Sangrado Gastrointestinal Alto Upper GI Bleeding

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2 Sangrado Gastrointestinal Alto Upper GI Bleeding Curso Internacional Retos Clinicos en la Gastroenterologia de Urgencias Asociacion Colombiana de Gastroenterologia 31 de Agosto, 2012 Pereira, Risaralda Hotel Movich John A. Martin, MD Associate Professor of Medicine and Surgery Director of Endoscopy Northwestern University Feinberg School of Medicine Chicago, Illinois

3 Acute non-variceal upper gastrointestinal bleed (UGIB) Proximal to ligament of Treitz 60 / 100,000 population 3 X LGIB incidence Introduction Higher mortality than LGIB (3.5-10%) Opportunity for high-impact intervention Proper management demonstrated to improve outcomes Endoscopy proven to improve outcome and reduce resource utilization

4 Acute upper gastrointestinal bleed (UGIB) Primary goal is triage Identify patient who needs urgent intervention Identify patients who may be discharged to outpatient management Deliver appropriate treatment with indicated urgency Predictive factors Introduction History of malignancy or cirrhosis Hematemesis Signs of hypovolemia Hgb < 8

5 Acute upper gastrointestinal bleed (UGIB) Initial assessment Introduction Inventory of predictive risk factors just enumerated Elicit history of NSAID / ASA use Since clinical factors do not adequately predict UGIB severity, prediction rules have been developed Clinical Rockall score Blatchford score

6 Acute upper gastrointestinal bleed (UGIB) Initial assessment Introduction Inventory of predictive risk factors just enumerated Elicit history of NSAID / ASA use Since clinical factors do not adequately predict UGIB severity, prediction rules have been developed Clinical Rockall score Blatchford score» Score > % sensitive in identifying severe UGIB in multiple studies» May allow early discharge in 16-25% Blatchford O, et al. Lancet 2000;356:

7 Hwang JH, et al. Gastrointest Endosc 2012;75:

8 DDW ASGE Abstract Su 1310: Nguyen, et al. (Holloway) Risk stratification with Glasgow- Blatchford bleeding score (GBS) for hospitalized patients with upper GI bleeding can avoid the need for urgent endotherapy GBS identifies pts with UGI bleeding who can be managed safely as outpts Comparison of GBS with pre-egd and post-egd Rockall score (PreR + PostR) in predicting need for endotherapy and further interventions in UGIB patients

9 DDW ASGE Abstract Su 1310: Nguyen, et al. (Holloway) GBS and Rockall for all UGIB pts admitted to Royal Adelaide Hosp over 18 mos ROC curves generated to examine performance of GBS and R to predict need for endoscopic & related interventions All pts received high-dose acid suppression 455 pts EGD for UGIB; 188 pts (41%) req endotherapy; 19 (4%) had surgery

10 DDW ASGE Abstract Su 1310: Nguyen, et al. (Holloway) Results Pts req endotherapy or surgery had higher GBS, PreR, PostR (p<0.001) On ROC, GBS + PostR superior to PreR in predicting Need for endotherapy (AUC 0.83 vs 0.72 vs 0.65) Need for rpt endoscopy for rebleeding or further endotherapy (AUC 0.64 vs 0.63 vs 0.56) GBS superior to both PreR + PostR in predicting need for transfusion (AUC 0.83 vs 0.72 vs 0.70)

11 DDW ASGE Abstract Su 1310: Nguyen, et al. (Holloway) Results (cont d) GBS superior to both PreR + PostR in predicting need for surgery (AUC 0.75 vs 0.67 vs 0.54) No pts with GBS 7 required surgery None of pts with GBS 3 required endotherapy, blood transfusion, or surgery

12 DDW ASGE Abstract Su 1310: Nguyen, et al. (Holloway) Conclusion GBS superior to Rockall in predicting need for endotherapy, rpt endoscopy, transfusion, surgery in acute UGIB pts GBS should be the preferred risk scoring system for acute UGIB

13 WHAT TO DO? WHAT TO DO?

14 Background Peptic ulcer underlies 50-70% of acute nonvariceal UGIB s (Barkun, et al., Ann Intern Med 2003;139:843) Most PUD result of NSAID therapy and H. pylori infection 80% stop bleeding spontaneously without recurrence Most morbidity and mortality occur among the remaining 20% who have continued or recurrent bleeding The latter are the ones that you need to target but how?

15 Background Via EGD, because it has proven potential to: Identify bleeding source in 90% of UGIB Stratify rebleeding risk Intervene in high-risk lesions, and thereby Reduce rebleeding risk (to 15-20%) Decrease hospital length of stay Possibly reduce mortality (Cooper, et al., Gastrointest Endosc 1999;49:145)

16 Initial assessment Detection & accurate identification of high-risk stigmata requires Copious lavage and diligent search for point source of bleeding Familiarity with classification and endoscopic appearance of highrisk stigmata

17 Initial assessment because successful endoscopic intervention is dependent upon definitive detection and accurate identification of the actual point source of bleeding

18 Rationale for endoscopic intervention Endoscopic hemostasis indicated only for patients with specifically defined, endoscopically identified high-risk lesions Active bleeding (a bleeding visible vessel) Non-bleeding visible vessel (NBVV) Probably adherent clots Thus, intervention must be preceded by Diligent search for active bleeding or NBVV Positive identification of active bleeding or NBVV Jensen, et al., Gastroenterology 2002;123:407

