It is my immense pleasure to introduce my co-director, Dr. Joanna Law. She's a therapeutic gastroenterologist at Virginia Mason in Seattle. She completed her medical school residency and general GI fellowship at UBC and her therapeutic fellowship at John Hopkins. She has a master's in education with an interest in the intersection of learning and technology. She has sat on multiple committees of the ASGE, including the training committee, standards of practice, and currently she's on the women's committee with me. She has an invested interest in EUS, pancreatic disease, and hereditary GI cancer syndromes. She's going to be speaking about what's new in GI bleeding in 2023. Dr. Law. Thank you. Thanks, Terrence. I want to thank all of you guys for being here. It's really been amazing just getting all of this set up. Thank you to ASG for supporting all of this as well. What's new in GI bleeding in 2023? These are my disclosures. By the end of my talk, I hope that you just have a quick review of the risk stratification for patients presenting with non-variceal upper GI bleeding, and I'm primarily focusing on that, talking about endoscopic therapies, including the new approaches, and then management of specific scenarios, specifically the anticoagulants, antiplatelet agents, and tumoral bleeding. Just as way of background, in context of things that we see and we do as women, especially, you know, currently the incidence per 100,000 population in the United States in 2022 for breast cancer is 128, non-variceal GI bleeding anywhere between 50 to 150, depending on the literature you look at, and then colon cancer is about 25 to 30. So in that context of things that we see and do, GI bleeding definitely up there. So you know, just as you approach a patient with any condition, you want to have a framework. I really, really want to emphasize that it's important that you have some sort of assessment score or some system that you look at or use to help in terms of predict your patient's severity of their GI bleeding. I like the Rockwell score because it does incorporate your endoscopy findings, but obviously that helps that you do need to do your endoscopy, whereas the Glasgow Blatchford does kind of give you a sense or aim 65, but choose some sort of scoring system that helps you kind of predict, is this person a low, intermediate, or high risk? Low risk patients are basically patients who you can manage as an outpatient, and these are the Rockwell scores. For those of you who haven't done this and do a lot of talks, CHAT-GPT can be your best friend. Literally, I was like sitting there using CHAT-GPT again, like, what is the indication of the Rockwell score of, what is a low Rockwell score, and what does it mean? And like, gave me all this information, I was like, wonderful. So I didn't have to like go all the papers, but I did correlate all of this just to confirm it. Obviously, you know, the higher the scores, and aim 65 does give us some mortality risk, especially inpatient mortality, which I think is important for us to be aware of, because no matter at the end of the day, we're still losing patients from GI bleeding, which is always really, really hard, because you know, we see so much GI bleeding, and then to have a patient die, it's still not a rare event. So force classification, this is your endoscopic evaluation of a peptic ulcer, starting from left to right, lowest to highest risk. So force class one is a far clean-based ulcer, two is the, the second one is the 2C, which is a flat pigmented spot, or 2A, I mean, sorry, 2B is the one next to it, which is the adherent clot, which is kind of that in the middle, do you, don't you, what are you going to do with that adherent clot? Then obviously the ones on the right, so your 2C, sorry, 2C, 2B, 2A, so 2A is the one with the visible vessel, and then the oozing vessel, and then the spreading vessels are the ones you definitely want to do therapeutic interventions to. So, and then your re-bleeding risk are below, so you have up to a 20% re-bleeding risk after endoscopic therapy in these lesions. So these are some of the therapeutic interventions that we do have, all of us know about epinephrine, which is a temporizing measure. You should always avoid only epinephrine monotherapy, you should use, if you do use epinephrine for controlling your bleeding, you should be thinking of a second therapy. Then there's the mechanical and thermal therapies that we're going to go, you're going to have experience with the mechanical therapies in the lab, but, you know, the different clips, and then also from thermal, basically bipolar and contact versus non-contact thermal therapies. And the more other novel thing under injectables or sprays are the hemostatic powders, which you will also have experience from when you hit the lab. So who, what, and where? So who are we going to do therapy on? And those are the patients who present with a spurting, oozing, or a non-bleeding visible vessel. In the ones with the adherent clot, that's kind of the gray zone, and that depends on what you're comfortable with, but most of us do, will do, highly recommend removing that clot to see what's underneath it to better risk stratify, is it just a clean base ulcer there? Is there a non-bleeding, is it a pigmented spot now? Because if there is indeed, you know, a non-bleeding visible vessel, then that makes them obviously a two-way. So the adherent clot, you should think about removing. And as I mentioned earlier, in terms of endoscopic therapies, I've discussed those, but think about having adjunct devices. So a lot of us, if it is in the duodenal bulb, or even if it's someone who's had an ERCP and you're worried about a