Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (33 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Upper gastrointestinal endoscopy is required for any patient with significant UGI bleeding. Patients with haemodynamic instability or evidence of continuing haemorrhage require emergency endoscopy, whereas the majority of patients will undergo endoscopy within 24 hours of admission. In a study from Hong Kong,
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70 patients aged less than 60 years with a clean ulcer base and stable vital signs were safely discharged on the same day as endoscopy with appropriate anti-ulcer medication. A systematic review of the literature supports a policy of early endoscopy, as this allows the safe discharge of patients with low-risk haemorrhage and improves outcome for patients with high-risk lesions.
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Early endoscopy is recommended for all patients with UGI haemorrhage.
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Endoscopy for UGI bleeding requires the support of a dedicated endoscopic unit with trained nursing staff, availability of additional endoscopes and equipment, ready access to anaesthetic staff and operating theatre, and, increasingly, access to interventional radiology services. These procedures are not ideal for the unsupervised trainee and should be performed or supervised by experienced consultant staff.
For the majority of stable patients, procedures can be safely carried out using standard diagnostic endoscopes. In the unstable patient or where continuing haemorrhage is suspected, the twin-channel or large (3.7-mm) single-channel endoscope is preferable and allows better aspiration of gastric contents as well as more flexibility with regard to the use of heater probes and other instruments. In unstable or obtunded patients, anaesthetic support is mandatory as an endotracheal tube should be passed before endoscopy to guard against aspiration. In rare cases, the use of a pharyngeal over-tube and gastric lavage tube is necessary to remove blood and clot from the stomach before adequate visualisation of the bleeding site can be achieved. Water is poured down the lavage tube via a funnel, which is then placed in a bucket at floor level, allowing siphoning of gastric contents. This, however, can be a time-consuming, unpleasant and messy experience, and in the presence of continuing bleeding should not be allowed to delay endostasis. The use of a tilting trolley allows repositioning of the patient, which can facilitate visualisation of the proximal stomach when obscured by blood and clot. Initially, placing the patient in an upright position may suffice, and if necessary rolling the patient into a right lateral and upright position may be needed for complete visualisation of the gastric fundus. In general, lavage is more successful in achieving visualisation than endoscopic aspiration, as endoscope working channels rapidly block with clot. Lavage can be achieved using repeated flushes of saline down the endoscope working channel or with the use of the powered endoscopic lavage catheters such as that provided with the heater probe. With experience, it should rarely be necessary to proceed to surgery or angiography because of inability to visualise the bleeding site due to blood and clot in the stomach or duodenum.
Bleeding gastric ulcers are most likely within the antrum or at the incisura (77%), or less commonly higher on the lesser curve (15%), with ulcers at other sites within the stomach being uncommon. Ulcers at the incisura and proximal lesser curvature can be readily overlooked unless the endoscope is retroflexed within the stomach. The most common site for a bleeding duodenal ulcer is the posterior wall, sometimes with involvement of the inferior and superior walls of the first part of duodenum. Superficial anterior duodenal wall ulcers can ooze, but usually these ulcers perforate. Ulcers elsewhere in the duodenum are seen in less than 10% of patients.
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The presence of active bleeding at the time of endoscopy and the size of the ulcer, rather than its anatomical site, are the main endoscopic determinants of the risk of therapeutic failure.
Gastritis/duodenitis
Bleeding due to gastritis or duodenitis may be associated with non-steroidal anti-inflammatory drug (NSAID) therapy or ingestion of alcohol. It may also be due to
Helicobacter pylori
and can be severe enough to cause superficial erosions. Such bleeding, however, is almost always self-limiting in the absence of bleeding disorders and therapeutic intervention is not required at the time of endoscopy. Treatment with appropriate acid suppression therapy and early discharge is usually appropriate in the absence of other comorbid illness.
Mallory–Weiss syndrome was first described in 1929 and refers to haematemesis following repeated or violent vomiting or retching. It is caused by a linear tear of the mucosa close to the oesophagogastric junction. It accounts for approximately 5% of patients with UGI haemorrhage and most will settle without the need for therapeutic intervention. However, if bleeding is seen at the time of endoscopy, several approaches have been described. The simplest and most readily available technique is the injection of 1:10 000 adrenaline, as for bleeding peptic ulcers, which is sufficient in the great majority of patients.
