Managing gastrointestinal (GI) bleeding effectively requires advanced endoscopic techniques that provide precise and efficient hemostasis. Here’s a look at the state-of-the-art approaches currently transforming the landscape of therapeutic endoscopy for GI bleeding.
Mechanical Techniques
Over-the-Scope Clips (OTSC): OTSCs have emerged as a highly effective tool for managing severe GI bleeding. These clips are made of a superelastic nitinol alloy that allows them to compress a broad area of tissue, providing robust hemostasis. Studies, such as the STING trial, have shown that OTSCs achieve significantly better outcomes in controlling recurrent peptic ulcer bleeding compared to standard therapies. The trial reported a primary endpoint success in 84.8% of the OTSC group versus 42.4% in the standard therapy group (The Practicing Endoscopist) (Gastroenterology and Hepatology).
Endoscopic Suturing: Endoscopic suturing devices, such as the OverStitch system, enable endoscopists to place sutures precisely in difficult-to-reach areas. This technique is particularly useful for managing post-surgical bleeding and complex lesions that are not amenable to clipping (The Practicing Endoscopist).
Thermal Coagulation Techniques
Argon Plasma Coagulation (APC): APC is a non-contact method that uses ionized argon gas to deliver a high-frequency electrical current to the bleeding site. This technique is effective in treating bleeding from angiodysplasia, radiation proctitis, and other vascular lesions. APC is favored for its ability to cover large surface areas and its minimal depth of tissue penetration, which reduces the risk of perforation (WJGnet).
Heater Probe and Bipolar Coagulation: These methods apply direct thermal energy to induce coagulation at the bleeding site. The heater probe, in particular, has been a staple in the management of peptic ulcers and other bleeding lesions due to its efficacy and simplicity. Bipolar coagulation provides targeted therapy with less surrounding tissue damage compared to monopolar electrocoagulation (SpringerLink).
Injection Therapies
Injection therapies involve injecting agents such as epinephrine, saline, or sclerosants directly into or around the bleeding lesion. Epinephrine induces vasoconstriction and tamponade, while sclerosants promote fibrosis and vessel closure. These methods are often used in combination with mechanical or thermal techniques to enhance hemostasis (The Practicing Endoscopist) (Ingenta Connect).
Topical Hemostatic Agents
Hemospray (TC-325): Hemospray is a mineral-based powder that forms a cohesive barrier over bleeding lesions. It is particularly useful for diffuse bleeding where other methods might be less effective. The GRAPHE registry showed that TC-325 achieved immediate hemostasis in 96.5% of cases, making it a valuable tool in the endoscopist’s arsenal (Gastroenterology and Hepatology) (WJGnet).
EndoClot and Other Hemostatic Powders: Similar to Hemospray, EndoClot uses starch-derived polysaccharides to promote clot formation. These powders are highly effective in providing temporary hemostasis and are particularly useful in emergency settings or as a bridge to definitive therapy (WJGnet).
Further reading: PREPARING PATIENTS FOR DIAGNOSTIC ENDOSCOPY: BEST PRACTICES FOR OPTIMAL RESULTS
Future Directions
The integration of artificial intelligence (AI) and enhanced imaging techniques are poised to further revolutionize endoscopic management of GI bleeding. AI can aid in real-time detection and characterization of bleeding lesions, improving the accuracy and efficiency of endoscopic interventions (SpringerLink).
In conclusion, the advancements in therapeutic endoscopy are significantly improving the management of GI bleeding. Techniques such as OTSCs, endoscopic suturing, APC, and topical hemostatic agents are providing endoscopists with more precise and effective tools to control bleeding and improve patient outcomes. Continuous innovation and research are essential to further enhance these techniques and integrate new technologies into clinical practice.
Photo: Dreamstime
References
- Treating Upper Gastrointestinal Bleeding: An Update on Endoscopic Techniques. The Practicing Endoscopist.
- New Techniques to Control Gastrointestinal Bleeding. Gastroenterology & Hepatology.
- Advancements in Hemostatic Strategies for Managing Upper Gastrointestinal Bleeding: A Comprehensive Review. World Journal of Gastroenterology.
- Advanced Endoscopic Procedures in Gastroenterology. SpringerLink.
- Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline. Ingenta Connect.
