NON VARICEAL GI BLEEDING - nddcbru.org.uk
Transcript of NON VARICEAL GI BLEEDING - nddcbru.org.uk
![Page 1: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/1.jpg)
NON VARICEAL GI BLEEDING
Adolfo Parra-BlancoConsultant Gastroenterologist
NUH9th Nottingham Endoscopy Masterclass 2016
![Page 2: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/2.jpg)
Type of lesion?
• Anamnesis – interview very helpful:
–GD ulcer
–Epigastric pain/dyspepsia
–NSAIDs
–ETOH, signs of Chronic liver failure
–Fresh blood without stool
–Previous episodes of bleeding
–Radiotherapy
![Page 3: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/3.jpg)
FIa FIIa FIIb FIIc FIII
Prediction of rebleeding Endoscopic variables (Forrest)
Active
Visible vessel
Adherent clot
Flat spot
No stigmata
![Page 4: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/4.jpg)
Forrest I-a (spurting)High risk: treat in all cases e.g. Adrenaline + clips or Gold probe
![Page 5: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/5.jpg)
Forrest I-b (oozing)
High risk of re-bleed (~55%) needs endoscopic Rx
![Page 6: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/6.jpg)
Forrest II-a (visible vessel)High risk of re-bleed ~43%, treat in all cases
![Page 7: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/7.jpg)
Forrest II-b (adherent clot)
High risk, re-bleed ~22%
Fresh clot, may wash away with water jet irrigation
Organised (stable) clot, may not wash away with irrigation, leave it alone!
![Page 8: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/8.jpg)
Forrest II-c (haem pigment)Low risk: re-bleed ~10%, leave alone and treat
with PPI
![Page 9: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/9.jpg)
Forrest III (clean base)Low risk of re-bleed ~ 5%, no need for endoscopic
Rx
![Page 10: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/10.jpg)
Choose adequate endoscope
Diagnostic Gastroscope
Pros:
- Less discomfort
- Adequate if stenosis
Therapeutic Gastroscope
Pros:
- Suction power
- Double channel
- Large channel-large devices
![Page 11: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/11.jpg)
Endoscopic therapy: Effect on risks
• Achieves hemostasis >90%
• Reduces rebleeding risk
• Reduces emergency surgery
• Reduces mortality
![Page 12: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/12.jpg)
![Page 13: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/13.jpg)
Perform OGD in adequate setting
• Haemodynamically stable?
• Active bleeding / haematemesis?
• Will tolerate OGD / risk of sedation?
• With GA – airway protection whenever needed
![Page 14: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/14.jpg)
Erythomycin to clean the stomach
• Erythromycin stimulates gi motility
• Residual blood/clots should be removed for endoscopic diagnosis-treatment.
• iv erythromycin (250 mg 30-120 min prior to OGD):
• - empty stomach more frequent (69%vs 37%)
• - reduced need repeat OGD reduced hospital stay
Bai et al. Aliemnt Pharmacol Ther 2011; 34: 166-71.
![Page 15: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/15.jpg)
Tools for OGD - Bleeding
• Water Pump: connected to biopsy valve
Connected to water jet channel
• Syringe
▫ 60ml
Symethicone 100 mg/100 ml
![Page 16: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/16.jpg)
Caps
![Page 17: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/17.jpg)
When should we use a cap?
• Usefulness:
▫ Facilitate observation beyond folds / swollen areas
▫ Facilitate identification of bleeding source if active
▫ Facilitate application of endotherapy (mainatins stability of tip of endoscope)
▫ Facilitate suction of clots
Use if:
- lesion not detected
- difficult approach to lesion (duodenum)
![Page 18: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/18.jpg)
Endoscopic methods to treat
bleeding
• Injection
• Thermal
▫ Non contact
▫ Contact
• Mechanical
• Spray
![Page 19: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/19.jpg)
Injection
• First treatment used for hemostasis (ref)
• Adrenaline, ethanol, sclerosants, cyanoacrylate
• Careful (not to harm channel)
• Not as single agent
![Page 20: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/20.jpg)
Communication
• Needle back / out
• Volume injected real time (ml ) (too deep injection?)