19 Endoscopic prognostic features Most common etiologies of UGIB PUD (20-50%) Gastroduodenal erosions (8-15%) Esophagitis (5-15%) Varices (5-20%) Mallory-Weiss tears (8-15%) Vascular malformations/ectasias (5%) Other etiologies including malignancy

20 Endoscopic prognostic features Hwang JH, et al. Gastrointest Endosc 2012;75:

21 Endoscopic intervention rationale: Risk stratification Forrest class Type of lesion (endoscopically identified) Risk of rebleeding if untreated Surgery Mortality IA Arterial spurting bleeding 100% IB Arterial oozing bleeding 55% (17-100%) 35% 11% IIA Non-bleeding visible vessel (NBVV) 43% (8-81%) 34% 11% IIB Sentinel clot 22% (14-36%) 10% 7% IIC Flat pigmented spot 10% (0-13%) 6% 3% III Clean based ulcer 5% (0-10%) 0.5% 2% Modified & adapted from Forrest, et al., Lancet 1974;17:394, and Laine, et al., N Engl J Med 1994;331:717.

22 Goal of treatment Goal of treatment is hemostasis of a specific bleeding vessel Laine, N Engl J Med 1987;316:1613; Jensen, N Engl J Med 1999;340:799.

23 What to do? Volume resuscitate / transfuse NG aspiration 15% active bleeding patients will have negative NG lavage Administer PPI therapy Cochrane meta-analysis of 6 RCT s No delta in mortality, rebleeding, progression to surgery vs controls Pre-procedure PPI significantly reduced rate of high risk stigmata on EGD and need for endotherapy Consider prokinetic pre-egd for better visualization (Barkun, et al. GIE 2010)

24 Endoscopic Management of UGIB Diagnostic considerations PPIs reduce stigmata Prokinetics improve visualization in some Irrigate overlying adherent clot Removal of clot resistant to removal by irrigation is controversial Therapeutic considerations Endoscopic therapy is indicated in active bleeding and non-bleeding visible vessel Meta-analysis of 6 RCTs shows endoscopic therapy is superior to medical for rebleeding

25 Endoscopic Therapy of UGIB Therapeutic modalities 2009 meta-analysis of 75 studies show thermal, injectables other than saline/epinephrine, and clips all effective in PUD hemostasis No single modality was superior Epi with second treatment modality more effective than epi alone Epi alone should not be used, but should be combined with second modality Laine L, McQuaid KR. Clin Gastroenterol Hepatol 2009;7:33-47.

26 Endoscopic Hemostatic Modalities Injection Generally, saline or 1:10,000 epinephrine in saline Not sclerosants Effects tamponade via volume effect: use higher volumes (Lin, et al., GIE 2002) Tamponade is temporary (unlike mechanical and thermal therapies), so data suggests against use of injection as monotherapy

27 Endoscopic Hemostatic Modalities Thermal devices Coaptive devices: tamponade + coagulation Multipolar electrocoagulation (MPEC) probe or heat probe probe All forms equivalent; limited data suggest combination with epin more effective than monotherapy APC Non-coaptive therapy for superficial lesions

28 Endoscopic Hemostatic Modalities Mechanical therapy Permanent tamponade via mechanical device Clips Bands Tissue, anatomy, operator preference may dictate choice Anatomical location Type of lesion Ease of deployment due to anatomical or technical considerations

29 Upper GI Vascular Abnormalities No prospective trials comparing methods for acute UGIB due to vascular abnormalities Vascular ectasias Dieulafoy lesions GAVE Endoscopic marking Consider tattooing difficult-to-locate lesions Place clip whether endotherapy succeeds or fails to facilitate IR / surgical intervention

30 A Peek at New Technologies in Doppler probe Hemostasis

31 A Peek at New Technologies in Hemostasis Monopolar coagulation grasping forcep

32 A Peek at New Technologies in Hemostasis New hemostatic clips

33 A Peek at New Technologies in Hemostasis New hemostatic clips

34 A Peek at New Technologies in Hemostasis New hemostatic clips

35 A Peek at New Technologies in Hemostasis New hemostatic clips

36 A Peek at New Technologies in Hemostasis New hemostatic clips

37 A Peek at New Technologies in Hemostasis New hemostatic clips

38 A Peek at New Technologies in Hemostasis New hemostatic spray

39 A Peek at New Technologies in Hemostasis New hemostatic spray

40 Upper GI Bleeding 2012: Summary Consult new 2012 ASGE Guidelines at The role of endoscopy in the management of acute non-variceal upper GI bleeding Gastrointest Endosc 2012;75: Resuscitate patients adequately Initiate antisecretory therapy with PPIs Consider prokinetic agents in select cases EGD to diagnose etiology urgently: within 24 hrs in patients with hematemesis, signs of hypovolemia, history of malignancy or cirrhosis

41 Upper GI Bleeding 2012: Summary Consult new 2012 ASGE Guidelines at The role of endoscopy in the management of acute non-variceal upper GI bleeding Gastrointest Endosc 2012;75: Management of PUD with adherent clot is controversial Injection, thermal, and mechanical therapies are all effective Epinephrine alone should not be used in PUD bleeding, but should be combined with 2 nd agent

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