Sangrado Gastrointestinal Alto - Inicio - Gastrocol · Sangrado Gastrointestinal Alto Upper GI Bleeding Curso Internacional Retos Clinicos en la Gastroenterologia de Urgencias Asociacion

Sangrado Gastrointestinal Alto Upper GI Bleeding

Curso Internacional Retos Clinicos en la Gastroenterologia de Urgencias

Asociacion Colombiana de Gastroenterologia 31 de Agosto, 2012

Pereira, Risaralda • Hotel Movich

John A. Martin, MD Associate Professor of Medicine and Surgery

Director of Endoscopy Northwestern University Feinberg School of Medicine • Chicago, Illinois

Acute non-variceal upper gastrointestinal bleed (UGIB) Proximal to ligament of Treitz 60 / 100,000 population

3 X LGIB incidence Higher mortality than LGIB (3.5-10%)

Opportunity for high-impact intervention Proper management demonstrated to improve

outcomes Endoscopy proven to improve outcome and

reduce resource utilization

Introduction

Acute upper gastrointestinal bleed (UGIB) Primary goal is triage

Identify patient who needs urgent intervention Identify patients who may be discharged to

outpatient management Deliver appropriate treatment with indicated

urgency Predictive factors

History of malignancy or cirrhosis Hematemesis Signs of hypovolemia Hgb < 8

Introduction

Acute upper gastrointestinal bleed (UGIB) Initial assessment

Inventory of predictive risk factors just enumerated

Elicit history of NSAID / ASA use Since clinical factors do not adequately predict

UGIB severity, prediction rules have been developed

– Clinical Rockall score – Blatchford score

Introduction

Acute upper gastrointestinal bleed (UGIB) Initial assessment

Inventory of predictive risk factors just enumerated

Elicit history of NSAID / ASA use Since clinical factors do not adequately predict

UGIB severity, prediction rules have been developed

– Clinical Rockall score – Blatchford score

» Score >0 99-100% sensitive in identifying severe UGIB in multiple studies

» May allow early discharge in 16-25%

Introduction

Blatchford O, et al. Lancet 2000;356:1318-21.

Hwang JH, et al. Gastrointest Endosc 2012;75:1132-38.

DDW ASGE Abstract Su 1310: Nguyen, et al. (Holloway)

Risk stratification with Glasgow-Blatchford bleeding score (GBS) for hospitalized patients with upper GI bleeding can avoid the need for urgent endotherapy GBS identifies pts with UGI bleeding

who can be managed safely as outpts Comparison of GBS with pre-EGD and

post-EGD Rockall score (PreR + PostR) in predicting need for endotherapy and further interventions in UGIB patients

GBS and Rockall for all UGIB pts admitted to Royal Adelaide Hosp over 18 mos ROC curves generated to examine

performance of GBS and R to predict need for endoscopic & related interventions

All pts received high-dose acid suppression

455 pts EGD for UGIB; 188 pts (41%) req endotherapy; 19 (4%) had surgery


Results Pts req endotherapy or surgery had higher

GBS, PreR, PostR (p<0.001) On ROC, GBS + PostR superior to PreR in

predicting Need for endotherapy (AUC 0.83 vs 0.72 vs

0.65) Need for rpt endoscopy for rebleeding or

further endotherapy (AUC 0.64 vs 0.63 vs 0.56) GBS superior to both PreR + PostR in

predicting need for transfusion (AUC 0.83 vs 0.72 vs 0.70)


Results (cont’d) GBS superior to both PreR + PostR in

predicting need for surgery (AUC 0.75 vs 0.67 vs 0.54)

No pts with GBS ≤ 7 required surgery None of pts with GBS ≤ 3 required

endotherapy, blood transfusion, or surgery


Conclusion GBS superior to Rockall in predicting need

for endotherapy, rpt endoscopy, transfusion, surgery in acute UGIB pts

GBS should be the preferred risk scoring system for acute UGIB


WH

AT T

O D

O? W

HAT TO

DO

?

Background

Peptic ulcer underlies 50-70% of acute nonvariceal UGIB’s (Barkun, et al., Ann Intern Med 2003;139:843) Most PUD result of NSAID therapy and

H. pylori infection 80% stop bleeding spontaneously

without recurrence Most morbidity and mortality occur

among the remaining 20% who have continued or recurrent bleeding

The latter are the ones that you need to target…but how?

Background

Via EGD, because it has proven potential to: Identify bleeding source in ≥90% of

UGIB Stratify rebleeding risk Intervene in high-risk lesions, and

thereby Reduce rebleeding risk (to 15-20%) Decrease hospital length of stay Possibly reduce mortality

(Cooper, et al., Gastrointest Endosc 1999;49:145)

Initial assessment

Detection & accurate identification of high-risk stigmata requires Copious lavage and diligent search

for point source of bleeding Familiarity with classification and

endoscopic appearance of high-risk stigmata…

Initial assessment

…because successful endoscopic intervention is dependent upon definitive detection and accurate identification of the actual point source of bleeding

Rationale for endoscopic intervention

Endoscopic hemostasis indicated only for patients with specifically defined, endoscopically identified high-risk lesions Active bleeding (a bleeding visible

vessel) Non-bleeding visible vessel (NBVV) Probably adherent clots

Thus, intervention must be preceded by Diligent search for active bleeding or

NBVV Positive identification of active

bleeding or NBVV

Jensen, et al., Gastroenterology 2002;123:407

Most common etiologies of UGIB PUD (20-50%) Gastroduodenal erosions (8-15%) Esophagitis (5-15%) Varices (5-20%) Mallory-Weiss tears (8-15%) Vascular malformations/ectasias (5%) Other etiologies including malignancy

Endoscopic prognostic features

Endoscopic prognostic features

Hwang JH, et al. Gastrointest Endosc 2012;75:1132-38.

