Role of emergency endoscopy in saving lives dr ravi gupta
DR RAVI GUPTACONSULTATNT G I ENDOSCOPIST LILAVATI HOSPITAL
UPPER G I ENDOSCOPY FOREIGN BODIES IN UPPER G I TRACT UPPER G I BLEED
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.
F B IN UPPER G I TRACT F B IN ESOPHAGUS SHARP FBS WITH RISK OF PERFORATION
Indian scenarioLimited studies on the prevalence of peptic ulcer bleeding in IndiaPeptic ulcer is widely prevalent in India, more common among the population of South India than North IndiaConflicting data exist from different studies on the MC type of presentationLifetime 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
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
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, NSAIDsA1: 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 recommendedA2: 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 stillA3: 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 pumpA5: 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 highA6: 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 restartedA7: 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 whoA8: 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 †
Overall management ABC’s and adequate resuscitation Early risk stratification pre-endoscopy at early endoscopyVery 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
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.
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
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
What about an elevated INR andendoscopy? 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
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
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
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
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.
ESOPHAGEAL & FUNDAL VARICES VARICEAL BAND LIGATION CYANOACRYLATE GLUE IF SPURTING VESSEL SEEN FUNDAL VARICES GLUE INJECTION ALL ATTEMPTS TO ARREST ACTIVE BLEEDING
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 SubgroupChiu 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% CIChiu 2006 5 80 8 84 13.4% 0.63 [0.20, 2.02] But not mortality OR=0.65; (0.26;1.62)Lee 2005Messman 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 62Heterogeneity: Chi² = 5.61, df = 5 (P = 0.35); I² = 11% 0.01 0.1 1 10 100Test 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
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
• 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
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
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.
Effect of PPIs on outcomes inpatients with PUD bleeding Outcome at 30 days after randomization Odds Ratio (95% CI) 0.53 Mortality (9*) 0.46 Re-bleeding (19*) 0.59PPI 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
FAILURE OF ENDOTHREPY TIPS ( TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNTS) SURGERY
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
NONVARICEAL BLEED INJECTION OF ULCERS WITH ADRENALIN THERMAL COAGULATION HAEMOCLIP APPLICATION COMBINATION OF ABOVE
UPPER G I BLEED RISK OF REBLEEDING ANGIOGRAPHIC INTERVENTION WHEN TO CONSIDER SURGERY
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
EMERGENCY ERCP IMPACTED STONE WITH SEVERE UNRELENTING PAIN ACUTE PANCREATITIS ACUTE CHOLANGITIS
EMERGENCY ERCP IMPACTED STONE WITH SEVERE UNRELENTING PAIN ACUTE PANCREATITIS ACUTE CHOLANGITIS
CONCLUSIONEMERGENCY ENDOSCOPIC INTERVENTIONS HAVE SAVED MANY LIVES & HAS HELPED AVOID MAJOR SURGERY IN ACTIVELY BLEEDING PATIENT