In the AGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review, Drs. Daniel K. Mullady, Andrew Y. Wang and Kevin A. Waschke provide the following best practice advice on endoscopic strategies to combat the age-old clinical dilemma of NVUGIB:
CLINICAL PRACTICE ADVICE:
- Endoscopic therapy should achieve hemostasis in the majority of patients with NVUGIB.
- Initial management of the patient with NVUGIB should focus on resuscitation, triage and preparation for upper endoscopy. After stabilization, patients with NVUGIB should undergo endoscopy with endoscopic treatment of sites with active bleeding or high-risk stigmata for rebleeding.
- Endoscopists should be familiar with the indications, efficacy and limitations of currently available tools and techniques for endoscopic hemostasis and be comfortable applying conventional thermal therapy and placing hemoclips.
- Monopolar hemostatic forceps with low-voltage coagulation can be an effective alternative to other mechanical and thermal treatments for NVUGIB, particularly for ulcers in difficult locations or those with a rigid and fibrotic base.
- Hemostasis using an over-the-scope clip should be considered in select patients with NVUGIB, in whom conventional electrosurgical coagulation and hemostatic clips are unsuccessful or predicted to be ineffective.
- Hemostatic powders are a noncontact endoscopic option that may be considered in cases of massive bleeding with poor visualization, for salvage therapy, and for diffuse bleeding from malignancy.
- Hemostatic powder should be preferentially used as a rescue therapy and not for primary hemostasis, except in cases of malignant bleeding or massive bleeding with inability to perform thermal therapy or hemoclip placement.
- Endoscopists should understand the risk of bleeding after therapeutic endoscopic interventions (e.g., endoluminal resection and endoscopic sphincterotomy) and be familiar with the endoscopic tools and techniques to treat intraprocedural bleeding and minimize the risk of delayed bleeding.
- In patients with endoscopically refractory NVUGIB, the etiology of bleeding (peptic ulcer disease, unknown source, post-surgical); patient factors (hemodynamic instability, coagulopathy, multi-organ failure, surgical history); risk of rebleeding; and potential adverse events should be taken into consideration when deciding on a case-by-case basis between transcatheter arterial embolization and surgery.
- Prophylactic transcatheter arterial embolization of high-risk ulcers after successful endoscopic therapy is not recommended.
