Endoscopic interventions are effective for treating acute nonvariceal gastrointestinal bleeding (NVGIB), reducing mortality. New technologies allow treatment of lesions that were previously difficult to access or treat with standard modalities. These include over-the-scope clips, padlock clips, radiofrequency ablation, topical hemostatic agents, fully covered self-expanding metal stents, endoscopic suturing, Doppler probe ultrasound, and EUS-guided therapy. Studies show these new technologies achieve hemostasis in difficult cases and reduce rebleeding rates compared to conventional endoscopy.

1. Kurdistan Board GEH/GIT Surgery J ClubKurdistan Board GEH/GIT Surgery J Club
Supervisor:Supervisor:
Professor Dr.Mohamed AlshekhaniProfessor Dr.Mohamed Alshekhani
MBChB-CABM-FRCP-EBGH.MBChB-CABM-FRCP-EBGH.

2. Introduction:Introduction:
 EndO intervention reduces high mortality of acute NVGIBEndO intervention reduces high mortality of acute NVGIB
 Inj +second endoscopic modality reduce re-bleeding, needInj +second endoscopic modality reduce re-bleeding, need
for surgery& mortality.for surgery& mortality.
 Mechanical hemostasis with hemoclips & thermo-Mechanical hemostasis with hemoclips & thermo-
coagulation are equivalent &used interchangeably bycoagulation are equivalent &used interchangeably by
therapeutic endoscopists, depending on individualtherapeutic endoscopists, depending on individual
preference.preference.
 For variceal bleeding, endoscopic therapy has emerged asFor variceal bleeding, endoscopic therapy has emerged as
1st-line treatment;includes endoscopic variceal ligation EV1st-line treatment;includes endoscopic variceal ligation EV
&cyanoacrylate (CYA) glue injection for gastric varices GV.&cyanoacrylate (CYA) glue injection for gastric varices GV.
 Despite successful primary endoscopic hemostasis ofDespite successful primary endoscopic hemostasis of
NVUGIB nearly 100%, recurrent in-hospital bleeding occurNVUGIB nearly 100%, recurrent in-hospital bleeding occur
in 8.2%, with overall mortality of 5%.in 8.2%, with overall mortality of 5%.

3. Introduction:Introduction:
 The results of traditional endoscopic therapies are far fromThe results of traditional endoscopic therapies are far from
perfect:perfect:
 Large ulcer defect >2cmLarge ulcer defect >2cm
 Visible vessel >2 mmVisible vessel >2 mm
 Inaccessible lesionsInaccessible lesions
 Challenging positions ( posterior wall stomach ,lesserChallenging positions ( posterior wall stomach ,lesser
curve , posterior bulbar wall)curve , posterior bulbar wall)
 Fibrotic base for hemoclip.Fibrotic base for hemoclip.

4. Introduction:Introduction:
 Failure to control bleeding from EV bleeding, is 17% , forFailure to control bleeding from EV bleeding, is 17% , for
GV, recurrent bleeding occurs in 37– 53% with sclerosantGV, recurrent bleeding occurs in 37– 53% with sclerosant
injs &40% after standard endoscopic CYA therapy.injs &40% after standard endoscopic CYA therapy.
 New endoscopic technologies & procedural techniques areNew endoscopic technologies & procedural techniques are
needed, especially in patients failing to respond to initialneeded, especially in patients failing to respond to initial
endoscopic therapy:endoscopic therapy:

