Hemodynamics after endoscopic submucosal injection of epinephrine in patients with nonvariceal upper gastrointestinal bleeding: a matter of concern

Is insertion of a plastic stent better and safer than epinephrine injection in post sphincterotomy bleeding?

OBJECTIVES

Epinephrine injection is the therapy of first choice in post sphincterotomy bleeding (PSB), but may not be efficient in all cases and can cause postprocedural myocardial infarction. Plastic stent insertion (PSI) may be a better treatment. The aim of this retrospective study was to compare epinephrine injection with PSI with respect to efficacy and safety.

METHODS

Clinical success, number of reinterventions and hospital stays after therapy, postprocedural myocardial infarction, bilirubin increase, and pancreatitis as well as factors influencing PSB were analyzed.

RESULTS

Seventy-nine PSBs in 5798 endoscopic retrograde cholangiopancreaticographies (ERCPs) from August 2002 through October 2018 were treated by epinephrine injection, PSI or both (n = 34, 30, 15). Clinical success of PSB therapy showed no difference: 33/34 (97%), 30/30 (100%), 14/15 (93%). Reinterventions were more frequent (n = 30 versus n = 1; P ≤ 0.0001) and hospital stay was longer [median: 3 (2-10) versus 2 (1-3) days; P = 0.0357] in patients who received PSI (versus epinephrine injection). Postprocedural adverse events were very rare: bilirubin increase (1/2/0) and pancreatitis (0/2/1). Intraprocedural episodes of hypertension (≥180 mmHg) were documented in 45-54%.

CONCLUSIONS

Epinephrine injection is better than PSI in PSB. PSI may be an adequate treatment in patients with otherwise indicated stent insertion. Intraprocedural episodes of hypertension may be a risk factor for PSB.

Devices for endoscopic hemostasis of nonvariceal GI bleeding (with videos)

Background

Endoscopic intervention is often the first line of therapy for GI nonvariceal bleeding. Although some of the devices and techniques used for this purpose have been well studied, others are relatively new, with few available outcomes data.

Methods

In this document, we review devices and techniques for endoscopic treatment of nonvariceal GI bleeding, the evidence regarding their efficacy and safety, and financial considerations for their use.

Results

Devices used for endoscopic hemostasis in the GI tract can be classified into injection devices (needles), thermal devices (multipolar/bipolar probes, hemostatic forceps, heater probe, argon plasma coagulation, radiofrequency ablation, and cryotherapy), mechanical devices (clips, suturing devices, banding devices, stents), and topical devices (hemostatic sprays).

Conclusions

Endoscopic evaluation and treatment remains a cornerstone in the management of nonvariceal upper- and lower-GI bleeding. A variety of devices is available for hemostasis of bleeding lesions in the GI tract. Other than injection therapy, which should not be used as monotherapy, there are few compelling data that strongly favor any one device over another. For endoscopists, the choice of a hemostatic device should depend on the type and location of the bleeding lesion, the availability of equipment and expertise, and the cost of the device.

Complications of therapeutic gastroscopy/colonoscopy other than resection

Gastrointestinal (GI) endoscopy is profoundly utilized for diagnostic and therapeutic purposes. The therapeutic potential of GI endoscopy has amplified many folds with the evolution of novel techniques as well as equipments. However, with the augmentation of therapeutic endoscopy, the extent, likelihood and severity of adverse events have increased as well. The attendant risks and adverse events with therapeutic endoscopy are many folds that of diagnostic endoscopy. Besides endoscopic resection, therapeutic endoscopy is widely utilized for hemostasis in GI bleeds, dilatation of stenosis, enteral stenting, foreign body removal, ablation of Barrett's esophagus etc. Major adverse events associated with interventional endoscopic procedures include bleeding and perforation. Adverse events of endoscopic interventions are diverse and related to the underlying disease, therapeutic modality used and operator's experience. Many of these adverse events can be prevented. Early recognition of an unavoidable adverse event is important to minimize the associated morbidity and mortality.

Cap-assisted hemoclip application with forward-viewing endoscope for hemorrhage induced by endoscopic sphincterotomy: a prospective case series study

Background

Endoscopic sphincterotomy (ES) is a therapeutic technique developed as an advanced application of endoscopic retrograde cholangiopancreatography (ERCP). An important adverse event associated with this procedure is hemorrhage, which may sometimes be uncontrollable. We sought to examine whether cap-assisted hemoclip application is effective in controlling ES–induced hemorrhage.

Methods

In this prospective study, we investigated the outcomes in 10 patients who had uncontrolled ES–induced hemorrhage and were treated by cap-assisted application of hemoclip with a forward-viewing endoscope.

Results

Nine of the 10 investigated patients were successfully treated using the cap-assisted hemoclip technique with forward-viewing endoscope, yielding a success rate of 90 %. The patient with hemorrhage non-responsive to hemoclipping required catheter embolization of the bleeding artery after its identification by digital subtraction angiography. One of the 10 patients developed mild pancreatitis after the procedure, but was successfully managed conservatively.

