ASGE Annual Postgraduate Course at DDW: UPPER GI Only (On-Demand) | May 2019-8B Barkun

8B Barkun_Overholt Lecture Acute GI Bleed

Pdf Summary

In this lecture, Dr. Alan Barkun discusses the management of acute upper gastrointestinal (GI) bleeding, focusing on the state-of-the-art hemostasis techniques. He begins by highlighting the decrease in mortality rates for non-variceal upper GI bleeding over the past decade. He emphasizes that hemostasis should only be performed for high-risk lesions, specifically active bleeding, non-bleeding visible vessels, and adherent clots. He suggests considering proton pump inhibitors (PPIs) as an adjuvant to endoscopic hemostasis.<br /><br />Dr. Barkun emphasizes the importance of timely endoscopy in the management of upper GI bleeding, particularly in sicker patients. He discusses the use of endoscopic Doppler probes in predicting rebleeding and the cost-effectiveness of their use.<br /><br />He explores various endoscopic hemostatic modalities, including injection tamponade, thermal methods, endoscopic clips, and hemostatic forceps with soft-mode coagulation. He presents evidence from trials comparing these modalities and concludes that combination therapies with epinephrine are more effective than monotherapy with any single modality.<br /><br />Dr. Barkun also discusses the use of hemostatic powders, such as Tc-325 (HemosprayTM), in actively bleeding ulcers. While Tc-325 has been shown to achieve immediate hemostasis, there is some concern regarding its residency time and the potential for rebleeding in high-risk patients.<br /><br />He recommends using Tc-325 as a temporizing therapy when conventional endoscopic therapies are not available or fail. However, he advises against using Tc-325 as a single therapeutic strategy compared to conventional endoscopic therapy.<br /><br />In cases of refractory bleeding, Dr. Barkun suggests repeat endoscopy using the discussed modalities. He also mentions the potential use of trans-arterial embolization in refractory patients, although it is a rare occurrence.<br /><br />Overall, Dr. Barkun provides several practice pearls for upper GI endoscopic hemostasis, including adequate resuscitation before any intervention, understanding the indications and limitations of Tc-325, and considering the use of over-the-scope clips in high-risk patients. He emphasizes the importance of performing procedures only in a clinical setting with appropriate support and one's comfort level.

Keywords

acute upper gastrointestinal bleeding

hemostasis techniques

non-variceal upper GI bleeding

high-risk lesions

proton pump inhibitors

endoscopic hemostasis

endoscopy

rebleeding

injection tamponade

hemostatic powders