Endoscopic Management of GI Bleeding

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Endoscopic Management of GI Bleeding

• John C. Rabine, MD, FACG, AGAF
• Division of Gastroenterology
• Sinai Hospital of Baltimore

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Incidence of GI Bleeding

• GI bleeding is the most common emergency in
  clinical gastroenterology
• Upper GI bleeding alone accounts for over 300,000
  hospitalizations annually in the United States
• In 90 of patients, the source of bleeding is in
  the esophagus, stomach or proximal small bowel
• 9 in the colon and 1 in the small bowel beyond
  the proximal duodenum

(Soehendra et al., 2001)
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Sources of Upper GI Bleeding

• Mallory-Weiss tears
• Gastric tumors
• Varices
• Esophagitis

• Peptic ulcer disease
• Dieulafoy lesions
• Angioectasias
• Small intestine diverticuli

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Peptic Ulcer Disease

• Most common source of UGI bleeding, accounting
  for 50-70 of non-variceal bleeds
• Appoximately 15 rebleeding rate, requiring
  repeated endoscopy
• Lifetime prevalence 5-10 (10-20 if H. Pylori
  )
• 150 hospital admissions per 100,000 population
  per year
• Overall mortality rate of 7 (unchanged over
  last 30 years)

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Peptic Ulcer Disease

• Gender Ratios
• Gastric Ulcer M W
• Duodenal Ulcer M gt W
• Incidence increases with age
• Incidence increased with certain diseases
• COPD
• cirrhosis
• chronic renal failure

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Peptic Ulcer DiseaseEtiologies

• More Common
• Helicobacter pylori
• NSAIDs
• Other drugs
• KCl
• bisphosphonates
• Immunosuppressives
• Idiopathic

• Less Common
• Other infections
• CMV, TB, Syphilis, HSV1
• Crohns disease
• Zollinger-Ellison Syndrome
• Systemic Mastocytosis
• Malignancy
• Lyphoma
• Carcinoma
• Radiation gastropathy

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Peptic Ulcer DiseaseRole of NSAIDs

• Impact of NSAIDs in the U.S.
• 2 billion spent yearly on prescription NSAIDs
• NSAID related ulcer complications cause
• 107,000 patient hospitalizations yearly
• 16,500 deaths yearly
• 4-fold increased risk for ulcer
  complications in the elderly

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Peptic Ulcer Disease
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Hemorrhagic Gastritis (vs. Gastropathy)
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Mallory-Weiss Tears

• Linear, longitudinal tear at the GE junction
• Account for 1-15 of cases of UGI bleeding
• Associated with
  excessive retching
  and vomiting
• Typical history
  absent in 1/3 of
  cases

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Dieulafoy Lesions

• Large bleeding artery that has eroded through the
  mucosa, unassociated with an ulcer
• Severe hemorrhage, with mortality of 25 if
  lesion undiscovered
• High rebleeding rates
• 50 after
  single-modality
  
  therapy
• 15 after
  combination
  
  therapy

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GAVE Syndrome
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Anastamotic Ulcer
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Sources of Lower GI Bleeding

• Colon polyps
• Colon cancers
• Diverticulosis
• AVMs
• Ileocolitis (IBD, ischemia, infection)
• Varices (rectal, ileal)

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Post-Polypectomy Bleeding
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Treatment Options

• Injection/Sclerotherapy
• Thermal coagulation therapy
• Endoscopic clipping
• Argon plasma coagulation/APC
• Endoscopic combination therapy
• Miscellaneous tissue sealants, NdYAG laser,
  banding

Endoscopic Clips
Combination Therapy
Injection Therapy
Thermal Coagulation
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Injection Therapy

• Sclerotherapy Needles
• Devices that pass through the working channel of
  the endoscope to inject sclerosing agents into
  the target tissue
• Epinephrine, sodium morrhuate, saline, etc.
• May be difficult
  to use in
  retroflexion

