1. 1 Biopsy Update & Current Treatment Modalities of GI Bleeds Spring ISGNA, March 4, 2016 By: Allison Miller, Territory Support Representative

2. 2 Agenda Get to know the audience activity! Biopsy Update: Taking Samples Like Never Before Current Modalities of GI Bleeding Closing & Questions

3. 3 Biopsy Update: Taking Samples Like Never Before

4. 4 Biopsy Incidence Update: Approximately, 6.5 million will have an endoscopic biopsy taken in the US per year. Of those procedures, almost ¾ of the procedures will be related to 4 common conditions: Gastritis, Colon Cancer, Barrett's, Esophagitis

5. 5 Disease States for Biopsy: A Closer Look

6. 6 Esophagitis and Barrett’s Esophagus Esophagitis Inflammation and irritation of the esophagus. Reflux is the most common root cause. Symptoms: (dysphagia), heartburn, a bitter taste in their mouth, or a feeling of food sticking in their chest after swallowing. Barrett’s Esophagus Abnormal change of cells in distal esophagus. Caused by the long-term presence of severe and chronic (GERD) and Esophagitis. Can evolve into Esophageal Cancer.

7. 7 Gastritis Inflammation of the stomach lining. Acute Gastritis –NSAIDS, Alcoholism, smoking or serious illness. –Mucosal damage occurs. Chronic Gastritis –Produces superficial changes in the antrum of the stomach. –H.pylori May be associated with gastric ulcers, pernicious anemia, or gastric cancer

8. 8 Crohn’s Disease & Ulcerative Colitis Crohn’s Disease Patchy areas of inflammation extend deep into the lining of the affected tissue Blockage of intestine most common complication. Ulcerative Colitis IBD that causes inflammation and ulcers in top layer of large intestine Typically occurs in rectum and lower part of colon, but may affect entire colon.

9. 9 Pathology: Digging Deeper

10. 10 What is important to the Pathologist? Specimen Size and Quality –This helps provide better orientation and improves interpretation. Crushed Artifact: What is it? –Unidentifiable tissue –Can be reduced by minimizing specimen handling, shaking and tapping.

11. 11 Why Are Biopsies Important? Although they may seem routine, biopsies help provide patients answers and guide physicians in their course of treatment. Forceps are cancer detecting devices!

12. 12 Current Modalities of GI Bleeds

13. 13 GI Bleeding Incidence/Statistic 1,2 GI Bleeding is a common medical emergency in gastroenterology. Over 300,000 hospital admissions annually in US. Cost estimated to exceed $2.5 billion in the US per year.

14. 14 Two Types of GI Bleeds: Variceal Bleeds –Portal Hypertension –Presents as Varices in distal esophagus. Non-Variceal Bleeds: –Peptic Ulcer Disease –Esophagitis –Mallory-Weiss Tear –Malignancy –GAVE –Post Polypectomy Sites

15. 15 Endoscopic Treatment Options

16. 16 Modalities Injection –Injection needle Thermal –Gold Probe –APC Mechanical –Clips –Band Ligation Combination

17. 17 Injection

18. 18 Thermal Gold ProbeAPC high-frequency monopolar alternating current conducted to target tissues through ionized argon gas –Coagulation depth dependent on: generator power setting duration of application distance from the probe top to the target tissue

19. 19 Mechanical Treatment: Clips

20. 20 Clip Indications: Prophylactic Clipping* Anchoring and Marking of Stents Hemostasis Closure Anchoring of a J-Tube

21. 21 Why Prophylactic Clipping? GI Healthcare is changing: –Talks about receiving penalties in GI for repeat bleed from colonoscopy in 2016 –Legislators want rebleed rate to be 1% –Current national rebleed rate is.5%-2%. 46% of delayed bleeds occur within 72 hours post resection.

22. 22 What is a delayed bleed? Bleeds that occur when angiogenesis is incomplete. What is Angiogenesis? –Rerouting of blood vessels –Can take up to 21 days –At risk of rebleed until this process has occurred

23. 23 HIGH RISK Patient for Delayed Bleed –Right-hemi colon (Theories behind the risk) Thinner mucosal wall More tension on cecum wall due to insufflation Illeal fluids that contain digestive enzymes have not been fully absorbed by the colon and can dissolve the clot –Anti-coagulants –Large Polyp (13% increase for every 1mm increase in diameter) –Age (4% increase for every year)

24. 24 Delayed Bleed Timeline

25. 25 Prophylactic Clip Closure to Reduce the Risk of Delayed Hemorrhage What does this study tell us? Reduction of delayed bleed rates by prophylactically clipping

26. 26 Prophylactic Clip Closure to Reduce the Risk of Delayed Hemorrhage Data Summary

27. 27 Cost of a Re-bleed Medicare costs roughly $10,000 Dr. Rex Study –100 high-risk patients –$88k = Cost of not clipping & managing complications –$56k = Cost of clipping –$86.49 = Negative cost to hospital for every clip not used

28. 28 Who do we clip prophylactically? Everyone? –No! High Risk Patients? –Yes! Study Recommends: –Anti-coagulants –Age –Right hemi-colon –Size –Traveling 4+ hours

29. 29 Questions?

30. 30