Scholarly article on topic 'Endoscopic Management of Nonvariceal Upper Gastrointestinal Bleeding'

Endoscopic Management of Nonvariceal Upper Gastrointestinal Bleeding Academic research paper on "Chemical sciences"

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Abstract of research paper on Chemical sciences, author of scientific article — SB Laursen, OB Schaffalitzky de Muckadell

Abstract This article describes the practical approach to endoscopic treatment of peptic ulcer bleeding and Dieulafoy's lesions including theoretical considerations of importance for the outcome. Endoscopic therapy is indicated in ulcers with active bleeding, a nonbleeding visible vessel, or an adherent clot. For high-risk ulcers (Forrest I–IIa), the authors of this article recommend initial treatment with injection of diluted adrenaline followed by a second hemostatic therapy (heater probe or clips). This article is part of an expert video encyclopedia.

Academic research paper on topic "Endoscopic Management of Nonvariceal Upper Gastrointestinal Bleeding"

Endoscopic Management of Nonvariceal Upper Gastrointestinal Bleeding (g)«**»*

SB Laursen and OB Schaffalitzky de Muckadell, Odense University Hospital, Odense, Denmark © 2013 Elsevier GmbH. All rights reserved.

Received 14 August 2012; Revision submitted 14 August 2012; Accepted 22 October 2012 Abstract

This article describes the practical approach to endoscopic treatment of peptic ulcer bleeding and Dieulafoy's lesions including theoretical considerations of importance for the outcome. Endoscopic therapy is indicated in ulcers with active bleeding, a nonbleeding visible vessel, or an adherent clot. For high-risk ulcers (Forrest I-IIa), the authors of this article recommend initial treatment with injection of diluted adrenaline followed by a second hemostatic therapy (heater probe or clips). This article is part of an expert video encyclopedia.

Keywords

Clips; Heater probe; Injection therapy; Standard endoscopy; Video.

Video Related to this Article

Video available to view or download at doi:10.1016/S2212-0971(13)70053-0

Materials

• Endoscope: Evis Exera GIF-H180 and Evis Exera GIF-2T160; Olympus, Mt Waverley, Australia.

• Heater probe: HeatProbe CD-110U; Olympus, Mt Waverley, Australia.

• Hemoclip: Resolution Clip M00522601; Boston Scientific, Natick, MA, USA.

Background and Endoscopic Procedures

Peptic ulcer bleeding (PUB) is the most common source of upper gastrointestinal bleeding. Performance of upper en-doscopy is crucial in order to diagnose the bleeding source and, in cases with high risk of adverse outcome, perform endoscopic therapy.

In general, patients with suspected PUB should undergo endoscopy within 24 h, which is shown to decrease the risk of rebleeding, need for surgical hemostasis, and duration of hospital stay.1 At endoscopy the mucosa of the esophagus, stomach, and the duodenum is thoroughly visualized. In cases where a peptic ulcer is found, the endoscopist should be able to perform adequate risk stratification based on the stigmata of recent bleeding. This is often done using the Forrest classification (Table 1).2

Endoscopic therapy is not indicated in cases with Forrest IIc-III ulcers as the risk of rebleeding is relatively low (< 10%).3 In ulcers with an adherent clot (defined as a clot resistant to forceful irrigation or suction), the risk of rebleeding is >20%

This article is part of an expert video encyclopedia. Click here for the full Table of Contents.

if endoscopic therapy is not applied.3 In these cases, we recommend quadrant-wise injection of aliquots of 1 ml of diluted adrenaline (1:10 000) until a total of 5-10 ml is injected. Following injection of diluted adrenaline, most clots are easily removed using irrigation, suction, a biopsy forceps, or a snare in case of larger clots. Following removal of the clot, the ulcer base is inspected for signs of a visible vessel or active bleeding.

In patients with active bleeding from the ulcer base or a nonbleeding visible vessel, performance of endoscopic therapy is crucial in order to achieve hemostasis, reduce the risk of rebleeding, need for surgical hemostasis, and mortality.4 The authors prefer to use injection of diluted adrenaline, treatment with heater probe, or application of clips.

Injection of diluted adrenaline is a good first-line therapy in order to achieve hemostasis and prevent rebleeding from high-risk ulcers (Forrest I-IIa). The technique used is quadrant-wise injection of aliquots of 1-2 ml of diluted adrenaline (1:10 000), as for ulcers with an adherent clot, but injection of a total volume of 13-30 ml is recommended, as this is associated with a lower rate of rebleeding compared to injection of a lower total volume (< 10 ml).5 Injection of more than 30 ml of diluted adrenaline is not recommended due to increased risk of perforation.6 It is preferable to avoid injection closer than 2-3 mm from the bleeding point in order to reduce the risk of intravascular injection and iatrogenic bleeding.

