Endoscopic management of bleeding PUD

1. Endoscopic management of
bleeding PUD.
Dr. Kagaruki
Facilitator: Dr. Mwanga

2. OBJECTIVE
Pre-endoscopic management
Endoscopic management
 Adrenaline Injection
 Sclerosant injection
 Thrombin Fibrin sealant
 Thermal application
Mechanical
Endoscopic clipping

3. Introduction
• PUD is the most common cause of non-variceal bleeding.
• Account for 40-50% of UGIB.
• Bleeding is the most common cause of ulcer-related death.
Fortunately 80% of bleeding pud stop spontaneously and not rebleed.
• Most mortality occurred in high risk patients.
• Overall mortality rate 5 to 10%.
• Need for selection of high risk patients.

4. Etiology
• Helicobacter pylori infection
• NSAID
• Stress-related
• Zollinger Ellison syndrome

5. Clinical Presentation
• Hematemesis and melena and sometime hematochezia
• Resting tachycardia(HR> 100bpm), or
• orthostatic changes (HR >20bpm or SBP lower by 20mmHg on standing).

6. Pre-endoscopic Management
• Airway control and protection (in high risk of aspiration).
• Volume resuscitation with crystalloid fluid and blood.
• Gastric lavage using Naso/Orogastric tube which is diagnostic and facilitate future
endoscopic visualization. 15% will have no bloody or coffee ground material on
NGT-aspirates are found to have high risk lesions on endoscopy
• Promotility agent such as iv erythromycin 250mg 30min to 60minutes before
endoscope/metoclopramide prior to endoscope help clearance of upper git.

7. Cont…
• High dose PPI infusion reduces the severity of bleeding and the need
for endoscopic treatment.
• Correct coagulopathy if present INR<1.5 and Platelet>50x109/l.
• Obtain the initial CBC, Electrolytes, RFT and cross-match blood
• Transfusion of Blood product 1:1:1.

8. Cont…
• Most patient the bleeding will stop except for 20% of high risk patients which
predispose to rebleeding.
• Rebleeding rate after endoscopic therapy 5-20%.
• Features for high risk of severe UGIB include:
• Age older than 60 years
• Concomitant liver disease
• Witness hematemesis or hematochezia (ongoing bleeding)
• Hemodynamic unstable during presentation
• Onset in the hospital
• Large PUD > 2 cm
• These patients require early endoscopy.

9. Indications
• After adequate resuscitation and within 24 hour after initial bleeding.
• Emergency endoscopy required if hemodynamically unstable after resuscitation.

11. Risk assessment
1. Rockall score:
Good for prediction of mortality and rebleeding in patient with Upper GI bleeding.
Score of 0 indicate the extremely low risk of rebleed or death and may be suitable
for early discharge or no admission (pre-endoscopic)
Score Value of <3 post-endoscopic have a low risk to rebleeding or death and can be
considered for early discharge
2Score <2 mean low risk of adverse outcome.

12. Rockall score

13. 2. Glasgow Blatchford score
Glasgow Blatchford score can be used to predict rebleeding and the
need for endoscopic therapy.
The score range from 0-23, with higher scores corresponding to
increasing acuity and mortality.
A score of O indicates the low risk to complications and need to be
discharged or no need for admission.

14. Glasgow Blatchford score

15. • During endoscopic the lesion may be classified according to stigmata
or recent hemorrhage which predict the rate of rebleeding.
• In patient with major stigmata of recent hemorrhage (active arterial
spurt, oozing and visible nonbleeding vessel have a high risk of
rebleeding
• Need Endoscopic hemostasis treatment , significantly reduces rates of
rebleeding, blood transfusions requirement, and need for surgical
intervention.

19. Endoscopic hemostasis
• Categorized into three:
Injection therapy
Thermal hemostasis
Mechanical hemostasis
• Combination of these method achieve best outcome.

20. Injection therapy
• Most commonly practiced hemostasis.
Include the use of diluted epinephrine, absolute alcohol, thrombin, and
fibrin sealant.
1. Diluted Epinephrine 1:10000-1:100000,injected submucosally;
work by local tamponade on vessel and vasoconstrictive effect.
• Larger volume injection 13-20ml more effective in preventing
rebleeding compared to small volume 5ml.
• It is safe to the tissues systemic complication rare but caution in
patient with Liver disease or ischemic heart disease.

24. 2. Sclerotherapy
Injection of sclerosant:
 polidocanol,
ethanolamine,
sodium tetradecyl sulfate (STD), and
absolute ethanol.
• Cause tissue necrosis and ulceration. The effect more with increasing
dose hence they have limited volume.

25. Thrombin and Fibrin sealant
• Fibrin sealant consists of two components: fibrinogen and thrombin
(reconstituted with calcium chloride solution and aprotinin).

27. • In ulcers with active bleeding, preinjection with epinephrine is
required.
• Four quadrants around the bleeding point are injected, each with
0.5mL of fibrinogen and thrombin (a total of 1mL fibrin sealant).
• After each injection, with the needle remaining in tissue, the
reconstituted sealant is immediately followed by 1.0–1.5mL of normal
saline in order to drive the sealant submucosally.
• Following four-quadrant injection, the bleeding point is then injected.

28. Thermal method
• Two methods
• Contact method heater probe and multipolar probe
• Non-contact neodymium: yttrium-aluminum-garnet laser and argon plasma
coagulation.
1. Contact methods using coaptive coagulation involved the use of a hemostat to
tamponade blood flow and coapt the vessel walls, followed by the application of
cautery to thermally seal the vessel.
• Effectively in sealing medium size arteries up to 2 mm in diameter.

32. CONT…
2. Non-contact method Argon plasma coagulation (APC) and laser deliver thermal
energy without contacting the tissue.
• Heating of tissue protein, contraction of the arterial wall, and vessel shrinkage.
However, there is a “heat-sink” effect from flowing arterial blood, leading to the
dissipation of thermal energy.
• Less effective for vessels >0.25mm and deeper bleeding. The burn is superficial
hence less risk for perforation but complications git overdistention.

33. Mechanical
• Endoscopic clip provide direct tissue approximation and superficial vessel closure.
• Clips are loaded through the instrument channel and are generally made of a two-
pronged metal clip attached to a deployment handle that allows opening, closing,
and firing of the clip.
• The handles allow rotation of the clip to facilitate positioning.

36. What is the role of second-look endoscopy in the
treatment of upper gastrointestinal bleeding
(UGIB)?
• A second attempt at endoscopic control is warranted if the initial
endoscopy fails to control the bleeding.
• Some authorities have concerns about the perils of a second
esophagogastroduodenoscopy (EGD), which may result in delayed surgery,
perforation, and increased morbidity and mortality.
• However, this approach has been validated in a large, randomized,
controlled trial that showed decreased morbidity and mortality
• Controversial, may be considered in select group of patients.
• For example obscured vision, inadequate endoscopic therapy.

37. References
• Shackelford surgery of alimentary tract 8th edition
• Gastrointestinal endoscopy in practice
• Gastroenterological endoscope 2nd edition