GI Hemorrhage

1
GI Hemorrhage

• Trauma and SICU Conference
• 12/18/2006

2
Upper GI Bleeding

• Esophageal Varices
• Mallory-Weiss Tear
• Duodenal Ulcer
• Gastric Ulcer
• Gastritis
• Cancer
• Hemobilia
• Cranberry Sauce

3
Lower Gastrointestinal Bleeding

• UGI Source
• Hemorrhoids, Fissure, Ulcer, Polyp
• Prolapse
• Volvulus/Malrotation
• Cancer
• Ulcerative Colitis
• Granulomatous Colitis
• Diverticulitis
• Other
• Meckels Diverticulum
• Colonic Polyp
• Peutz-Jeghers Syndrome
• Osler-Weber-Rendu Syndrome
• Ileal Diverticula
• Duplication of Bowel

4
Endoscopic Interventions for Gastrointestinal
Bleeding

• Stephanie Chao, Trauma R1
• Trauma Conference
• December 18, 2006

5
Endoscopic techniques

• Anoscopy
• Sigmoidoscopy
• lt45 years old with small volume bleed, may be
  sufficient for investigation unless
  bleeding/recurrence found
• Identifies anorectal disease, infectious colitis,
  inflammatory bowel disease
• EGD
• Colonoscopy

6
Injection Rx

• Epinephrine
• 1-1.5ml of 110,000 or 120,000 in 4 quadrants
• Mechanism vasoconstriction, volume tamponade
• Sclerosant (ethanolamine)
• Mechanism Induces inflammation then fibrosis
• Fibrin Sealant
• Fibrinogen/Factor XIII and Thrombin/Calcium
• Mechanism Instantaneous formation of hemostatic
  clot by mimicking last step of coagulation
  cascade
• Sclerosant trials vs. Fibrin sealant
• No advantage of epi sclerosant over epi alone
• Saline
• Mechanism volume tamponade
• Ethanol

7
Thermal Coagulation

• Heater probe
• Mechanism tissue coagulation via heated ceramic
  tip
• Not limited by tissue water resistance, deeper
  heat penetration
• Higher risk of perforation
• Multipolar probe
• Mechanism coagulates tissue by heating tissue
  temperature to gt60 degrees Celsius via
  alternating positive and negative electrodes at
  tip
• Tissue desiccation prevents conduction to lower
  layers
• Argon Plasma Coagulant
• Mechanism uses argon gas to deliver a plasma of
  evenly distributed thermal energy
• No contact, wider spray, less depth

8
Coagulation
Post Coagulation
Active bleed
9
Thermal Coagulation

• Heater probe
• Mechanism tissue coagulation via heated ceramic
  tip
• Not limited by tissue water resistance, deeper
  heat penetration
• Higher risk of perforation
• Multipolar probe
• Mechanism coagulates tissue by heating tissue
  temperature to gt60 degrees Celsius via passing
  electricity between alternating positive and
  negative electrodes at tip
• Tissue desiccation prevents conduction to lower
  layers
• Argon Plasma Coagulant
• Mechanism uses argon gas to deliver a plasma of
  evenly distributed thermal energy
• No contact, wider spray, less depth

10
Multipolar Probe
11
Thermal Coagulation

• Heater probe
• Mechanism tissue coagulation via heated ceramic
  tip
• Not limited by tissue water resistance, deeper
  heat penetration
• Higher risk of perforation
• Multipolar probe
• Mechanism coagulates tissue by heating tissue
  temperature to gt60 degrees Celsius via
  alternating positive and negative electrodes at
  tip
• Tissue desiccation prevents conduction to lower
  layers
• Argon Plasma Coagulant
• Mechanism uses argon gas to deliver a plasma of
  evenly distributed thermal energy
• No contact, wider spray, less depth

12
Argon Plasma Coagulant
13
Hemostatic Clips

• Occludes vessel
• Radiographic marker

14
Risk Stratification Peptic Ulcer Disease

• Low risk
• Flat spot, clean ulcer
• Rx No endoscopic intervention, PPI only
• Intermediate Risk
• Ooze without clot or visible vessel
• Rx Monotherapy with oral PPI
• High Risk
• Active bleed, non-bleeding visible vessel with
  clot
• Rx Combination therapy (injection and
  coagulation, IV PPI)
• Visible vessel
• Rx clip or coagulation and PPI

15
Risk Stratification

• Low risk
• Flat spot, clean ulcer
• Rx No endoscopic intervention, PPI only
• Intermediate Risk
• Ooze without clot or visible vessel
• Rx Monotherapy with oral PPI
• High Risk
• Active bleed, non-bleeding visible vessel with
  clot
• Rx Combination therapy (injection and
  coagulation, IV PPI)
• Visible vessel
• Rx clip or coagulation and PPI

16
Risk Stratification

• Low risk
• Flat spot, clean ulcer
• Rx No endoscopic intervention, PPI only
• Intermediate Risk
• Ooze without clot or visible vessel
• Rx Monotherapy with oral PPI
• High Risk
• Active bleed, non-bleeding visible vessel with
  clot
• Rx Combination therapy (injection and
  coagulation, IV PPI)
• Visible vessel
• Rx clip or coagulation and PPI

17
Risk Stratification

• Low risk
• Flat spot, clean ulcer
• Rx No endoscopic intervention, PPI only
• Intermediate Risk
• Ooze without clot or visible vessel
• Rx Monotherapy with oral PPI
• High Risk
• Active bleed, non-bleeding visible vessel with
  clot
• Rx Combination therapy (injection and
  coagulation, IV PPI)
• Visible vessel
• Rx clip or coagulation and PPI

18
Varices

• Banding

19
References

• Kubba, AK, Palmer, KR. Role of endoscopic
  injection therapy in the treatment of bleeding
  peptic ulcer. Br J Surg 1996 83461.
• Laine, L, Peterson, WL. Bleeding peptic ulcer. N
  Engl J Med 1994 331717.
• Jensen DM, Machicado GA. Endoscopic Hemostasis of
  Ulcer Hemorrhage with Injection, Thermal, or
  Combination Methods. Techniques in
  Gastrointestinal Endoscopy 2005 7124.
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