Lower GI bleeding Management DR EHSANI PROFESSOR IN GASTROENTEROLOGY AND HEPATOLOGY

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1 Lower GI bleeding Management DR EHSANI PROFESSOR IN GASTROENTEROLOGY AND HEPATOLOGY 15 FEB 2018

2 Sources

3 Sources

4 Sources

5 Initial evaluation History Physical examination Laboratory evaluation Obtained at the time of patient presentation assess the severity of bleeding possible location and etiology

6 Risk assessment and stratification Should be performed distinguish patients at high- and low-risk of adverse outcomes assist in patient triage timing of colonoscopy level of care

7 Fluid resuscitation Hemodynamic instability and/or Suspected ongoing bleeding should receive intravenous fluid normalization of blood pressure and heart rate before endoscopic evaluation/intervention

8 Packed red blood cells (RBCs) Maintain the hemoglobin above 7 g/dl 9 g/dl massive bleeding significant comorbid illness (especially cardiovascular ischemia) possible delay in receiving therapeutic interventions

9 Endoscopic hemostasis in patient with prolonged PT INR of Colonoscopy may be considered before or concomitant with the administration of reversal agents INR >2.5 Reversal agents before endoscopy

10 Platelet transfusion Maintain a platelet count of / ml in patients with severe bleeding those requiring endoscopic hemostasis

11 Prevention of recurrent bleeding NSAID Should be avoided in patients with a history of acute LGIB particularly if secondary to diverticulosis or angiectasia

12 ASA and risk of recurrent LGIB A retrospective cohort study involving patients with LGIB those who continued aspirin after the bleeding event significantly higher rates of recurrent LGIB over the ensuing 5 years of aspirin (18.9% vs. 6.9%) significantly lower rates of serious cardiovascular events and death Gastroenterology 2016; 151: 271-7

13 ASA, secondary prophylaxis Patients with established cardiovascular disease who require aspirin (secondary prophylaxis) should generally resume aspirin as soon as possible after bleeding ceases and at least within 7 days The exact timing depends on the severity of bleeding perceived adequacy of hemostasis risk of a thromboembolic event

14 Aspirin for primary prevention of cardiovascular events Should be avoided in most patients with LGIB

15 Dual antiplatelet therapy Data are lacking to guide the care of patients who have LGIB The patient who have undergone stenting in the previous 30 days acute coronary syndrome in the previous 90 days High risk for myocardial infarction and death after discontinuation of dual antiplatelet therapy generally advised to continue taking both medications

16 Dual antiplatelet therapy Should not be discontinued in patients with an acute coronary syndrome within the past 90 days coronary stenting within the past 30 days

17 Dual antiplatelet therapy In patients on dual antiplatelet therapy Monotherapy with non-aspirin antiplatelet agents (thienopyridine) non-aspirin antiplatelet therapy should be resumed as soon as possible and at least within 7 days based on multidisciplinary assessment of cardiovascular and GI risk and the adequacy of endoscopic therapy aspirin use should not be discontinued or

18 Dual antiplatelet therapy In patients who underwent coronary stenting coronary syndrome Less recently discontinuation of the second antiplatelet agent is recommended for 1 to 7 days Circulation 2009; 119:

19 Multidisciplinary approach In patients on anticoagulant agents Hematology Cardiology Neurology Gastroenterology deciding whether to discontinue medications use reversal agents to balance the risk of ongoing bleeding with the risk of thromboembolic events

20 Randomized trials Lacking to assess the effects of endoscopic hemostasis for acute LGIB The choice of hemostasis method is generally guided cause and location of bleeding ability to access the site operator experience

21 Efficacy and safety of endoscopic hemostasis in LGIB Observational studies and case series of diverticular hemorrhage A comprehensive review showed successful endoscopic hemostasis in 92% of patients early rebleeding in 8% late rebleeding in 12% Clin Gastroenterol Hepatol 2010; 8:

22 Endoscopic hemostasis methods for acute LGIB Injection (usually diluted epinephrine) Contact and noncontact thermal devices bipolar electrocoagulation heater probe argon plasma coagulation Mechanical therapies endoscopic clips band ligation

23 Epinephrine injection therapy 1:10,000 or 1:20,000 dilution with saline initial control of an active bleeding lesion improve visualization In combination with a second hemostasis modality mechanical contact thermal therapy To achieve definitive hemostasis

