The role of endoscopy in the management of non-variceal acute upper gastrointestinal bleeding

0016-5107/92/3806-0760$03.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1992 by the American Society for Gastrointestinal Endoscopy

The role of endoscopy in the management of non-variceal acute upper gastrointestinal bleeding Guidelines for clinical application This is one of a series of new statements discussing the use of gastrointestinal endoscopy in common clinical situations that has been prepared using a new standardized guideline methodology. This guideline is intended to aid endoscopists in determining whether endoscopic therapy is necessary for an individual patient with acute, non-variceal upper gastrointestinal bleeding and to critically evaluate the endoscopic therapeutic treatment alternatives. A subcommittee of the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE), with the input of a national expert on the subject, selected the references that were the core material for the guideline through a Medline searcha • The references chosen for inclusion were selected according to their importance in providing the historical background and magnitude of the clinical problem, technical details regarding endoscopic therapy, and the quality of their study design which considered the number of subjects, validity of comparative techniques, and analysis of data. The 48 references cited include 1 NIH consensus statement; 8 randomized, controlled trials; 19 articles that assess risk from bleeding; 20 clinical reports on the efficacy of treatment modalities; and 2 clinical surveys. When there was little or no data from well-designed controlled trials, recommendations were based on clinical experience, animal models, and the recommendation of experts. In preparing the guideline, the subcommittee and expert consultant developed an outline and wrote several drafts before the guideline was reviewed by the entire Standards of Practice Committee line-by-line. A draft reflecting the full Committee's input was then reviewed by the ASGE Governing Board and several experts who had not been involved previously in the process. The American Gastroenterological Association (AGA), American College of Gastroenterology Available on request from the A/S/G/E office. The Standard of Practice Committee members included Drs. K. W. O'Connor, Chairman; Malcolm Robinson, Gregory Boyce, Richard Baerg, Thomas Browning, Richard Satava, and Gregory Zuccaro. Subcommittee members were Drs. Douglas Wolf and Patrick Griffin. The Medline search was performed by Dr. Wolf. a

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(ACG), Society of American Gastrointestinal Endoscopic Surgeons (SAGES), and the American College of Physicians (ACP) were invited to offer their own criticisms and suggestions for improving the document. The final guideline reflects the input from this broadly based review process. The final draft of the guideline has been reviewed and approved by the Patient Care Committee of the AGA, the Practice Parameters Committee of the ACG, and by the governing boards of the ASGE, AGA, ACG, and SAGES. The names of the members of the subcommittee in charge of developing this guideline and that of the full committee are available on request from the ASGE. The suggestions made by the external reviewers provided valuable perspective and strengthened the document. The ASGE acknowledged its great debt to Dr. David Fleischer for the gracious gift of his time and expertise in the development of this guideline. Standards of Practice Committee August 13, 1992

I. INTRODUCTION

The purpose of this guideline is to provide a current and practical strategy for the use of endoscopy in the management of patients with upper gastrointestinal hemorrhage of non-variceal origin. The predictive value of both clinical and endoscopic criteria used to assess bleeding severity are reviewed and new established endoscopic techniques to control bleeding are compared. This statement incorporates information available since the Society's previous document was published in 1986. 1 A separate statement entitled The Role of Endoscopic Sclerotherapy in the Management of Variceal Bleeding" has been written to address this specific clinical situation. 2 II. DEFINITION

For the purposes of this guideline, upper gastrointestinal bleeding (UGIB) should be considered in three general categories. Active hemorrhage is usually manGASTROINTESTINAL ENDOSCOPY

ifest by hematemesis, return of red or pink blood per nasogastric tube, melena with continuing transfusion requirement, or evidence of hypovolemia. Acute selflimited blood loss is defined as cessation of active bleeding indicated by hemodynamic stability with no evidence of ongoing blood loss or melena without evidence of hemodynamic compromise. Chronic bleeding occurs over weeks or months, is manifest as occult bleeding, recurrent blood loss of obscure source, or iron deficiency anemia. These three presentations of UGIB are approached differently with regard to endoscopic indications and intervention. When endoscopy is performed by a well-trained endoscopist, it is the most sensitive and specific diagnostic procedure for determining the cause and site of UGIB. However, endoscopy in the bleeding patient generally requires a higher level of skill and is technically more demanding than an elective procedure. Therefore, when possible, the endoscopist should have the necessary knowledge and skills to perform therapeutic maneuvers. Although complications from endoscopy are slightly higher in the actively bleeding patient than for non-bleeding patients, the procedure is generally well tolerated and no convincing evidence exists that the procedure will provoke further bleeding. 3,4 Endoscopy is appropriate in all bleeding patients except the few in whom bleeding is so rapid that surgery or other emergency measures are required and in the few who cannot cooperate or be safely sedated. Specific indications are delineated in the ASGE Appropriate Use of Gastrointestinal Endoscopy document, but that is not absolutely inclusive. 5

