Upper gastrointestinal bleeding endoscopic intervention: Difference between revisions
Jump to navigation
Jump to search
Aditya Ganti (talk | contribs) No edit summary |
Aditya Ganti (talk | contribs) No edit summary |
||
| Line 4: | Line 4: | ||
==Overview== | ==Overview== | ||
In UGIB, diagnostic and therapeutic endoscopy is be performed simultaneously. Therapeutic upper gastrointestinal endoscopy should be performed in all patients with suspected UGIB to evaluate and possibly treat the source of bleeding. The urgency of endoscopy depends on the anticipated source of bleeding, rapidity of blood loss, and hemodynamic stability of the patient. The common procedures used to manage upper GI bleeding caused by the peptic ulcer disease and esophageal | In UGIB, diagnostic and therapeutic [[endoscopy]] is be performed simultaneously. Therapeutic [[Endoscopy|upper gastrointestinal endoscopy]] should be performed in all patients with suspected UGIB to evaluate and possibly treat the [[Bleeding|source of bleeding]]. The urgency of [[endoscopy]] depends on the anticipated source of [[bleeding]], rapidity of [[blood loss]], and [[Hemodynamics|hemodynamic]] stability of the patient. The common procedures used to manage upper GI bleeding caused by the [[peptic ulcer disease]] and [[Esophageal varices|esophageal varice]]<nowiki/>s are [[sclerotherapy]] (EIS), [[coagulation]] ([[Thermal ablation|thermal]], electric, and argon plasma), [[Hemostatic clamp|hemostatic clips]] and variceal band [[ligation]]. | ||
==Endoscopic intervention== | ==Endoscopic intervention== | ||
In UGIB, diagnostic and therapeutic endoscopy is be performed simultaneously. Therapeutic upper gastrointestinal endoscopy should be performed in all patients with suspected UGIB to evaluate and possibly treat the source of bleeding. The urgency of endoscopy depends on the anticipated source of bleeding, rapidity of blood loss, and hemodynamic stability of the patient. Endoscopic intervention should be undertaken within 24 hours, as early intervention is associated with reduced transfusion needs and a decreased length of stay in high-risk patients with nonvariceal bleeding.<ref name="pmid27744662">{{cite journal |vauthors=Garber A, Jang S |title=Novel Therapeutic Strategies in the Management of Non-Variceal Upper Gastrointestinal Bleeding |journal=Clin Endosc |volume=49 |issue=5 |pages=421–424 |year=2016 |pmid=27744662 |pmc=5066413 |doi=10.5946/ce.2016.110 |url=}}</ref> | In UGIB, diagnostic and therapeutic [[endoscopy]] is be performed simultaneously. Therapeutic [[Endoscopy|upper gastrointestinal endoscopy]] should be performed in all patients with suspected UGIB to evaluate and possibly treat the [[Bleeding|source of bleeding]]. The urgency of [[endoscopy]] depends on the anticipated source of [[bleeding]], rapidity of [[blood loss]], and [[Hemodynamics|hemodynamic]] stability of the patient. Endoscopic intervention should be undertaken within 24 hours, as early intervention is associated with reduced [[Blood transfusion|transfusion]] needs and a decreased length of stay in high-risk patients with nonvariceal bleeding.<ref name="pmid27744662">{{cite journal |vauthors=Garber A, Jang S |title=Novel Therapeutic Strategies in the Management of Non-Variceal Upper Gastrointestinal Bleeding |journal=Clin Endosc |volume=49 |issue=5 |pages=421–424 |year=2016 |pmid=27744662 |pmc=5066413 |doi=10.5946/ce.2016.110 |url=}}</ref> | ||
* The American Society of Gastrointestinal Endoscopy guidelines recommend the use of two different endoscopic procedures, rather than a single procedure to better control bleeding and decrease the incidence of re-bleeding.<ref name="HwangShergill2014">{{cite journal|last1=Hwang|first1=Joo Ha|last2=Shergill|first2=Amandeep K.|last3=Acosta|first3=Ruben D.|last4=Chandrasekhara|first4=Vinay|last5=Chathadi|first5=Krishnavel V.|last6=Decker|first6=G. Anton|last7=Early|first7=Dayna S.|last8=Evans|first8=John A.|last9=Fanelli|first9=Robert D.|last10=Fisher|first10=Deborah A.|last11=Foley|first11=Kimberly Q.