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  • 8/14/2019 Endoscopic Interventions for Gi Bleeds

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    GI Hemorrhage

    Trauma and SICU Conference

    12/18/2006

  • 8/14/2019 Endoscopic Interventions for Gi Bleeds

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    Upper GI Bleeding

    Esophageal Varices

    Mallory-Weiss Tear

    Duodenal Ulcer

    Gastric Ulcer

    Gastritis

    Cancer

    Hemobilia

    Cranberry Sauce

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    Lower Gastrointestinal Bleeding

    UGI Source

    Hemorrhoids, Fissure, Ulcer, Polyp Prolapse Volvulus/Malrotation Cancer Ulcerative Colitis Granulomatous Colitis Diverticulitis

    Other: Meckels Diverticulum Colonic Polyp Peutz-Jeghers Syndrome Osler-Weber-Rendu Syndrome Ileal Diverticula Duplication of Bowel

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    Endoscopic Interventions forGastrointestinal Bleeding

    Stephanie Chao, Trauma R1

    Trauma Conference

    December 18, 2006

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    Endoscopic techniques

    Anoscopy

    Sigmoidoscopy

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    Injection Rx

    Epinephrine

    1-1.5ml of 1:10,000 or 1:20,000 in 4 quadrants

    Mechanism: vasoconstriction, volume tamponade

    Sclerosant (ethanolamine)

    Mechanism: Induces inflammation then fibrosis

    Fibrin Sealant

    Fibrinogen/Factor XIII and Thrombin/Calcium

    Mechanism: Instantaneous formation of hemostatic clot by mimicking laststep of coagulation cascade

    Sclerosant trials vs. Fibrin sealant

    No advantage of epi + sclerosant over epi alone Saline

    Mechanism: volume tamponade

    Ethanol

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    Thermal Coagulation

    Heater probe

    Mechanism: tissue coagulation via heated ceramic tip

    Not limited by tissue water resistance, deeper heat penetration

    Higher risk of perforation

    Multipolar probe

    Mechanism: coagulates tissue by heating tissue temperature to>60 degrees Celsius via alternating positive and negativeelectrodes at tip

    Tissue desiccation prevents conduction to lower layers

    Argon Plasma Coagulant Mechanism: uses argon gas to deliver a plasma of evenly

    distributed thermal energy

    No contact, wider spray, less depth

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    Coagulation

    Active bleedPost Coagulation

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    Thermal Coagulation

    Heater probe

    Mechanism: tissue coagulation via heated ceramic tip

    Not limited by tissue water resistance, deeper heat penetration

    Higher risk of perforation

    Multipolar probe

    Mechanism: coagulates tissue by heating tissue temperature to>60 degrees Celsius via passing electricity between alternatingpositive and negative electrodes at tip

    Tissue desiccation prevents conduction to lower layers

    Argon Plasma Coagulant Mechanism: uses argon gas to deliver a plasma of evenly

    distributed thermal energy

    No contact, wider spray, less depth

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    Multipolar Probe

  • 8/14/2019 Endoscopic Interventions for Gi Bleeds

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    Thermal Coagulation

    Heater probe

    Mechanism: tissue coagulation via heated ceramic tip

    Not limited by tissue water resistance, deeper heat penetration

    Higher risk of perforation

    Multipolar probe

    Mechanism: coagulates tissue by heating tissue temperature to>60 degrees Celsius via alternating positive and negativeelectrodes at tip

    Tissue desiccation prevents conduction to lower layers

    Argon Plasma Coagulant Mechanism: uses argon gas to deliver a plasma of evenly

    distributed thermal energy

    No contact, wider spray, less depth

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    Argon Plasma Coagulant

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    Hemostatic Clips

    Occludes vessel

    Radiographic marker

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    Risk StratificationPeptic Ulcer Disease Low risk

    Flat spot, clean ulcer

    Rx: No endoscopic intervention, PPI only

    Intermediate Risk

    Ooze without clot or visible vessel

    Rx: Monotherapy with oral PPI

    High Risk

    Active bleed, non-bleeding visible vessel with clot

    Rx: Combination therapy (injection and coagulation, IV PPI)

    Visible vessel

    Rx: clip or coagulation and PPI

    http://content.nejm.org.laneproxy.stanford.edu/cgi/content/full/331/11/717/F2

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    Risk Stratification Low risk

    Flat spot, clean ulcer

    Rx: No endoscopic intervention, PPI only

    Intermediate Risk

    Ooze without clot or visible vessel

    Rx: Monotherapy with oral PPI

    High Risk

    Active bleed, non-bleeding visible vessel with clot

    Rx: Combination therapy (injection and coagulation, IV PPI)

    Visible vessel

    Rx: clip or coagulation and PPI

    http://content.nejm.org.laneproxy.stanford.edu/cgi/content/full/331/11/717/F2

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    Risk Stratification Low risk

    Flat spot, clean ulcer

    Rx: No endoscopic intervention, PPI only

    Intermediate Risk

    Ooze without clot or visible vessel

    Rx: Monotherapy with oral PPI

    High Risk

    Active bleed, non-bleeding visible vessel with clot

    Rx: Combination therapy (injection and coagulation, IV PPI)

    Visible vessel

    Rx: clip or coagulation and PPI

    http://content.nejm.org.laneproxy.stanford.edu/cgi/content/full/331/11/717/F2

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    Risk Stratification Low risk

    Flat spot, clean ulcer

    Rx: No endoscopic intervention, PPI only

    Intermediate Risk

    Ooze without clot or visible vessel

    Rx: Monotherapy with oral PPI

    High Risk

    Active bleed, non-bleeding visible vessel with clot

    Rx: Combination therapy (injection and coagulation, IV PPI)

    Visible vessel

    Rx: clip or coagulation and PPI

    http://content.nejm.org.laneproxy.stanford.edu/cgi/content/full/331/11/717/F2

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    Varices

    Banding

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    References

    Kubba, AK, Palmer, KR. Role of endoscopic injection

    therapy in the treatment of bleeding peptic ulcer. Br JSurg 1996; 83:461.

    Laine, L, Peterson, WL. Bleeding peptic ulcer. N Engl JMed 1994; 331:717.

    Jensen DM, Machicado GA. Endoscopic Hemostasis ofUlcer Hemorrhage with Injection, Thermal, orCombination Methods. Techniques in GastrointestinalEndoscopy 2005; 7:124.

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