sphincterotomy bleed, having a distal cap, attachment cap, can help in terms of exposing, stabilizing, allowing you to do therapeutics. If you're comfortable using a duodenoscope in someone who's had a recent ERCP or is in a difficult position in the duodenum, then think about using a side-viewing or a duodenoscope. The other adjuncts you have to think about are using like, say, some of these clot-busting tubing, or the larger therapeutic endoscope with the larger therapeutic channel that allows for more suction power. However, re-bleeding still occurs. It can occur in anywhere between 8% to 26% of our patients after primary endoscopic therapy. And once you start talking about repeat or secondary therapy for a repeat bleed, your endoscopic hemostasis decreases by 27% after conventional therapy, so after using either epinephrine, CLIPS, or thermal therapy. So I'm now going to talk a little bit about contact thermal therapy, of which there are two available types on the market. There used to be heater probes. Those are no longer available. So the two ones that are available are the multipolar probes and the monopolar probes or hemostatic forceps. I'm not going to talk much about the forceps because they are quite expensive and not a lot of centers have them. They're more commonly used by people who are doing ESDs and EMRs, but the multipolar probes are probably the ones you guys are most familiar with. The take-home really is that you should be using 15 to 20 watts for bipolar or multipolar probes. You should be doing forceful contact for 10 to 14 seconds, which are probably the longest 10 seconds I can imagine. As I sit there going, one buttercup, two buttercup, and it's just watching the fellow do it and you're just like, oh, this is going to hurt. But think about using also the 10 French catheters, a lot of the guidelines. So a lot of this is from the AGA guidelines are recommending the 10 French catheters that do require the larger working channel to pass through because otherwise it's a seven French catheter. In terms of non-contact thermal therapy, this is really reserved for the superficial bleeding. So the gastric, the AVMs or GAVE or portal hypertensive bleedings of which most of us are probably most familiar with our argon plasma. And then let's now focus a little bit about the new hemostatic techniques of which there are really two types that are evolving in the literature and getting more evidence. The over-the-scope clips of which there are two types and we're going to see them in the lab as well, the Ovesco and the Padlock. Currently there's no head-to-head trial comparing the through-the-scope clips, which is what we're most used to with over-the-scope versus thermal therapy in primary therapy for GI bleeding. Most of us are agreeing that this is probably a rescue modality. So in someone who you couldn't get control of bleeding on your index scope or presents now with a re-bleed and you know where the lesion is, you may want to think about using your over-the-scope clips. Also there's a question about maybe this should be your first line therapy for the large fibrotic ulcer beds with a visible vessel. And then hemostatic powder is usually reserved as a rescue therapy. However, there are some guidelines and recommendations saying that maybe you should be using this as a primary therapy at this time if you're unable to get index control or in tumor bleeding. So currently I know of two available products that are quite readily available. There is a third here in the United States. The most common one is the Cook spray or Hemo spray TC325, Olympus makes the Endoclot. How many people are using these sprays right now or have experience with them? And how many are using the Cook spray? Great. Perfect. And then how many are using Olympus? Wonderful. For those of you who haven't seen this video, this is Andy Tao's video that he published in Video GIE on using the hemostatic spray. You're going to have a link to it on your cards that we're giving out to you. But basically, the thing as many of you guys know is that the hemostatic sprays clot up or basically gum up in your channels when it gets in contact with fluid or blood or water. I love this trick because it was really, really, really easy. What they did was with the Cook system, they put a little bit of bone wax on the tip of the catheter that they were going to introduce into the scope so you don't have to worry about cleaning your channel. You don't have to worry about not using your water button. And then basically what you do is you advance that catheter with the bone wax on the tip through your scope. And on the other end, the working end, instead of hooking directly the catheter to the spray gun, they put a three-way stock cock and then a 60cc filled syringe so that when you're in position, all you do is you're just basically going to use your 60cc syringe, push off that bone wax, and then you can start spraying right away. It's a great little technique if you're not using this already, but it's wonderful in terms of especially with trainees, there's less pressure about screwing up your catheter. The Olympus system kind of has that already built in because it's got a continuous CO2 delivery mechanism that allows that. You can also modify this system as well so that you can actually take your CO2 from your scope, from your processor, put it on that three-way stock cock as well, and then just use air for insufflation. So I'm not sure if that made sense to everyone. So here it is with the three-way stock cock on. He's just going to use it in water, but he's got the bone wax on. And see, he's got it in the water. No big deal. You can be in blood. You can be using your