5. New technologies:New technologies:Cap-mountedCap-mounted
ClipsClips Over-the-scope Clip System:Over-the-scope Clip System:
 Allow suction of tissue before release of the clip by using aAllow suction of tissue before release of the clip by using a
hand wheel, similar to band ligation.hand wheel, similar to band ligation.
 OTSC used for endoscopic closure of perforations& fistulas.OTSC used for endoscopic closure of perforations& fistulas.
 Endoscopic hemostasis with OTSC promising with 90%Endoscopic hemostasis with OTSC promising with 90%
successsuccess
 Lesions managed:bleeding PUD,MW tears, anastomoticLesions managed:bleeding PUD,MW tears, anastomotic
bleeding, post EMR orbleeding, post EMR or ESD, orESD, or diverticular bleeding.diverticular bleeding.
 OTCS particularly advantageous along the posterior wall ofOTCS particularly advantageous along the posterior wall of
the duodenal bulb, where standard therapy is prone tothe duodenal bulb, where standard therapy is prone to
failure.failure.
 Excellent results with LGIB failed conventional therapiesExcellent results with LGIB failed conventional therapies
&recurrent bleeding occurred in only 2 patients.&recurrent bleeding occurred in only 2 patients.
 OTSC is cleared by FDA for:OTSC is cleared by FDA for:


6. New technologies:New technologies:Cap-mountedCap-mounted
ClipsClips Padlock ClipPadlock Clip::
 FDA-clearedFDA-cleared
 Consists of a nitinol ring with 6 inner needles preassembledConsists of a nitinol ring with 6 inner needles preassembled
on an applicator cap (for 9.5–11 mm scope tips).on an applicator cap (for 9.5–11 mm scope tips).
 The trigger wire is located alongside the shaft of theThe trigger wire is located alongside the shaft of the
endoscope, thus freeing up the working channel forendoscope, thus freeing up the working channel for
continuous suction of blood/secretions.continuous suction of blood/secretions.
 This design may allow for more efficient suction of tissueThis design may allow for more efficient suction of tissue
into the cap, thereby not requiring other instruments forinto the cap, thereby not requiring other instruments for
tissue retraction.tissue retraction.
 Used to treat 5 patients withUsed to treat 5 patients with GIB with recurrent bleedingGIB with recurrent bleeding
from a bleeding rectal ulcer&delayed post-polypectomyfrom a bleeding rectal ulcer&delayed post-polypectomy
bleeding, &duodenalbleeding, &duodenal Dieulafoy lesion bleed.Dieulafoy lesion bleed.

7. Padlock clip:Padlock clip:

8. New technologies:New technologies: Thermocoag or Ablative TherapyThermocoag or Ablative Therapy
 Radiofrequency Ablation:Radiofrequency Ablation:
 FDA cleared it for the treatment of GAVE & radiation colitisFDA cleared it for the treatment of GAVE & radiation colitis
failed previous APC with 87% GAVE treated with RFA didfailed previous APC with 87% GAVE treated with RFA did
not require further transfusion.not require further transfusion.
 There are endoscopic differences between classicThere are endoscopic differences between classic
watermelon-striped type & punctate type of GAVE, latterwatermelon-striped type & punctate type of GAVE, latter
consists of sharply demarcated red punctate lesions ofconsists of sharply demarcated red punctate lesions of
nearly even size diffusely scattered over a large area in thenearly even size diffusely scattered over a large area in the
antrum &associated withantrum &associated with cirrhosis.cirrhosis.

9. New technologies:New technologies: Topical Hemostatic AgentsTopical Hemostatic Agents
 New tools used in endoscopic hemostasis.New tools used in endoscopic hemostasis.
 Three different powders available: Hemospray, AnkaferdThree different powders available: Hemospray, Ankaferd
Blood Stopper, EndoClot& CYA topical spray.Blood Stopper, EndoClot& CYA topical spray.

10. New technologies:New technologies: Topical Hemostatic AgentsTopical Hemostatic Agents
 Hemospray:Hemospray:
 11stst
used to control external bleeding in battlefield.used to control external bleeding in battlefield.
 Mechanisms of action:Mechanisms of action:
 A a mechanical barrier over bleeding site.A a mechanical barrier over bleeding site.
 Absorbent & serum separator, increase the conc of clottingAbsorbent & serum separator, increase the conc of clotting
Fs.Fs.
 Electrostatic because of its negative charge.Electrostatic because of its negative charge.
 Activates the intrinsic clotting cascade.Activates the intrinsic clotting cascade.
 In Forrest I bleeding peptic ulcers it achieved goodIn Forrest I bleeding peptic ulcers it achieved good
hemostasis >90% with a low recurrent bleeding.hemostasis >90% with a low recurrent bleeding.
 Alone or in combination with other modalities showedAlone or in combination with other modalities showed
successful hemostasis of 92%.successful hemostasis of 92%.
 Bleeding sources treated include:Bleeding sources treated include: portal hypertension,portal hypertension,
varices,tumors,iatrogenicvarices,tumors,iatrogenic (post-sphincterotomy), post-ESD.(post-sphincterotomy), post-ESD.

