GI HemorrhageGI Hemorrhage

Trauma and SICU ConferenceTrauma and SICU Conference12/18/200612/18/2006

Upper GI BleedingUpper GI Bleeding

Esophageal VaricesEsophageal Varices Mallory-Weiss TearMallory-Weiss Tear Duodenal UlcerDuodenal Ulcer Gastric UlcerGastric Ulcer GastritisGastritis CancerCancer HemobiliaHemobilia Cranberry SauceCranberry Sauce

Lower Gastrointestinal BleedingLower Gastrointestinal Bleeding UGI SourceUGI Source Hemorrhoids, Fissure, Ulcer, PolypHemorrhoids, Fissure, Ulcer, Polyp ProlapseProlapse Volvulus/MalrotationVolvulus/Malrotation CancerCancer Ulcerative ColitisUlcerative Colitis Granulomatous ColitisGranulomatous Colitis DiverticulitisDiverticulitis Other:Other:

Meckel’s DiverticulumMeckel’s Diverticulum Colonic PolypColonic Polyp Peutz-Jeghers SyndromePeutz-Jeghers Syndrome Osler-Weber-Rendu SyndromeOsler-Weber-Rendu Syndrome Ileal DiverticulaIleal Diverticula Duplication of BowelDuplication of Bowel

Endoscopic Interventions for Endoscopic Interventions for Gastrointestinal BleedingGastrointestinal Bleeding

Stephanie Chao, Trauma R1Stephanie Chao, Trauma R1Trauma ConferenceTrauma Conference

December 18, 2006December 18, 2006

Endoscopic techniquesEndoscopic techniques

AnoscopyAnoscopy SigmoidoscopySigmoidoscopy

<45 years old with small volume bleed, may be sufficient for investigation <45 years old with small volume bleed, may be sufficient for investigation unless bleeding/recurrence foundunless bleeding/recurrence found

Identifies anorectal disease, infectious colitis, inflammatory bowel diseaseIdentifies anorectal disease, infectious colitis, inflammatory bowel disease

EGDEGD

ColonoscopyColonoscopy

Injection RxInjection Rx

EpinephrineEpinephrine 1-1.5ml of 1:10,000 or 1:20,000 in 4 quadrants1-1.5ml of 1:10,000 or 1:20,000 in 4 quadrants Mechanism: vasoconstriction, volume tamponadeMechanism: vasoconstriction, volume tamponade

Sclerosant (ethanolamine)Sclerosant (ethanolamine) Mechanism: Induces inflammation then fibrosisMechanism: Induces inflammation then fibrosis

Fibrin SealantFibrin Sealant Fibrinogen/Factor XIII and Thrombin/CalciumFibrinogen/Factor XIII and Thrombin/Calcium Mechanism: Instantaneous formation of hemostatic clot by mimicking last Mechanism: Instantaneous formation of hemostatic clot by mimicking last

step of coagulation cascade step of coagulation cascade Sclerosant trials vs. Fibrin sealantSclerosant trials vs. Fibrin sealant

No advantage of epi + sclerosant over epi aloneNo advantage of epi + sclerosant over epi alone SalineSaline

Mechanism: volume tamponadeMechanism: volume tamponade EthanolEthanol

Thermal CoagulationThermal Coagulation

Heater probeHeater probe Mechanism: tissue coagulation via heated ceramic tipMechanism: tissue coagulation via heated ceramic tip Not limited by tissue water resistance, deeper heat penetrationNot limited by tissue water resistance, deeper heat penetration Higher risk of perforationHigher risk of perforation

Multipolar probeMultipolar probe Mechanism: coagulates tissue by heating tissue temperature to Mechanism: coagulates tissue by heating tissue temperature to

>60 degrees Celsius via alternating positive and negative >60 degrees Celsius via alternating positive and negative electrodes at tipelectrodes at tip

Tissue desiccation prevents conduction to lower layersTissue desiccation prevents conduction to lower layers

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

distributed thermal energydistributed thermal energy No contact, wider spray, less depthNo contact, wider spray, less depth

CoagulationCoagulation

Active bleedPost Coagulation

Thermal CoagulationThermal Coagulation

Heater probeHeater probe Mechanism: tissue coagulation via heated ceramic tipMechanism: tissue coagulation via heated ceramic tip Not limited by tissue water resistance, deeper heat penetrationNot limited by tissue water resistance, deeper heat penetration Higher risk of perforationHigher risk of perforation

Multipolar probeMultipolar probe Mechanism: coagulates tissue by heating tissue temperature to Mechanism: coagulates tissue by heating tissue temperature to

>60 degrees Celsius via passing electricity between alternating >60 degrees Celsius via passing electricity between alternating positive and negative electrodes at tippositive and negative electrodes at tip

Tissue desiccation prevents conduction to lower layersTissue desiccation prevents conduction to lower layers

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

distributed thermal energydistributed thermal energy No contact, wider spray, less depthNo contact, wider spray, less depth