|last12=Fonkalsrud|first12=Lisa|last13=Jue|first13=Terry|last14=Khashab|first14=Mouen A.|last15=Lightdale|first15=Jenifer R.|last16=Muthusamy|first16=V. Raman|last17=Pasha|first17=Shabana F.|last18=Saltzman|first18=John R.|last19=Sharaf|first19=Ravi|last20=Cash|first20=Brooks D.|title=The role of endoscopy in the management of variceal hemorrhage|journal=Gastrointestinal Endoscopy|volume=80|issue=2|year=2014|pages=221–227|issn=00165107|doi=10.1016/j.gie.2013.07.023}}</ref> | * The American Society of Gastrointestinal Endoscopy guidelines recommend the use of two different [[Endoscopic surgery|endoscopic]] procedures, rather than a single procedure to better control [[bleeding]] and decrease the incidence of re-bleeding.<ref name="HwangShergill2014">{{cite journal|last1=Hwang|first1=Joo Ha|last2=Shergill|first2=Amandeep K.|last3=Acosta|first3=Ruben D.|last4=Chandrasekhara|first4=Vinay|last5=Chathadi|first5=Krishnavel V.|last6=Decker|first6=G. Anton|last7=Early|first7=Dayna S.|last8=Evans|first8=John A.|last9=Fanelli|first9=Robert D.|last10=Fisher|first10=Deborah A.|last11=Foley|first11=Kimberly Q.|last12=Fonkalsrud|first12=Lisa|last13=Jue|first13=Terry|last14=Khashab|first14=Mouen A.|last15=Lightdale|first15=Jenifer R.|last16=Muthusamy|first16=V. Raman|last17=Pasha|first17=Shabana F.|last18=Saltzman|first18=John R.|last19=Sharaf|first19=Ravi|last20=Cash|first20=Brooks D.|title=The role of endoscopy in the management of variceal hemorrhage|journal=Gastrointestinal Endoscopy|volume=80|issue=2|year=2014|pages=221–227|issn=00165107|doi=10.1016/j.gie.2013.07.023}}</ref> | ||
==Management of upper GI bleeding caused by the peptic ulcer disease== | ==Management of upper GI bleeding caused by the peptic ulcer disease== | ||
The most common procedures used to manage upper GI bleeding caused by the peptic ulcer disease are:<ref name="pmid26142038">{{cite journal |vauthors=Fujii-Lau LL, Wong Kee Song LM, Levy MJ |title=New Technologies and Approaches to Endoscopic Control of Gastrointestinal Bleeding |journal=Gastrointest. Endosc. Clin. N. Am. |volume=25 |issue=3 |pages=553–67 |year=2015 |pmid=26142038 |doi=10.1016/j.giec.2015.02.005 |url=}}</ref><ref name="pmid18986845">{{cite journal |vauthors=Laine L, McQuaid KR |title=Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials |journal=Clin. Gastroenterol. Hepatol. |volume=7 |issue=1 |pages=33–47; quiz 1–2 |year=2009 |pmid=18986845 |doi=10.1016/j.cgh.2008.08.016 |url=}}</ref><ref name="pmid15605000">{{cite journal |vauthors=Park CH, Lee SJ, Park JH, Park JH, Lee WS, Joo YE, Kim HS, Choi SK, Rew JS, Kim SJ |title=Optimal injection volume of epinephrine for endoscopic prevention of recurrent peptic ulcer bleeding |journal=Gastrointest. Endosc. |volume=60 |issue=6 |pages=875–80 |year=2004 |pmid=15605000 |doi= |url=}}</ref> | The most common procedures used to manage upper GI bleeding caused by the [[peptic ulcer disease]] are:<ref name="pmid26142038">{{cite journal |vauthors=Fujii-Lau LL, Wong Kee Song LM, Levy MJ |title=New Technologies and Approaches to Endoscopic Control of Gastrointestinal Bleeding |journal=Gastrointest. Endosc. Clin. N. Am. |volume=25 |issue=3 |pages=553–67 |year=2015 |pmid=26142038 |doi=10.1016/j.giec.2015.02.005 |url=}}</ref><ref name="pmid18986845">{{cite journal |vauthors=Laine L, McQuaid KR |title=Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials |journal=Clin. Gastroenterol. Hepatol. |volume=7 |issue=1 |pages=33–47; quiz 1–2 |year=2009 |pmid=18986845 |doi=10.1016/j.cgh.2008.08.016 |url=}}</ref><ref name="pmid15605000">{{cite journal |vauthors=Park CH, Lee SJ, Park JH, Park JH, Lee WS, Joo YE, Kim HS, Choi SK, Rew JS, Kim SJ |title=Optimal injection volume of epinephrine for endoscopic prevention of recurrent peptic ulcer bleeding |journal=Gastrointest. Endosc. |volume=60 |issue=6 |pages=875–80 |year=2004 |pmid=15605000 |doi= |url=}}</ref> | ||
*'''Sclerotherapy (EIS)''' | *'''Sclerotherapy (EIS)''' | ||
*'''Coagulation''' (thermal, electric, and argon plasma) | *'''Coagulation''' (thermal, electric, and argon plasma) | ||
