gi bleeding and endoscopic management · 10/4/2014 1 gi bleeding: diagnosis & endoscopic...
TRANSCRIPT
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GI Bleeding:
Diagnosis & Endoscopic
ManagementMaria Cirocco, RN, BScN, MA CGN(C)
St. Michael’s Hospital
Toronto, Canada
Cook calendar
Objectives
• To define gastrointestinal bleeding and
identify major causes
• To describe endoscopic treatments for
gastrointestinal bleeding
• To discuss the nursing role in caring for
patients with GI bleeding
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On arrival in the endoscopy unit
the patient may have:
• Hematemesis: vomiting blood
• May be red or “coffee grounds”
• Melena: black tarry odorous stool
• Hematochezia: rectal bleeding, ranging in colour
from bright red to dark maroon
• Pre-syncope, syncope • (and other symptoms of ↓ Hb)
• Occult: no symptoms
But the bleeding could be from
anywhere…
wikimedia.org
UGIB vs. LGIB
• UPPER GI Bleeding: proximal to ligament of Treitz
(esophagus, stomach, duodenum, rarely
biliary/pancreatic): presents as hematemesis,
melena or hematochezia IF BRISK
• LOWER GI Bleeding: distal to ligament of Treitz
(jejunum, ileum, colon) presents as hematochezia
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Why endoscopy?
• to establish the cause of bleed and,
using endoscopic therapy, control the
bleeding or reduce the risk of further
bleeding
Causes of UGIBPeptic ulcer disease
Causes of UGIB
Esophageal varices Gastric varices
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Causes of UGIB
Esophagitis Mallory- Weiss tear
Causes of UGIB
Gastric antral vascular ectasia Gastric AVM
Causes of UGIB
Dieulafoy lesion Gastritis (NSAID induced)
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Causes of UGIB
Neoplams – esophageal Neoplams - gastric
Causes of UGIB
Sleisenger & Fordtran. 2010, ch. 19, pg 293
Presentation of UGIB
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Upper GI bleeding: what we know
• Mortality remains high between 5-10%
• Shift to predominantly the elderly
• up to 80% of cases stop spontaneously
• 15-25% rebleed after endoscopic treatment
Gralnek et al N. Engl J Med 2008;359:9 928-37
Mortality in ulcer bleedingAge Year N
>60 >80 Death
(%)
Jones 40-47 687 33 2 9.9
Schiller 53-67 2149 48 8 8.9
Johnston 67-68 817 49 9 10.6
Mayberry 72-78 583 NA NA 10.3
Katchinski 84-86 1017 63 18 11.8
Rockall 1993 4185 68 27 11.0
Risk of re-bleeding by Forrest grade
Forrest I* Forrest IIa Forrest IIb Forrest IIc Forrest III
55
43
22
10 50
20
40
60
80
100
Patients with endoscopic or clinical re-bleeding (%)
Laine L & Peterson WL. N Engl J Med 1994;331:717–27
Oozing/spurting
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ACTIVE BLEEDING
NON BLEEDING VISIBLE VESSEL
Who to treat?
ADHERENT CLOT?
Management
• Clinical status - A B C
• Early endoscopy to localize and treat
bleeding
• Achieve hemostasis• Refer to surgery or interventional radiology if bleeding
cannot be controlled by the above measure
Clear the fieldBioVac® direct suction lavage
Different endoscopes
Irrigation systems
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Endoscopic treatmentsThermal
Bipolar probeArgon plasma coagulationHeater probe
MechanicalHemoclipsBand ligation
MedicationsInjection sclerotherapy
CombinationInjection + thermal + clip
Other
Duodenal Ulcer
Hemoclips
• Mechanical compression of vessel
• Immediate and complete hemostasis (if vessel
properly clamped)
• Minimum tissue injury
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GAVE
Varices – what we know
• 60% of patients with cirrhosis develop
varices
• 1/3 of patients with varices bleed from them
• rebleeding: 15 - 50% in 6 wks (most occur
within the 1st 10 days)
• mortality: 15 - 40% (1 yr) & 60 - 80% (4 yrs)
• Liver transplantation can improve survival in
selected patients
Which endoscopic therapy?