11. New technologies:New technologies: Topical Hemostatic AgentsTopical Hemostatic Agents
 LGIB from diffuse ulceration, post-polypectomy bleeding,LGIB from diffuse ulceration, post-polypectomy bleeding,
radiation proctitis, AVM with increased risk of delayedradiation proctitis, AVM with increased risk of delayed
bleeding because of impaired hemostasis caused bybleeding because of impaired hemostasis caused by
antithrombotic agents, anticoagulation, or thrombocytopenia.antithrombotic agents, anticoagulation, or thrombocytopenia.
 Advantages:Advantages:
 ease of use, act as an “extinguisher” even in difficultease of use, act as an “extinguisher” even in difficult
locations&potential efficacy for different bleeding lesions.locations&potential efficacy for different bleeding lesions.
 DisadvantageDisadvantage::
 Inability to use another modality if hemostasis should fail,Inability to use another modality if hemostasis should fail,
because the powder obscures the target site.because the powder obscures the target site.
 Only works when there is active bleeding or oozing from theOnly works when there is active bleeding or oozing from the
vessel or lesionvessel or lesion..

12. New technologies:New technologies: Topical Hemostatic AgentsTopical Hemostatic Agents
 AnkaferdAnkaferd
 Ankaferd Blood Stopper (ABS) (Ankaferd Blood Stopper (ABS) ( Turkey) is a traditionalTurkey) is a traditional
Turkish herbal mixture(Thymus vulgarisTurkish herbal mixture(Thymus vulgaris Glycyrrhiza glabra,Glycyrrhiza glabra,
Vitis vinifera, Alpinia officinarum, Urtica dioica)Vitis vinifera, Alpinia officinarum, Urtica dioica)
 ABS is delivered through the scope with a spray catheter.ABS is delivered through the scope with a spray catheter.
 Exact mechanism of action remains incompletelyExact mechanism of action remains incompletely
understood.understood.
 Hemostatic efficiency of ABS for UGIH of various origins:Hemostatic efficiency of ABS for UGIH of various origins:
ulcers, tumors, variceal bleeding.ulcers, tumors, variceal bleeding.
 Ankaferd is not FDA cleared.Ankaferd is not FDA cleared.

13. New technologies:New technologies: Topical Hemostatic AgentsTopical Hemostatic Agents
 Endoclot:Endoclot:
 Endo Clot Polysaccharide Hemostatic System used as anEndo Clot Polysaccharide Hemostatic System used as an
adjunct hemostat to control bleeding from capillary, venous,adjunct hemostat to control bleeding from capillary, venous,
or arteriolar vessels in the GI tract.or arteriolar vessels in the GI tract.
 It consists of starch, which explains its relatively low cost.It consists of starch, which explains its relatively low cost.
 The applicator comprises a powder/gas mixing chamber, aThe applicator comprises a powder/gas mixing chamber, a
delivery catheter (7F width, 1800 or 2300 mm length),delivery catheter (7F width, 1800 or 2300 mm length),
connecting tube between a gas filter & external gas source.connecting tube between a gas filter & external gas source.
 A large study described its usefulness for controlling&A large study described its usefulness for controlling&
preventing bleeding related topreventing bleeding related to
 Immediate hemostasis in UGIH, although not as mono orImmediate hemostasis in UGIH, although not as mono or
primary therapy.primary therapy.
 Demonstrate its ease of use.Demonstrate its ease of use.
 Not FDA cleared.Not FDA cleared.

