Best of DDW: GI Bleeding Melissa Latorre, MD MS Director, Inpatient - - PowerPoint PPT Presentation

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Best of DDW: GI Bleeding Melissa Latorre, MD MS Director, Inpatient - - PowerPoint PPT Presentation

Dec 23, 2023 109 likes •450 views

Best of DDW: GI Bleeding Melissa Latorre, MD MS Director, Inpatient Gastroenterology Services Tisch/Kimmel Assistant Professor of Medicine NYU Langone Health June 1, 2019 Agenda 1. Review the newest tool on the endo cart 2. Rethink our

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Best of DDW: GI Bleeding

Melissa Latorre, MD MS Director, Inpatient Gastroenterology Services Tisch/Kimmel Assistant Professor of Medicine NYU Langone Health June 1, 2019

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Agenda

  • 1. Review the newest tool on the endo cart
  • 2. Rethink our choice of clip
  • 3. Reevaluate a common problem
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HEMOSPRAY

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What is Hemospray?

  • Inert mineral powder
  • FDA approved for non-variceal GI bleeds
  • Available in 7F or 10F
  • No human, animal or allergen products
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How Does it Work?

  • Water absorption
  • Cohesive +

Adhesive

  • Barrier Formation
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How Do You Use It?

Graham, T. https://www.kpaonline.com/roles/ehs/fire-extinguisher-safety/

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How Do You Use It?

Push the catheter Aim the tip Squeeze the button Sweep the scope

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Challenges

  • Advancing the catheter
  • White out!
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Outcomes on the Use of Hemospray in Upper GI Bleeds Secondary to Peptic Ulcers: Prospective Multicentre International Hemospray Registry

Mohamed Hussein1, Durayd Alzoubaidi2, Miguel Fraile López3, Jacobo Ortiz Fernández-Sordo3, Krish Ragunath3, Radu Rusu4, Jason Mark Dunn4, Johannes Wilhelm Rey5, Shraddha Gulati6, Bu Hayee6, Selena Dixon7, Sulleman Moreea7, Duncan Napier8, John Anderson8, Martin Dahan9, Max Hu10, Patricia Duarte10, Phil Boger10, John McGoran11, Inder Mainie11, Alberto Murino12, Sina Jameie-Oskooei12, Edward J. Despott12, Cora Steinheber13, Martin Goetz13, Sharmila Subramaniam14, Pradeep Bhandari14, Laurence Lovat2, Emmanuel Coron9, Ralf Kiesslich5, Rehan Haidry1,2

1University College London Hospital, London, United Kingdom; 2University College London, London, United Kingdom; 3NIHR Nottingham

Digestive Diseases Biomedical Research Unit, Nottingham University Hospital, Nottingham, United Kingdom; 4Guy’s and St Thomas Hospitals, London, United Kingdom; 5Horst Schmidt Kliniken, Weisbaden, Germany; 6Kings College London, London, United Kingdom; 7Bradford Hospitals Foundation Trust, Bradford, United Kingdom; 8Gloustershire Hospitals NHS Foundation trust, Cheltenham, United Kingdom; 9University Hospital of Nantes, Nantes, France; 10University Hospital Southampton, Southampton, United Kingdom; 11Belfast health and social care trust, Belfast, United Kingdom; 12Royal Free Hospital, London, United Kingdom; 13Tübingen University Hospital, Tübingen, Germany; 14University of Portsmouth, Portsmouth, United Kingdom;

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Design

  • Prospective
  • UK, France, Germany
  • Jan 2016 - Sept 2018
  • PUD: Esophageal, Gastric & Duodenal
  • Hemospray monotherapy, dual (with epi), rescue therapy
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Outcomes

PRIMARY SECONDARY

  • Hemostasis: cessation of bleeding

within 5 minutes

  • Hemostasis by ulcer type & location
  • Rebleeding: following EGD

➢ Drop > 2g/l ➢ Hematemesis/Melena + hemodynamic instability

  • 7 and 30 day all-cause mortality
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Results

  • 196 patients
  • Hemostasis: 87%
  • Duodenal (63%)

Gastric (22%) Esophageal (15%)

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Results

Alzoubaidi D, et al. Frontline Gastroenterology 2019;10:35-42.