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Electrocautery
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Principles of Electrocautery
Monopolar grounding pad completes
circuit May interfere with AICD/pacemaker
function

• Bipolar active return electrode
• Energy can be applied tangentially from sides of
  probe

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Electrocautery
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Argon Plasma Coagulator

• Utilizes alternating monopolar current conducted
  to target tissue through ionized argon gas
• As no direct tissue contact, there is no
  tamponade effect and limited depth of burn

www.erbe-med.com/us
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Endoscopic Clips

• Mechanical clips are delivered through the
  endoscope
• Hemostasis is achieved by mechanical compression
• Can be used
  regardless of
  coagulation status

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Quick Clip 2

• Pre-loaded
• Opens to 9.5mm between prongs
• Rotating control mechanism for easy targeting
• Once the clip is opened cannot be reopened and
  repositioned

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TriClip

• Pre-loaded
• 3 pronged clip
• Integrated port for flushing the field of view
• Opens to 12mm between prongs
• Once the clip is opened cannot be reopened and
  repositioned

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Resolution Clip

• Pre-Loaded
• 11 mm-wide Jaw Opening
• 155 and 235 cm lengths
• Once the clip is opened can be opened up to 5
  times before deployment

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Contraindications to Clipping

• When hemostasis cannot be verified visually
  within endoscopic field of view
• If MRI procedures are anticipated/necessary
• Consider x-ray if clip placed within 2-4 weeks
• Bleeding ulcers and arteries greater than 2 mm
• Polyps greater than 1.5 cm in diameter
• Mucosal/submucosal defects greater than 3 cm

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Post-Polypectomy Bleeding
Video provided by Boston Scientific, Inc.
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Endoscopic Band Ligation

• Ligating device consists of a friction-fit
  adapter affixed to the tip of the endoscope with
  a preloaded elastic band and release
  mechanism
• Effective in treating
  esophageal varices but can
  be used on other
  bleeding
  lesions as well
• Coagulation status is not
  relevant

Video by Dr Peter Kelsey, Harvard Medical School.
DAVE Project, www.daveproject.org
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PEG/PEJ Tubes
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PEG/PEJ Indications
Oropharyngeal dysphagia CVA/stroke Parkinsons
disease ALS Laryngeal cancer Esophageal
dysphagia Radiation esophagitis Esophageal
cancer Malnutrition Dementia Severe pancreatitis
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PEG Contraindications

• Anticoagulation
• Significant medical comorbidities
• High-grade esophageal obstruction
• Prior surgical interventions in LUQ
• Inability to trans-illuminate and identify safe
  PEG position

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PEG Tubes/Buttons
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PEG-J Tubes
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Initial PEG Procedure

• Incision site selection and preparation
• Endoscope introduced
• Stomach insufflated
• Abdominal wall trans-illuminated
• Finger pressure applied at trans-illumination
  site and visually confirmed by endoscopist
• Proposed site cleansed and anesthetized

Permission by Boston Scientific, Inc.
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Initial PEG Procedure

• Wire Placement
• End of insertion wire passed through cannula into
  stomach

Permission by Boston Scientific, Inc.
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Initial PEG Procedure
Permission by Boston Scientific, Inc.
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Initial PEG Procedure

• Post Tube Placement
• PEG tube/catheter cut approximately 12 inches
  from the skin
• External bolster is advanced down the PEG tube, 1
  cm from abdominal wall to avoid tissue
  compression
• C-clamp and Y-port are then positioned on the PEG
  tube
• Wound treated with triple antibiotic ointment and
  dressed with T cut 2 x 2 gauze pad over the
  external bolster

Permission by Boston Scientific, Inc.
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PEG/PEJ Complications

• Infection
• Perforation
• Aspiration pneumonia
• Bleeding
• Buried bumper syndrome and pressure ulcers
• Tube migration, clogging, or degradation

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