14. New technologies:New technologies: Topical Hemostatic AgentsTopical Hemostatic Agents
 Cyanoacrylate Spray:Cyanoacrylate Spray:
 CYA used off label for the endoscopic treatment ofCYA used off label for the endoscopic treatment of
recalcitrant NVUGIB&bleeding with malignant tumors.recalcitrant NVUGIB&bleeding with malignant tumors.
 Despite its ease of application & availability, there are noDespite its ease of application & availability, there are no
large scale trials.large scale trials.
 It can destroy eye/endoscopic equipments &appropriateIt can destroy eye/endoscopic equipments &appropriate
precautions are neededprecautions are needed..

15. New technologies:FCSEMSsNew technologies:FCSEMSs
 Persistent immediate post-sphincterotomy bleeding requiresPersistent immediate post-sphincterotomy bleeding requires
endoscopic intervention.endoscopic intervention.
 When conventional hemostatic modalities fail, placement ofWhen conventional hemostatic modalities fail, placement of
FCSEMS achieve durable uncontrolled bleeding afterFCSEMS achieve durable uncontrolled bleeding after
balloon sphincteroplasty,post-transplant anastomoticballoon sphincteroplasty,post-transplant anastomotic
stricture dilatation& intraductal biopsy,esophageal varicealstricture dilatation& intraductal biopsy,esophageal variceal
bleeding refractory to conventional therapy such as bandbleeding refractory to conventional therapy such as band
ligation.ligation.
 Success of therapy was more frequent in the esophagealSuccess of therapy was more frequent in the esophageal
stent than in the balloon tamponade &considered as anstent than in the balloon tamponade &considered as an
alternativealternative to balloon tamponadeto balloon tamponade with less aspirationwith less aspiration
pneumonia in VUGIBpneumonia in VUGIB ..

16. New technologies:New technologies: Endoscopic SuturingEndoscopic Suturing
 Requires a double-channel endoscope & consists of a sutureRequires a double-channel endoscope & consists of a suture
anchor with a detachable needle tip carrying absorbable oranchor with a detachable needle tip carrying absorbable or
non-absorbable sutures ,mounted on the scope tip &attachednon-absorbable sutures ,mounted on the scope tip &attached
by a wire that runs alongside the scope shaft to the handleby a wire that runs alongside the scope shaft to the handle
portion of the system to the ports of the working channel.portion of the system to the ports of the working channel.
 The main application; closure of perforations&post-bariatric,The main application; closure of perforations&post-bariatric,
large bleeding gastric ulcers achieving durable hemostasislarge bleeding gastric ulcers achieving durable hemostasis
by using a figure-of-eight suture to mimic surgical ulcerby using a figure-of-eight suture to mimic surgical ulcer
exclusionexclusion
 To prevent GI bleeding after ESD.To prevent GI bleeding after ESD.

17. New technologies:New technologies: Doppler Probe UltrasoundDoppler Probe Ultrasound
 A feeding artery may be “invisible” beneath theA feeding artery may be “invisible” beneath the
endoscopically visualized lesion&require DOP-US.endoscopically visualized lesion&require DOP-US.
 Two DOP-US systems are available for use in endoscopy.Two DOP-US systems are available for use in endoscopy.
 Adverse events associated with the through-the-scopeAdverse events associated with the through-the-scope
probes rare (< 2%); bleeding (oozing or spurting) by probeprobes rare (< 2%); bleeding (oozing or spurting) by probe
contact.contact.
 A negative DOP-US signal reduces or eliminates the needA negative DOP-US signal reduces or eliminates the need
for routine second-look endoscopy&persistently positivefor routine second-look endoscopy&persistently positive
DOP-US signal found immediately after primary endoscopicDOP-US signal found immediately after primary endoscopic
therapy may be a marker for recurrent bleeding.therapy may be a marker for recurrent bleeding.
 RCTs are needed to determine whether DOP-US hasRCTs are needed to determine whether DOP-US has
beneficial impact on the managementbeneficial impact on the management of GI bleeding.of GI bleeding.