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Conclusions

  • Hemospray is effective for hemostasis and

in PUD.

  • Best outcomes in Forrest 2B

– Hemostasis – Rebleeding – 7 and 30 day mortality

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OVER-THE-SCOPE CLIPS

Image: Goelder SK, et al. World J Gastrointest Endosc. Feb 2016.

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Why Over-the-Scope-Clip Is Potentially More Effective Than Standard Endoscopic Hemostasis as Primary Treatment of Severe Non-Variceal Upper GI Bleeding

Dennis M. Jensen2,1,3, Thomas O. Kovacs2,1, Kevin A. Ghassemi2,1, Marc Kaneshiro2,1, Gareth Dulai2,1, Gustavo

  • A. Machicado2,1

1David Geffen School of Medicine Medicine at UCLA, Santa Monica, California, United States; 2CURE

Digestive Diseases Research Center, Los Angeles, California, United States; 3West Los Angeles Veterans Administration Medical Center, Los Angeles, California, United States;

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Design

  • Prospective
  • USA
  • Severe non-variceal upper GI bleeding
  • Intervention: Over-the-Scope Clip (OTSC) + Doppler

Endoscopic Probe (DEP)

  • Results were compared to 2 prior studies using OTSC,

standard clips and DEP

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Outcomes

PRIMARY SECONDARY

  • Obliteration of arterial

blood flow (ABF)

  • 30 day rebleeding
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Results: OTSC Patients

Lesion Total (n=20) Duodenal Ulcer 12 (60%) Gastric Ulcer 7 (35%) Dieulafoy 1 (5%)

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Results: Residual ABF

Placement Residual ABF

OTSC placement alone 1/20 (5%) OTSC + DEP 0/63 (0%) Standard hemoclip alone 23/88 (26%)

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Results: 30 day Rebleeding

Placement Rebleeding

OTSC placement alone 1/20 (5%) OTSC + DEP 0/63 (0%) Standard hemoclip alone 20/76 (23.6%)

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Conclusions

  • OTSC is more effective than standard

endoscopic hemostasis at obliterating blood flow in severe NVUGIB.

  • Residual ABF correlates to higher rebleeding.
  • OTSC has the potential to reduce rebleeding
  • ver standard hemoclips.
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PROPHYLACTIC HEMOCLIPPING

Image: Goelder SK, et al. World J Gastrointest Endosc. Feb 2016.

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A Prospective, Randomized Trial of Prophylactic Hemoclipping for Preventing Delayed Post-Polypectomy Bleeding in Patients with Large Colonic Polyps

Linda A. Feagins2,1, Andrew David Smith2, Daniel Kim2, Akeel Halai2, Suneetha Duttala2, Benjamin Chebaa2, Tisha Lunsford3,4, John A. Vizuete4, Miriam Mara3, Ranjan Mascarenhas5, Rabia Meghani5, Leon Kundrotas3,4, Kerry Brandt Dunbar2,1, Daisha J. Cipher6, William V. Harford2,1, Stuart J. Spechler7

1University of Texas Southwestern Internal Medicine, Dallas, Texas, United States; 2VA North Texas

Healthcare System, Dallas, Texas, United States; 3South Texas Veterans Healthcare System, San Antonio, Texas, United States; 4UT San Antonio Health Sciences Center, San Antonio, Texas, United States; 5Central Texas Veterans Healthcare System, Austin, Texas, United States; 6University of Texas at Arlington, Arlington, Texas, United States; 7Baylor University Medical Center, Dallas, Texas, United States;

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Design

  • Prospective
  • USA – Four VA Centers
  • Random, stratified by antiplatelet & anticoagulant
  • Prophylactic clipping or not for polyp ≥ 1 cm
  • Follow-up at 7 and 30 days for delayed bleeding
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Outcomes

PRIMARY SECONDARY

Important delayed bleeding

  • Hg drop ≥ 2g/dL
  • Hemodynamic instability
  • Repeat endoscopic evaluation
  • Angiography
  • Surgery

Unimportant delayed bleeding

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Results: Demographics

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Results: Polyps

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Results: Important Delayed PPB

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Conclusions

  • Remember the option of Hemospray in GI

bleeding.

  • Consider all options when clipping.
  • Contemplate whether prophylactic clipping

is really necessary.

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Questions?