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Mechanical methods of endostasis such as endoscopic band ligation or clip application have not been shown to be superior to adrenaline injection alone but are appropriate alternatives, particularly when major bleeding or shock has occurred or where adrenaline injection fails to achieve endostasis.
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,
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Gastro-oesophageal reflux disease is responsible for approximately 10% of cases of UGI haemorrhage and is rarely severe. Treatment is with oral PPI therapy.
Major bleeding is occasionally associated with oesophageal, gastric or duodenal tumours. Gastrointestinal stromal tumours (GISTs) may present with bleeding, which can be severe in very occasional cases. Malignancies of the UGI tract commonly cause occult, chronic bleeding but major bleeding can occur and may be difficult to control endoscopically. Management will be dependent on the specific circumstances and may include endoscopic techniques such as argon plasma coagulation, angiographic embolisation or, as a last resort, surgical resection. Where possible, however, if a malignancy is suspected, non-operative methods of achieving haemostasis should be employed, allowing full staging investigations to be organised to guide appropriate management.
This rare cause of UGI bleeding is due to spontaneous rupture of a submucosal artery, usually in the stomach and often within 6 cm of the cardia. The characteristic endoscopic appearance is of a protruding vessel with no evidence of surrounding ulceration. They are commonly missed due to their small size and relatively inaccessible position. Endoscopic clip application or band ligation offers durable and definitive treatment when the lesion is identified. In a small randomised trial,
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haemoclip application was associated with a lower rate of re-bleeding than adrenaline injection, although both achieved similar rates of initial haemostasis.
Endoscopy has a central role in the management of non-variceal UGI bleeding. It enables an early diagnosis and allows for risk stratification. Endoscopic signs or stigmata of bleeding are of prognostic value and, in patients with actively bleeding ulcers or stigmata associated with a high risk of recurrent bleeding, endoscopic therapy stops ongoing bleeding and reduces re-bleeding.
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When compared to placebo in pooled analyses, endoscopic therapy has been shown not only to reduce recurrent bleeding, but also the need for surgery and mortality.
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,
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Forrest et al.
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categorised endoscopic findings of bleeding peptic ulcers into those with active bleeding, stigmata of bleeding and a clean base. A modified nomenclature has been in common use in the endoscopy literature. Laine and Peterson
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summarised published endoscopic series of ulcer appearances in which endoscopic therapy was not used and provided crude figures in both the prevalence and rate of recurrent bleeding associated with these stigmata of bleeding. In ulcers that are actively bleeding (
Fig. 7.1
) or exhibit a non-bleeding visible vessel (NBVV;
Fig. 7.2
), endoscopic treatment should be offered. There has, however, been observer variation in the interpretation of endoscopic signs
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and the National Institutes of Health Consensus Conference
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defined an NBVV as ‘protuberant discoloration’ (
Fig. 7.2
). The endoscopist should search the ulcer base diligently in patients judged to have bled significantly or when there is circumstantial evidence of ongoing or recent bleeding, e.g. presence of fresh blood or coffee-ground materials in the gastroduodenal tract. There has been until recently a controversy whether to wash away adherent clot overlying an ulcer (
Fig. 7.3
). Endoscopists vary in their vigour in clot irrigation before declaring a clot adherent. There have been several randomised studies and a pooled analysis has demonstrated that recurrent bleeding is reduced following clot elevation and treatment to the underlying vessel when compared to medical therapy alone.
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Techniques for clot elevation include target irrigation using a heat probe and cheese-wiring using a snare with or without pre-injection with diluted adrenaline. One should, however, be cautious in elevation of clots overlying large deep bulbar and lesser curve ulcers as some of these may have eroded into larger arteries. A recourse to angiographic embolisation without clot elevation and possible provocation of bleeding may be a better option in sucvh cases. Ulcers with flat pigmentation and clean base (
Fig. 7.4
) are associated with minimal risk of recurrent bleeding. Stable patients with such ulcers can be discharged home early on medical treatment (
Table 7.3
).
Table 7.3
Prevalence and outcomes of ulcers based on endoscopic appearance
Data from Laine L, Peterson WL. Bleeding peptic ulcer. N Engl J Med 1994; 331 (11):717–27.