18. New technologies:New technologies: EUS –guided TherapyEUS –guided Therapy
 In recent years, vascular access & therapy are emerging asIn recent years, vascular access & therapy are emerging as
new targets for endoscopic ultrasound (EUS)–guidednew targets for endoscopic ultrasound (EUS)–guided
interventions.interventions.

19. New technologies:New technologies: EUS–guided TherapyEUS–guided Therapy
 Non-variceal Gastrointestinal BleedingNon-variceal Gastrointestinal Bleeding
 In refractory bleeding fromIn refractory bleeding from hemosuccus pancreaticus, ahemosuccus pancreaticus, a
Dieulafoy lesion, duodenalDieulafoy lesion, duodenal ulceration&GIST with at least 3ulceration&GIST with at least 3
bleeding episodes & required multiple units of packed RBCsbleeding episodes & required multiple units of packed RBCs
& repeated ineffective endoscopic / vascular therapies.& repeated ineffective endoscopic / vascular therapies.
 EUS-guided inj therapy of absolute alcohol&/or CYA wasEUS-guided inj therapy of absolute alcohol&/or CYA was
delivered directly into the bleeding vessels.delivered directly into the bleeding vessels.
 Control of the bleeding source was achieved in all of theseControl of the bleeding source was achieved in all of these
refractory cases without any complications.refractory cases without any complications.

20. New technologies:New technologies: EUS–guided TherapyEUS–guided Therapy
 Variceal Gastrointestinal Bleeding:EVVariceal Gastrointestinal Bleeding:EV
 Recurrent bleeding seen in 15–65% result of failure to treatRecurrent bleeding seen in 15–65% result of failure to treat
the feeder vessels (perforating veins / collateral vessels).the feeder vessels (perforating veins / collateral vessels).
 EUS enables the visualization/targeting of perforatingEUS enables the visualization/targeting of perforating
veins /collaterals for sclerotherapy.veins /collaterals for sclerotherapy.
 The sclerosant was injected into the esophageal varicesThe sclerosant was injected into the esophageal varices
directed at the perforating vessels until flow was completelydirected at the perforating vessels until flow was completely
impeded.impeded.

21. New technologies:New technologies: EUS–guided TherapyEUS–guided Therapy
 GV bleeding: less common but present in up to 20% withGV bleeding: less common but present in up to 20% with
PHT.PHT.
 65% of GV present with bleeding over 2 years.65% of GV present with bleeding over 2 years.
 Direct endoscopic CYA inj of bleeding GV, widely consideredDirect endoscopic CYA inj of bleeding GV, widely considered
first-line therapy with hemostasis 58–100%& recurrentfirst-line therapy with hemostasis 58–100%& recurrent
bleeding 0%–40%.bleeding 0%–40%.
 The most serious adverse event is systemic embolization,PEThe most serious adverse event is systemic embolization,PE
in 58% ,Sepsis, Embolization into the artery (via PFO or AVin 58% ,Sepsis, Embolization into the artery (via PFO or AV
pulmonary shunt) result in stroke&multiorgan infarction.pulmonary shunt) result in stroke&multiorgan infarction.
 Factors increase the embolization: overdilution with lipiodol,Factors increase the embolization: overdilution with lipiodol,
excessively rapid inj, inj of too large a volume in a singleexcessively rapid inj, inj of too large a volume in a single
inj& isolated GV type 1 that have high blood-flow rates.inj& isolated GV type 1 that have high blood-flow rates.
 Rectal variceal bleeding 38-94%&Clin significant bleeding isRectal variceal bleeding 38-94%&Clin significant bleeding is
uncommon (0.5 – 5%).uncommon (0.5 – 5%).
 EUS-guided CYA inj or +coil used for effective hemostasis.EUS-guided CYA inj or +coil used for effective hemostasis.

