turning off the tap: endoscopy - transfusion guidelines · •in general, huge support for...
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Turning off the tap: Endoscopy
Blood & Guts:
Transfusion and bleeding in the medical patient
John Greenaway11
Turning off the tap: Endoscopy
Answer the questions– Benefits and risks of endoscopy
– Urgency of endoscopy• Who needs an Out-of-Hours (OOH) endoscopy?
• How to do this safely
– Who needs intervention?
– What interventions are available?• Non-variceal upper GI haemorrhage
– Post procedure care
– What are the outcomes?
– When to repeat the endoscopy or use other options
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Augustine Gibsonaka “AUGIB”
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AUGIB - Current aetiologyEndoscopic finding %
Oesophagitis 24
Gastritis/ erosions 22
Ulcer 36
Erosive duodenitis 13
Malignancy 4
Mallory- Weiss 4
Varices 11
Portal Gastropathy 5
Vascular malformation 3
None 174
6%1993
32%SRH
BSG 2007 (http://bsg.org.uk/pdf_word_docs/blood_audit_report _2007.pdf),
AUGIB – Mortality Factors
• 7,000 deaths per annum in UK
• Compared to other major acute killers
– ACS @ 5%, stroke @ 11%
On average a 3-fold increase in mortality for AUGIB in patients already admitted with another condition
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Study Mortality –All
Mortality –1o Admission
Mortality –In-patient
Rockall 1995 14% 11% 33%
Blatchford 1997
8.1 6.7% 42%
BSG 2007 10% 7% 26%
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“Rockall” risk scoring system
Rockall et al Gut 1996 & BMJ 1995
AUGIB - Mortality Factors
Co-morbidity• One co-morbidity - OR 1.8 / Malignancy – OR 3.8
• Liver Disease - doubles mortality, higher risk of interventions (overall mortality for variceal bleeding 14%)
Haemodynamic factors - modifiable• Shock – Mortality OR of 3.8
• Continued bleeding – up to 50-fold increased mortality
7BSG 2007 (http://bsg.org.uk/pdf_word_docs/blood_audit_report _2007.pdf), Blatchford et al. BMJ 1997, Rockall et al. BMJ 1995, Klebl et al. Int J Colorectal Dis 2005, Zimmerman et al. Scand J Gastroenterol 1995, Cameron et al. Eur J Hepatol 2002, Lecleire et al. J Clin Gastroenterol2005.
Age Mortality
< 60 yoa 3%
60 – 79 yoa 11%
> 79 yoa 20%
Age
Benefits & Risks of Endoscopy
• AUGIB OGD deemed safe procedure – Mortality < 0.1% (50% cardio-pulmonary)
– Major complication 0.9%
• Risk stratification more related to patient factors
– Elderly frail with multiple co-morbidities
– Drugs – NSAIDs, anti-platelet and anticoagulants
• In general, huge support for endoscopy unless futile
8Katon RM: Complications of upper gastrointestinal endoscopy in the gastrointestinal bleeder. Dig Dis Sci 27:47s-54s, 1981, NICE 2012 – Acute upper gastrointestinal bleeding management (CG 141) & ESGE 2015
Urgency of Endoscopy
• NICE 2012 (CG 141) - “Offer endoscopy to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation”
• NICE 2013 (QS38) - “GI bleed and haemodynamic instability should have 24/7access to an OGD within two hours of optimal resuscitation”
– ESGE “within 12 hours”
• “Offer endoscopy within 24 hours of admission to all other patients with upper gastrointestinal bleeding”
• Units > 330 cases per annum = daily endoscopy lists
9NICE 2012 – Acute upper gastrointestinal bleeding management (CG 141), NICE 2013 (QS38) , http://www.ncepod.org.uk/2015gih.htmNational Confidential Enquiry into Patient Outcome and Death - Time to Get Control? A review of the care received by patients who had a severe gastrointestinal haemorrhage. ESGE 2015 – Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage. Endoscopy;47:a1-a46.
Who needs out-of-hours endoscopy?
• 2-tier treatment based on pre-endoscopy clinical scoring system
– Integrated with clinical acumen and concern – occult liver disease (particularly in the young)
– Rockall score less than 3• 30% fall into category where mortality < 0.3%
– Home after swift endoscopy within 24 hours
– Rockall score of 3 or more• Discuss with endoscopy unit / Gastroenterologist within office hours
SpR contacts on-call endoscopist out of hours
10http://www.ncepod.org.uk/2015gih.htm National Confidential Enquiry into Patient Outcome and Death - Time to Get Control? A review of the care received by patients who had a severe gastrointestinal haemorrhage. NICE 2012 – Acute upper gastrointestinal bleeding management (CG 141). ESGE 2015 – Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage. Endoscopy;47:a1-a46.