• SCLEROTHERAPY or LIGATION
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Esophageal Variceal Ligation (EVL):
a Success Story
• Bleeding controlled in 90%
• Rebleeding rate 10-30%
Get the nipple first
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Cyanoacrilate obliteration of gastric varices:
Patient selection
• Glue injection
recommended for gastric
varices that are:
• Actively bleeding
• Have a stigmata of
recent bleeding (e.g.,
fibrin plug, clot)
• Not recommended for
Primary prophylaxis
Cyanoacrylate obliteration
of gastric varices
Histoacryl®
(n-butyl-2 cyanoacrylate)
Prime the injection catheter with sterile water
(note volume required to see liquid at the tip)
Mix
Histoacryl R 0.5 ml
+ 3 ml syringe
Lipiodol R 0.5 ml
gently shake syringe to ensure mixed
Getting ready
Cyanoacrylate obliteration of gastric varices
Priming
• Attach CYA syringe and inject 0.5 ml of solution into primed injection catheter
• The endoscopist places catheter down biopsy channel of gastroscope
Injection
• Inject remaining CYA into catheter and attach a 10ml syringe with sterile water
• The endoscopist will thrust the needle into the varix and ask the nurse to inject water equal to dead space of injection catheter (usually about 2 mls)
Retraction
• The endoscopist will remove needle from varix and ask the nurse to inject 1-2 mls of water into the stomach to ensure catheter is patent
• Keep needle at least 2 cm beyond tip of endoscope to prevent cyanoacrylate contamination of endoscope
Repeat
• Repeat the process until desired injections have occurred
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Gastric varix
Follow up
• Repeat EGD in 1-4 wks Glue injection of
residual GV
• Glue cast May remain visible for months
• Once GV obliterated, EGD every 3-6 months
to monitor for recurrence
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What are the risks?
What are the risks?
Bleeding gastric varices
ModalityInitial hemostasis
(%)
Re-bleeding
(%)
Sclerotherapy 40-60 20-90
Banding 45-100 0-50
Glue injection 90-100 5-30
TIPS 90-100 10-30
Adapted from Ryan BM et al. Gastroenterology 2004;126:1175
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Other causes ?
During/post therapeutic
intervention
• EMR
• ESD
• EBS
• Etc……
Nursing implications
• Nursing history to augment the physician’s
• Be prepared for emergencies
• Intra procedural care• Supportive measures
• Assess patient post procedure and facilitate assessments in the event of a complication
• Communication
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The ultimate device?
Google images accessed 09/2014
Novel endoscopic hemostatic
treatmentsThermal
CryotherapyRFA
Mechanical Coagulating forceps (perhaps bipolar)Sewing devices?
Medications/otherhemospray polimers ?surgical fibrin?
Cryotherapy• Compressed CO2 as
cryogen (-78°C; 8 L/min)
• Catheter-based
cryospray
• Necessitates gastric
length overtube or
dedicated evac tube for
Venting of CO2 gas
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Or RFA?
Hemospray
• Hemospray is a mineral blend powder developed for
endoscopic hemostasis.
• It has no known allergens.
• Hemospray is metabolically inert and deemed nontoxic
• Over the years, similar materials have been used by the
military for topical battlefield hemostasis applications.
How does Hemospray work? When Hemospray comes in contact with blood, the powder absorbs water, then
acts both cohesively and adhesively, forming a mechanical barrier over the
bleeding site.
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Hemospray
Conclusion
• UGI bleeding is a medical emergency
• Patients require care from an
experienced team
• Nurses shine as part of the team
Selected references
• Alan N. Barkun et al. International Consensus Recommendations on
the Management of Patients With Nonvariceal Upper Gastrointestinal
Bleeding. Ann Intern Med. 2010;152:101-113.
• ASGE Technology Committee. Endoscopic hemostatic devices GIE :
2009; 69 (6) 987-994
• Felman, M., Friedman, L.S., & Brandt, L.J. (eds) (2010) Sleisenger and
Fortrand Gastrointestinal and Liver Disease. Pathophysiology/
Diagnosis/ Management. 9th Edition. Philidelphia: Saunders/Elsvier
(ch. 19 and 90)
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Thank you
• Questions?