Endoscopic haemostasis in gastrointestinal bleeding

What it is

Endoscopy in a bleeding patient does two things at once: it establishes the bleeding site and it treats the lesion. Which tool is used depends on what the endoscope finds, and for variceal bleeding the endoscopic step sits inside a wider drug and antibiotic plan.

How it is treated

Timing first. EGD is recommended within 24 hours of an upper GI bleeding episode; more urgent endoscopy does not improve outcomes, although it can benefit patients with active bleeding. Therapeutic endoscopy performed within 6 to 24 hours is associated with significantly better clinical outcomes than endoscopy performed before 6 hours or between 24 and 48 hours. In lower GI bleeding, colonoscopy is recommended early, usually within the first 48 hours of admission.

Then the tool, by lesion:

• Bleeding peptic ulcer: injection of epinephrine, thermal hemostasis, endoclips.
• Diverticular bleeding, which is arterial: adrenaline injection with thermal coagulation and clips.
• Esophageal varices: endoscopic band ligation, or sclerotherapy. Start octreotide or vasopressin infusion before the endoscopy and continue it for 3 to 5 days, complete 7 days of antibiotics, and repeat endoscopic banding every 10 to 14 days until the varices are eliminated. For active variceal bleeding the first choice is octreotide with endoscopic band ligation and prophylactic antibiotics such as oral norfloxacin, IV ciprofloxacin or ceftriaxone, and the second choice is TIPS or shunt surgery if endoscopic therapy is unsuccessful.

Antimicrobial prophylaxis should be administered during variceal bleeding even if ascites is absent, and the patient is kept on a B-blocker to decrease the portal HTN. The hemoglobin transfusion goal is 7 g/dL: transfusion to a hemoglobin above 7.0 g/dL increases portal pressures and the risk of further bleeding.