Bleeding Ulcers Management after Primary Hemostasis and in Special Cases

■ Management after Primary Hemostasis

Figure 4.25 outlines the follow-through regimen after primary hemostasis has been achieved. Scheduling an early repeat en-doscopy does not improve the prognosis. When rebleeding occurs after primary hemostasis, the success rate of repeat endo-scopic hemostasis is 50-70%.

■ Hemostasis of a Mallory-Weiss Lesion

A Mallory-Weiss lesion (Fig.4.26a) is infiltrated with epinephrine diluted 1: 10000 in physiological saline solution, or it may be obliterated with fibrin glue.

■ Hemostasis of a Bleeding Dieulafoy Ulcer

The methods of choice are epinephrine injection and hemoclip application.

■ Hemostasis in Hemorrhagic Gastritis

Hemorrhagic gastritis (Fig.4.26b) usually does not require specific endoscopic hemostasis. It can be adequately managed with PPI.

Primary hemostasis

Surveillance in ICU

Rebleeding

a Bleeding Mallory-Weiss lesion

No rebleeding

a Bleeding Mallory-Weiss lesion

Indications for surgery

- Refractory shock

- Primary bleeding from posterior bulb wall

- Significant comorbidity

In all other cases, repeat endoscopy

No need for early repeat endoscopy

b Hemorrhagic gastritis

Fig. 4.25 Follow-through after primary hemostasis b Hemorrhagic gastritis

Endoscopy Injection Adrenaline

Fig. 4.24a-c Argon plasma coagulation in GAVE syndrome

Fig. 4.24a-c Argon plasma coagulation in GAVE syndrome

Indications

Endoscopy is the ideal medium for the selective collection of tissue and fluid specimens for further analysis. The risk ofbleed-ing or perforation is minimal when some very simple rules are followed.

Whenever gastroscopy is performed, biopsy specimens should be taken from the gastric antrum for H. pylori detection. The degree of sampling from normal-appearing mucosa will vary greatly from one examiner to the next.

Additionally, of course, all abnormal-appearing mucosal areas that cannot be classified by gross inspection should be bi-opsied, with due regard for contraindications. The endoscopic specimens are sent for histological, microbiological, or other testing (polymerase chain reaction [PCR], etc.).

Procedures

The methods most commonly used to collect specimens during EGD are as follows:

► Brush cytology

► Fluid sampling

Indications

► Any normal-appearing antral mucosa (and gastric body mucosa) for H. pylori detection

► Any abnormal-appearing area that cannot be positively classified by gross inspection

Contraindications

► Coagulation defect (coumarin use, hepatic cirrhosis); the use of aspirin and other NSAIDs is not a contraindication.

► Planned enucleation of a submucosal tumor

► In the area of diverticula

► In areas of radiation-induced esophagitis

Fig. 4.27 Biopsy forceps

Fig. 4.27 Biopsy forceps

Techniques

Simple forceps biopsy

- Forceps jaws come in various designs (large, small, sharp, blunt, with or without a central prong, etc.) for use in different situations (Fig. 4.27).

Buttonhole biopsy

- Used to sample tissue from submucosal masses.

- First the mucosa over the mass is resected, then a deeper specimen is taken from the submucosal lesion.

- Indication: submucosal mass

- Complications: bleeding, perforation

- Caution: This type of biopsy is contraindicated if tumor enucleation is planned.

► Suction biopsy

- The biopsy tube is passed endoscopically into the second part of the duodenum; tissue is sucked into the port, cut off with a sliding blade, and retained in a trap.

- Formerly used to sample tissue in cases of suspected celiac disease. Today has been largely superseded by forceps biopsy due to the substantial perforation risk.

Brush Cytology

Indications

Larger lesions that are difficult to sample adequately with biopsy forceps (e.g., strictures) Adjunct to biopsy in Barrett epithelium

Fig. 4.28 Brush attachment for endoscopic brush cytology

Fig. 4.28 Brush attachment for endoscopic brush cytology

Contraindications

Coagulation defect

Caution: The bristles of an endoscopic brush have significant traumatic potential and can cause considerable bleeding!

Technique

► The brush (Fig. 4.28) is rubbed repeatedly across the suspicious lesion, retracted into the guide sleeve, and both are withdrawn through the endoscope channel.

► The material is wiped onto glass slides and air-dried.

■ Fluid Sampling

Indications

► pH determination of the gastric juice (e.g., to assess response to PPI therapy)

► Obtaining material for microbiological testing (e.g., Giardia in duodenal secretions)

Contraindications

Fig. 4.29 Tube for fluid sampling

Fig. 4.29 Tube for fluid sampling

Technique

► The sampling tube (Fig. 4.29) is passed down the working channel of the endoscope, and a fluid sample is aspirated with a syringe.

► The specimen is processed according to requirements.

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