Conclusions

Cap-assisted hemoclip application with a forward-viewing endoscope appears to be an effective therapeutic modality for achieving hemostasis in cases of ES–induced hemorrhage, without the occurrence of any severe adverse events; we believe that this method should be considered as an option in the management of ES–induced hemorrhage.

Endoscopic mucosal resection

EMR has become an established therapeutic option for premalignant and early-stage GI malignancies, particularly in the esophagus and colon. EMR can also aid in the diagnosis and therapy of subepithelial lesions localized to the muscularis mucosa or submucosa. Several dedicated EMR devices are available to facilitate these procedures. Adverse event rates, particularly bleeding and perforation, are higher after EMR relative to other basic endoscopic interventions but lower than adverse event rates for ESD. Endoscopists performing EMR should be knowledgeable and skilled in managing potential adverse events resulting from EMR.

Injection and Cautery Methods for Nonvariceal Bleeding Control

Upper gastrointestinal bleeding remains one of the most common challenges faced by gastroenterologists and endoscopists in daily clinical practice. Endoscopic management of nonvariceal bleeding has been shown to improve clinical outcomes, with significant reduction of recurrent bleeding, need for surgery, and mortality. Early upper gastrointestinal endoscopy is recommended in all patients presenting with upper gastrointestinal bleeding within 24 hours of presentation, although appropriate resuscitation, stabilization of hemodynamic parameters, and optimization of comorbidity before endoscopy are essential.

Snare tip soft coagulation achieves effective and safe endoscopic hemostasis during wide-field endoscopic resection of large colonic lesions (with videos)

BACKGROUND

Wide-field EMR (WF-EMR) of large colonic lesions exposes submucosal vessels, which may result in intraprocedural bleeding (IPB). Ongoing bleeding may obscure the endoscopic field, prolonging the procedure and reducing safety and accuracy. A number of potential interventions to control bleeding exist; however, they have inherent limitations. Safe, readily applicable, inexpensive, and effective therapy to control EMR-IPB has not yet been described.

OBJECTIVE

To evaluate the safety and efficacy of the snare tip soft coagulation (STSC) technique to control IPB after WF-EMR of large colonic lesions.

DESIGN

Single-center, prospective cohort study.

SETTING

Tertiary care referral center.

PATIENTS

A total of 196 patients undergoing wide-field colonic EMR for flat and sessile lesions 20 mm or larger.

INTERVENTIONS

A standard inject-and-resect EMR technique was applied. IPB was defined as bleeding obscuring the endoscopic field that persisted for 60 seconds or longer. STSC was performed by using the tip of the polypectomy snare to apply soft coagulation (80 W) to sites of IPB.

MAIN OUTCOME MEASUREMENTS

Immediate hemostasis, postprocedural bleeding, and other adverse events.

RESULTS

A total of 198 lesions (mean size 41.5 mm, 64% in the right colon) were removed in 196 patients (mean age 68 years, 52.5% male). STSC alone achieved effective hemostasis in 40 of 44 cases of IPB (91%). In the remaining 4 cases, additional treatment with coagulating forceps or clips was required to achieve hemostasis. There were no immediate STSC-related adverse events. There was no statistically significant difference between the IPB and non-IPB groups in relation to the use of antiplatelet (P = .2) or anticoagulation agents (P = .4), postprocedural bleeding (P = .8) and adverse event rates (P = .7).

LIMITATIONS

Nonrandomized study.

CONCLUSIONS

STSC is a simple and efficient first-line technique for achieving hemostasis of IPB during WF-EMR in the colon. It succeeds in the majority of cases and appears to be safe.

Mallory-Weiss syndrome: clinical and endoscopic characteristics

BACKGROUND

Mallory-Weiss syndrome is defined by upper gastrointestinal bleeding from vomiting-induced mucosal lacerations at the esophago-gastric junction. This study was purposed to investigate the incidence, location, clinical manifestation, diagnosis and effectiveness of treatment (including endoscopic treatment and conservative medical treatment) of Mallory-Weiss syndrome in China.

METHODS

All patients who received emergency upper gastrointestinal endoscopy due to Mallory-Weiss syndrome from September 2007 to August 2011 at gastrointestinal endoscopy center of Renmin Hospital of Wuhan University were included in this study. The clinical presentation, medical history, location and characteristics of Mallory-Weiss syndrome methods and effectiveness of therapy of patients with Mallory-Weiss syndrome were retrospectively analyzed by chart reviews. Long-term follow-up data were collected at outpatient clinics or telephone interviews.

RESULTS

Sixteen patients were diagnosed with Mallory-Weiss syndrome, which account for 3.08% of 519 patients with acute non-variceal upper gastrointestinal bleeding. Common comorbidities were found in one patient with hepatic cirrhosis. Conservative medical treatment, local injection, hemoclipping, or multipolar electrocoagulation produced primary hemostasis in 87.5% (14/16) of patients.