Endoscopic intervention rationale: Risk stratification

Modified & adapted from Forrest, et al., Lancet 1974;17:394, and Laine, et al., N Engl J Med 1994;331:717.

Forrest class

Type of lesion (endoscopically identified)

Risk of rebleeding if untreated

Surgery Mortality

IA Arterial spurting bleeding 100%

IB Arterial oozing bleeding 55% (17-100%) 35% 11%

IIA Non-bleeding visible vessel (NBVV)

43% (8-81%)

34% 11%

IIB Sentinel clot 22% (14-36%) 10% 7%

IIC Flat pigmented spot 10% (0-13%) 6% 3%

III Clean based ulcer 5% (0-10%) 0.5% 2%

Goal of treatment

Goal of treatment is hemostasis of a specific

bleeding vessel

Laine, N Engl J Med 1987;316:1613; Jensen, N Engl J Med 1999;340:799.

What to do? Volume resuscitate / transfuse NG aspiration

15% active bleeding patients will have negative NG lavage

Administer PPI therapy Cochrane meta-analysis of 6 RCT’s

No delta in mortality, rebleeding, progression to surgery vs controls

Pre-procedure PPI significantly reduced rate of high risk stigmata on EGD and need for endotherapy

Consider prokinetic pre-EGD for better visualization (Barkun, et al. GIE 2010)

Diagnostic considerations PPIs reduce stigmata Prokinetics improve visualization in some Irrigate overlying adherent clot

Removal of clot resistant to removal by irrigation is controversial

Therapeutic considerations Endoscopic therapy is indicated in active

bleeding and non-bleeding visible vessel Meta-analysis of 6 RCTs shows endoscopic

therapy is superior to medical for rebleeding

Endoscopic Management of UGIB

Therapeutic modalities 2009 meta-analysis of 75 studies show

thermal, injectables other than saline/epinephrine, and clips all effective in PUD hemostasis

No single modality was superior Epi with second treatment modality more

effective than epi alone Epi alone should not be used, but should be

combined with second modality

Endoscopic Therapy of UGIB

Laine L, McQuaid KR. Clin Gastroenterol Hepatol 2009;7:33-47.

Injection Generally, saline or 1:10,000

epinephrine in saline Not sclerosants Effects tamponade via volume effect: use

higher volumes (Lin, et al., GIE 2002) Tamponade is temporary (unlike mechanical

and thermal therapies), so data suggests against use of injection as monotherapy

Endoscopic Hemostatic Modalities

Thermal devices Coaptive devices: tamponade +

coagulation Multipolar electrocoagulation probe

(MPEC) probe or heat probe All forms equivalent; limited data suggest

combination with epin more effective than monotherapy

APC Non-coaptive therapy

for superficial lesions


Mechanical therapy Permanent tamponade via

mechanical device Clips Bands

Tissue, anatomy, operator preference may dictate choice Anatomical location Type of lesion Ease of deployment due to anatomical or

technical considerations


No prospective trials comparing methods for acute UGIB due to vascular abnormalities Vascular ectasias Dieulafoy lesions GAVE

Endoscopic marking Consider tattooing difficult-to-locate lesions Place clip whether endotherapy succeeds or

fails to facilitate IR / surgical intervention

Upper GI Vascular Abnormalities

Doppler probe

A Peek at New Technologies in Hemostasis

Monopolar coagulation grasping forcep


New hemostatic clips












New hemostatic spray


New hemostatic spray


Consult new 2012 ASGE Guidelines at www.asge.org “The role of endoscopy in the management

of acute non-variceal upper GI bleeding” Gastrointest Endosc 2012;75:1132-1138. Resuscitate patients adequately Initiate antisecretory therapy with PPIs Consider prokinetic agents in select cases EGD to diagnose etiology urgently: within 24 hrs

in patients with hematemesis, signs of hypovolemia, history of malignancy or cirrhosis

Upper GI Bleeding 2012: Summary

http://www.asge.org/

Consult new 2012 ASGE Guidelines at www.asge.org “The role of endoscopy in the management

of acute non-variceal upper GI bleeding” Gastrointest Endosc 2012;75:1132-1138. Management of PUD with adherent clot is

controversial Injection, thermal, and mechanical therapies are

all effective Epinephrine alone should not be used in PUD

bleeding, but should be combined with 2nd agent

Upper GI Bleeding 2012: Summary

http://www.asge.org/

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Sangrado Gastrointestinal Alto - Inicio - Gastrocol · Sangrado Gastrointestinal Alto Upper GI Bleeding Curso Internacional Retos Clinicos en la Gastroenterologia de Urgencias Asociacion