III. PROGNOSIS

Clinical prognostic features

Several clinical features portend an adverse outcome or a high re-bleeding risk. 6,7 Vital signs are the most important, with clinical shock predicting rebleeding in almost half of patients (48%); about onefifth of patients with tachycardia re-bleed. 8 Red or black hematemesis at presentation is indicative of active UGIB and also predicts high re-bleeding rates and poorer outcome. 9 A red nasogastric aspirate which does not clear with lavage usually suggests a substantial blood loss, increased probability for transfusion, and death. There is a 30% mortality when both the nasogastric aspirate and stool contain red blood. 7,9 Predictive factors not associated with the volume of initial blood loss have also been studied. Age over 60, increasing number of associated illnesses, and concomitant NSAID use predict higher mortality;lO while coagulopathy, chronic renal failure, and the onset of bleeding in an already hospitalized patient predict recurrent bleeding. 7 VOLUME 38, NO.6, 1992

Endoscopic prognostic features

The endoscopic examination should provide information regarding: (1) location and identity of the bleeding source, (2) bleeding rate (oozing versus spurting), (3) which of multiple lesions is the source of bleeding, and (4) whether stigmata of recent hemorrhage (SRH) are present. Certain endoscopic characteristics are important in predicting re-bleeding from peptic ulcers and influence endoscopic therapy and the need for emergency surgeryY-13 Visual endoscopic characteristics of ulcer bleeding are referred to as "stigmata of recent hemorrhage" and include (1) pulsatile arterial bleeding, (2) adherent clot, (3) a pigmented protuberance, and (4) a flat blood spot on the ulcer base. 12,14, 15 For arterial bleeding, the probability of continued bleeding or re-bleeding is as high as 85%, for a fresh clot on an ulcer it is approximately 40%, and for a flat, pigmented blood spot only 5 to 10%. A clean ulcer base without stigmata of bleeding is a reliable indicator that the ulcer is not likely to re-bleed. The term "visible vessel" may be a misnomer since this finding may also represent organizing clot or an aneurysmal dilation of the vessel. The NIH Consensus Conference decided that the term "pigmented protuberance" is preferred when a protruding red, blue, or white mound is found in the base of the ulcer. 6 Most large clinical studies of peptic ulcer have not carefully stratified pigmented protuberances by color, size, height, or the presence of overlying clot. Stigmata of recent hemorrhage are found more frequently when endoscopy is performed within 12 to 18 hours of hospital admission. 15 Deep ulcers high on the lesser curvature of the stomach or in the posterior-inferior wall of the duodenal bulb may be at greater risk for severe bleeding due to their anatomical proximity to large vessels. 16 In the cirrhotic patient, lesions other than varices frequently bleed, although the incidence varies between 10 and 78%.17,18 Clinical features and endoscopic findings may have an additive effect in predicting re-bleeding rates, e.g., the re-bleeding rate when endoscopic SRH were present in association with hypotension was 67%, but when the same stigmata were present without hypotension, it was 27%.8,19 The significance of SRH may be applied to any lesion with an exposed submucosal arterial vessel. Such lesions include a postpolypectomy base, mucosal vascular ectasia, Mallory-Weiss tear, and Dieulafoy's lesion. 20 Endoscopic therapy has been shown to be effective in these lesions,20-22 although the role of endoscopy in these causes ofUGIB has been subjected to less intense and controlled study than peptic ulcer disease. Gastroduodenal vascular malformations (VMs) are 761

uncommon,23 but VMs may be associated with substantial re-bleeding. 24 In patients with renal failure,25 VMs are the most frequent source of UGIB and have an increased frequency of recurrent bleeding. Because a large volume of blood in the stomach, significant hypotension, or suction ecchymoses may obscure VM, early repeat endoscopy may confirm their presence when clinical suspicion is high. Neoplasms accounted for only 4% of all bleeding lesions in the ASGE Survey, but 45% were actively bleeding or demonstrated SRH. Post-endoscopic evaluation of undiagnosed continued bleeding

In spite of the sensitivity and specificity of EGD, diagnosis of the bleeding source may not be possible in 8 to 10% of patients; therefore, under these circumstances, repeat EGD may be indicated. Bleeding scans and angiography have been employed in this clinical setting. However, recent data question the accuracy of a positive scan with misleading results in as many as 42% of patients studied. 26 Nonetheless, scintigraphy may playa role in conjunction with angiography in the patient whose bleeding site remains obscure following endoscopic evaluation. 27 When upper endoscopy, visceral angiography, and/ or labeled red blood cell scintigraphy fail to identify a source of blood loss in those patients who continue to bleed, enteroscopy or intraoperative endoscopy has been successful in localizing small bowel bleeding sites. 28-3o The exact role of enteroscopy in acute bleeding beyond the ligament of Treitz, particularly with the sonde enteroscope, has yet to be defined. Upper gastrointestinal contrast studies have no primary role in the patient with acute UGIB.