Out of Hours “Emergency” endoscopy
• Performed in endoscopy unit– Gold standard (NCEPOD – “scoping our practice”)
– Theatre with untrained staff less appropriate (Varices?)
• Experienced therapeutic endoscopists and nursing staff– Usual environment where feasible – medical & nursing help
– Rapid assessment & management
• May require critical care input (HDU / ITU) or CCU– Patient instability
• Consider theatre (+/- GA) – Suspected variceal bleeds
– High chance of progression to surgery11
http://www.ncepod.org.uk/2015gih.htm National Confidential Enquiry into Patient Outcome and Death - Time to Get Control? A review of the care received by patients who had a severe gastrointestinal haemorrhage. NICE 2012 – Acute upper gastrointestinal bleeding management (CG 141).
Non-variceal bleeding
Forrest classification: Stigmata of recent haemorrhage in peptic ulcer bleeding
• Acute haemorrhage– Forrest I a (Spurting haemorrhage)
– Forrest I b (Oozing haemorrhage)
• Signs of recent haemorrhage– Forrest II a (Visible vessel)
– Forrest II b (Adherent clot)
– Forrest II c (Flat pigmented haematin on ulcer base)
• Lesions without active bleeding– Forrest III (Lesions without signs of recent haemorrhage or fibrin-covered
clean ulcer base)
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Forrest, JA.; Finlayson, ND.; Shearman, DJ. (Aug 1974). "Endoscopy in gastrointestinal bleeding.". Lancet. 2 (7877): 394–7. PMID 4136718. doi:10.1016/s0140-6736(74)91770-x. Is the Forrest classification a useful tool for planning endoscopic therapy of
bleeding peptic ulcers? Endoscopy. 1989; 21: 258-261
Non-variceal bleeding
Forrest classification: Stigmata of recent haemorrhage in peptic ulcer bleeding
• Acute haemorrhage– Forrest I a (Spurting haemorrhage) – treat; very high-risk re-bleed (90%)
– Forrest I b (Oozing haemorrhage) – treat & high-risk re-bleed (55%)
• Signs of recent haemorrhage– Forrest II a (Visible vessel) – treat; high-risk re-bleed (43%)
– Forrest II b (Adherent clot) – Controversy; risk re-bleed (22%)
– Forrest II c (Flat pigmented haematin on ulcer base) - risk re-bleed (10%)
• Lesions without active bleeding– Forrest III (Lesions without signs of recent haemorrhage or fibrin-covered
clean ulcer base) - risk re-bleed (5%)
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Forrest, JA.; Finlayson, ND.; Shearman, DJ. (Aug 1974). "Endoscopy in gastrointestinal bleeding.". Lancet. 2 (7877): 394–7. PMID 4136718. doi:10.1016/s0140-6736(74)91770-x. Is the Forrest classification a useful tool for planning endoscopic therapy of
bleeding peptic ulcers? Endoscopy. 1989; 21: 258-261
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“Rockall” risk scoring system
Rockall et al Gut 1996 & BMJ 1995
Mortality by post-endoscopy (Full) Rockall risk score
Rockall: BMJ, Volume 311(6999).July 22, 1995.222-226
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ScoreMortalityNo rebleed
MortalityRebleed
3 2% 10%
4 4% 16%
5 8% 23%
6 10% 33%
7 15% 43%
8+ 28% 53%
The (Forrest) II-b or not II-b question
• High risk: Re-bleed risk - 22%
• Vigorous wash
– water jet irrigation
– If still adherent – leave alone & start IV PPI
– If comes off then treat underlying lesion
– Or cold snare removal of clot and treat underlying lesion (controversial)
• Meta-analysis shows no outcome change though numerous positive and negative studies exist
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Laine L, McQuaid KR. Clin Gastroenterol Hepatol. 2009
What interventions are available?
Standard
• Injection – Adrenaline (1:10,000), Fibrin, Sclerosants
• Thermal - Heater probe, Gold probe diathermy
• Mechanical devices - clips
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What interventions are available?
Novel
• Barrier methods
– Hemospray, Endoclot & Ankaferd
• New “bear claw” clips
– Ovesco, Padlock
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Landmarks in Interventional outcomes• Adrenaline Injection – 1988
– 1:10,000 – 100% haemostasis with 24% re-bleed
• Volume of Adrenaline – 2002– 16 ml (15%) v 8ml (30%) re-bleed after peptic ulcer injection
– RCT evidence for >13ml (increased pain & perforation risk >40ml)
• Combination therapy – 1997– Combined treatment significantly reduced re-bleeding and emergency
surgery in those with spurting vessels
– Heater probe produces coaptive coagulation in addition to the vasoconstriction and tamponade effect of adrenaline injection
• Combination therapy – 2004.– Adrenaline + Thermal / clips in high-risk bleeding ulcers
– Reduced re-bleeding (18.4 to 10.6%), Emergency surgery (11.3 to 7.6%) and mortality (5.1 to 2.6%)
20Chung SC et al. BMJ 1988, Lin HJ et al. GI Endosc 2002, Chung SC et al. BMJ 1997, Calvert X et al. Gastroenterology 2004, NICE 2012.
