Turning Off the Tap: Endoscopy

Turning off the tap: Endoscopy

Blood & Guts: Transfusion and bleeding in the medical patient John Greenaway 1 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

2 Augustine Gibson aka “AUGIB”

3 AUGIB - Current aetiology

Endoscopic finding % Oesophagitis 24 Gastritis/ erosions 22 Ulcer 36 32% SRH Erosive duodenitis 13 Malignancy 4 Mallory- Weiss 4 Varices 11 6% 1993 Portal Gastropathy 5 Vascular malformation 3 None 17 4 BSG 2007 (http://bsg.org.uk/pdf_word_docs/blood_audit_report _2007.pdf), AUGIB – Mortality Factors

Study Mortality – Mortality – Mortality – All 1o Admission In-patient Rockall 1995 14% 11% 33% Blatchford 8.1 6.7% 42% 1997 BSG 2007 10% 7% 26%

• 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

5 “Rockall” risk scoring system

Rockall et al Gut 1996 & BMJ 1995 6 AUGIB - Mortality Factors Age Age Mortality < 60 yoa 3% 60 – 79 yoa 11%

> 79 yoa 20% 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

BSG 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. 7 Int J Colorectal Dis 2005, Zimmerman et al. Scand J Gastroenterol 1995, Cameron et al. Eur J Hepatol 2002, Lecleire et al. J Clin Gastroenterol 2005. 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

Katon 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 8 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

NICE 2012 – Acute upper gastrointestinal bleeding management (CG 141), NICE 2013 (QS38) , 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 9 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

http://www.ncepod.org.uk/2015gih.htm National Confidential Enquiry into Patient Outcome and Death - Time to Get Control? A review of10 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 surgery 11 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)

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 12 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%)

Rockall et al Gut 1996 & BMJ 1995 15 Mortality by post-endoscopy (Full) Rockall risk score

Mortality Mortality Score No rebleed Rebleed 3 2% 10% 4 4% 16% 5 8% 23% 6 10% 33% 7 15% 43% 8+ 28% 53%

Rockall: BMJ, Volume 311(6999).July 22, 1995.222-226

16 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

17 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

18 What interventions are available?

Novel • Barrier methods – Hemospray, Endoclot & Ankaferd • New “bear claw” clips – Ovesco, Padlock

19 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%)

20 Chung 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

Laine L & Jensen D. AJG 2012;107:345-360, Sung et al. Gut 2007, Barkun A et al. Ann Intern Med 2003 & 2010;139:843, 21 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

Sofia et al. Hepatogastroenterol 2000, Sung et al. Gut 2007, Barkun A et al. Ann Intern Med 2003 & 2010;139:843, Palmer K et 22 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 ? more 23 Outcome of Endoscopic Management • 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” 24 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. pylori

Lau JY et al. NEJM 2007;356:1631, Al-S, Bakun et al. Ann Intern Med 2010. NICE 20012 & ESGE 2015 25 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”

NICE 2012 – Acute upper gastrointestinal bleeding management (CG 141). ESGE 2015 – Diagnosis and management of 26 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?

Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of 27 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 therapy 28 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