Crayola Stool Color
Spectrum: Red Salsa to
Eerie Black
John R Saltzman MD
Director of Endoscopy
Brigham and Women’s Hospital
Associate Professor of Medicine
Harvard Medical School
Crayola colors
• Crayola company founded in 1903
• Headquarters in Lehigh Valley, PA
• In 1984, Crayola became a whollyowned subsidiary of Hallmark Cards
• Early products included:
– Red oxide pigment used as barn paint
– Carbon black used in car tires
Objectives
• To be familiar with changes in initial
management recommendations
• To know the recommended timing of
endoscopy in upper GI bleeding
• To understand recent advances in
endoscopic hemostatic techniques
Initial assessment and
risk stratification
• Assess hemodynamic status immediately
• Insert 2 large bore IVs and resuscitate
• Blood transfusions
– Target hemoglobin >7 g/dl
(>10 g/dl if intravascular volume depletion or CAD)
– Target INR <2.5
Laine L, Jensen D. Am J Gastroenterol 2012;107:345
Overall Survival (%)
Survival according to
transfusion strategy
Days
Villanueva C et al. N Engl J Med 2013;368(1):11-21
Timing of endoscopy
“Early endoscopy (within 24 hours of
presentation) is recommended for most
patients with acute upper gastrointestinal
bleeding”
– International Consensus Guidelines. Barkun A. Ann Intern
Med 2010;152:101
“Patients with upper GI bleeding should
generally undergo endoscopy within 24 hours
of admission, following resuscitative efforts to
optimize hemodynamic parameters”
ACG 2012 Practice Guidelines. Laine L, Jensen D. Am J
Gastroenterol 2012;107:345
Emergent or urgent endoscopy?
• Emergent (<6-8 hours) endoscopy (EE) vs.
urgent (8-24 hours) endoscopy (UE)
• Retrospective series (n=860)
• More endoscopic therapy in EE group
• No differences in:
– Rebleeding rate
– Length of stay, transfusions, surgery & mortality
Tai CM et al. Am J Emerg Med 2007;25:273
Targownik LE et al. Can J Gastroenterol 2007;21:425
Sarin N et al. Can J Gastroenterol 2009;23:489
Emergent endoscopy
(<12 hours)
• Always after hemodynamic resuscitation
and stabilization
• Hemodynamically unstable initially
• Hematemesis
• Suspected active bleeding
• Suspected variceal bleeding
Laine L, Jensen D. Am J Gastroenterol 2012;107:345;
Tsoi KKF. Nat Rev Gastroenterol Hepatol 2009; 6:463-469
Emergent upper endoscopy may
improve outcomes in high-risk patients
• Retrospective review of endoscopy
timing (< 13 h vs. > 13 h) in 934 patients
• Blatchford risk score calculated
– Low-risk = score <12
– High-risk = score >12
• Mortality same in low-risk patients
• Mortality greater in high-risk patients with
endoscopy >13 hours (44% vs. 0%)
Lim LG et al. Endoscopy 2011;43:300
Mortality and endoscopy timing
• Analysis of 3 national, multi-center prospective
databases (PNED 1 & 2 and PROMETIO)
• 3207 patients with non-variceal upper GI bleed
• Timing of endoscopy <6 hours, 7-12 hours or
13-24 hours
• Risk categorized as low, intermediate, or high
using 10 independent clinical prognosticators
• Endpoint of mortality (overall 4.45%)
Marmo R et al. DDW 2011
Mortality and endoscopy timing
“In patients clinically categorized as high risk, the
performance of the endoscopy 13-24 hours of the
bleeding episode is associated with a significantly lower
mortality (p=0.001) compared to endoscopy performed
sooner (≤12 hours)”
Marmo R et al. DDW 2011
Worse outcomes may occur
with emergent endoscopy
• Emergent endoscopy may be associated with
inadequate resuscitation
• Procedure may be done without usual supports
(endoscopy RNs and techs)
• Procedure often done at off hours (i.e. 11 PM to 7
AM) and endoscopist may be fatigued and/or have a
decrease in endoscopy performance quality
• Lack of back-up support immediately available
(interventional radiology and surgery)
What is new in endoscopic
therapeutic options
• Hemoclips
• Doppler probe
• Sprays
•
Ankaferd
• Hemospray
• EndoClot
• Cyanoacrylate
•
Over-the-scope clips
Combination therapy vs.