| Line 20: | Line 20: | ||
==== Contact probes ==== | ==== Contact probes ==== | ||
* Contact probes physically tamponade a blood vessel to stop bleeding and interrupt underlying blood flow. | * Contact probes physically tamponade a [[blood vessel]] to stop [[bleeding]] and interrupt underlying [[blood flow]]. | ||
* Thermal energy is then applied to seal the underlying vessel (coaptive coagulation). | * [[Thermal energy]] is then applied to seal the underlying [[vessel]] (coaptive coagulation). | ||
* The most commonly used probe is a multipolar electrocoagulation (MPEC) probe, also referred to as a ''bipolar electrocoagulation | * The most commonly used probe is a [[Electrocoagulation|multipolar electrocoagulation]] (MPEC) probe, also referred to as a ''[[Electrocoagulation|bipolar electrocoagulation probe]] '', with which heat is created by current flowing between intertwined electrodes on the tip of the [[probe]]. | ||
* Heater probes provide a predetermined amount of joules of energy, which does not vary with tissue resistance and can effectively coagulate arteries up to 2 mm in diameter | * Heater probes provide a predetermined amount of joules of energy, which does not vary with [[tissue]] resistance and can effectively coagulate [[arteries]] up to 2 mm in diameter. | ||
* The main risk of using a thermal probe is perforation with excessive application of coagulation or pressure, especially in acute or nonfibrotic lesions. | * The main risk of using a thermal probe is [[perforation]] with excessive application of coagulation or pressure, especially in acute or nonfibrotic lesions. | ||
* Thermal probes can also cause a coagulation injury that can make lesions larger and deeper and may induce delayed bleeding in patients with a coagulopathy. | * Thermal probes can also cause a coagulation [[injury]] that can make lesions larger and deeper and may induce delayed bleeding in patients with a [[coagulopathy]]. | ||
==== '''Noncontact types''' ==== | ==== '''Noncontact types''' ==== | ||
* Noncontact thermal therapy includes argon plasma coagulation and laser | * Noncontact thermal therapy includes [[argon plasma coagulation]] and [[laser]]. | ||
* Noncontact types rarely used now in endoscopic management. | * Noncontact types rarely used now in endoscopic management. | ||
=== Endoscopic '''Hemostatic clips''' === | === Endoscopic '''Hemostatic clips''' === | ||
* Hemostatic clips apply mechanical pressure to a bleeding site and control bleeding.<ref name="pmid26894683">{{cite journal |vauthors=Albert JG, Peiffer KH |title=[New methods for endoscopic hemostasis: focus on non-variceal gastrointestinal bleeding] |language=German |journal=Z Gastroenterol |volume=54 |issue=3 |pages=250–5 |year=2016 |pmid=26894683 |doi=10.1055/s-0035-1566987 |url=}}</ref> | * [[Hemostatic clamp|Hemostatic clips]] apply mechanical pressure to a bleeding site and control [[bleeding]].<ref name="pmid26894683">{{cite journal |vauthors=Albert JG, Peiffer KH |title=[New methods for endoscopic hemostasis: focus on non-variceal gastrointestinal bleeding] |language=German |journal=Z Gastroenterol |volume=54 |issue=3 |pages=250–5 |year=2016 |pmid=26894683 |doi=10.1055/s-0035-1566987 |url=}}</ref> | ||
* The first-generation hemoclips could not stop bleeding in vessels larger than a diameter of 1 mm, but subsequent hemoclips have been larger and stronger and have had a grasp and release mechanism that improves endoscopic deployment and hemostasis. | * The first-generation [[Hemostatic clamp|hemoclips]] could not stop bleeding in [[Blood vessel|vessels]] larger than a diameter of 1 mm, but subsequent [[Hemostatic clamp|hemoclips]] have been larger and stronger and have had a grasp and release mechanism that improves [[Endoscopy|endoscopic]] deployment and [[hemostasis]]. | ||
* Hemoclips are useful for patients with malnutrition or | * Hemoclips are useful for patients with [[malnutrition]] or [[coagulopathy]] but can also be difficult to deploy depending on the location of the bleeding site, the degree of [[fibrosis]] of the underlying lesion, and limitations to endoscopic access. | ||
