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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