Figure 7.1
Bleeding vessel in base of ulcer.
Figure 7.2
Visible vessel.
Figure 7.3
Adherent clot.
Figure 7.4
Ulcer with clean base.
Modalities of endoscopic treatment can be broadly categorised into: injection, thermocoagulation, haemoclipping and, recently, the use of haemostatic nano-powder.
Injection therapy has been widely used because of its simplicity. Injection therapy works principally by volume tamponade. Aliquots (0.5–1 mL) are injected near the bleeding point at four quadrants using a 21- or 23-gauge injection needle. Adrenaline 1:10 000 has an added local vasoconstrictive effect. There is no role for the use of sclerosants as there have been fatal case reports of gastric necrosis following its injection and the added injection of a sclerosant such as polidocanol or sodium tetradecylsulphate after pre-injection of diluted adrenaline does not confer any advantage over injection of diluted adrenaline alone. Injection of fibrin or thrombin has been shown to be effective in some studies but repeated injections are required. These products are costly.
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,
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In a canine mesenteric artery model, contact thermocoagulation is superior to injection therapy and non-contact coagulation such as laser photocoagulation in securing haemostasis. Contact thermocoagulation using a 3.2-mm probe consistently seals arteries up to 2 mm in diameter in ex vivo models. Johnston and colleagues emphasised the need for firm mechanical tamponade before sealing of the artery with thermal energy, introducing the term ‘coaptive thermocoagulation’. Mechanical compression alone stops bleeding, reduces heat-sink effect and dissipation of thermal energy. The footprint after treatment provides a clear end-point to therapy. Non-contact thermocoagulation in the form of laser photocoagulation is no longer used as a laser unit is bulky and difficult to be transported. At least in animal experiments, non-contact coagulation in the form of laser photocoagulation is not as effective as contact thermocoagulation. There has also been interest in the use of argon plasma thermocoagulation, with two randomised trials comparing this to injection sclerotherapy or heat-probe treatment, respectively.
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Neither demonstrated any significant difference in treatment outcome.
Haemoclips are commonly used. Their application may be difficult in awkwardly placed ulcers such as those on the lesser curvature of the stomach and the posterior bulbar duodenum. In a meta-analysis of 15 studies with 390 patients
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that compared haemoclipping versus injection and thermocoagulation, successful application of haemoclips (81.5%) was superior to injection alone (75.4%) but comparable to thermocoagulation (81.2%) in producing definitive haemostasis. In this pooled analysis, haemoclipping also led to a reduced need for surgery when compared to injection alone.
Recently the endoscopic use of a haemostatic nano-powder was reported in a small series of 20 patients with actively bleeding peptic ulcers.
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The powder was approved in the United States for external use in traumatic injuries. During endoscopy, the tip of a catheter is placed 1–2 cm from the ulcer. With the push of a button, the powder is then sprayed onto the bleeding ulcer with a pressurised canister with carbon dioxide. It was successful in the control of bleeding in 19 of 20 patients. Comparative studies are required to determine the efficacy of this haemostatic powder. The simplicity of its application certainly appeals to endoscopists.
Soehendra introduced the concept of combination treatment that involved pre-injection with adrenaline allowing a clear view of the vessel, which then allowed targeted therapy using a second modality to induce thrombosis. In a meta-analysis of 16 studies and 1673 patients,
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adding a second modality after adrenaline injection further reduces bleeding from 18.4% to 10.6% (odds ratio (OR) 0.53, 95% CI 0.4–0.69), emergency surgery from 11.3% to 7.6% (OR 0.64, 95% CI 0.46–0.90) and mortality from 5.1% to 2.6% (OR 0.51, 95% CI 0.31–0.84). In an independent meta-analysis of 22 studies (2472 patients),
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dual therapy was shown to be superior to injection alone. However, treatment outcomes following combination treatments were not better than either mechanical or thermal therapy alone. Based on the above pooled analyses, adrenaline alone should no longer be considered an adequate treatment for bleeding peptic ulcers. The current evidence suggests that after initial adrenaline injection to stop bleeding, the vessel should either be clipped or thermocoagulated. In ulcers with a clear view to the vessel, direct clipping or thermocoagulation should yield similar results.
