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Endoscopic Management of Ulcer Bleeding Dr Redha Lajam, MD Consultant gastroenterologist UST Hospital

Outline Epidemiology and natural history Risk assessment and pre-endoscopic management Endoscopic therapy Post endoscopic management

Bleeding Peptic Ulcer －Epidemiology－ More than 300,000 hospital admissions annually in the US1 Incidence: 103 cases/100,000 adults/year2 Mortality: 5~14%3, unchanged for the past two decades, exclusively among elderly patients with significant co morbidities 1Yavorski RT et al. Am J Gastroenterol 1995; 90:568-73 2Longstreth GF. Am J Gastroenterol 1995; 90:206-10 3Rockall TA et al. BMJ 1995; 38:222-6

Bleeding Peptic Ulcer －Natural History－ Approximately 80-85% bleeding stops spontaneously Remaining 15-20% recurrent or continuous bleeding Re-bleeding increase mortality by 10 times

Pre-Endoscopic Resuscitation Assess hemodynamic status Tachycardia (pulse, ≥100 beats per minute) Hypotension (systolic blood pressure, <100 mm Hg), postural changes (an increase in the pulse of ≥20 beats per minute or a drop in systolic blood pressure of ≥20 mm Hg on standing) Mucous membranes, neck veins, urine output Obtain CBC, electrolytes, BUN/Cr, PT INR/ APTT, blood type, and cross-match

Pre-Endoscopic Resuscitation Initiate resuscitation with crystalloid intravenous fluids with the use of large-bore IV-access catheters PRBC If tachycardia or hypotension is present If the hemoglobin level is less than 10 g per deciliter. Patients who received transfusion within 12 h of presentation had a twofold increased rate of re-bleeding (OR 2.26; 95% CI 1.76–2.90) and a 28% increase in mortality (OR 1.28; 95% CI 0.94–1.74) compared to those not early transfused. Oxygen correction of coagulopathy Hearnshaw SA, Logan RF, Palmer KR, Card TR, Travis SP, Murphy MF.Aliment Pharmacol Ther. 2010 Jul;32(2):215-24.

Active bleeding by endoscopy NG tube aspirate Active bleeding by endoscopy Requires Surgery Death Clear 16 % 10 % 6 % Coffee ground 30 % 13 % Red blood 48 % 23 % 18 % American Society For Gastrointestinal Endoscopy

Mortality according NGT aspirate Stool color NGT aspirate Black Red Clear 5 % 7 % Coffee ground 9 % 20 % 12 % 30 %

Pharmacotherapy Prior to Endoscopy Consider initiating treatment with an IV PPI (80-mg bolus dose plus continuous infusion at 8 mg/hr) while awaiting early endoscopy down-staging of endoscopic lesions by stabilizing clot with decrease need for endoscopic therapy (19 % vs. 28% p value 0.007) not have an effect on outcomes (mortality , re-bleeding , transfusion requirement ) The cost- effectiveness remains controversial No role for H2 blocker Consider octeriotide infusion may be beneficial Lau JY, N Engl J Med. 2007 Apr 19;356(16):1631-40.

Risk assessment Clinical Predictors of Poor Outcomes Older age (>60years) Severe comorbidity Active bleeding Hypotension or shock RBC transfusion6 unit Inpatient bleeding Severe coagulopathy Adler DG et al. Gastrointest Endosc 2004; 60:497-504

Risk-Stratification Tools for Upper Gastrointestinal Hemorrhage The Rockall score : Used clinical and endoscopic criteria The scale ranges from 0 to 11 points, with higher scores indicating higher risk. Blatchford scores from 0 to 23, with higher scores indicating higher risk

Timing of endoscopy Should be performed within 24 hours for high risk patients Improve certain outcomes the number of units of blood transfused the length of the hospital stay Treatment recommendations have focused on the first 72 hours after presentation and endoscopic evaluation and therapy, since this is the period when the risk of rebleeding is greatest (90 %)

Am J Emerg Med 2007; 25,273-278

Outcomes of total cases Total, n (%) EE, n (%) UE, n (%) P 189 88 101 Transfusion requirements Total (%) Total (U) 144 (76) 3.54.3 65 (74) 3.5.8 79 (78) 3.43.9 0.499 0.765 Need for 2nd modality Angiography (%) Surgery (%) 6 (3) 0 (0) 2 (2) 4 (4) 0.687 － Days in hospital (d) 6.110.1 6.312.4 6.07.7 0.440 Days in hospitala (d) 5.66.6 5.15.0 0.522 Inhosptial mortality (%) 7 (4) 1 (1) 6 (6) 0.124 a One patient in the emergency group with hospitalization for 112 days was excluded No difference in outcome between emergent vs. urgent endoscopy

Role of Endoscopy Diagnosis : 90-95% sensitive at locating bleeding site Prognosis : likelihood of persistent or recurrent bleeding can be predicted Therapy : provide therapeutic options ( inject , burn ,clip )

Forrest classification Forrest grade Ia Forrest grade Ib Forrest grade IIa

Forrest classification Forrest grade IIb Forrest grade IIc Forrest grade III

Endoscopic Risk Stratification Endoscopic Finding Rebleed Mortality Active bleeding 55% 11% Visible vessels 43% 11% Adherent dot 22% 7% Flat spots 10% 3% CLEAN UCLER BASE 5% 2% Laine et al. NEJM 1994; 331:717

Endoscopic predictors stigmata of recent bleeding Percent Johnston JH. Endoscopic risk factors for bleeding peptic ulcer. Gastrointest Endosc 1990;36:S16.

