DJ. (Aug 1974). "Endoscopy in gastrointestinal bleeding.". Lancet. 2 (7877): PMID doi: /s (74)91770-x. Is the Forrest classification a useful tool for planning endoscopic therapy of bleeding peptic ulcers? Endoscopy. 1989; 21:

13 Non-variceal bleeding Forrest classification: Stigmata of recent haemorrhage in peptic ulcer bleeding Acute haemorrhage Forrest I a (Spurting haemorrhage) treat; very high-risk re-bleed (90%) Forrest I b (Oozing haemorrhage) treat & high-risk re-bleed (55%) Signs of recent haemorrhage Forrest II a (Visible vessel) treat; high-risk re-bleed (43%) Forrest II b (Adherent clot) Controversy; risk re-bleed (22%) Forrest II c (Flat pigmented haematin on ulcer base) - risk re-bleed (10%) Lesions without active bleeding Forrest III (Lesions without signs of recent haemorrhage or fibrin-covered clean ulcer base) - risk re-bleed (5%) Forrest, JA.; Finlayson, ND.; Shearman, DJ. (Aug 1974). "Endoscopy in gastrointestinal bleeding.". Lancet. 2 (7877): PMID doi: /s (74)91770-x. Is the Forrest classification a useful tool for planning endoscopic therapy of bleeding peptic ulcers? Endoscopy. 1989; 21:

14 14

15 Rockall risk scoring system Rockall et al Gut 1996 & BMJ

16 Mortality by post-endoscopy (Full) Rockall risk score Score Mortality No rebleed Mortality Rebleed 3 2% 10% 4 4% 16% 5 8% 23% 6 10% 33% 7 15% 43% 8+ 28% 53% Rockall: BMJ, Volume 311(6999).July 22,

17 The (Forrest) II-b or not II-b question High risk: Re-bleed risk - 22% Vigorous wash water jet irrigation If still adherent leave alone & start IV PPI If comes off then treat underlying lesion Or cold snare removal of clot and treat underlying lesion (controversial) Meta-analysis shows no outcome change though numerous positive and negative studies exist Laine L, McQuaid KR. Clin Gastroenterol Hepatol

18 What interventions are available? Standard Injection Adrenaline (1:10,000), Fibrin, Sclerosants Thermal - Heater probe, Gold probe diathermy Mechanical devices - clips 18

19 What interventions are available? Novel Barrier methods Hemospray, Endoclot & Ankaferd New bear claw clips Ovesco, Padlock 19

20 Landmarks in Interventional outcomes Adrenaline Injection :10, % haemostasis with 24% re-bleed Volume of Adrenaline ml (15%) v 8ml (30%) re-bleed after peptic ulcer injection RCT evidence for >13ml (increased pain & perforation risk >40ml) Combination therapy 1997 Combined treatment significantly reduced re-bleeding and emergency surgery in those with spurting vessels Heater probe produces coaptive coagulation in addition to the vasoconstriction and tamponade effect of adrenaline injection Combination therapy Adrenaline + Thermal / clips in high-risk bleeding ulcers Reduced re-bleeding (18.4 to 10.6%), Emergency surgery (11.3 to 7.6%) and mortality (5.1 to 2.6%) Chung SC et al. BMJ 1988, Lin HJ et al. GI Endosc 2002, Chung SC et al. BMJ 1997, Calvert X et al. Gastroenterology 2004, NICE

21 Endoclip Treatment Through-the-scope Quick > Resolution > Instinct Use what you are used to Clip Meta-analysis (Sung et al. 2007) Equivalent to thermal modalities Better haemostasis than injection Reduced re-bleed & surgery rates Try to access at 90 o Prior injection can aid vision Failed Endoclip locations posterior duodenal bulb, posterior wall of gastric body & lesser curve of Stomach Laine L & Jensen D. AJG 2012;107: , Sung et al. Gut 2007, Barkun A et al. Ann Intern Med 2003 & 2010;139:843, Palmer K et al. BMJ 2008;337:a1832, Sofia et al. Hepatogastroenterol 2000, 21

22 Thermal Treatments Coaptive coagulation Pressure to stigmata and temporarily interrupts blood supply through vessel Reduces heat sink effect can seal arteries up to 2mm diameter Effective for active bleeding / high risk stigmata Sofia et al. Hepatogastroenterol 2000, Sung et al. Gut 2007, Barkun A et al. Ann Intern Med 2003 & 2010;139:843, Palmer K et al. BMJ 2008;337:a

23 Novel Treatments Barrier Methods Hemospray / Endoclot Inert, non-allergic, inorganic powder Inserted via catheter down scope Licenced for non-variceal bleeding Only effective when bleeding Adheres to bleeding site Mechanical tamponade Promotes thrombus formation by Concentrating & activating platelet & Clotting factors Rescue therapy but? more 23

24 Outcome of Endoscopic Management - irrespective of any optimal endoscopic & medical treatment Prospective cohort study >10,000 cases Majority of patients died from non-bleeding-related causes Optimisation of management should aim at reducing the risk of multi-organ failure and cardio-pulmonary death instead of focussing merely on successful hemostasis Am J Gastroenterol 2010; 105:

25 IV PPI treatment Post Endoscopy Intra-gastric ph > 6 [Omeprazole 80mg bolus then 8mg/hr for 72 hrs; Hong-Kong regime] For all receiving endoscopic therapy and those with adherent clots (IIb) stabilises clots with reduced re-bleeding in high-risk Significant reduction in :- Re-bleeding (NNT 13), Need for surgery (NNT 34), Need for further endoscopy (NNT 10), LOS and BTx Only reduced mortality in high-risk lesion sub group Supported by all major guidelines NB H. pylori Lau JY et al. NEJM 2007;356:1631, Al-S, Bakun et al. Ann Intern Med NICE & ESGE

26 When to repeat the endoscopy or use other options Consider second-look Endoscopy To treat any residual high risk lesion again Review when ongoing bleeding in absence of identifiable lesion Initial view sub-optimal Re-bleeding post index endoscopic therapy associated with increased mortality Law of diminishing returns NICE 2012 Acute upper gastrointestinal bleeding management (CG 141). ESGE 2015 Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage. Endoscopy;47:a1-a46. 26

27 Failure of endoscopic therapy Do we really know where the patient is bleeding from? Was the therapy accurately delivered? Clot removed, adequate coagulation, better endoscopist? Re-bleed endoscopic review Lau et al 1999 Main study finding no better than surgery BUT Less complications TTS Ovesco clip, Barrier methods or Coagulation graspers (70W) J Clin Gastroenterol 2014 Possibly better than 10Fr gold probe safe & effective Time to phone a friend? Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. Lau et al & ASGE Guidelines 2012, J Clin Gastroenterol

28 Conclusions (1) Use a therapeutic scope with irrigator for highrisk (?all) patients Risk stratify and treat Forrest 1a, 1b & IIa ulcers Consider removing clot from IIb Combination therapy Usually Adrenaline with thermal or clips Clip use dictated by location of bleeding Novel treatments for rescue therapy Barrier agents may have role as primary therapy 28

29 Conclusions (2) IV PPI for high-risk stigmata post endoscopy Most patients can be fed within 24 hours H. pylori testing for PUD patients with eradication repeat test / high false negative rate in acute setting Endoscopy is 1 st and 2 nd choice in non-variceal upper GI bleeding Recurrent severe bleeding can be treated by IR or surgery former preferable when available 29

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