Table 1 Forrest classification and associated risk of rebleeding

Forrest Endoscopic appearance Risk of

score rebleeding"

Ia Ulcer with active pulsating bleeding 55%

Ib Ulcer with active nonpulsating bleeding

I Ia Ulcer with a visible nonbleeding vessel 43%

I Ib Ulcer with an adherent clot 22%

I Ic Ulcer with hematin on ulcer base 10%

III Ulcer with a clean base without signs of 5%

recent bleeding

aRisk of rebleeding if endoscopic therapy is not performed.

Source: Adapted from Laine, L.; Peterson, W. L. Bleeding Peptic Ulcer. N. Engl. J. Med.

1994, 331, 717-727.

Video Journal and Encyclopedia of GI Endoscopy http://dx.doi.org/10.1016/S2212-0971(13)70053-0

Monotherapy with injection of diluted adrenaline is associated with a high risk of rebleeding (19%).7 Therefore, the authors recommend adding a second endoscopic method (heater probe or clips), which is shown to reduce the rate of rebleeding as well as need for surgical hemostasis.7

The advantage of the heater probe is its ability to achieve coaptive coagulation. Use of a 10 F probe is recommended. The heater probe is initially applied around the bleeding site in order to stop the blood supply to the bleeding point. The probe is applied using a firm tamponade in order to promote coaptive coagulation. Three to four 30 J pulses should be delivered before irrigation and change of position. Finally, the area of previous bleeding is coagulated. The endpoint of treatment is a footprint at the site of the vessel. A meta-analysis has suggested that monotherapy with heater probe is associated with a higher rebleeding rate compared with combined therapy with diluted adrenaline.8 Consequently, combined therapy with preceding injection of diluted adrenaline or application of clips is recommended.

Clips are useful for both achieving hemostasis and preventing recurrent bleeding from ulcers with protruding vessels. In general, the clip should be held as close as possible to the endoscope, as this enables the endoscopist to exert maximum downward force on the clip during application and increases the precision.9 Therefore, the endoscope should be placed close to the bleeding site. When applying the hemoclip, it is placed slightly away from the base of the artery in order to entrap the immediately surrounding tissue. Once the clip is correctly placed it is slowly closed. Simultaneous suction during application of the clip can increase the capture. In some cases application of several clips is needed in order to achieve hemostasis. When applied correctly, monotherapy with clips seems equally efficient as endoscopic combination therapy.8,10

Key Learning Points/Tips and Tricks

• Endoscopy should be performed within 24 h in patients with suspected PUB.

• Endoscopic treatment is indicated in ulcers with an adherent clot, a visible nonbleeding vessel, or an active bleeding.

• In most cases with adherent clots, the clot is easily moved after injection of diluted adrenaline.

• After removal of an adherent clot the ulcer base is inspected for bleeding stigmata indicating further treatment.

• Generally, for high-risk ulcers (Forrest I-IIa) initial treatment is recommended with injection of 13-30 ml of diluted adrenaline followed by a second hemostatic therapy (heater probe or clips), although monotherapy with clips might be equally efficient.

Scripted Voiceover

Time Voiceover text

(min:sec)

00:05 Peptic ulcer bleeding is the most common source of nonvariceal upper gastrointestinal bleeding.

00:21 In this patient an ulcer with an adherent clot was found in the duodenal bulb.

00:30 An adherent clot is usually defined as a clot resistant to forceful irrigation or suction.

00:40 Ulcers with an adherent clot are classified as a lib ulcer according to the Forrest classification.

00:50 These ulcers are associated with a rate of rebleeding above 20% if endoscopic treatment is not performed.

01:00 Before proceeding to endoscopic therapy it is important to check for other bleeding sources and gastric biopsies should be taken as part of investigation of possible H. pylori infection.

01:14 Regarding treatment we recommend quadrant-wise injection of aliquots of 1 ml of diluted adrenaline.

01:27 When injecting diluted adrenaline the needle is inserted about 3 mm from the bleeding point in order to avoid intravasal injection.

01:51 The total volume injected depends on the type of ulcer.

02:00 In most ulcers with an adherent clot injection of a total volume of 5-10 ml of diluted adrenaline is sufficient.

02:10 By contrast, injection of a total volume between 13-30 ml is recommended in ulcers with active bleeding, or a visible non-bleeding vessel, in order to decrease the risk of rebleeding.

02:28 Injection of more than 30 ml of diluted adrenaline is not recommended due to increased risk of perforation.

02:44 Following injection of diluted adrenaline most clots are easily removed using irrigation, suction, a biopsy forceps or a snare in case of larger clots.

03:49 When the clot is removed the ulcer is inspected for active bleeding, or signs of a non-bleeding vessel, requiring further endoscopic therapy.

