It's now my pleasure to introduce Dr. Jennifer Christie, who is professor of medicine at Emory University, and as of the end of this meeting will be our present elect. Okay. Welcome. All right, good afternoon, everyone, and I am honored to discuss with you controlling GI bleeding following the guidelines. So in preparing for this talk, I looked at guidelines from across the globe, and a lot of the guidelines, they have a range from either nine statements or suggestions to about 27. I decided to distill it down to about eight statements because there was consensus around those eight statements, or I know that these are common questions that we deal with when patients come into our units with GI bleeding. Here are my disclosures. So the objectives are one, to review the guidelines as it relates to initial management, understand the role of endoscopy in these patients who present with GI bleeding, review the guidelines on hemostatic techniques, and then lastly, discuss post-endoscopic management. So as a foundation, as we know, GI bleeding is the most common GI-related reason for hospitalization in the United States. With about 500,000 hospitalizations per year, most of these are upper GI bleeds, and we're still at about a 10% 30-day mortality rate. So we know the sources of GI bleeding are vast. As it relates to upper GI bleeding, it can be divided into variceal and non-variceal. For the purposes of this talk, I'll focus mostly on non-variceal bleeding. So the overarching goals in terms of controlling GI bleeding are to, one, risk stratify these patients, so when they hit the door, know who needs to be scoped when and by whom. We have to stabilize them, and then again, decide when to perform endoscopy, and usually for upper GI bleeding, and I'll show you some data on this, it's within 24 hours. And then do whatever we can to decrease the risk of recurrent bleeding, and that involves also managing their endothrombotics. And then lastly, and ultimately, to minimize morbidity and overall mortality. So this is just some of the guidelines I reviewed, and they come from the American societies, Asian societies, as well as European societies, and then an international consensus group. So as I mentioned, number one, risk stratification is key. And for upper GI bleeding, we most commonly use the Glasgow-Blatchford scale, and this particular scale utilizes hemodynamics as well as comorbidities. But ultimately, the goal is to decide which patients may be able to be discharged from the ER and followed up as an outpatient. And these are patients who have a score of either zero to one. And for lower GI bleeding, a lot of countries, specifically in Europe, use the Oakland score. And again, the Oakland score employs seven variables, age, hemodynamics, as well as previous lower GI bleeding admissions. And if an individual has a Oakland score of less than eight, oftentimes these patients can also be discharged and followed up as an outpatient. But of course, there are individual nuances that we have to consider. So the second statement or suggestion that I want to highlight is to use a restrictive transfusion approach. And that is keeping the hemoglobin somewhere between seven and eight. So this recommendation comes from individual as well as pooled studies looking at re-bleeding rates as well as death. So in this particular study by Adetayo and colleagues that was published in Lancet shows that a more restrictive approach favors decrease of re-bleeding as well as mortality. So generally, that's what we try to do. Of course, patients who are coming in and exsanguinating, this does not apply to them. Or patients who are coming in with acute coronary syndrome. The third statement that I chose was to discuss timing of endoscopy. So specifically for upper endoscopy, there's been some controversy in the past. But this recent study by Lau and colleagues that was published in the New England Journal in 2020 showed that for patients who underwent urgent upper endoscopy for upper GI bleeding, so that's within six hours of hitting the door, compared to 24 hours of hitting the door, that the patients who actually underwent endoscopy within 24 hours, there was really no difference between the six-hour group and the 24-hour group in terms of mortality as well as death. And this is reflected on these Kaplan-Meier curves. So as far as lower GI bleeding, again, we know colonoscopy is the procedure of choice in patients who present with a lower GI bleed, specifically if they're not super unstable. And this particular meta-analysis and systematic review by Kawanda and colleagues that was published in GIE show that if patients who were scoped within 24 hours of hitting the door versus 24 hours after hitting the door, there really was no difference in terms of transfusions, re-bleeding rates, as well as adverse events and mortality rates. So patients who are coming with bleeding, it's