• Feedback about resistance
![Page 21: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/21.jpg)
Types of needles
Use needle we are familiar with21G/23G/25G (no comparative studies)4-6mm
![Page 22: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/22.jpg)
![Page 23: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/23.jpg)
Thermal methods
• Laser probes
• Bipolar probes
• Heater probes
• Argon Plasma Coagulation (APC)
• Coagulation forceps
![Page 24: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/24.jpg)
![Page 25: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/25.jpg)
Bipolar probes
![Page 26: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/26.jpg)
Bipolar probes
www.gastrotraining.com
![Page 27: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/27.jpg)
Settings for GoldProbe
Dr. Dennis Jensen-CURE Group.
![Page 28: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/28.jpg)
Heater probe
![Page 29: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/29.jpg)
APC
• Non contact
• Argon gas passes through probe, ioinised by high voltage discharge: plasma
• Gas flow / power / pulses can be controlled
![Page 30: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/30.jpg)
APC
![Page 31: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/31.jpg)
The 10 commandments of APC in
endoscopy• 1. You shall not confuse Argon Plasma with Argon Laser
• With Argon Laser.
• 2. You shall always test APC ignition and electric arc outside the endoscope befor inserting probe into channel.
• 3. You shall insert at least far enough into working channel for first distal black ring to become visible.
• 4. You shall always carry out APC under visual control
• 5. You shall take care that APC probe does not touch the organ wall during activation: however application shall be near enough to ensure plasma ignition.
Grund, Farin. Endosc Surg 1994; 2:71-7.
![Page 32: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/32.jpg)
• 6. You shall never press activated probe into tissue or against organ wall, since this can lead to emphysema or wall damage.
• 7. You shall not touch metal stents directly with the APC probe; here, too, you shall maintain an adequate distance.
• 8. You shall avoid distension caused by inflowing argon and shall therefore check and vacuum repeatedly and place decompression cathether if necessary.
• 9. You shall set power limit and activation duration adequately in relation to wall thickness in affected organ (maximum upper limit 40W right colon).
• 10. You shall prefer short duration activations to a few long-duration activations.
Grund, Farin. Endosc Surg 1994; 2:71-7.
![Page 33: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/33.jpg)
Communication
• Neutral pad needed (in place before starting procedure)
• Settings set by endoscopist beforehand
• Check adequate function
![Page 34: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/34.jpg)
![Page 35: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/35.jpg)
![Page 36: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/36.jpg)
Coagulation forceps
• Monopolar (Coagrasper, Olympus)
• Bipolar (Hemostat Y, Pentax)
![Page 37: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/37.jpg)
Use of Coagulation forceps
• Identify vessel (washing – push with cap – washing)
• Grasp vessel – washing: persistent bleeding?
• Coagulate (soft coagulation)
![Page 38: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/38.jpg)
![Page 39: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/39.jpg)
Mechanical
• Conventional clips
• Over the scope clips
• Endoloops
![Page 40: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/40.jpg)
Conventional clips
![Page 41: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/41.jpg)
Available Clips for hemostasis
- Size- Rotation
![Page 42: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/42.jpg)
![Page 43: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/43.jpg)
“Over the scope” Clips
![Page 44: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/44.jpg)
![Page 45: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/45.jpg)
Mangiavillano. Endoscopy 2012; 44: E221.
![Page 46: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/46.jpg)
![Page 47: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/47.jpg)
What is Hemospray?
Intended Use: Used for nonvariceal gastrointestinal bleeding
• Disposable
• Preassembled with C02 cartridge
• Available with 7 or 10 FR Catheter
▫ 220 cm catheter length
▫ Packaged with extra catheter
![Page 48: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/48.jpg)
How does Hemospray work? When Hemospray comes in contact with blood, the powder absorbs water, then acts both cohesively and adhesively, forming a mechanical barrier over the bleeding site.
![Page 49: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/49.jpg)
![Page 50: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/50.jpg)
![Page 51: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/51.jpg)
![Page 52: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/52.jpg)
![Page 53: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/53.jpg)
Endoclot
Beg et al. EIO 2015; 03: E605-E609.
![Page 54: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/54.jpg)
![Page 55: NON VARICEAL GI BLEEDING - nddcbru.org.uk](https://reader031.fdocuments.in/reader031/viewer/2022012510/61878210f0309f63b91dccfa/html5/thumbnails/55.jpg)