Overview
Definition:
Endoscopic hemostasis refers to a group of techniques performed during esophagogastroduodenoscopy (EGD) to stop or prevent bleeding from peptic ulcers
It aims to achieve rapid cessation of hemorrhage, reduce the need for surgery, and improve patient outcomes.
Epidemiology:
Peptic ulcer bleeding (PUB) affects approximately 150-200 per 100,000 adults annually
It is a common cause of upper gastrointestinal bleeding (UGIB), with a mortality rate of 2-10%
Factors like age, comorbidities, and ulcer characteristics influence risk.
Clinical Significance:
Effective endoscopic hemostasis is crucial for managing acute life-threatening gastrointestinal bleeding
It directly impacts patient morbidity and mortality, influences hospital stay duration, and reduces the necessity for invasive surgical interventions, making it a cornerstone of modern gastroenterological and surgical practice.
Clinical Presentation
Symptoms:
Hematemesis (vomiting blood, can be bright red or coffee-ground
Melena (black, tarry stools
Hematochezia (less common in upper GI, but can occur with massive bleeding
Abdominal pain
Dyspepsia
Symptoms of hypovolemic shock: dizziness, syncope, weakness, hypotension, tachycardia.
Signs:
Pallor
Hypotension
Tachycardia
Orthostatic hypotension
Abdominal tenderness
Signs of hypovolemic shock
Rectal examination may reveal melena.
Diagnostic Criteria:
Diagnosis is based on clinical presentation suggestive of upper GI bleeding, confirmed by the presence of a bleeding peptic ulcer on endoscopy
Risk stratification scores like the Rockall score and Oakland score help predict outcomes and guide management decisions.
Diagnostic Approach
History Taking:
Detailed history of bleeding episodes, duration and character of symptoms
Previous history of ulcers, H
pylori infection, NSAID or aspirin use
Comorbidities (liver disease, renal disease, coagulopathy
Medications (anticoagulants, antiplatelets, NSAIDs
Alcohol and smoking history.
Physical Examination:
Assess hemodynamic stability (vital signs, pulse rate, blood pressure, orthostatic measurements
Assess for pallor, jaundice, or stigmata of chronic liver disease
Perform abdominal examination for tenderness or masses
Rectal examination for melena or hematochezia.
Investigations:
Complete blood count (CBC) to assess hemoglobin and hematocrit
Coagulation profile (PT, aPTT, INR) to assess bleeding risk
Liver function tests (LFTs) and renal function tests (RFTs)
Chest X-ray (to rule out perforation)
ECG (especially in elderly or those with cardiac risk factors
Endoscopy (EGD) is the gold standard for diagnosis and treatment.
Differential Diagnosis:
Esophageal varices bleeding
Mallory-Weiss tear
Gastritis or duodenitis
Esophagitis
Angiodysplasia
Dieulafoy's lesion
Malignancy (gastric or esophageal
Boerhaave syndrome (esophageal rupture.
Management
Initial Management:
Immediate resuscitation with intravenous fluids (crystalloids, colloids
Transfusion of packed red blood cells (PRBCs) to maintain hemoglobin >7 g/dL (or >9 g/dL in patients with significant comorbidities
Early EGD within 12-24 hours for most patients, or urgently for hemodynamically unstable patients
Administration of proton pump inhibitors (PPIs) intravenously (e.g., pantoprazole 80 mg bolus followed by 8 mg/hr infusion).
Endoscopic Hemostasis Techniques:
Combination therapy is often most effective
Thermal methods: Monopolar electrocoagulation (APC, Heater probe, Bipolar electrocoagulation
Mechanical methods: Endoscopic clips, Endoscopic band ligation
Injection therapy: Epinephrine (vasoconstriction, followed by sclerosant like ethanolamine oleate or polidocanol for deeper effect.
Medical Management:
Intravenous PPI therapy is standard
If H
pylori is identified, eradication therapy should be initiated after bleeding control
Careful review and discontinuation of offending agents like NSAIDs and anticoagulants, with appropriate bridging therapy if needed.
Surgical Management:
Reserved for patients with persistent or recurrent bleeding despite maximal endoscopic therapy, hemodynamic instability not corrected by resuscitation, or massive transfusions required
Procedures include vagotomy and pyloroplasty with antrectomy, or gastrectomy depending on ulcer location and extent.
Supportive Care:
Continuous hemodynamic monitoring
Close monitoring of fluid balance and urine output
Nutritional support (may require nasogastric feeding tube if oral intake is compromised
Monitoring for signs of rebleeding
Post-endoscopic care to manage pain and nausea.
Complications
Early Complications:
Rebleeding is the most common complication, occurring in 5-20% of patients
Perforation (rare, associated with thermal methods
Esophageal or gastric injury from instrumentation
Post-polypectomy syndrome (if polyp removal was part of the procedure.
Late Complications:
Stricture formation (rare, usually from thermal injury or previous surgery
Chronic anemia from recurrent minor bleeding
Gastric outlet obstruction if ulcer is near the pylorus and heals with scarring.
Prevention Strategies:
Aggressive PPI therapy post-endoscopy
Risk stratification to identify high-risk patients
Careful selection of endoscopic modality based on ulcer characteristics
Prompt recognition and management of rebleeding
Judicious use of NSAIDs and anticoagulants.
Prognosis
Factors Affecting Prognosis:
Severity of bleeding
Hemodynamic stability at presentation
Presence of comorbidities (especially cardiovascular disease, renal failure, liver cirrhosis
Age
Ulcer size and location
Stigmata of recent hemorrhage on endoscopy (e.g., active bleeding, visible vessel
Need for surgery.
Outcomes:
With effective endoscopic hemostasis and appropriate management, mortality rates can be reduced to <2%
Rebleeding rates vary but are significantly lower than historical rates without intervention
Surgical intervention carries higher morbidity and mortality.
Follow Up:
Patients with peptic ulcer bleeding require follow-up to ensure complete healing, address underlying causes (e.g., H
pylori eradication, NSAID cessation
Repeat endoscopy may be indicated for high-risk lesions or recurrent symptoms
Long-term PPI therapy may be necessary for select patients.
Key Points
Exam Focus:
Understand the indications for endoscopic therapy in PUD bleeding
Differentiate between injection, thermal, and mechanical hemostasis techniques
Know the management of high-risk ulcers (Forrest Ia, Ib, IIa, IIb
Recognize factors predicting rebleeding and indications for surgery
Remember the importance of IV PPI infusion.
Clinical Pearls:
Always assess hemodynamic stability first
Use combination therapy (e.g., epinephrine injection followed by clip or thermal coagulation) for high-risk stigmata
Consider octreotide infusion for variceal bleeding, but PPIs are key for PUD
Surgical consultation is crucial for refractory bleeding
Post-endoscopic PPI therapy is vital.
Common Mistakes:
Delaying endoscopy in unstable patients
Inadequate resuscitation
Not using IV PPI infusion appropriately
Failure to identify and manage high-risk stigmata of bleeding
Discharging patients without adequate follow-up or treatment for underlying causes
Over-reliance on injection therapy alone for actively spurting vessels.