GI Lecture Series - UGI Bleeding - Peptic Ulcer Bleeding Endoscopic Therapy

New Section

In this section, the speaker discusses endoscopic therapeutic options for peptic ulcer bleeding based on the latest guideline from the American College of Gastroenterology published in 2021.

Endoscopic Options for Peptic Ulcer Bleeding

• Bipolar Electrocoagulation: This technique involves using a probe to deliver heat through bipolar electrocoagulation to coagulate and seal the blood vessel. It has been shown to reduce bleeding and mortality.

• Heater Probe Therapy: Using a probe, heat is applied directly to occlude and seal the vessel. This therapy has also been shown to reduce bleeding and mortality.

• Injection of Sclerosis (Alcohol): Alcohol is injected into the bleeding site using a needle. This therapy has been shown to reduce bleeding and mortality.

• Mechanical Hemostasis with Clips: Clips are deployed over the bleeding site to catch the bleeding vessel. This technique has been shown to reduce bleeding.

• Soft Monopolar Coagulation: Soft coagulation is applied using monopolar coagulation forceps with limited depth of injury. It has been shown to reduce bleeding.

• Argon Plasma Coagulation: Argon plasma coagulation is delivered using a catheter, reducing bleeding when applied correctly.

• Over-the-Scope Clip (OTSC): A clip is placed over the scope end and deployed onto the bleeding site, reducing bleeding.

Each therapy mentioned above has varying levels of evidence supporting its effectiveness, as indicated by recommendations from the American College of Gastroenterology.

Conclusion

This summary provides an overview of various endoscopic therapeutic options for peptic ulcer bleeding. The techniques discussed include bipolar electrocoagulation, heater probe therapy, injection of sclerosis (alcohol), mechanical hemostasis with clips, soft monopolar coagulation, argon plasma coagulation, and over-the-scope clip (OTSC). Each technique has shown effectiveness in reducing bleeding and mortality to varying degrees.

Hemostatic Powder Spray

This section discusses the use of hemostatic powder spray for controlling bleeding during endoscopy.

Hemostatic Powder Spray Technique

• Insert a catheter that delivers the hemostatic powder (TC325 material).

• Position the catheter tip 1 to 2 centimeters from the bleeding site.

• Apply the powder in one to two second bursts until the bleeding stops and the area is fully covered.

• This technique has been shown to reduce bleeding, but with very low quality of evidence.

Injection of Epinephrine

This section explores the role of epinephrine injection in managing bleeding during endoscopy.

Epinephrine Injection Technique

• Use an injection needle and dilute epinephrine (1 in 10,000).

• Inject 0.5 to 2 ml per injection at the bleeding site.

• The maximum volume has not been determined, but some centers have used higher volumes.

• Epinephrine injection alone reduces bleeding, but it may recur.

• It is recommended to use epinephrine in combination with either heat therapy (bipolar probe or heater probe) or a mechanical device (clip).

• Strong recommendation with very low to moderate quality of evidence.

Combination Therapy with Epinephrine

This section discusses using epinephrine injection in combination with other modalities for managing bleeding during endoscopy.

Recommended Combination Therapies

• The college recommends using epinephrine alone against their recommendation.

• Strong recommendation for using epinephrine in combination with thermal modality (bipolar coagulation or heater probe) or mechanical modality (clip).

• Other modalities have shown to reduce bleeding with a conditional recommendation.

• Epinephrine injection alone without additional therapy is not favored.

Summary

The transcript covers different techniques for managing bleeding during endoscopy. The use of hemostatic powder spray and epinephrine injection are discussed. Hemostatic powder spray involves delivering the powder to the bleeding site using a catheter, while epinephrine injection is done at the bleeding site using an injection needle. It is recommended to use epinephrine in combination with heat therapy or a mechanical device for better results. Epinephrine injection alone is not as effective in preventing recurrent bleeding.