* Endoscopic hemoclips differ from surgical clips in that they do not have as much compressive strength, and the currently available clips do not close completely but leave a small space between the prongs. | * Endoscopic hemoclips differ from surgical clips in that they do not have as much compressive strength, and the currently available clips do not close completely but leave a small space between the prongs. | ||
{{#ev:youtube|59uO-8UVC2A}} | {{#ev:youtube|59uO-8UVC2A}} | ||
==Management of upper GI bleeding caused by the esophageal varices== | ==Management of upper GI bleeding caused by the esophageal varices== | ||
The most common procedures used to manage esophageal varices are:<ref name="pmid1530782">{{cite journal |vauthors=Cook DJ, Guyatt GH, Salena BJ, Laine LA |title=Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis |journal=Gastroenterology |volume=102 |issue=1 |pages=139–48 |year=1992 |pmid=1530782 |doi= |url=}}</ref> | The most common procedures used to manage [[esophageal varices]] are:<ref name="pmid1530782">{{cite journal |vauthors=Cook DJ, Guyatt GH, Salena BJ, Laine LA |title=Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis |journal=Gastroenterology |volume=102 |issue=1 |pages=139–48 |year=1992 |pmid=1530782 |doi= |url=}}</ref> | ||
*'''Sclerotherapy''' | *'''Sclerotherapy''' | ||
*'''Variceal band ligation''' | *'''Variceal band ligation''' | ||
===Endoscopic band ligation (EBL)=== | ===Endoscopic band ligation (EBL)=== | ||
*EBL involves the placement of elastic circular ring ligatures around the varices to cause strangulation.<ref name="pmid18818787">{{cite journal |vauthors=Zepeda-Gómez S, Marcon NE |title=Endoscopic band ligation for nonvariceal bleeding: a review |journal=Can. J. Gastroenterol. |volume=22 |issue=9 |pages=748–52 |year=2008 |pmid=18818787 |pmc=2661278 |doi= |url=}}</ref><ref name="pmid11905861">{{cite journal |vauthors=Ertekin C, Taviloglu K, Barbaros U, Guloglu R, Dolay K |title=Endoscopic band ligation: alternative treatment method in nonvariceal upper gastrointestinal hemorrhage |journal=J Laparoendosc Adv Surg Tech A |volume=12 |issue=1 |pages=41–5 |year=2002 |pmid=11905861 |doi=10.1089/109264202753486911 |url=}}</ref> | *EBL involves the placement of elastic circular ring ligatures around the [[varices]] to cause [[strangulation]].<ref name="pmid18818787">{{cite journal |vauthors=Zepeda-Gómez S, Marcon NE |title=Endoscopic band ligation for nonvariceal bleeding: a review |journal=Can. J. Gastroenterol. |volume=22 |issue=9 |pages=748–52 |year=2008 |pmid=18818787 |pmc=2661278 |doi= |url=}}</ref><ref name="pmid11905861">{{cite journal |vauthors=Ertekin C, Taviloglu K, Barbaros U, Guloglu R, Dolay K |title=Endoscopic band ligation: alternative treatment method in nonvariceal upper gastrointestinal hemorrhage |journal=J Laparoendosc Adv Surg Tech A |volume=12 |issue=1 |pages=41–5 |year=2002 |pmid=11905861 |doi=10.1089/109264202753486911 |url=}}</ref> | ||
*Bands are typically delivered at the gastroesophageal junction first, then proximally six to ten bands may be delivered with a single intubation. | *Bands are typically delivered at the [[gastroesophageal junction]] first, then [[Proximal|proximally]] six to ten bands may be delivered with a single intubation. | ||
*Endoscopic therapy can halt bleeding in 80% to 90% of patients. | *Endoscopic therapy can halt [[bleeding]] in 80% to 90% of patients. | ||
*Follow-up endoscopies are recommended at various intervals depending on the size/appearance of varices and severity of liver disease. | *Follow-up [[endoscopies]] are recommended at various intervals depending on the size/appearance of [[varices]] and severity of [[Liver diseases|liver disease]]. | ||
*EBL is equivalent to EIS in establishing initial control of bleeding. | *EBL is equivalent to EIS in establishing initial control of [[bleeding]]. | ||