22. New technologies:New technologies: EUS–guided TherapyEUS–guided Therapy
 Delivery of CYA under EUS guide has advantage of enablingDelivery of CYA under EUS guide has advantage of enabling
precise delivery of glue into varix lumen&enablesprecise delivery of glue into varix lumen&enables
assessment with Doppler to confirm vessel obliteration afterassessment with Doppler to confirm vessel obliteration after
trt with prognostic significance, as recurrent bleeding risktrt with prognostic significance, as recurrent bleeding risk
linked to residual patency of treated varices.linked to residual patency of treated varices.
 Treatment can be performed without dependency on directTreatment can be performed without dependency on direct
varix visualization; even in the presence of retained food orvarix visualization; even in the presence of retained food or
blood that may obstruct the endoscopic view&varix lumenblood that may obstruct the endoscopic view&varix lumen
can be accurately targeted for glue injection.can be accurately targeted for glue injection.
 Targeting the perforating “feeder vessel,” rather than theTargeting the perforating “feeder vessel,” rather than the
varix lumen proper, under EUS to achieve obliteration of GVvarix lumen proper, under EUS to achieve obliteration of GV
to reduce the risk of embolization.to reduce the risk of embolization.
 Glue + lipiodol enabled fluoroscopic visualization of theGlue + lipiodol enabled fluoroscopic visualization of the
injected vessel&confirmation feeder vessel accuratelyinjected vessel&confirmation feeder vessel accurately
targeted.targeted.

23. New technologies:New technologies: EUS–guided TherapyEUS–guided Therapy
 Limitations: identification of the perforating vessel with EUSLimitations: identification of the perforating vessel with EUS
can be difficult &time-consuming.can be difficult &time-consuming.
 Because the perforating vessel may be afferent or efferent,Because the perforating vessel may be afferent or efferent,
contrast medium must be injected before treatment tocontrast medium must be injected before treatment to
determine directional flow relative to the varix.determine directional flow relative to the varix.
 EUA–guided coiling:EUA–guided coiling:
 Vascular coils under EUS guidance via standard fine-needleVascular coils under EUS guidance via standard fine-needle
aspiration needles.aspiration needles.
 The overall obliteration was 97%.The overall obliteration was 97%.
 Higher number of sessions were required to achieveHigher number of sessions were required to achieve
complete obliteration in the CYA versus coil group.complete obliteration in the CYA versus coil group.
 Adverse events were significantly higher in the CYA.Adverse events were significantly higher in the CYA.

24. New technologies:New technologies: EUS–guided TherapyEUS–guided Therapy
 The deployment of a coil before CYA injection should serveThe deployment of a coil before CYA injection should serve
several functions:several functions:
 1. The coil itself contributes to varix obliteration/hemostasis1. The coil itself contributes to varix obliteration/hemostasis
 2. The coil concentrates the glue at the site of coil2. The coil concentrates the glue at the site of coil
deployment.deployment.
 3. The coil may prevent glue embolization.3. The coil may prevent glue embolization.

25. New technologies:New technologies: EUS–guided TherapyEUS–guided Therapy
 Prophylactic treatment of gastric varices.Prophylactic treatment of gastric varices.
 Isolated GV have the highest flow rates, are larger in size,Isolated GV have the highest flow rates, are larger in size,
have deeper feeding vessels, resulting in more severehave deeper feeding vessels, resulting in more severe
bleeding.bleeding.
 The mortality from the first variceal bleeding event hasThe mortality from the first variceal bleeding event has
remained high at 20% within 6 weeks of the index event.remained high at 20% within 6 weeks of the index event.
 Used for primary prophylaxis, CYA injn shown to reduce theUsed for primary prophylaxis, CYA injn shown to reduce the
risk of bleeding & mortality from type 2 GV or type 1 isolatedrisk of bleeding & mortality from type 2 GV or type 1 isolated
GV >10-mm diameter as compared with propranolol alone.GV >10-mm diameter as compared with propranolol alone.
 Effectiveness showed of undiluted CYA/Effectiveness showed of undiluted CYA/
methacryloxysulfolane inj in achieving obliteration of GV.methacryloxysulfolane inj in achieving obliteration of GV.
 Combined coil/ glue therapy experienced minor bleeding >1Combined coil/ glue therapy experienced minor bleeding >1
year after & high obliteration (96%)& acceptable risk profileyear after & high obliteration (96%)& acceptable risk profile
support strong consideration of this type of therapy assupport strong consideration of this type of therapy as

