EMERGENCY ENDOSCOPIC INTERVENTIONS HAVE SAVED MANY LIVES & HAS HELPED AVOID MAJOR SURGERY IN ACTIVELY BLEEDING PATIENT

1. DR RAVI GUPTA
CONSULTATNT G I ENDOSCOPIST
LILAVATI HOSPITAL

2. UPPER G I ENDOSCOPY
 FOREIGN BODIES IN UPPER G I TRACT
 UPPER G I BLEED

4. Acute Upper GI bleed
 The annual rate of hospitalization for acute UGIB in the
United States is 160 hospital admissions per 100,000
population, which translates into more than 400,000 per
year
 In most settings, the vast majority of acute episodes of
upper gastrointestinal bleeding (80 to 90%) have non-
variceal causes, with gastroduodenal peptic ulcer
accounting for the majority of lesions
 Mortality associated with peptic ulcer bleeding remains
high at 5 to 10%
N Engl J Med 2008;359:928-37.

5. F B IN UPPER G I TRACT
 F B IN ESOPHAGUS
 SHARP FBS WITH RISK OF PERFORATION

6. Indian scenario
Limited studies on the prevalence of peptic ulcer bleeding in India
Peptic ulcer is widely prevalent in India, more common among the
population of South India than North India
Conflicting data exist from different studies on the MC type of
presentation
Lifetime prevalence of PU in India
 Delhi – 0.61%
 Chandigarh – 0.69
 Chennai – 0.75%
These studies have limitations in diagnostic method and not considering
asymptomatic population
Khuroo et al Gut 1989;30;930-934

7. ROLE OF PRIMARY PHYSICIAN
 PAEDIATRIC AGE GROUP
 LOOK FOR BREATHING DIFFICULTY OR COUGH
 SALIVATION
 ABDOMENAL SIGNS IF ANY
 ASK FOR X RAY NECK CHEST & ABDOMEN
 SOS REFER TO HOSPITAL
 KEEP THE CHILD NBM

8. A: Resuscitation, risk
assessment & pre- D: Non-endoscopic,
endoscopy C: Pharmacological non-meds in- E: Post discharge,
management B: Endoscopic management management hospital Rx ASA, NSAIDs
A1: Immediately evaluate and B1: Develop institution- B7: Endoscopic C1: Histamine2-receptor D1: Patients at low-risk E1: In patients with a prior
initiate appropriate specific protocols for hemostatic after endoscopy ulcer bleed who
antagonists are
resuscitation* multidisciplinary therapy is can be fed within require an NSAID,
management* not recommended
A2: Prognostic scales are indicated for 24 hours* it should be
- Include access to an for patients with
recommended for early endoscopist trained in patients with D2: Most patients having recognized that
acute ulcer
stratification of patients endoscopic high-risk undergone treatment with a
into low-and high-risk stigmata (active bleeding* endoscopic traditional NSAID
hemostasis*
categories for rebleeding B2: Have available on an bleeding or a C2: Somatostatin and hemostasis for plus PPI or a COX-
and mortality† urgent basis, support visible vessel in octreotide are not high-risk stigmata 2 (-) alone is still
A3: Consider placement of a staff trained to assist an ulcer bed)* routinely should be associated with a
naso-gastric tube in in endoscopy* B8: Epinephrine alone hospitalized for at clinically important
recommended for
B3: Early endoscopy (within
selected patients because provides patients with least 72 hours risk of recurrent
24 hours of
the findings may have presentation) is suboptimal acute ulcer thereafter ulcer bleeding
prognostic value* recommended in most efficacy and D3: Seek surgical E2: In patients with prior
bleeding*
A4: Blood transfusions should patients with acute should be used consultation for ulcer bleeding who
C3. An intravenous
be administered to a upper gastrointestinal in combination patients who have require an NSAID
patient with a bleeding† with another bolus followed by failed endoscopic the combination of
hemoglobin level ≤70 g/L B4: Endoscopic hemostatic modality† continuous- therapy* a proton pump
A5: In patients on therapy is not B9: No single method infusion proton- D4: Where available inhibitor and a
indicated for patients
anticoagulants, of endoscopic pump inhibitor percutaneous COX-2 (-) is
with low-risk stigmata
correction of (a clean based ulcer, thermal should be used to embolization can recommended to
coagulopathy is or a non-protuberant coaptive therapy decrease be considered as reduce the risk of
recommended but pigmented dot in an is superior to rebleeding and an alternative to recurrent bleeding
should not delay ulcer bed)* another* surgery in patients from that of COX-2
mortality in
endoscopy B5: A finding of a clot in an B10: Clips, thermal or having failed (-) alone
ulcer bed warrants patients with high
A6: Promotility agents should sclerosant endoscopic E3: In patients receiving
not be used routinely targeted irrigation in injection should risk stigmata therapy low-dose ASA who
an attempt at having undergone
before endoscopy to be used in D5: Patients with develop an acute
dislodgement, with an
increase the diagnostic patients with successful bleeding peptic ulcer bleed, ASA
appropriate treatment
yield of the underlying high risk lesions, endoscopic ulcer should be should be restarted
A7: Selected patients with acute lesion† alone or in therapy† tested for H. p and as soon as the risk
ulcer bleeding at low B6: The role of endoscopic combination C4: Patients should be receive of cardiovascular
risk for rebleeding based therapy for ulcers with with eradication if complication is
discharged on a
on clinical and adherent clots is epinephrine present, with thought to outweigh
controversial. single daily dose
endoscopic criteria may injection† confirmation of the risk of bleeding
Endoscopic therapy oral PPI for a
be discharged promptly B11: Routine second- eradication† E4: In patients with a prior
may be considered, duration as
after endoscopy† although intensive PPI look endoscopy D6: Negative H. p test ulcer bleed who
A8: Pre-endoscopic, PPI is not dictated by the results obtained in require CV
therapy alone may be
therapy may be sufficient† recommended† underlying the acute setting prophylaxis, it
considered to downstage B12: A second attempt etiology should be repeated should be
the endoscopic lesion at endoscopic recognized that
and decrease the need Rx is generally clopidogrel alone
for endoscopic recommended in has a higher risk of
intervention, but should cases of re- rebleeding vs ASA
†