04:01 In this case there was minor active bleeding from the ulcer base indicating the presence of an underlying artery.

04:10 In ulcers with active bleeding, or ulcers containing a non-bleeding visible vessel, monotherapy with diluted adrenaline is associated with a rebleeding rate around 20% and is therefore considered insufficient.

04:28 Combined treatment with heater probe or hemoclips will reduce the rate of rebleeding.

04:40 In this case we used the heater probe.

04:54 The heater probe is initially applied around the bleeding site in order to stop the blood supply to the bleeding point.

05:07 The heater probe is applied using a firm tamponade in order to promote coaptive coagulation.

05:14 Three to four 30 J pulses should be delivered before irrigation and change of position.

05:22 After treatment a footprint should be visible at the site of the vessel.

05:28 A meta-analysis has indicated that monotherapy with heater probe is associated with increased rebleeding

rate compared to combined therapy with diluted adrenaline.

05:38 Thus, we prefer to combine heater probe therapy with a second endoscopic treatment.

05:44 In another patient a large ulcer containing a non-bleeding vessel was found at the minor gastric curvature.

05:53 This type of ulcer is classified as a IIa ulcer according to the Forrest classification.

06:01 In protruding vessels a hemoclip is useful both to achieve hemostasis and to prevent recurrent bleeding.

06:13 In general, the clip should be held as close to the

endoscope as possible as this enables the endoscopist to exert maximum downward force on the clip during application and increases precision.

06:30 The hemoclip is placed slightly away from the base of the artery in order to entrap the immediately surrounding tissue.

06:40 When the clip is correctly placed it is slowly closed and released. Simultaneous suction during application of the clip can increase the capture.

06:51 In some cases application of several clips is needed in order to achieve hemostasis.

06:58 Monotherapy with clips seems to be equally efficient to endoscopic combination therapy.

07:04 In another patient a Dieulafoy's lesion was found in the lower esophagus.

07:25 In order to achieve hemostasis, injection of diluted adrenaline was chosen as first type of therapy.

07.57 Following injection of 2-3 ml of diluted adrenaline the bleeding ceased.

08.03 In order to prevent recurrent bleeding a clip was applied at the site of the lesion.

References

1. Cooper, G. S.; Chak, A.; Connors, A. F.; Harper, D. L.; Rosenthal, G. E. The Effectiveness of Early Endoscopy for Upper Gastrointestinal Hemorrhage: A Community-Based Analysis. Med. Care 1998, 36, 462-474.

2. Forrest, J. A.; Finlayson, N. D.; Shearman, D. J. Endoscopy in Gastrointestinal Bleeding. Lancet 1974, 2, 394-397.

3. Laine, L.; Peterson, W. L. Bleeding Peptic Ulcer. N. Eng. J. Med. 1994, 331, 717-727.

4. Cook, D. J.; Guyatt, G. H.; Salena, B. J.; Laine, L. A. Endoscopic Therapy for Acute NonvaricealUpper Gastrointestinal Hemorrhage: A Meta-Analysis. Gastroenterology 1992, 102, 139-148.

5. Lin, H. J.; Hsieh, Y. H.; Tseng, G. Y.; et al. A Prospective, Randomized Trialof Large- Versus Small-Volume Endoscopic Injection of Epinephrine for Peptic Ulcer Bleeding. Gastrointest. Endosc. 2002, 55, 615-619.

6. Liou, T. C.; Lin, S. C.; Wang, H. Y.; Chang, W. H. Optimallnjection Volume of Epinephrine for Endoscopic Treatment of Peptic Ulcer Bleeding. World J. Gastroenterol. 2006, 12, 3108-3113.

7. Vergara, M.; Calvet, X.; Gisbert, J. P. Epinephrine Injection Versus Epinephrine Injection and a Second Endoscopic Method in High Risk Bleeding Ulcers. Cochrane Database Syst. Rev. 2007, 2. CD005584. DOI: 10.1002/ 14651858.CD005584.pub2.

8. Barkun, A. N.; Martel, M.; Toubouti, Y.; Rahme, E.; Bardou, M. Endoscopic Hemostasis in Peptic Ulcer Bleeding for Patients with High-Risk Lesions: A Series of Meta-Analyses. Gastrointest. Endosc. 2009, 69, 786-799.

9. Kaltenbach, T. K.; Friedland, S.; Barro, J.; Soetikno, R. Clipping for Upper Gastrointestinal Bleeding. Am. J. Gastroenterol. 2006, 101, 915-918.

10. Marmo, R.; Rotondano, G.; Piscopo, R.; et al. Dual Versus Endoscopic Monotherapy in Bleeding Peptic Ulcers. Am. J. Gastroenterol. 2007, 102, 279-289.