Endoscopic Intervent..

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Endoscopic Intervent..

  1. 1. GI Hemorrhage Trauma and SICU Conference 12/18/2006
  2. 2. Upper GI Bleeding <ul><li>Esophageal Varices </li></ul><ul><li>Mallory-Weiss Tear </li></ul><ul><li>Duodenal Ulcer </li></ul><ul><li>Gastric Ulcer </li></ul><ul><li>Gastritis </li></ul><ul><li>Cancer </li></ul><ul><li>Hemobilia </li></ul><ul><li>Cranberry Sauce </li></ul>
  3. 3. Lower Gastrointestinal Bleeding <ul><li>UGI Source </li></ul><ul><li>Hemorrhoids, Fissure, Ulcer, Polyp </li></ul><ul><li>Prolapse </li></ul><ul><li>Volvulus/Malrotation </li></ul><ul><li>Cancer </li></ul><ul><li>Ulcerative Colitis </li></ul><ul><li>Granulomatous Colitis </li></ul><ul><li>Diverticulitis </li></ul><ul><li>Other: </li></ul><ul><ul><li>Meckel’s Diverticulum </li></ul></ul><ul><ul><li>Colonic Polyp </li></ul></ul><ul><ul><li>Peutz-Jeghers Syndrome </li></ul></ul><ul><ul><li>Osler-Weber-Rendu Syndrome </li></ul></ul><ul><ul><li>Ileal Diverticula </li></ul></ul><ul><ul><li>Duplication of Bowel </li></ul></ul>
  4. 4. Endoscopic Interventions for Gastrointestinal Bleeding Stephanie Chao, Trauma R1 Trauma Conference December 18, 2006
  5. 5. Endoscopic techniques <ul><li>Anoscopy </li></ul><ul><li>Sigmoidoscopy </li></ul><ul><ul><li><45 years old with small volume bleed, may be sufficient for investigation unless bleeding/recurrence found </li></ul></ul><ul><ul><li>Identifies anorectal disease, infectious colitis, inflammatory bowel disease </li></ul></ul><ul><li>EGD </li></ul><ul><li>Colonoscopy </li></ul>
  6. 6. Injection Rx <ul><li>Epinephrine </li></ul><ul><ul><li>1-1.5ml of 1:10,000 or 1:20,000 in 4 quadrants </li></ul></ul><ul><ul><li>Mechanism: vasoconstriction, volume tamponade </li></ul></ul><ul><li>Sclerosant (ethanolamine) </li></ul><ul><ul><li>Mechanism: Induces inflammation then fibrosis </li></ul></ul><ul><li>Fibrin Sealant </li></ul><ul><ul><li>Fibrinogen/Factor XIII and Thrombin/Calcium </li></ul></ul><ul><ul><li>Mechanism: Instantaneous formation of hemostatic clot by mimicking last step of coagulation cascade </li></ul></ul><ul><ul><li>Sclerosant trials vs. Fibrin sealant </li></ul></ul><ul><li>No advantage of epi + sclerosant over epi alone </li></ul><ul><li>Saline </li></ul><ul><ul><li>Mechanism: volume tamponade </li></ul></ul><ul><li>Ethanol </li></ul>
  7. 7. Thermal Coagulation <ul><li>Heater probe </li></ul><ul><ul><li>Mechanism: tissue coagulation via heated ceramic tip </li></ul></ul><ul><ul><li>Not limited by tissue water resistance, deeper heat penetration </li></ul></ul><ul><ul><li>Higher risk of perforation </li></ul></ul><ul><li>Multipolar probe </li></ul><ul><ul><li>Mechanism: coagulates tissue by heating tissue temperature to >60 degrees Celsius via alternating positive and negative electrodes at tip </li></ul></ul><ul><ul><li>Tissue desiccation prevents conduction to lower layers </li></ul></ul><ul><li>Argon Plasma Coagulant </li></ul><ul><ul><li>Mechanism: uses argon gas to deliver a plasma of evenly distributed thermal energy </li></ul></ul><ul><ul><li>No contact, wider spray, less depth </li></ul></ul>
  8. 8. Coagulation Active bleed Post Coagulation
  9. 9. Thermal Coagulation <ul><li>Heater probe </li></ul><ul><ul><li>Mechanism: tissue coagulation via heated ceramic tip </li></ul></ul><ul><ul><li>Not limited by tissue water resistance, deeper heat penetration </li></ul></ul><ul><ul><li>Higher risk of perforation </li></ul></ul><ul><li>Multipolar probe </li></ul><ul><ul><li>Mechanism: coagulates tissue by heating tissue temperature to >60 degrees Celsius via passing electricity between alternating positive and negative electrodes at tip </li></ul></ul><ul><ul><li>Tissue desiccation prevents conduction to lower layers </li></ul></ul><ul><li>Argon Plasma Coagulant </li></ul><ul><ul><li>Mechanism: uses argon gas to deliver a plasma of evenly distributed thermal energy </li></ul></ul><ul><ul><li>No contact, wider spray, less depth </li></ul></ul>
  10. 10. Multipolar Probe