Endoclip Treatment • Through-the-scope
– Quick > Resolution > Instinct
– Use what you are used to
– Clip Meta-analysis (Sung et al. 2007)
• Equivalent to thermal modalities
• Better haemostasis than injection
• Reduced re-bleed & surgery rates
– Try to access at 90o
– Prior injection can aid vision
– Failed Endoclip locations – posterior duodenal bulb, posterior wall of gastric body & lesser curve of Stomach
21Laine L & Jensen D. AJG 2012;107:345-360, Sung et al. Gut 2007, Barkun A et al. Ann Intern Med 2003 & 2010;139:843, Palmer K et al. BMJ 2008;337:a1832, Sofia et al. Hepatogastroenterol 2000,
Thermal Treatments • Coaptive coagulation
– Pressure to stigmata and temporarily interrupts blood supply through vessel
– Reduces heat sink effect
– can seal arteries up to 2mm diameter
– Effective for active bleeding / high risk stigmata
22Sofia et al. Hepatogastroenterol 2000, Sung et al. Gut 2007, Barkun A et al. Ann Intern Med 2003 & 2010;139:843, Palmer K et al. BMJ 2008;337:a1832
Novel Treatments • Barrier Methods – Hemospray / Endoclot
– Inert, non-allergic, inorganic powder
– Inserted via catheter down scope
• Licenced for non-variceal bleeding
• Only effective when bleeding
• Adheres to bleeding site
• Mechanical tamponade
• Promotes thrombus formation by
Concentrating & activating platelet &
Clotting factors
– Rescue therapy but ? more23
Outcome of Endoscopic Management
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• Haemostasis @95%
• Re-bleeding @15%
• Death @6-8% - irrespective of any optimal endoscopic & medical treatment
– Prospective cohort study >10,000 cases
– “Majority of patients died from non-bleeding-related causes”
– “Optimisation of management should aim at reducing the risk of multi-organ failure and cardio-pulmonary death instead of focussing merely on successful hemostasis”
Am J Gastroenterol 2010; 105:84-89
IV PPI treatment – Post Endoscopy• Intra-gastric pH > 6 [Omeprazole 80mg bolus then
8mg/hr for 72 hrs; “Hong-Kong” regime]
– For all receiving endoscopic therapy and those with adherent clots (IIb)
– stabilises clots with reduced re-bleeding in high-risk
• Significant reduction in :-
– Re-bleeding (NNT 13), Need for surgery (NNT 34), Need for further endoscopy (NNT 10), LOS and BTx
• Only reduced mortality in high-risk lesion sub group
• Supported by all major guidelines
• NB H. pylori25Lau JY et al. NEJM 2007;356:1631, Al-S, Bakun et al. Ann Intern Med 2010. NICE 20012 & ESGE 2015
When to repeat the endoscopy or use other options
• Consider “second-look” Endoscopy
– To treat any residual high risk lesion again
– Review when ongoing bleeding in absence of identifiable lesion
– Initial view sub-optimal
• Re-bleeding post index endoscopic therapy associated with increased mortality
• Law of “diminishing returns”
26NICE 2012 – Acute upper gastrointestinal bleeding management (CG 141). ESGE 2015 – Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage. Endoscopy;47:a1-a46.
Failure of endoscopic therapy
• Do we really know where the patient is bleeding from?
• Was the therapy accurately delivered?
– Clot removed, adequate coagulation, better endoscopist ?
• Re-bleed endoscopic review – Lau et al 1999
– Main study finding – no better than surgery
– BUT Less complications
• TTS Ovesco clip, Barrier methods or
Coagulation graspers (70W) – J Clin Gastroenterol 2014
– Possibly better than 10Fr gold probe – safe & effective
• Time to phone a friend?
27Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. Lau et al. 1999 & ASGE Guidelines 2012, J Clin Gastroenterol 2014.
Conclusions (1)
• Use a therapeutic scope with irrigator for high-risk (?all) patients
• Risk stratify and treat Forrest 1a, 1b & IIa ulcers
• Consider removing clot from IIb
• Combination therapy –
– Usually Adrenaline with thermal or clips
– Clip use dictated by location of bleeding
• Novel treatments for rescue therapy
– Barrier agents may have role as primary therapy28
Conclusions (2)
• IV PPI for high-risk stigmata post endoscopy
• Most patients can be fed within 24 hours
• H. pylori testing for PUD patients with eradication – repeat test / high false negative rate in acute setting
• Endoscopy is 1st and 2nd choice in non-variceal upper GI bleeding
• Recurrent severe bleeding can be treated by IR or surgery – former preferable when available
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