ASGE Annual Postgraduate Course: Clinical Challenges and Real-Time Decision Making in GI Endoscopy (Live and Virtual) | May 2023-Barkun

Barkun_New tools for Non-Variceal UGI Bleeding

Pdf Summary

This document discusses new tools and modalities for the management of non-variceal upper gastrointestinal (GI) bleeding. It begins with an introduction to the current mortality rates and management strategies for this condition, emphasizing the importance of endoscopic hemostasis and adjuvant Proton Pump Inhibitors (PPIs). The document then explores the newer modalities available for treating patients, including hemostatic topical products such as Tc325 (Hemospray) and cap-mounted over-the-scope clips. <br /><br />Several studies are referenced, highlighting the predictors of rebleeding in refractory lesions and the timing of endoscopy in high-risk patients. The authors also discuss the use of various hemostatic therapies for peptic ulcer bleeding, presenting a table of different modalities, their certainty of evidence, and strength of recommendation. <br /><br />The document specifically focuses on Tc-325 (Hemospray) as a hemostatic powder spray for actively bleeding ulcers, with evidence supporting its efficacy in achieving hemostasis. However, the high cost of this modality in certain countries raises concerns. <br /><br />Furthermore, the use of topical hemostatic agents, mainly Tc-325 (Hemospray), is discussed in detail, with a large meta-analysis showing its effectiveness in achieving immediate hemostasis. However, there is conflicting evidence regarding rebleeding rates. The document also briefly touches on hemostatic powders/gels and their role in managing bleeding ulcers. <br /><br />Regarding malignant bleeding, very few approaches have been found to be helpful, and there are no guideline recommendations in this population. The document mentions limited high-quality studies in this group and suggests that further research is needed. <br /><br />Additionally, the use of over-the-scope clips (OTSC) for recurrent bleeding due to ulcers is explored. Evidence suggests that OTSC is superior to standard therapy in reducing further bleeding. However, there are methodological issues and varying definitions of endpoints in the studies. Adverse events such as pseudopolyp formation or perforation are also mentioned. <br /><br />In conclusion, the document emphasizes the importance of endoscopic hemostasis in improving outcomes for patients with refractory bleeding and potentially malignant bleeding. Newer modalities like hemostatic topical agents (particularly Tc-325) and over-the-scope clips are highlighted as useful for refractory bleeding and rescue therapy. However, the roles of these modalities as initial therapies in peptic ulcers and other causes of non-variceal upper GI bleeding remain uncertain. The document suggests that guidelines will likely recommend the use of topical agents and over-the-scope clips. Optimal patient selection and cost-effective implications are still under investigation. Overall, the document advises performing endoscopic hemostasis in an optimized setting and seeking consultation from colleagues in refractory cases.

Keywords

non-variceal upper gastrointestinal bleeding

endoscopic hemostasis

Proton Pump Inhibitors

hemostatic topical products

Tc325

Hemospray

cap-mounted over-the-scope clips

peptic ulcer bleeding

malignant bleeding

over-the-scope clips