hemoclips study
• Prospective randomized controlled trial of acute
non-variceal upper GI bleeding
• All patients on high dose proton pump inhibitors
Primary control
%
Rebleeding rate
30
100
90
80
70
60
50
40
20
Hemoclips
Combination
Hemoclips
Combination
%
10
30
20
10
0
0
P=0.45
P=0.49
Saltzman J. Am J Gastroenterol 2005;100:1503
Hemoclips for upper GI bleed
• Meta-analysis of 15 RCT’s of 1156 patients
(mostly peptic ulcer disease patients)
– 390 clips alone
– 242 clips and injection
– 359 injection alone
– 165 thermocoagulation with or without injection
• Hemoclips superior than injection therapy alone
– Definitive hemostasis 86.5% vs. 75.4%
• Hemoclips comparable to thermal coagulation
– Definitive hemostasis 81.5% vs. 81.2%
Sung JJ et al. Gut 2007;56:1364
Available hemoclips in 2013
Olympus
Boston
Scientific
Cook
Trade name
Quickclip-2
Resolution
Instinct
Open-close
No
Yes
Yes
Rotate
Yes
No
Yes
11 mm
11 mm
16 mm
No
Yes
Yes
Clip diameter
MRI conditional
approval
Endpoint of endoscopic therapy
Wong RC. Gastroenterology 2009;137:1897
Doppler signal before and
after endoscopic therapy
Application of Doppler guided hemostasis has the
potential to help reduce ulcer rebleeding
Jensen DM. DDW 2010
Topical hemostatic agents
Barkun A et al. Gastrointest Endosc 2013;77:692-700
Hemostatic nanopowder spray
Mechanism of action:
• Tamponade (rapid velocity application)
• Dehydration of fluid within blood
• Activation of clotting cascade
• Activation of platelets
Aims: To assess the efficacy and safety of a novel
hemostatic nanomaterial in short and long term
hemostasis in a survival GI bleeding animal model
Conclusions: Endoscopic application of this nanopowder
is safe and highly effective in achieving hemostasis in
an anticoagulated severe GI bleeding animal model
Giday SA. Endoscopy 2011;43:296
Delivery
catheter
Bleeding
peptic ulcer
Human hemostatic
spray initial trial
Sung JJY. Endoscopy
2011;43:291
Spray to treat bleeding
• Post - endoscopic intervention with
12/12 patients successfully stopped
– Esophageal EMR: 5 patients
– Duodenal EMR: 4 patients
– Ampullary resection: 2 patients
– Biliary sphincterotomy: 1 patient
• Malignant bleeding - 10/10 patients
stopped, but 20% rebleeding
Leblanc S et al. Gastrointest Endosc 2013;78:169-175
Chen TI, et al. Gastrointest Endosc 2012;75:1278-81
Barkun A et al. Gastrointest Endosc 2013;77:692-700
Hemospray considerations
• Effective only in actively oozing or
spurting bleeding lesions
• Does not require special expertise
• Can be rapidly used if bleeding occurs
after polypectomy or sphincterotomy
• May be effective in difficult locations
• Second treatment modality needed if
high risk of rebleeding
• Potential role for malignant bleeding
The bear claw:
over-the-scope clip (OTSC)
Kirschniak A. Gastrointest Endosc 2007;66:162
OTSC results for GI
bleeding after prior failures
• Primary
hemostasis:
– 97% (29/30)
• Rebleeding:
– 7% (2/30 pts)
Manta R et al. Surg Endosc
2013;27:3162-3164
Upper GI bleeding summary
• Resuscitate promptly, but do not over transfuse
• Perform endoscopy within 24 hours
• Use effective endoscopic treatments
(hemoclips and combination therapies)
• Further improvements are coming