9. Overall management
ABC’s and adequate resuscitation

 Early risk stratification
 pre-endoscopy
 at early endoscopy
Very Low risk patients All other patients
 discharge home  admit
High-risk patients Low-risk patients
 Endoscopic hemostasis  Initiate daily dose PPI
 Initiate high-dose IV PPI
 Consider secondary prophylaxis
 H pylori testing and treating
 NSAID/COX2 use
 ASA use

10. ROLE OF PRIMARY PHYSICIAN
 ADULT AGE GROUP
 ALCOHOL INTOXICATION
 X RAY NECK CHEST & ABDOMEN
 PLEASE DO NOT TRY ANY BANANA DIET ETC IF FB
IN THE ESOPHAGUS OR IF SHARP FB, IT DELAYS
ENDOSCOPIC INTEVENTION.

11. So what to do?
- subgroup selection
 Efficacy at best marginal, so PPI should NOT replace the role
of adequate resuscitation and early endoscopy
 Can provide PPI before endoscopy or not; more likely to be
cost-effective IF:
 Delay to endoscopy (over 16 hours)
 Patient more likely to be bleeding from
 a non variceal source
 high-risk lesion (hematemesis, bloody NGT)
 If you are going to use, high-dose preferred
Barkun AN, GI Endosc 2008

12. F B ESOPHAGUS
 PAEDIATRIC AGE GROUP
 ADMISSION, DONE UNDER G A WITH
TRACHEAL INTUBATION.
 SHARP OBJECTS USE OVERTUBE OR
UMBRELLA
 ADULTS SUSPECT A STRICTURE BELOW
THE FB

15. UPPER G I BLEED
 VARICEAL
 NON VARICEAL

16. What about an elevated INR and
endoscopy?
 A presenting INR >1.5 does not predict rebleeding, yet is an
independent predictor of subsequent death following an
admission due to NVUGIB
 Correction of INR to 1.8 as part of intensive resuscitative
measures may improve mortality
 Endoscopic treatment may be safely performed in patients
with an INR of <2.5
“In patients on anticoagulants, correction of coagulopathy is
recommended but should not delay endoscopy”
Barkun DDW 2009, Wolf AJG 2007, Baradarian AJG 2004, Choudari Gut, 1994