  11. 11. Thermal Coagulation <ul><li>Heater probe </li></ul><ul><ul><li>Mechanism: tissue coagulation via heated ceramic tip </li></ul></ul><ul><ul><li>Not limited by tissue water resistance, deeper heat penetration </li></ul></ul><ul><ul><li>Higher risk of perforation </li></ul></ul><ul><li>Multipolar probe </li></ul><ul><ul><li>Mechanism: coagulates tissue by heating tissue temperature to >60 degrees Celsius via alternating positive and negative electrodes at tip </li></ul></ul><ul><ul><li>Tissue desiccation prevents conduction to lower layers </li></ul></ul><ul><li>Argon Plasma Coagulant </li></ul><ul><ul><li>Mechanism: uses argon gas to deliver a plasma of evenly distributed thermal energy </li></ul></ul><ul><ul><li>No contact, wider spray, less depth </li></ul></ul>
  12. 12. Argon Plasma Coagulant
  13. 13. Hemostatic Clips <ul><li>Occludes vessel </li></ul><ul><li>Radiographic marker </li></ul>
  14. 14. Risk Stratification – Peptic Ulcer Disease <ul><li>Low risk </li></ul><ul><ul><li>Flat spot, clean ulcer </li></ul></ul><ul><ul><li>Rx: No endoscopic intervention, PPI only </li></ul></ul><ul><li>Intermediate Risk </li></ul><ul><ul><li>Ooze without clot or visible vessel </li></ul></ul><ul><ul><li>Rx: Monotherapy with oral PPI </li></ul></ul><ul><li>High Risk </li></ul><ul><ul><li>Active bleed, non-bleeding visible vessel with clot </li></ul></ul><ul><ul><li>Rx: Combination therapy (injection and coagulation, IV PPI) </li></ul></ul><ul><ul><li>Visible vessel </li></ul></ul><ul><ul><li>Rx: clip or coagulation and PPI </li></ul></ul>
  15. 15. Risk Stratification <ul><li>Low risk </li></ul><ul><ul><li>Flat spot, clean ulcer </li></ul></ul><ul><ul><li>Rx: No endoscopic intervention, PPI only </li></ul></ul><ul><li>Intermediate Risk </li></ul><ul><ul><li>Ooze without clot or visible vessel </li></ul></ul><ul><ul><li>Rx: Monotherapy with oral PPI </li></ul></ul><ul><li>High Risk </li></ul><ul><ul><li>Active bleed, non-bleeding visible vessel with clot </li></ul></ul><ul><ul><li>Rx: Combination therapy (injection and coagulation, IV PPI) </li></ul></ul><ul><ul><li>Visible vessel </li></ul></ul><ul><ul><li>Rx: clip or coagulation and PPI </li></ul></ul>
  16. 16. Risk Stratification <ul><li>Low risk </li></ul><ul><ul><li>Flat spot, clean ulcer </li></ul></ul><ul><ul><li>Rx: No endoscopic intervention, PPI only </li></ul></ul><ul><li>Intermediate Risk </li></ul><ul><ul><li>Ooze without clot or visible vessel </li></ul></ul><ul><ul><li>Rx: Monotherapy with oral PPI </li></ul></ul><ul><li>High Risk </li></ul><ul><ul><li>Active bleed, non-bleeding visible vessel with clot </li></ul></ul><ul><ul><li>Rx: Combination therapy (injection and coagulation, IV PPI) </li></ul></ul><ul><ul><li>Visible vessel </li></ul></ul><ul><ul><li>Rx: clip or coagulation and PPI </li></ul></ul>
  17. 17. Risk Stratification <ul><li>Low risk </li></ul><ul><ul><li>Flat spot, clean ulcer </li></ul></ul><ul><ul><li>Rx: No endoscopic intervention, PPI only </li></ul></ul><ul><li>Intermediate Risk </li></ul><ul><ul><li>Ooze without clot or visible vessel </li></ul></ul><ul><ul><li>Rx: Monotherapy with oral PPI </li></ul></ul><ul><li>High Risk </li></ul><ul><ul><li>Active bleed, non-bleeding visible vessel with clot </li></ul></ul><ul><ul><li>Rx: Combination therapy (injection and coagulation, IV PPI) </li></ul></ul><ul><ul><li>Visible vessel </li></ul></ul><ul><ul><li>Rx: clip or coagulation and PPI </li></ul></ul>
  18. 18. Varices <ul><li>Banding </li></ul>
  19. 19. References <ul><li>Kubba, AK, Palmer, KR. Role of endoscopic injection therapy in the treatment of bleeding peptic ulcer. Br J Surg 1996; 83:461. </li></ul><ul><li>Laine, L, Peterson, WL. Bleeding peptic ulcer. N Engl J Med 1994; 331:717. </li></ul><ul><li>Jensen DM, Machicado GA. Endoscopic Hemostasis of Ulcer Hemorrhage with Injection, Thermal, or Combination Methods. Techniques in Gastrointestinal Endoscopy 2005; 7:124. </li></ul><ul><li>Up-To-Date </li></ul><ul><li>CMDT </li></ul>

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