24 Metallic injection sclerotherapy needle

25 Injection treatment

26 Diverticular hemorrhage Is arterial Painless hematochezia Occurs from either the neck or the dome of the diverticulum

27 Diverticular hemorrhage Candidates for endoscopic treatment active bleeding (spurting or oozing) non-bleeding visible vessel an adherent clot (that cannot be removed with vigorous washing and suctioning) Found at the time of colonoscopy

28 Diverticular hemorrhage Mechanical therapy endoscopic clips reduce the theoretical risk of transmural colonic injury associated with contact thermal therapy Kaltenbach T, Watson R, Shah J, et al. Clin Gastroenterol Hepatol 2012;10: 131-7

29 Diverticular bleeding Through-the-scope endoscopic clips may be safer in the colon than contact thermal therapy easier to perform than band ligation particularly for right-sided colon lesions

30 Different types of hemoclip

31 Diverticular Hemorrhage postendoscopic clip placement

32 Heat probe Irrigation ports are locate 1cm proximal to the Teflon-coated tip, allowing targeted irrigation of an ulcer bed

33 Principle of coaptive thermocoagulation. The artery is compresse firmly, reducing the heat-sink effect. The two walls of the artery are then sealed using thermal energy

34 Angiectasia bleeding Colonic angioectasias including radiation proctopathy common in the elderly Usually manifest as mild overt rectal bleeding Severe hematochezia in patients who are taking antithrombotic agents

35 An oozing angiodysplastic lesion in the ascending colon.

36 Angiectasia bleeding APC treatment of choice ease of use safety profile observations of increased Hb levels reduced blood-transfusion requirements

37 Argon plasma coagulation probes

38 A 7-Fr lateral-firing APC probe

39 Lesion after APC directed around and then to the center in precise mode

40 Area after APC in pulsed mode

41 Pneumatosis intestinalis of the transverse colon, 3months after APC treatment for polyps

42 Post-polypectomy bleeding Mechanical (clip) Contact thermal endotherapy with or without the combined use of dilute epinephrine injection

43 Postpolypectomy bleeding in the sigmoid colon

44 Bleeding polypectomy site after an initial APC treatment that only coagulated the surface blood, but not the underlying bleeding source

45 Clips for post-polypectomy bleeding Preferred limit tissue injury tattoo or clip (if not already used for hemostasis) Strate LL, Gralnek IM. ACG clinical guideline: management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol 2016; 111:

46 Clips on polypectomy site

47 Detachable snare at the base of a pedunculated polyp

48 Roles of surgery For the prevention of recurrent LGIB individualized source of bleeding should be carefully localized before resection

49 Surgical consultation In patients with High-risk clinical features Ongoing bleeding After other therapeutic options have failed Should take into consideration extent and success of prior bleeding control measures severity and source of bleeding level of comorbid disease

50 Radiographic interventions In patients high-risk clinical features ongoing bleeding Who have negative upper endoscopy do not respond adequately to hemodynamic resuscitation efforts unlikely to tolerate bowel preparation and urgent colonoscopy

51 Radiographic interventions Successful embolization (no further contrast extravasation) 73 to 100% Rates of clinical success (cessation of bleeding) 63 to 96% Rebleeding rates 11 to 50% American College of Radiology (ACR) Appropriateness Criteria: radiologic management of lower gastrointestinal tract bleeding (updated 2014) ( / acsearch.acr.org/ docs/ 69457/ Narrative/ )

52 Angiographic Diagnosis and Therapy of Acute Colonic Bleeding.

53 Other causes of LGIB Ischemic colitis Inflammatory ulcerative colitis Colorectal neoplasms not amenable to durable endoscopic hemostasis usually treated with supportive medical care, surgical care, or both

54 Procedures for the Evaluation and Treatment of Acute LGIB

55

56 Adverse events in interventions Perforation Worsened bleeding Congestive heart failure 0.3 to 1.3% Bowel ischemia, in radiologic intervention 1 to 4% Strate LL, Naumann CR. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding. Clin Gastroenterol Hepatol 2010

57 Areas of Uncertainty RCT needed better delineate the most effective timing of colonoscopy the role of colonoscopy versus radiography as the initial diagnostic method the choice among radiographic imaging studies the efficacy and safety of endoscopic hemostasis treatments (including topical powders, band ligation, over-the scope clips, and Doppler ultrasonography as an adjunct to endoscopic hemostasis)

58 Areas of Uncertainty The efficacy of conebeam CT technology as an adjunctive diagnostic method in selective angiography Embolic agent of choice in endovascular therapy better risk-stratification tools are needed to improve the triage of patients

59 Thanks for your attention

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