Upper gastrointestinal bleeding endoscopic intervention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Endoscopic intervention

In UGIB, diagnostic and therapeutic endoscopy may be performed simultaneously. Therapeutic upper gastrointestinal endoscopy should be performed in all patients with suspected UGIB to evaluate and possibly treat the source of bleeding. The urgency of endoscopy depends on the anticipated source of bleeding, rapidity of blood loss, and hemodynamic stability of the patient. Endoscopic intervention should be undertaken within 24 hours, as early intervention is associated with reduced transfusion needs and a decreased length of stay in high-risk patients with nonvariceal bleeding.

• The American Society of Gastrointestinal Endoscopy guidelines recommend the use of two different endoscopic procedures, rather than a single procedure to better control bleeding and decrease the incidence of re-bleeding.

Management of upper GI bleeding caused by the peptic ulcer disease

The most common procedures used to manage upper GI bleeding caused by the peptic ulcer disease are:

• Sclerotherapy (EIS)
• Coagulation (thermal, electric, and argon plasma)
• Hemostatic clips

Endoscopic Coagulation

• Thermal contact probes are the mainstay of endoscopic hemostasis in upper GI bleeding.
  • Contact types :Heater probe, monopolar and bipolar electrocoagulation
  • Noncontact types :Laser treatment, argon plasma coagulation 

Contact probes

• Contact probes physically tamponade a blood vessel to stop bleeding and interrupt underlying blood flow.
• Thermal energy is then applied to seal the underlying vessel (coaptive coagulation).
• The most commonly used probe is a multipolar electrocoagulation (MPEC) probe, also referred to as a bipolar electrocoagulation probe , with which heat is created by current flowing between intertwined electrodes on the tip of the probe.
• Heater probes provide a predetermined amount of joules of energy, which does not vary with tissue resistance and can effectively coagulate arteries up to 2 mm in diameter, a diameter considerably larger than most secondary or tertiary branches of arteries (usually 1 mm) found in resected bleeding human peptic ulcers.
• The main risk of using a thermal probe is perforation with excessive application of coagulation or pressure, especially in acute or nonfibrotic lesions.
• Thermal probes can also cause a coagulation injury that can make lesions larger and deeper and may induce delayed bleeding in patients with a coagulopathy.

Noncontact types

• Noncontact thermal therapy includes argon plasma coagulation and laser;
• Noncontact types rarely used now in endoscopic management.

Endoscopic Hemostatic clips

• Hemostatic clips apply mechanical pressure to a bleeding site and control bleeding.
• The first-generation hemoclips could not stop bleeding in vessels larger than a diameter of 1 mm,  but subsequent hemoclips have been larger and stronger and have had a grasp and release mechanism that improves endoscopic deployment and hemostasis.
• Hemoclips are useful for patients with malnutrition or coagulopathy  but can also be difficult to deploy depending on the location of the bleeding site, the degree of fibrosis of the underlying lesion, and limitations to endoscopic access.
• Endoscopic hemoclips differ from surgical clips in that they do not have as much compressive strength, and the currently available clips do not close completely but leave a small space between the prongs.

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Management of upper GI bleeding caused by the esophageal varices

The most common procedures used to manage esophageal varices are:

• Sclerotherapy
• Variceal band ligation

Endoscopic band ligation (EBL)

• EBL involves the placement of elastic circular ring ligatures around the varices to cause strangulation.
• Bands are typically delivered at the gastroesophageal junction first, then proximally six to ten bands may be delivered with a single intubation.
• Endoscopic therapy can halt bleeding in 80% to 90% of patients.
• Follow-up endoscopies are recommended at various intervals depending on the size/appearance of varices and severity of liver disease.
• EBL is equivalent to EIS in establishing initial control of bleeding.
• EBL is widely favored over EIS for primary prevention due to similar or superior efficacy with fewer complications.
• The primary drawback of EBL is that during active bleeding, operator visibility is limited by the device holding the bands prior to their delivery.

Endoscopic injection sclerotherapy (EIS)

• Comprises endoscopic delivery of a sclerosant, such as ethanol, morrhuate sodium, polidocanol, or sodium tetradecyl sulfate.
• Injections may be intravariceal or be delivered into the esophageal wall near the varices.
• Bucrylate is an adhesive that has been used successfully.
• Typical injection volume is 1 to 2 mL per injection, for a total volume of 10 to 15 mL.
• Interval between injections varies according to patient tolerance and response, and complications.
• After an initial injection to control bleeding, there is usually a follow-up injection 2 to 3 days later, followed by weekly or biweekly procedures until complete obliteration of the varices is achieved, which usually takes five or six sessions.

Second Look endoscopy

• Second-look endoscopy refers to the practice of performing a planned follow-up endoscopy, generally within 24 hours of the initial endoscopy.
• The 2010 recommendations on the management of patients with nonvariceal UGIB from the International Consensus Upper Gastrointestinal Bleeding Conference Group, however, do not recommend the use of routine second-look endoscopy