IV. THERAPY OF ACUTE NON-VARICEAL UPPER GASTROINTESTINAL BLEEDING General management

Patients with acute non-variceal UGIB require immediate clinical evaluation, resuscitation, and continuous re-evaluation. Determination of the severity of initial bleeding and co-morbid factors guide the clinician to the type of intravenous access, urgency for transfusion, need for other supportive measures, and need for interdisciplinary (angiography and surgery) back-up. More than two-thirds of cases of non-variceal UGIB stop spontaneously. Medical therapy has not been shown to alter the immediate outcome of acute non-variceal UGIB. In contrast, well-designed clinical studies demonstrate that endoscopic hemostatic therapy improves the outcome of patients with acute nonvariceal UGIB. 31 -46 A nasogastric tube is often placed in a patient with gastrointestinal bleeding to confirm that bleeding is 762

from the upper gastrointestinal tract and to assess the color of the blood. Nonetheless, in the patient with a clear nasogastric aspirate, there is a 12% chance that major bleeding from the upper gastrointestinal tract has occurred. 7 Endoscopic management

Appropriate skill and training in endoscopic hemostasis are prerequisites which will increase the safety of the procedure and likelihood of success. Several endoscopic therapeutic techniques greatly increase the utility of upper endoscopy in patients with gastrointestinal bleeding, i.e., bipolar or multipolar electrocoagulation (MPEC), heat probe (HP), injection (INJ), endoscopic laser therapy (ELT), and monopolar electrocoagulation. Topical therapeutic agents 6 have no role at present in the treatment of UGIB. 1. MPEC. Parameters of outcome such as need for transfusion, length of hospital stay, and need for emergency surgery are significantly improved as a result of MPEC therapy.32,33,40 2. HP. Available data suggest that outcomes are improved with HP therapy, similar to that shown for MPEC. 41 ,42 3. Injection therapy. There is little definitive evidence as to which injected material (epinephrine, ethanol, hypertonic saline) is most efficacious. A recent study showed benefit in patients with non-variceal UGIB. Need for surgery, need for emergency surgery, and overall mortality were all significantly decreased in the treatment group compared with control.36,42-44 4. ELT. Most studies suggest that ELT is effective in controlling UGIB from peptic ulcer with significant reductions in re-bleeding, need for surgery, and mortality.35, 37-40, 44, 45 5. Monopolar electrocoagulation. While the oldest effective endoscopic hemostatic device controlled bleeding in up to 93 % of cases in one controlled study, problems with tissue adherence, unpredictable energy deposition, and the absence of an irrigation port have been better solved with newer devices. 46 Combination therapy

Several investigators believe that combination therapy is more efficacious than mono-hemostatic therapy.40, 43, 44 While combining modalities which achieve hemostasis by different techniques is logical, there is as yet no consensus on which agents should be used and in which situations. Comparative studies

Differences in study design and populations treated do not allow ranking of techniques from most effective to least effective. GASTROINTESTINAL ENDOSCOPY

Retreatment of re-bleeding

The use of a second session of hemostatic therapy to obtain optimal endoscopic results is supported by several studies,40, 43, 44 although endoscopic retreatment of the same site within a few days appears to be associated with an increased risk of perforation. The decision to retreat or operate on the patient should be individualized in coordination with surgical consultation. Follow-up of treated patients

There is no consensus on how to follow patients after they receive endoscopic hemostatic therapy. It is not established that a repeat elective endoscopy is necessary.42-44 Most patients who have had a major episode of UGIB secondary to duodenal ulcer disease may be candidates for long-term acid suppressive maintenance therapy.47 Complications

Complications of endoscopic hemostatic therapy have been reported for all types of therapies (HP, ELT, MPEC, Monopolar, and INJ) and include ulceration, induced or worsened bleeding, and perforation. Ulceration results from the application of all thermal and sclerosant hemostatic therapies, appears to be self-limited, and does not seem to prolong peptic ulcer healing rates. Induced bleeding is most likely to occur with pigmented protuberances. Most studies report a low frequency of complications, with perforation occurring in 0 to 3% of cases. 31-34 ,40-42. 44 Cost-efficacy

Increasing evidence supports the concept that urgent endoscopy in conjunction with hemostatic therapy is cost effective in terms of reductions in blood units transfused, length of hospital stay, need for elective or emergency surgery, and overall hospitalization costS. 31 ,32, 41, 48

v.

CONCLUSION

Recent studies confirm that urgent endoscopy is appropriate in active and acute self-limited UGIB and that endoscopic hemostatic therapy can provide significant benefits in terms of achieving initial hemostasis, preventing re-bleeding, and reducing the need for emergency surgery, with its attendant morbidity and mortality. Careful prospective study has also shown that significant cost-benefits can be achieved through the use of endoscopic hemostatic therapy. MPEC and HP are the thermal devices of choice because of their low initial and maintenance costs, high efficacy, portability, and ease of use. Injection therapy may be an equally desirable choice because of VOLUME 38, NO.6, 1992

recently confirmed efficacy comparable to HP and MPEC, extremely low cost and portability, as well as great ease of use. While equally effective, ELT is less portable, more expensive initially and long-term, and it requires special expertise. The role or necessity of combination therapy is less clear, but evolving. Endoscopic hemostatic therapy should be reserved for patients who demonstrate active bleeding at endoscopy or those who are at high risk for recurrent bleeding, typically those with a pigmented protuberance in the ulcer base. In the hands of a qualified therapeutic endoscopist, hemostatic therapy is effective and has an acceptably low complication rate.

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