Description
Gastrointestinal (GI) bleeding requires rapid diagnosis and intervention. Endoscopic approaches include thermal coagulation, hemoclips, injection therapy (epinephrine), and argon plasma coagulation, primarily for peptic ulcers, varices, and angiodysplasia. Interventional radiology offers angiographic embolization for refractory bleeding using microcoils, glue, or gelfoam. Transjugular Intrahepatic Portosystemic Shunt (TIPS) is used for variceal bleeding in cirrhosis. For massive bleeding unresponsive to other methods, surgical options like resection may be needed. Endoscopic therapy is first-line, with angiographic embolization as a backup for persistent or high-risk cases, ensuring effective bleeding control while minimizing invasiveness.
Summary Listen
- **Overview of GI Bleed**
- GI Bleeds are categorized into upper, mid, and lower, with upper GI bleeds being the most prevalent. Non-variceal upper GI bleeds are the primary focus due to the rarity of mid-GI bleeds and the distinct nature of lower GI bleeds. Peptic ulcers are the predominant cause of upper GI bleeds, accounting for 50-60% of cases. Despite advancements in treatment, mortality ranges from 6-10%.
- **Pre-Endoscopic Management**
- Initial management of GI bleeds involves securing IV access and considering intubation if necessary. Severity is assessed using the Glasgow Blatchford score, with low scores indicating outpatient management. Transfusion strategies favor a restrictive approach, targeting a hemoglobin level of 7-9 g/dL, except in elderly or cardiac patients where it should be above 8 g/dL.
- **Reversal of Anticoagulation and PPI Use**
- Pre-endoscopically, anti-coagulation effects must be reversed. Prothrombin complex concentrate and Vitamin K are used for warfarin reversal, while specific antidotes are available for direct oral anti-coagulants. PPI administration pre-endoscopy is recommended to improve outcomes and reduce high-risk criteria.
- **Endoscopic Management Timing and Forrest Classification**
- Emergency endoscopy is unnecessary unless the patient is experiencing massive bleeding, diagnostic uncertainty, or high-risk conditions. The Forrest classification guides the need for endoscopic intervention, with 1A, 1B, 2A, and 2B categories requiring it. Clean bases do not require endoscopic intervention.
- **Endoscopic Modalities for Hemostasis**
- Endoscopic hemostasis modalities include non-contact methods (argon plasma coagulation, laser) and contact methods (injection, thermal probes, mechanical clips). Dual therapy, combining injection with mechanical methods, yields better outcomes than monotherapy.
- **Post-Endoscopic Management**
- Post-endoscopic management involves PPI administration to stabilize clots and reduce re-bleeding. IV PPIs are preferred, followed by oral PPIs. H. pylori eradication is crucial to prevent recurrence, reducing the relapse rate significantly.
- **Novel Therapies and Intervention**
- Novel endoscopic therapies such as OVSCO clips, hemosprae, and suturing are available when primary therapies fail. Intervention radiology is considered for embolization after failed endoscopic attempts. Surgery is reserved for limited cases.
- **Esophageal Varices Management**
- For esophageal varices management in chronic liver disease, screening endoscopy should be used. Non-selective beta blockers prevent variceal bleeding. Endoscopic band ligation is the preferred treatment to eradicate the varices. Cyanoacrylate glue injection alone or with US guided glue plus coil can be used for Gastric varices.
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About the Speakers
Dr. Ekant Budhwani
Medical Consultant Gastroenterology, Aakash Healthcare Super Speciality Hospital, Hyderabad
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