*EBL is widely favored over EIS for primary prevention due to similar or superior efficacy with fewer complications. | *EBL is widely favored over EIS for primary prevention due to similar or superior efficacy with fewer [[complications]]. | ||
*The primary drawback of EBL is that during active bleeding, operator visibility is limited by the device holding the bands prior to their delivery. | *The primary drawback of EBL is that during [[Bleeding|active bleeding]], operator visibility is limited by the device holding the bands prior to their delivery. | ||
===Endoscopic injection sclerotherapy (EIS)=== | ===Endoscopic injection sclerotherapy (EIS)=== | ||
*Comprises endoscopic delivery of a sclerosant, such as ethanol, morrhuate sodium, polidocanol, or sodium tetradecyl sulfate.<ref name="pmid18567095">{{cite journal |vauthors=Shi B, Wu W, Zhu H, Wu YL |title=Successful endoscopic sclerotherapy for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol |journal=World J. Gastroenterol. |volume=14 |issue=22 |pages=3598–601 |year=2008 |pmid=18567095 |pmc=2716629 |doi= |url=}}</ref><ref name="pmid21037987">{{cite journal |vauthors=Al-Ali J, Pawlowska M, Coss A, Svarta S, Byrne M, Enns R |title=Endoscopic management of gastric variceal bleeding with cyanoacrylate glue injection: safety and efficacy in a Canadian population |journal=Can. J. Gastroenterol. |volume=24 |issue=10 |pages=593–6 |year=2010 |pmid=21037987 |pmc=2975471 |doi= |url=}}</ref> | *Comprises endoscopic delivery of a sclerosant, such as [[ethanol]], morrhuate sodium, [[polidocanol]], or [[sodium tetradecyl sulfate]].<ref name="pmid18567095">{{cite journal |vauthors=Shi B, Wu W, Zhu H, Wu YL |title=Successful endoscopic sclerotherapy for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol |journal=World J. Gastroenterol. |volume=14 |issue=22 |pages=3598–601 |year=2008 |pmid=18567095 |pmc=2716629 |doi= |url=}}</ref><ref name="pmid21037987">{{cite journal |vauthors=Al-Ali J, Pawlowska M, Coss A, Svarta S, Byrne M, Enns R |title=Endoscopic management of gastric variceal bleeding with cyanoacrylate glue injection: safety and efficacy in a Canadian population |journal=Can. J. Gastroenterol. |volume=24 |issue=10 |pages=593–6 |year=2010 |pmid=21037987 |pmc=2975471 |doi= |url=}}</ref> | ||
*Injections may be intravariceal or be delivered into the esophageal wall near the varices. | *[[Injections]] may be intravariceal or be delivered into the [[Esophageal|esophageal wall]] near the [[varices]]. | ||
*Bucrylate is an adhesive that has been used successfully. | *Bucrylate is an adhesive that has been used successfully. | ||
*Typical injection volume is 1 to 2 mL per injection, for a total volume of 10 to 15 mL. | *Typical injection volume is 1 to 2 mL per [[injection]], for a total volume of 10 to 15 mL. | ||
*Interval between injections varies according to patient tolerance and response, and complications. | *Interval between [[injections]] varies according to patient [[tolerance]] and response, and complications. | ||
*After an initial injection to control bleeding, there is usually a follow-up injection 2 to 3 days later, followed by weekly or biweekly procedures until complete obliteration of the varices is achieved, which usually takes five or six sessions. | *After an initial injection to control bleeding, there is usually a follow-up injection 2 to 3 days later, followed by weekly or biweekly procedures until complete obliteration of the [[varices]] is achieved, which usually takes five or six sessions. | ||
==Second Look endoscopy== | ==Second Look endoscopy== | ||
*Second-look endoscopy refers to the practice of performing a planned follow-up endoscopy, generally within 24 hours of the initial endoscopy.<ref name="pmid25674738">{{cite journal |vauthors=Tano S, Horiki N, Omata F, Tanaka K, Hamada Y, Katsurahara M, Ninomiya K, Nishikawa K, Nojiri K, Yamada R, Inoue H, Gabazza EC, Katayama N, Takei Y |title=Second and third-look endoscopy for the prevention of post-ESD bleeding |journal=Medicine (Baltimore) |volume=94 |issue=6 |pages=e491 |year=2015 |pmid=25674738 |pmc=4602741 |doi=10.1097/MD.0000000000000491 |url=}}</ref> | *Second-look endoscopy refers to the practice of performing a planned follow-up endoscopy, generally within 24 hours of the initial [[endoscopy]].<ref name="pmid25674738">{{cite journal |vauthors=Tano S, Horiki N, Omata F, Tanaka K, Hamada Y, Katsurahara M, Ninomiya K, Nishikawa K, Nojiri K, Yamada R, Inoue H, Gabazza EC, Katayama N, Takei Y |title=Second and third-look endoscopy for the prevention of post-ESD bleeding |journal=Medicine (Baltimore) |volume=94 |issue=6 |pages=e491 |year=2015 |pmid=25674738 |pmc=4602741 |doi=10.1097/MD.0000000000000491 |url=}}</ref> | ||