17. The benefits of early endoscopy
 Early endoscopy (first 24 hours) allows for
 safe and prompt discharge of patients classified as low risk
 improves patient outcomes for patients classified as high risk
 reduces resource utilization for patients classified as either low or
high risk
 Recent observational data suggest early endoscopy
decreases the need for surgery and may improve mortality
 In a recent UK audit of 208 hospitals (6750 patients), after
hours endoscopy just failed to be associated with a drop in
mortality
Barkun 2003, Ananthakrishnan CGH 2009, Cooper 2009, Hearnshaw 2010

18. Optimal timing of Endoscopy

20. ESOPHAGEAL & GASTRIC VARICES
 CHRONIC LIVER DISEASE ETHANOL OR VIRAL
 BILIARY CIRRHOSIS DUE TO BILIARY ATRESIA
PAED AGE
 PORTAL VEIN THROMBOSIS CONGENITAL
PRESENTING AS PORTAL CAVERNOMA, POST
BILIARY SEPSIS, TUMORS
 SPLENIC VEIN THROMBOSIS FOLLOWING
PANCREATITIS

21. ROLE OF PRIMARY PHYSICIAN
 SEVERE HAEMETEMESIS RUSH TO HOSPITAL
 INJECTION TERLIPRESSIN 2mg IV STAT
 INJECTION OF PPI AND VIT K
 DO NOT IGNOR EVEN MINOR BLEEDING IT
COULD BE A WARNING OF A CATASTROPHY
 PLEASE KEEP NBM
 IV FLUIDS AT BRISK RATE

22. VARICEAL BLEED
 TIMING OF ENDOSCOPIC INTERVENTION
 WITHIN 24 HOURS OF ADMISSION
 STABILISE, INVESTIGATE ,TRANSFUSIONS
CORRECT COAGULOPATHY, AIRWAY
PROTECTION, INITIAL PHARMACOTHEARPY
 VERY URGENT ENDOSCOPY ONLY IF VERY
UNSTABLE PATIENT & VERY PROFUSE BLEED.

23. ESOPHAGEAL & FUNDAL VARICES
 VARICEAL BAND LIGATION
 CYANOACRYLATE GLUE IF SPURTING VESSEL
SEEN
 FUNDAL VARICES GLUE INJECTION
 ALL ATTEMPTS TO ARREST ACTIVE BLEEDING

24. Results
 Rebleeding was significantly decreased by routine
second-look endoscopy
Second-look endoscopy Other Odds Ratio Odds Ratio
 As was surgery OR=0.43; (0.19;0.96)
Study or Subgroup
Chiu 2003
Events
5
Total
100
Events
13
Total
94
Weight
23.3%
M-H, Fixed, 95% CI
0.33 [0.11, 0.96]
M-H, Fixed, 95% CI
Chiu 2006 5 80 8 84 13.4% 0.63 [0.20, 2.02]
 But not mortality OR=0.65; (0.26;1.62)
Lee 2005
Messman 1998 11
7 70
52
12
9
73
53
19.4%
12.9%
0.56 [0.21, 1.53]
1.31 [0.49, 3.49]
Saeed 1996 0 19 5 21 9.4% 0.08 [0.00, 1.50]
Villanueva 1994 11 52 15 52 21.7% 0.66 [0.27, 1.62]
Total (95% CI) 373 377 100.0% 0.59 [0.38, 0.91]
Total events 39 62
Heterogeneity: Chi² = 5.61, df = 5 (P = 0.35); I² = 11%
0.01 0.1 1 10 100
Test for overall effect: Z = 2.39 (P = 0.02)
Favours Second-endoscopy Favours other
BUT when taking into account trial limitations, study heterogeneity (both clinical
& statistical), and current standard of high-dose IV PPI, this approach should
probably be reserved to selected patients at especially high risk of rebleeding

26. Conclusion
 ABC’s and appropriate resuscitation critical
 Early risk stratification, including early endoscopy
 Early discharge for very low-risk patients
 Endoscopic hemostasis for high-risk lesions
 High dose IV PPI are an adjuvant to endoscopic
hemostasis
 Secondary prophylaxis needed for patients
 H pylori
 NSAIDs / COX2
 ASA /clopidogrel