26. Forrest grade Ia Forrest grade Ib
Forrest classification
Forrest grade IIa

27. Forrest grade IIc Forrest grade III
Forrest classification
Forrest grade IIb

28. High risk lesionsHigh risk lesions

29. Adherent clotAdherent clot

30. Endoscopic therapyEndoscopic therapy
injectioninjection
 Reduce blood flow by temporary local tamponadeReduce blood flow by temporary local tamponade
 Vasoconstricting agents reduce blood flowVasoconstricting agents reduce blood flow
--Adrenaline 1:10,000 -1:100,000Adrenaline 1:10,000 -1:100,000
 SclerosantsSclerosants
 EthanolamineEthanolamine
 PolidocanolPolidocanol
 EthanolEthanol
 Tissue adhesiveTissue adhesive
 HistoacrylHistoacryl
 Fibirin glueFibirin glue

31. Endoscopic therapyEndoscopic therapy
ablativeablative
 Contact ablativeContact ablative
therapy bytherapy by
1.1. Thermo coagulationThermo coagulation
heat probeheat probe
2.2. Electro coagulationElectro coagulation
BICAP, Gold probeBICAP, Gold probe
 Non contact ablativeNon contact ablative
argon plasmaargon plasma
cougulationcougulation

32. Endoscopic therapyEndoscopic therapy
ablativeablative
 Coaptive coagulationCoaptive coagulation
compress vessel &compress vessel &
cougulate 15-20 wattscougulate 15-20 watts
for 8-12 seconds forfor 8-12 seconds for
4-6 pulses4-6 pulses
 Larger 10 FrenchLarger 10 French
more effective than 7more effective than 7
French probesFrench probes

33. Endoscopic therapyEndoscopic therapy
mechanical hemoclipsmechanical hemoclips

34. Application of a clip in upper
GI bleeding

38. Iv erythromycinIv erythromycin
 Consider giving a
single 250-mg IV dose
of erythromycin 30 to
60 minutes before
endoscopy
– promote gastric motility and
substantially improve
visualization of the gastric
mucosa on initial endoscopy.
– not improve the diagnostic yield
of endoscopy substantially or to
improve the outcome
We can only treat what we can see

39. HemosprayHemospray

40. HemosprayHemospray
95% acute hemostasis
Sung JJ Endoscopy. 2011 Apr;43(4):291-5. Epub 2011 Mar 31.

41. Abstract:Abstract:
 Endoscopic interventions are first-line therapy for U&L GIB.Endoscopic interventions are first-line therapy for U&L GIB.
 Injection therapy + second endoscopic modality has reducedInjection therapy + second endoscopic modality has reduced
re-bleeding, need for surgery&mortality in NVGIBre-bleeding, need for surgery&mortality in NVGIB ..
 For variceal bleeding endoscopic bandingFor variceal bleeding endoscopic banding or cyanoacrylateor cyanoacrylate
injection techniques are recommended interventions.injection techniques are recommended interventions.
 Despite ease of application&general acceptance of theseDespite ease of application&general acceptance of these
techniques, there is an ongoing re-bleeding rate associatedtechniques, there is an ongoing re-bleeding rate associated
with significant in-hospital mortality.with significant in-hospital mortality.
 So new advances in endoscopic technologies&proceduralSo new advances in endoscopic technologies&procedural
techniques emerged to improve patient outcomestechniques emerged to improve patient outcomes ..
 New endoscopic technologies & procedural advances shownNew endoscopic technologies & procedural advances shown
promise in improving outcomes in failed conventional modes.promise in improving outcomes in failed conventional modes.
 The incorporation of EUS to guide therapy is expanding,The incorporation of EUS to guide therapy is expanding,
specially EUS-guided CYA glue&/or coils for bleeding GV .specially EUS-guided CYA glue&/or coils for bleeding GV .