*The 2010 recommendations on the management of patients with nonvariceal UGIB from the International Consensus Upper Gastrointestinal Bleeding Conference Group, however, do not recommend the use of routine second-look endoscopy | *The 2010 recommendations on the management of patients with nonvariceal UGIB from the International Consensus Upper Gastrointestinal Bleeding Conference Group, however, do not recommend the use of routine second-look endoscopy | ||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
Revision as of 21:28, 16 November 2017
|
Upper gastrointestinal bleeding Microchapters |
|
Differentiating Upper Gastrointestinal Bleeding from other Diseases |
|---|
|
Diagnosis |
|
Treatment |
|
Management |
|
Surgery |
|
Case Studies |
|
Upper gastrointestinal bleeding endoscopic intervention On the Web |
|
American Roentgen Ray Society Images of Upper gastrointestinal bleeding endoscopic intervention |
|
FDA on Upper gastrointestinal bleeding endoscopic intervention |
|
CDC on Upper gastrointestinal bleeding endoscopic intervention |
|
Upper gastrointestinal bleeding endoscopic intervention in the news |
|
Blogs on Upper gastrointestinal bleeding endoscopic intervention |
|
Directions to Hospitals Treating Upper gastrointestinal bleeding |
|
Risk calculators and risk factors for Upper gastrointestinal bleeding endoscopic intervention |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
In UGIB, diagnostic and therapeutic endoscopy is be performed simultaneously. Therapeutic upper gastrointestinal endoscopy should be performed in all patients with suspected UGIB to evaluate and possibly treat the source of bleeding. The urgency of endoscopy depends on the anticipated source of bleeding, rapidity of blood loss, and hemodynamic stability of the patient. The common procedures used to manage upper GI bleeding caused by the peptic ulcer disease and esophageal varices are sclerotherapy (EIS), coagulation (thermal, electric, and argon plasma), hemostatic clips and variceal band ligation.
Endoscopic intervention
In UGIB, diagnostic and therapeutic endoscopy is be performed simultaneously. Therapeutic upper gastrointestinal endoscopy should be performed in all patients with suspected UGIB to evaluate and possibly treat the source of bleeding. The urgency of endoscopy depends on the anticipated source of bleeding, rapidity of blood loss, and hemodynamic stability of the patient. Endoscopic intervention should be undertaken within 24 hours, as early intervention is associated with reduced transfusion needs and a decreased length of stay in high-risk patients with nonvariceal bleeding.[1]
- The American Society of Gastrointestinal Endoscopy guidelines recommend the use of two different endoscopic procedures, rather than a single procedure to better control bleeding and decrease the incidence of re-bleeding.[2]
Management of upper GI bleeding caused by the peptic ulcer disease
The most common procedures used to manage upper GI bleeding caused by the peptic ulcer disease are:[3][4][5]
- Sclerotherapy (EIS)
- Coagulation (thermal, electric, and argon plasma)
- Hemostatic clips
Endoscopic Coagulation
- Thermal contact probes are the mainstay of endoscopic hemostasis in upper GI bleeding.[6]
- Contact types :Heater probe, monopolar and bipolar electrocoagulation
- Noncontact types :Laser treatment, argon plasma coagulation
Contact probes
- Contact probes physically tamponade a blood vessel to stop bleeding and interrupt underlying blood flow.