CONCLUSION

Mallory-Weiss syndrome is uncommon in China in comparison with reported experience in the west when the same group of patients is selected. Different approaches to treatment are to be recommended depending on whether or not active hemorrhage is present.

Endoscopic hemostasis with metallic hemoclips for iatrogenic Mallory-Weiss tear caused by endoscopic examination

AIM

Applied endoscopic techniques including mucosal resection, sclerotherapy and endoscopic retrograde cholangiopancreatography (ERCP) have been advanced and iatrogenic complications including Mallory-Weiss tear (MWT) occasionally occur in daily endoscopic procedures. The present study aimed to examine the advantages of clipping for MWT complications that occur during endoscopic examination.

METHODS

Over 10 years, we experienced 47 patients with bleeding caused by MWT. Metallic hemoclips were applied for 38 patients for hemostasis. These patients were categorized into two groups: 18 patients in group A whose bleeding tear occurred during endoscopic examination in an iatrogenic condition, and 20 patients in group B visited the emergency unit due to other etiology of MWT.

RESULTS

The background characteristics, including length of tears, were not different between the two groups. Initial hemostasis was 100% in groups A and B. Rebleeding was 0/18 (0%) in group A and 1/20 (5 %) in group B. Number of patients who received blood transfusion was significantly higher in group B (group A: 0/18, group B: 4/20). Hemoglobin level before hemostasis was 12.5 g/dL in group A which was not different to that in group B, 10.9 g/dL.

CONCLUSION

Application of hemoclips was effective for bleeding MWT during endoscopic procedures, which warranted prophylactic application of hemoclips on MWT during endoscopic examination.

Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy

Acute upper gastrointestinal bleeding is a relatively common,potentially life-threatening condition that causes more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper gastrointestinal bleeding lesions. Endoscopic therapy is indicated for lesions with high risk stigmata of recent hemorrhage, including active bleeding, oozing, a visible vessel, and possibly an adherent clot. Endoscopic therapies include injection therapy, such as epinephrine or sclerosant injection; ablative therapy, such as heater probe or argon plasma coagulation; and mechanical therapy, such as endoclips or endoscopic banding. Endoscopic therapy reduces the risk of rebleeding,the need for blood transfusions, the requirement for surgery, and patient morbidity.

Post-sphincterotomy bleeding: who, what, when, and how

Endoscopic biliary sphincterotomy (ES) is the cornerstone of therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Bleeding is one of the most frequent complications following ES. Rates of post-ES bleeding vary widely and its presentation may be immediate (intraprocedural) or several days later. Clinically, bleeding can range from insignificant to life threatening. Most bleeding episodes are managed successfully by conservative measures with or without endoscopic therapy. Endoscopic treatment options include injection, thermal, and mechanical methods-alone or in combination. For refractory cases, angiographic embolization, or surgery, is necessary. Both technical risk factors and patient risk factors contribute to the development of post-ES bleeding. When these risk factors are present, measures can be taken to reduce the risk of bleeding. In this manuscript the literature on post-ES bleeding is reviewed.

Comparison of postpolypectomy bleeding between epinephrine and saline submucosal injection for large colon polyps by conventional polypectomy: A prospective randomized, multicenter study

AIM: To evaluate and compare the clinical outcomes of prophylactic submucosal saline-epinephrine injection and saline injection alone for large colon polyps by conventional polypectomy.

METHODS: A prospective study was conducted from July 2003 to July 2004 at 11 tertiary endoscopic centers. Large colon polyps (> 10 mm in diameter) were randomized to undergo endoscopic polypectomy with submucosal saline-epinephrine injection (epinephrine group) or normal saline injection (saline group). Endoscopic polypectomy was performed by the conventional snare method, and early (< 12 h) and late bleeding complications (12 h-30 d) were observed.

RESULTS: A total of 561 polyps in 486 patients were resected by endoscopic polypectomy. Overall, bleeding complications occurred in 7.6% (37/486) of the patients, including 4.9% (12/244) in the epinephrine group, and 10.3% (25/242) in the saline group. Early and late postpolypectomy bleeding (PPB) occurred in 6.6% (32/486) and 1% (5/486) of the patients, respectively, including 4.5% (11/244), 0.4% (1/244) in the epinephrine group, and 8.7% (21/242), 1.7% (4/242) in the saline group. No significant differences in the rates of overall, early and late PPB were observed between the 2 groups. Multivariate stepwise logistic regression analysis revealed that large size (> 2 cm) and neoplastic polyps were independently and significantly associated with the presence of PPB.

CONCLUSION: The prophylactic submucosal injection of diluted epinephrine does not appear to provide an additional advantage over the saline injection alone for the prevention of PPB.