Upper gastrointestinal bleeding endoscopic intervention: Difference between revisions
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*The American Society of Gastrointestinal Endoscopy guidelines recommend the use of two different endoscopic procedures, rather than a single procedure to better control bleeding and decrease the incidence of rebleeding. | *The American Society of Gastrointestinal Endoscopy guidelines recommend the use of two different endoscopic procedures, rather than a single procedure to better control bleeding and decrease the incidence of rebleeding. | ||
====Endoscopic band ligation (EBL)==== | ====Endoscopic band ligation (EBL)==== | ||
*EBL involves the placement of elastic circular ring ligatures around the varices to cause strangulation | *EBL involves the placement of elastic circular ring ligatures around the varices to cause strangulation. | ||
*Bands are typically delivered at the gastroesophageal junction first, then proximally; six to ten bands may be delivered with a single intubation. | *Bands are typically delivered at the gastroesophageal junction first, then proximally; six to ten bands may be delivered with a single intubation. | ||
*The primary drawback of EBL is that during active bleeding, operator visibility is limited by the device holding the bands prior to their delivery. | *The primary drawback of EBL is that during active bleeding, operator visibility is limited by the device holding the bands prior to their delivery. | ||
Revision as of 00:21, 8 November 2017
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Upper gastrointestinal bleeding Microchapters |
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Differentiating Upper Gastrointestinal Bleeding from other Diseases |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
Endoscopic intervention
In UGIB, diagnostic and therapeutic endoscopy may be performed simultaneously. Therapeutic upper gastrointestinal endoscopy should be performed in all patients with suspected UGIB to evaluate and possibly treat the source of bleeding. The urgency of endoscopy depends on the anticipated source of bleeding, rapidity of blood loss, and hemodynamic stability of the patient. Endoscopic intervention should be undertaken within 24 hours, as early intervention is associated with reduced transfusion needs and a decreased length of stay in high-risk patients with nonvariceal bleeding.
Endoscopic procedures
- The most common procedures used to manage upper GI bleeding caused by the peptic ulcer disease are:
- Injection
- Coagulation (thermal, electric, and argon plasma)
- Hemostatic clips.
- The most common procedures used to manage esophageal varices are:
- Sclerotherapy
- Variceal band ligation
- The American Society of Gastrointestinal Endoscopy guidelines recommend the use of two different endoscopic procedures, rather than a single procedure to better control bleeding and decrease the incidence of rebleeding.
Endoscopic band ligation (EBL)
- EBL involves the placement of elastic circular ring ligatures around the varices to cause strangulation.
- Bands are typically delivered at the gastroesophageal junction first, then proximally; six to ten bands may be delivered with a single intubation.
- The primary drawback of EBL is that during active bleeding, operator visibility is limited by the device holding the bands prior to their delivery.
- Endotracheal intubation is prudent in patients with active bleeding to reduce the risk of aspiration pneumonia.
- Systemic antibiotics should be considered in patients with ascites to reduce the risk of bacterial infection
- Follow-up endoscopies are recommended at various intervals depending on the size/appearance of varices and severity of liver disease.
- Typically, visits every 2 to 4 weeks until obliteration. An interval of 1 to 3 months is recommended for initial surveillance of recurrence of varices, then every 6 to 12 months
- Endoscopic therapy can halt bleeding in 80% to 90% of patients
- EBL is equivalent to EIS in establishing initial control of bleeding, but EBL is challenging in the actively bleeding patient
- EBL is widely favored over EIS for primary prevention due to similar or superior efficacy with fewer complications
Endoscopic injection sclerotherapy (EIS)
- Comprises endoscopic delivery of a sclerosant, such as ethanol, morrhuate sodium, polidocanol, or sodium tetradecyl sulfate, while patient is under sedation and analgesia.
- Injections may be intravariceal or be delivered into the esophageal wall near the varices.
- Bucrylate is an adhesive that has been used successfully.
- Typical injection volume is 1 to 2 mL per injection, for a total volume of 10 to 15 mL. Interval between injections varies according to patient tolerance and response, and complications
- After an initial injection to control bleeding, there is usually a follow-up injection 2 to 3 days later, followed by weekly or biweekly procedures until complete obliteration of the varices is achieved, which usually takes five or six sessions