- Thermal energy is then applied to seal the underlying vessel (coaptive coagulation).
- The most commonly used probe is a multipolar electrocoagulation (MPEC) probe, also referred to as a bipolar electrocoagulation probe , with which heat is created by current flowing between intertwined electrodes on the tip of the probe.
- Heater probes provide a predetermined amount of joules of energy, which does not vary with tissue resistance and can effectively coagulate arteries up to 2 mm in diameter.
- The main risk of using a thermal probe is perforation with excessive application of coagulation or pressure, especially in acute or nonfibrotic lesions.
- Thermal probes can also cause a coagulation injury that can make lesions larger and deeper and may induce delayed bleeding in patients with a coagulopathy.
Noncontact types
- Noncontact thermal therapy includes argon plasma coagulation and laser.
- Noncontact types rarely used now in endoscopic management.
Endoscopic Hemostatic clips
- Hemostatic clips apply mechanical pressure to a bleeding site and control bleeding.[7]
- The first-generation hemoclips could not stop bleeding in vessels larger than a diameter of 1 mm, but subsequent hemoclips have been larger and stronger and have had a grasp and release mechanism that improves endoscopic deployment and hemostasis.
- Hemoclips are useful for patients with malnutrition or coagulopathy but can also be difficult to deploy depending on the location of the bleeding site, the degree of fibrosis of the underlying lesion, and limitations to endoscopic access.
- Endoscopic hemoclips differ from surgical clips in that they do not have as much compressive strength, and the currently available clips do not close completely but leave a small space between the prongs.
{{#ev:youtube|59uO-8UVC2A}}
Management of upper GI bleeding caused by the esophageal varices
The most common procedures used to manage esophageal varices are:[8]
- Sclerotherapy
- Variceal band ligation
Endoscopic band ligation (EBL)
- EBL involves the placement of elastic circular ring ligatures around the varices to cause strangulation.[9][10]
- Bands are typically delivered at the gastroesophageal junction first, then proximally six to ten bands may be delivered with a single intubation.
- Endoscopic therapy can halt bleeding in 80% to 90% of patients.
- Follow-up endoscopies are recommended at various intervals depending on the size/appearance of varices and severity of liver disease.
- EBL is equivalent to EIS in establishing initial control of bleeding.
- EBL is widely favored over EIS for primary prevention due to similar or superior efficacy with fewer complications.
- The primary drawback of EBL is that during active bleeding, operator visibility is limited by the device holding the bands prior to their delivery.
Endoscopic injection sclerotherapy (EIS)
- Comprises endoscopic delivery of a sclerosant, such as ethanol, morrhuate sodium, polidocanol, or sodium tetradecyl sulfate.[11][12]
- Injections may be intravariceal or be delivered into the esophageal wall near the varices.
- Bucrylate is an adhesive that has been used successfully.
- Typical injection volume is 1 to 2 mL per injection, for a total volume of 10 to 15 mL.
- Interval between injections varies according to patient tolerance and response, and complications.
- After an initial injection to control bleeding, there is usually a follow-up injection 2 to 3 days later, followed by weekly or biweekly procedures until complete obliteration of the varices is achieved, which usually takes five or six sessions.
Second Look endoscopy
- Second-look endoscopy refers to the practice of performing a planned follow-up endoscopy, generally within 24 hours of the initial endoscopy.[13]
- The 2010 recommendations on the management of patients with nonvariceal UGIB from the International Consensus Upper Gastrointestinal Bleeding Conference Group, however, do not recommend the use of routine second-look endoscopy
References
- ↑ Garber A, Jang S (2016). "Novel Therapeutic Strategies in the Management of Non-Variceal Upper Gastrointestinal Bleeding". Clin Endosc. 49 (5): 421–424. doi:10.5946/ce.2016.110. PMC 5066413. PMID 27744662.