Multipolar ProbeMultipolar Probe

Thermal CoagulationThermal Coagulation

Heater probeHeater probe Mechanism: tissue coagulation via heated ceramic tipMechanism: tissue coagulation via heated ceramic tip Not limited by tissue water resistance, deeper heat penetrationNot limited by tissue water resistance, deeper heat penetration Higher risk of perforationHigher risk of perforation

Multipolar probeMultipolar probe Mechanism: coagulates tissue by heating tissue temperature to Mechanism: coagulates tissue by heating tissue temperature to

>60 degrees Celsius via alternating positive and negative >60 degrees Celsius via alternating positive and negative electrodes at tipelectrodes at tip

Tissue desiccation prevents conduction to lower layersTissue desiccation prevents conduction to lower layers

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

distributed thermal energydistributed thermal energy No contact, wider spray, less depthNo contact, wider spray, less depth

Argon Plasma CoagulantArgon Plasma Coagulant

Hemostatic ClipsHemostatic Clips

Occludes vesselOccludes vessel

Radiographic markerRadiographic marker

Risk Stratification – Peptic Ulcer DiseaseRisk Stratification – Peptic Ulcer Disease Low riskLow risk

Flat spot, clean ulcerFlat spot, clean ulcer Rx: No endoscopic intervention, PPI onlyRx: No endoscopic intervention, PPI only

Intermediate RiskIntermediate Risk Ooze without clot or visible vesselOoze without clot or visible vessel Rx: Monotherapy with oral PPIRx: Monotherapy with oral PPI

High RiskHigh Risk Active bleed, non-bleeding visible vessel with clot Active bleed, non-bleeding visible vessel with clot Rx: Combination therapy (injection and coagulation, IV PPI)Rx: Combination therapy (injection and coagulation, IV PPI) Visible vesselVisible vessel Rx: clip or coagulation and PPIRx: clip or coagulation and PPI

Risk StratificationRisk Stratification Low riskLow risk

Flat spot, clean ulcerFlat spot, clean ulcer Rx: No endoscopic intervention, PPI onlyRx: No endoscopic intervention, PPI only

Intermediate RiskIntermediate Risk Ooze without clot or visible vesselOoze without clot or visible vessel Rx: Monotherapy with oral PPIRx: Monotherapy with oral PPI

High RiskHigh Risk Active bleed, non-bleeding visible vessel with clot Active bleed, non-bleeding visible vessel with clot Rx: Combination therapy (injection and coagulation, IV PPI)Rx: Combination therapy (injection and coagulation, IV PPI) Visible vesselVisible vessel Rx: clip or coagulation and PPIRx: clip or coagulation and PPI

Risk StratificationRisk Stratification Low riskLow risk

Flat spot, clean ulcerFlat spot, clean ulcer Rx: No endoscopic intervention, PPI onlyRx: No endoscopic intervention, PPI only

Intermediate RiskIntermediate Risk Ooze without clot or visible vesselOoze without clot or visible vessel Rx: Monotherapy with oral PPIRx: Monotherapy with oral PPI

High RiskHigh Risk Active bleed, non-bleeding visible vessel with clot Active bleed, non-bleeding visible vessel with clot Rx: Combination therapy (injection and coagulation, IV PPI)Rx: Combination therapy (injection and coagulation, IV PPI) Visible vesselVisible vessel Rx: clip or coagulation and PPIRx: clip or coagulation and PPI

Risk StratificationRisk Stratification Low riskLow risk

Flat spot, clean ulcerFlat spot, clean ulcer Rx: No endoscopic intervention, PPI onlyRx: No endoscopic intervention, PPI only

Intermediate RiskIntermediate Risk Ooze without clot or visible vesselOoze without clot or visible vessel Rx: Monotherapy with oral PPIRx: Monotherapy with oral PPI

High RiskHigh Risk Active bleed, non-bleeding visible vessel with clot Active bleed, non-bleeding visible vessel with clot Rx: Combination therapy (injection and coagulation, IV PPI)Rx: Combination therapy (injection and coagulation, IV PPI) Visible vesselVisible vessel Rx: clip or coagulation and PPIRx: clip or coagulation and PPI

VaricesVarices

BandingBanding

ReferencesReferences

Kubba, AK, Palmer, KR. Role of endoscopic injection Kubba, AK, Palmer, KR. Role of endoscopic injection therapy in the treatment of bleeding peptic ulcer. Br J therapy in the treatment of bleeding peptic ulcer. Br J Surg 1996; 83:461. Surg 1996; 83:461.

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

Jensen DM, Machicado GA. Endoscopic Hemostasis of Jensen DM, Machicado GA. Endoscopic Hemostasis of Ulcer Hemorrhage with Injection, Thermal, or Ulcer Hemorrhage with Injection, Thermal, or Combination Methods. Techniques in Gastrointestinal Combination Methods. Techniques in Gastrointestinal Endoscopy 2005; 7:124. Endoscopy 2005; 7:124.

Up-To-DateUp-To-Date CMDTCMDT