27. • Clopidogrel alone, aspirin alone, and their combination are all associated
with increased risk of GI bleeding
• Patients with prior GI bleeding are at highest risk for recurrent bleeding on
antiplatelet therapy
• PPIs are appropriate in patients with multiple risk factors for GI bleeding
who require antiplatelet therapy
• Observational studies and a single randomized clinical trial (RCT) have
shown inconsistent effects on CV outcomes of concomitant use of
thienopyridines and PPIs
J. Am. Coll. Cardiol. 2010;56;2051-2066

28. PUB bleeder on ASA – acute management
 ASA non-adherence/withdrawal carries a 3x risk of
major adverse cardiac events
 The delay to the thrombotic event is usually 7-10
days
 Immediate reintroduction of ASA is associated
with
 a statistically non significant increase in recurrent PUD
bleeding, BUT
 ASA discontinuation causes significantly increased CV
mortality*
Biondi-Zoccai GG, Eur Heart J, 2006; ; Aguejouf O. Clin Appl Thromb Hemost. 2008 ; Sibon I,
Neurology. 2004. Burger W, J Intern Med. 2005; Sung J, Gut (abstract) 2007; Ng, APT, 2004;
Sung AIM, 2010, barkun AIM 2010

29. Management of patients who have bled on ASA

30. PUD bleeders who need an NSAID
 If past PUD bleed, treatment with a traditional
NSAID plus PPI or a COX-2 inhibitor alone is still
associated with a clinically important risk of
recurrent ulcer bleeding
Lanza Am J Gastro, 2009; Rostom, APT, 2009.

31. Management of patient who is on NSAIDs

32. Effect of PPIs on outcomes in
patients with PUD bleeding
Outcome at 30 days after randomization
Odds Ratio (95% CI)
0.53
Mortality (9*)
0.46
Re-bleeding (19*)
0.59
PPI improve mortality in patients w HRS only if they have
Surgical Intervention (17*)
initially undergone endoscopic haemostasis (i.e.: mainly
high dose IV)
Also, these findings have been confirmed
in a “real-life” setting
0 0.5 1 1.5 2
*Number of trials Favors PPI Favors control
Modified from Leontiadis et al, The Cochrane Database of Systematic
Reviews 2005 + update in 2006; Barkun et al., AJG 2004

33. Role of PPI therapy following endoscopy

35. FAILURE OF ENDOTHREPY
 TIPS
( TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC
SHUNTS)
 SURGERY

36. NONVARICEAL BLEED
 MALLORY WEISS TEAR
 GASTRIC OR DUODENAL ULCER BLEED
 MALIGNANT ULCER OR GROWTH BLEED
 VASCULAR LESIONS VIZ DIEULAFOYS’S,
 AV MALFORMATIONS, VASCULAR ECTASIAE
 POST SCLERO ULCERS
 PAPILLOTOMY BLEED

37. NONVARICEAL BLEED
 INJECTION OF ULCERS WITH ADRENALIN
 THERMAL COAGULATION
 HAEMOCLIP APPLICATION
 COMBINATION OF ABOVE

41. UPPER G I BLEED
 RISK OF REBLEEDING
 ANGIOGRAPHIC INTERVENTION
 WHEN TO CONSIDER SURGERY

43. LOWER G I BLEED
 ALL BLEEDING PRS ARE NOT PILES BLEEDING
 ALL SIGNIFICANT BLEEDS MUST BE REFERRED
 COMPARATIVELY YOU GET MORE TIME
 IF PATIENT IS UNSTABLE SUSPECT MASSIVE
UPPER G I BLEED PRESENTING AS
HAEMOTOCHASIA
 ALL ELEDERLY PATIENTS MUST UNDERGO A
COLONOSCOPY EVEN IF MINOR BLEED

44. EMERGENCY ERCP
 IMPACTED STONE WITH SEVERE
UNRELENTING PAIN
 ACUTE PANCREATITIS
 ACUTE CHOLANGITIS

46. EMERGENCY ERCP
 IMPACTED STONE WITH SEVERE
UNRELENTING PAIN
 ACUTE PANCREATITIS
 ACUTE CHOLANGITIS

48. CONCLUSION
EMERGENCY ENDOSCOPIC INTERVENTIONS
HAVE SAVED MANY LIVES & HAS HELPED
AVOID MAJOR SURGERY IN ACTIVELY
BLEEDING PATIENT