- ↑ Hwang, Joo Ha; Shergill, Amandeep K.; Acosta, Ruben D.; Chandrasekhara, Vinay; Chathadi, Krishnavel V.; Decker, G. Anton; Early, Dayna S.; Evans, John A.; Fanelli, Robert D.; Fisher, Deborah A.; Foley, Kimberly Q.; Fonkalsrud, Lisa; Jue, Terry; Khashab, Mouen A.; Lightdale, Jenifer R.; Muthusamy, V. Raman; Pasha, Shabana F.; Saltzman, John R.; Sharaf, Ravi; Cash, Brooks D. (2014). "The role of endoscopy in the management of variceal hemorrhage". Gastrointestinal Endoscopy. 80 (2): 221–227. doi:10.1016/j.gie.2013.07.023. ISSN 0016-5107.
- ↑ Fujii-Lau LL, Wong Kee Song LM, Levy MJ (2015). "New Technologies and Approaches to Endoscopic Control of Gastrointestinal Bleeding". Gastrointest. Endosc. Clin. N. Am. 25 (3): 553–67. doi:10.1016/j.giec.2015.02.005. PMID 26142038.
- ↑ Laine L, McQuaid KR (2009). "Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials". Clin. Gastroenterol. Hepatol. 7 (1): 33–47, quiz 1–2. doi:10.1016/j.cgh.2008.08.016. PMID 18986845.
- ↑ Park CH, Lee SJ, Park JH, Park JH, Lee WS, Joo YE, Kim HS, Choi SK, Rew JS, Kim SJ (2004). "Optimal injection volume of epinephrine for endoscopic prevention of recurrent peptic ulcer bleeding". Gastrointest. Endosc. 60 (6): 875–80. PMID 15605000.
- ↑ Szura M, Pasternak A (2015). "Upper non-variceal gastrointestinal bleeding - review the effectiveness of endoscopic hemostasis methods". World J Gastrointest Endosc. 7 (13): 1088–95. doi:10.4253/wjge.v7.i13.1088. PMC 4580950. PMID 26421105.
- ↑ Albert JG, Peiffer KH (2016). "[New methods for endoscopic hemostasis: focus on non-variceal gastrointestinal bleeding]". Z Gastroenterol (in German). 54 (3): 250–5. doi:10.1055/s-0035-1566987. PMID 26894683.
- ↑ Cook DJ, Guyatt GH, Salena BJ, Laine LA (1992). "Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis". Gastroenterology. 102 (1): 139–48. PMID 1530782.
- ↑ Zepeda-Gómez S, Marcon NE (2008). "Endoscopic band ligation for nonvariceal bleeding: a review". Can. J. Gastroenterol. 22 (9): 748–52. PMC 2661278. PMID 18818787.
- ↑ Ertekin C, Taviloglu K, Barbaros U, Guloglu R, Dolay K (2002). "Endoscopic band ligation: alternative treatment method in nonvariceal upper gastrointestinal hemorrhage". J Laparoendosc Adv Surg Tech A. 12 (1): 41–5. doi:10.1089/109264202753486911. PMID 11905861.
- ↑ Shi B, Wu W, Zhu H, Wu YL (2008). "Successful endoscopic sclerotherapy for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol". World J. Gastroenterol. 14 (22): 3598–601. PMC 2716629. PMID 18567095.
- ↑ Al-Ali J, Pawlowska M, Coss A, Svarta S, Byrne M, Enns R (2010). "Endoscopic management of gastric variceal bleeding with cyanoacrylate glue injection: safety and efficacy in a Canadian population". Can. J. Gastroenterol. 24 (10): 593–6. PMC 2975471. PMID 21037987.
- ↑ Tano S, Horiki N, Omata F, Tanaka K, Hamada Y, Katsurahara M, Ninomiya K, Nishikawa K, Nojiri K, Yamada R, Inoue H, Gabazza EC, Katayama N, Takei Y (2015). "Second and third-look endoscopy for the prevention of post-ESD bleeding". Medicine (Baltimore). 94 (6): e491. doi:10.1097/MD.0000000000000491. PMC 4602741. PMID 25674738.