High risk lesions

Indication of endoscopic therapy Stigmata Endoscopic therapy Active bleeding Yes Non-bleeding visible vessel Yes Adherent clot Probable Flat spot No Clean base No

Adherent clot

Re-bleeding rates in RCT’s of treatment of adherent clots This is pre PPI data H2RA used in these trials So still controversial Jensen D.Gastroenterlogy 2002;123407 Bleau B Gastrointest Endosc 2002;56:1

Potential Triage for UGI Bleeding UGIB (Non-variceal) Stable Hemodynamics Blatchford score <2 (10%) Blatchford score 2 (90%) Outpatient care Elective Endoscopy PPI Urgent Endoscopy Definitive Care based on endoscopic findings Rockall score<3 (20-30%) Rockall Score3 High Risk Stigmata High Risk Stigmata Endoscopic Therapy No High Risk Stigmata Outpatient Therapy Outpatient Care PPI H. Pylori Treatment Endoscopic Therapy Hospital Admission ICU Care based on comorbidity

Types of endoscopic therapy Injection Ablative Mechanical combination Novel techniques

Endoscopic therapy injection Reduce blood flow by temporary local tamponade Vasoconstricting agents reduce blood flow -Adrenaline 1:10,000 -1:100,000 Sclerosants Ethanolamine Polidocanol Ethanol Tissue adhesive Histoacryl Fibirin glue

Endoscopic therapy ablative Contact ablative therapy by Thermo coagulation heat probe Electro coagulation BICAP, Gold probe Non contact ablative argon plasma cougulation

Endoscopic therapy ablative Coaptive coagulation compress vessel & cougulate 15-20 watts for 8-12 seconds for 4-6 pulses Larger 10 French more effective than 7 French probes

Endoscopic therapy mechanical hemoclips

Application of a clip in upper GI bleeding A vessel in a bleeding ulcer was provided with a clip.

Endoscopic therapy combination Injection combined with thermo-coagulation therapy Inject first 1:10,000 adrenaline Can use combination probe May inject and clip

Dual vs. Monotherapy in High-risk Bleeding Ulcers: A meta-analysis of Controlled trials Group Comparison # studies # pts A Injection+Mechanical vs. Injection 4 362 B Injection+Thermal vs.Injection 3 376 C Injection+Injection vs. Injection 10 1075 D Injection+Mechanical vs. Mechanical 234 E Injection+Thermal vs. Thermal 425 20 2472 Marmo R et al. Am J Gastroenterol 2007; 102:279-89

Outcome recurrent bleeding

Outcome need of surgery

Outcome death

Safety of Dual vs. Monotherapy P value Overall morbidity 38 (3.5%) 35 (3.3%) NS Induced bleeding 18 Perforation 7* 0.03 *5 cases with injection plus thermal & 2 cases with double injection therapy

Summary of Endoscopic Therapy Injection therapy less effectiveNo injection aloneADD SOMETHING ELSE No significant clinical advantage for dual therapy over thermal or mechanical monotherapy (? active bleeder) Single therapy?thermal or if applicable, mechanical therapy Single therapy is safer than dual therapy Barkun A et al. Ann Intern Med 2003; 139:843-57 Adler DG et al. Gastrointest Endsoc 2004; 60:497-504

Injection- Bicap vs. injection-Hemoclip INJ-CLIP INJ-BICAP 29 30 Patients with ulcer 20.7 43.3 Re-bleeding(%) 10.3 Retreatment(%) 3.5 23.3 Failure of hemostasis(%) 20 Surgery 6.7 Deaths Jensen DM.Gastrointrst Endosc 2008:67;AB106

Limitation of endoscopic therapy We can only treat what we see Double or wide channel scope NG tube lavage pre-endoscopy Water pump/jet External large suction device Iv erythromycin

Iv erythromycin We can only treat what we can see Consider giving a single 250-mg IV dose of erythromycin 30 to 60 minutes before endoscopy promote gastric motility and substantially improve visualization of the gastric mucosa on initial endoscopy. not improve the diagnostic yield of endoscopy substantially or to improve the outcome We can only treat what we can see

Limitation of endoscopic therapy challenging lesions Large ulcer defect more than 2cm Visible vessel more than 2 mm Inaccessible lesions Challenging positions ( posterior wall stomach ,lesser curve , posterior bulbar wall) Fibrotic base for hemoclip

Addition of a Second Endoscopic Treatment Following Injection: Two is better than one may be? Meta-analysis of 16 studies: 1673 patients Rebleeding 18.410.6% OR 0.53 (0.40~0.69) Need for surgery 11.37.6% OR 0.64 (0.46~0.90) Mortality 5.12.6% OR 0.51 (0.31~0.84) Risk decreased regardless of which second procedure was applied ACG guidelines not recommend routine second look Calvet X et al. Gastroenterology 2004; 126:441-50

Outcome of Endoscopic Management Hemostasis>95% Recurrent bleeding<15% Death 6-8% (irrespective of any optimal endoscopic & medical treatment) Barkun A et al. Ann Intern Med 2003; 139:843-5, Cipolletta L et al. Endoscopy 2007; 39:7-10 Treat the patient and Not just the source of bleeding

Hemospray

Hemospray 95% acute hemostasis Sung JJ Endoscopy. 2011 Apr;43(4):291-5. Epub 2011 Mar 31.

Post endoscopic therapy Surgery when 2nd endoscopic attempt failed or unapplicable Angiography Antisecretory treatment H pylori eradication confirmation

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