best to stabilize them, make sure we can get a good prep so we can actually see where the bleeding is coming from, and then making sure an experienced endoscopist is available to scope them. Now, as far as what we do endoscopically, so still, endoscopic therapy for active spurting, oozing, and non-bleeding visible vessels, and this is a strong recommendation, and this is based on moderate quality evidence. And dual therapy is still always the way to go. So we know that bipolar coagulation heater probe as well as sclerosant injections are very effective, and there's really no difference between these therapies in terms of efficacy and decreased re-bleeding rates. Also, through the scope clips can be very effective, similar outcomes, particularly in diverticular bleeding, and then we also know that argon plasma coagulation is also effective as well as soft monopolar electrocoagulation. And still, has not changed, epinephrine can be used to gain control, but never as model therapy in either upper GI or lower GI bleeding. So in this particular patient that came in, he came in bleeding and had a scope at an outside hospital, and his wife said he was cauterized. When we went in, it was clear that it looked like an AVM, but it was ulcerated. So we injected it with epi first, and then decided to put some clips on it. It was still kind of oozing, so we washed it and then applied two more clips. You see there's just some mucosal oozing there, but otherwise we got good hemostasis. So in terms of soft monopolar electrocoagulation, this was first used for hemostasis in ESD. However, studies have shown that it's very effective in patients who are presenting with peptic ulcer disease as well as a diverticular bleed. Basically, the catheter is closed, and the tip is placed on the bleeding site, and between 50 and 80 watts of energy is applied, and we get good cautery there. Sometimes you can actually grasp the bleeding site with the forceps. So this particular study by Tonka showed that when they randomized patients to either get injection and monopolar electrocoagulation versus hemoclip, that actually the patients in the monopolar group achieved higher hemostasis rates initially compared to the hemoclip group and also had lower re-bleeding rates. The fifth recommendation or suggestion I want to highlight is that in patients who are having ongoing or recurrent bleeding, that some of these other new hemostatic techniques may be applied, such as hemospray and over-the-scope clips. So the hemosprays, typically it's a nanopowder or a polysaccharide that forms an adhesive barrier when it hits moisture, and it's been shown to increase clot formation and actually decrease coagulation time. This particular study by Chen and colleagues in 2020 showed that in 20 patients who were randomized to either receive the spray versus standard of care, that the patients that achieved the hemostasis were in the hemospray group. As far as over-the-scope clips, these clips can be very effective in those large fibrotic ulcers that are otherwise hard to clip with a standard hemoclip. So it can be very helpful. And usually it's used with a distal cap on the end and then suctioned into the cap and deployed onto the bleeding vessel, similar to what we do for variceal ligation. So far, as far as PPI use, controversial or not clear as far as using PPIs pre-endoscopy. However, it's very clear that after you intervene endoscopically, that high-dose PPI therapies for four days is much better than placebo. Studies have shown all of these guidelines, looking at randomized controlled trials, have shown that it decreases further bleeding, mortality rates, and surgery. But there's really no difference between either doing continuous IV PPI or intermittent. However, the IV or oral bolus dose may be helpful initially. So the seventh recommendation I wanted to highlight was that if your patient's coming back still bleeding, scope them again. And this is particularly clear for colonoscopy. If patients who are at high risk or still bleeding, then we recommend IR or surgery. And specifically IR for patients who are unstable, however, with a CT angio first. Other techniques that I wanted to highlight is this red diachromatic imaging that may enhance the visualization of the actual bleeding site, as opposed to white light. And also CAP-assisted endoscopy can be very helpful to move folds, move clots, et cetera, but kind of difficult when getting around some areas. And then also Doppler ultrasound. So the two take-home points, risk stratification and stabilization, are foundational. Dual therapy is still the dogma. Hemostatic sprays and over-the-scope clips can be used as a second-line therapy. And of course, PPI after endoscopic intervention and decision regarding surgery or IR should be based on patient characteristics. Thank you.

GI bleeding

guidelines

risk stratification

endoscopy

hemostatic techniques