endoscopic interventions for gi bleeds
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8/14/2019 Endoscopic Interventions for Gi Bleeds
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GI Hemorrhage
Trauma and SICU Conference
12/18/2006
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8/14/2019 Endoscopic Interventions for Gi Bleeds
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Upper GI Bleeding
Esophageal Varices
Mallory-Weiss Tear
Duodenal Ulcer
Gastric Ulcer
Gastritis
Cancer
Hemobilia
Cranberry Sauce
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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
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8/14/2019 Endoscopic Interventions for Gi Bleeds
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Endoscopic Interventions forGastrointestinal Bleeding
Stephanie Chao, Trauma R1
Trauma Conference
December 18, 2006
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Endoscopic techniques
Anoscopy
Sigmoidoscopy
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Injection Rx
Epinephrine
1-1.5ml of 1:10,000 or 1:20,000 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 laststep of coagulation cascade
Sclerosant trials vs. Fibrin sealant
No advantage of epi + sclerosant over epi alone Saline
Mechanism: volume tamponade
Ethanol
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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>60 degrees Celsius via alternating positive and negativeelectrodes 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
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Coagulation
Active bleedPost Coagulation
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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>60 degrees Celsius via passing electricity between alternatingpositive 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
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8/14/2019 Endoscopic Interventions for Gi Bleeds
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Multipolar Probe
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8/14/2019 Endoscopic Interventions for Gi Bleeds
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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>60 degrees Celsius via alternating positive and negativeelectrodes 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
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8/14/2019 Endoscopic Interventions for Gi Bleeds
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Argon Plasma Coagulant
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Hemostatic Clips
Occludes vessel
Radiographic marker
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Risk StratificationPeptic 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
http://content.nejm.org.laneproxy.stanford.edu/cgi/content/full/331/11/717/F2 -
8/14/2019 Endoscopic Interventions for Gi Bleeds
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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
http://content.nejm.org.laneproxy.stanford.edu/cgi/content/full/331/11/717/F2 -
8/14/2019 Endoscopic Interventions for Gi Bleeds
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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
http://content.nejm.org.laneproxy.stanford.edu/cgi/content/full/331/11/717/F2 -
8/14/2019 Endoscopic Interventions for Gi Bleeds
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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
http://content.nejm.org.laneproxy.stanford.edu/cgi/content/full/331/11/717/F2 -
8/14/2019 Endoscopic Interventions for Gi Bleeds
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Varices
Banding
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References
Kubba, AK, Palmer, KR. Role of endoscopic injection
therapy in the treatment of bleeding peptic ulcer. Br JSurg 1996; 83:461.
Laine, L, Peterson, WL. Bleeding peptic ulcer. N Engl JMed 1994; 331:717.
Jensen DM, Machicado GA. Endoscopic Hemostasis ofUlcer Hemorrhage with Injection, Thermal, orCombination Methods. Techniques in GastrointestinalEndoscopy 2005; 7:124.
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