water button. And basically push. That piece of bone wax comes off, switch your three-way stock cock to firing, start firing away your hemo spray. And you almost never have to reach for your second catheter in the box for that. Has anyone actually used this or does this in their institution, using this trick? Have you tried it, Amandeep, since we chatted? I honestly do love this, especially with trainees and especially when you're in a difficult situation or if you're with a new tech or a new nurse. It's sometimes very difficult because it's so stressful because that blood can clot it up and then you've gummed up your view and you've gummed up your catheter and you're already in a stressful situation. So I do love this technique, and we will have that set up for you for those of you who are interested in doing the hemo spray. Can we go back to my PowerPoint now, please? But yeah, so you can see this beautiful view he's got all the entire time. And you can see there's fluid. It doesn't have to be a dry field, but... Thank you. So that was a little trick I love and hoping that we can all walk away with. Can we go to the next? Perfect. So as I mentioned earlier, the AGA guidelines published in 2020 basically incorporates the hemostatic sprays in the management of upper GI bleeding. So they're here, they're like your findings at initial endoscopy. If you have poor visibility or it's diffuse bleeding, you really don't think you're going to have any targeted mechanical or thermal control, then you can spray hemostatic powder. And that's the first branch. If it's malignancy, then you consider radiation. If it's non-malignancy, consider further endoscopic therapy. So repeat look after 24 hours. If your initial attempts at bleeding to control with standard endoscopic therapy are not successful, then consider hemostatic spray as second line modality and retreat as needed. And then obviously your regular... So it's just like your normal guidelines that we were all trained in our fellowship, except including hemostatic sprays. So a couple of new considerations, and again, showing my age, DOACS, NOACS, DAPT, I was And you're like, oh, wait, okay, I know anti-platelets are different from, oh, but yeah, so they're not novel anymore. They're just non-vitamin K oral anticoagulants. So we're still allowed to say NOACS, just not novel. But special considerations, so the patient comes in with her hemoglobin is six, but there's going to be that one patient who's got a tumor in addition, a gastric tumor, but also has a pulmonary embolism and also had a recent coronary stent placed. And you're just like, really, buddy? So the things about oral anticoagulants is they are associated with a fourfold increase in GI bleeding, which is also associated with an increase in all cause mortality and need for surgery and higher number of transfusions needed. Of the oral anticoagulants, we all know that there are really the two types, the vitamin K antagonists and the non-vitamin K antagonists. And basically, the non-vitamin K antagonists are felt to be less risk for GI bleeding overall compared to warfarin. However, re-bleeding on any oral anticoagulant is associated with higher comorbidities or presenting with duodenal bleeding. So if you do have a patient that comes in on some anticoagulant and you fix them, but you know that they're a sick patient or they're presented with duodenal bleeding, like sick prior comorbidities, then those are the ones who are going to re-bleed after your index. So those are the higher, higher risks. Shreya briefly talked about, in terms of your pre-procedure in these patients, do you reverse, not reverse? Most of us are not giving vitamin K, are not giving fresh frozen plasmas. You want to think about these PCCs if you're going to give them. And that's really an institutional decision. At endoscopy, basically, you want to think about mechanical versus thermal monotherapy or consider other therapies if you don't think you have control. Second line, endoscopic therapy, if someone re-bleeds, is usually appropriate unless you don't think that you're going to be able to get, because of the type of bleeding, you may want to consider IR. And then post-bleeding, in terms of these oral anticoagulants, when to resume and what to resume for them. With regards to anti-platelet agents, this is a great chart. The only thing I disagree with, perhaps, in this chart from 2018 is the aspirin. Most of us will not stop aspirin for, and I will, though, plead for the lowest dose of aspirin possible. So I'm not sure when an indication for 650 milligrams daily of aspirin ever is indicated, I do understand 325 in some patients is much more better, is better for them than 81, but I think most people do get away with 81. But otherwise, if this is for primary prevention, then most people would say your anti-platelets can probably be held, but I will still say that, and I do think that the new guidelines say that in primary prevention, aspirin is really not necessary anyway. So you can probably get away with holding your aspirin, but I thought this flowchart was otherwise quite helpful. And then with regards to tumoral bleeding, there is a randomized control literature that does suggest that hemostatic sprays should be first-line treatment when they present with bleeding. So I hope that by the end of today, all of you guys are comfortable with hemostatic sprays in addition to the other adjuncts, including the over-the-scope clips. But from this talk, I hope that you guys have learned or recognized the high-risk factors and the different endoscopic approaches.

gastrointestinal bleeding

endoscopic therapies

bleeding ulcers

hemostatic techniques

tumoral bleeding