Klinik fr Gastroenterologie und Hepatologie Etiologies of Upper GI - - PowerPoint PPT Presentation

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Klinik fr Gastroenterologie und Hepatologie Etiologies of Upper GI - - PowerPoint PPT Presentation

Nov 13, 2022 203 likes •614 views

Klinik fr Gastroenterologie und Hepatologie Etiologies of Upper GI Bleeding Duodenal ulcerations 27% Gastric ulcerations 24% Varices 19% Gastroduodenal erosions 13% Reflux esophagitis 10% Mallory-Weiss

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Klinik für Gastroenterologie und Hepatologie

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  • Duodenal ulcerations

27%

  • Gastric ulcerations

24%

  • Varices

19%

  • Gastroduodenal erosions

13%

  • Reflux esophagitis

10%

  • Mallory-Weiss lesions

7%

  • Tumores

3%

  • Angiodysplasia

1%

  • not identifiable

6%

Ell, DMW 1995

Etiologies of Upper GI Bleeding

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Klinik für Gastroenterologie und Hepatologie

  • Risk of development in liver cirrhosis:

30-40% with compensated cirrhosis 60 % with decompensated cirrhosis New onset of esophageal varices in liver cirrhosis 5-10%/year

Esophageal Varices

  • Epidemiology -

1°: collaps on insufflation 2°: 1/3 of luminal diameter 3°: >50% of luminal diameter

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  • Total bleeding risk of esophageal varices 25-50%
  • Factors determining risk of hemorrhage
  • Mortality after hemorrhage  (up to 50% in 6 weeks)
  • 70% re-bleeding within first year without secondary prophylaxis

Esophageal Varices

  • Epidemiology -

García-Pagán, Sem Respir Crit Care Med 2012

 HPVG >12mmHg  Large varices  Child-Pugh stage  MELD score  Alcohol consumption

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  • Primary prevention
  • Acute variceal bleeding
  • Prevention of recurrent bleeding

Esophageal Varices

  • Therapeutic Scenarios -
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Use hepatic venous pressure gradient (HPVG) for estimation of indication/prognosis (if available)

De Franchis, J Hepatol. 2010 (Baveno V Consensus Workshop)

Variceal Bleeding

  • Primary Prevention-

Non-selective betablockers Band ligation Small varices without risk factors ± no Small varices with red spots or CHILD C yes no Medium or large varices Either betablockers or band ligation

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Esophageal Variceal Bleeding

  • Preendoscopic therapy -
  • Venous access (multiple large catheters)
  • Volume resuscitation
  • ICU treatment, stabilization
  • Blood transfusions (hemoglobin cut-off 7g/dl)
  • Pharmacotherapy: terlipressin (on suspicion of variceal bleeding)

Terlipressin Placebo Active VB (endoscopy) 17% 28% Recurent bleeding (12h) 12% 26% Mortality (20d) 20% 42% Levacher, Lancet 1995 De Franchis, Dig Liver Dis. 2004

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 Band ligation superior to sclerotherapy (early and long term results)

Villanueva, J Hepatol 2006

Therapy (+pharmacoth.) Primary failure Early recurrence Complications Band ligation 4% 5% 14% Sclerotherapy 15% 9% 28%

Esophageal Variceal Bleeding

  • Endoscopic standard therapy -
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Esophageal Variceal Bleeding

  • Endoscopic standard therapy -
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Esophageal Variceal Bleeding

  • Endoscopic standard therapy -
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Esophageal Variceal Bleeding

  • TIPS -

Hepatic vein Portal vein

TIPS

Transiugular Intrahepatic Portosystemic Shunt

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TIPS in high-risk patients after EBL High risk: Child B + active bleeding Child C (all pts) Early TIPS:  Failure of therapy  Recurrent bleeding  1year mortality

Garcia-Pagan, N Engl J Med. 2010

Problem: TIPS in salvage situation – death in >50%

Esophageal Variceal Bleeding

  • TIPS -
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Klinik für Gastroenterologie und Hepatologie

Survey 01

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Failure to control bleeding

Esophageal Variceal Bleeding

  • Treatment Failure -

Baveno IV

  • Time frame 120 hours
  • Fresh hematemesis ≥2 hours after treatment

/ endoscopic intervention

  • >3g/dl drop in hemoglobin (no transfusions)
  • Death
  • Adjusted blood transfusion requirement index (ABRI)≥0.75

Baveno V

  • Time frame 120 hours
  • Fresh hematemesis / NG tube aspiration

≥2 hours after treatment / endoscopic intervention

  • >3g/dl drop in hemoglobin (no transfusions)
  • Hypovolemic shock or death

De Franchis, J Hepatol 2005 De Franchis, J Hepatol. 2010

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Balloon tamponade

Esophageal Variceal Bleeding

  • Treatment Failure -

Sengstaken – Blakemore - Tube

Limited time frame (<24 hours, if possible) Frequent decompression necessary to avoid esophageal necrosis High complication rate – aspiration / regurgitation / perforation

Panes, Dig Dis Sci 1988

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Self-expanding metal stent (SEMS) SX Ella Stent DANIS

Esophageal Variceal Bleeding

  • Treatment Failure -

Work principle:

  • distension of esophageal wall
  • compression of esophageal varices
  • termination of hemorrhage

Device properties: - fully covered metal stent

  • flares on both ends
  • retrieval lassos on both ends
  • delivery system with positioning balloon
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SX Ella Stent Danis

  • System Demonstration -
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SX Ella Stent Danis

  • Recommendations for Placement -

 SEMS placement possible without endoscopic guidance  Confirm esophageal bleeding source whenever possible  Use a guidewire (guide wire included) when possible  Adhere strictly to implantation manual  Endoscopic and/or radiographic guidance during stent deployment possible

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SX Ella Stent Danis

  • Follow-up care -

 Confirm proper stent placement by endoscopy as soon as possible  Check stent position after 24h (by X-ray or endoscopy) or in signs of bleeding  After stent placement, stabilize pt. and evaluate TIPS indication  Remove stent after a week, longer indwelling time often possible  Remove stent urgently on suspicion of airway compression

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Survey 02

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SX Ella Stent Danis

  • Extraction -
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SX Ella Stent Danis

  • Clinical Case -
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Pilot study 11/02-05/05 143 episodes of esophageal variceal bleeding 15 refractory bleedings + 3 pts. with balloon compression + 2 pts. without primary endoscopic therapy

  • Three stent designs (diameter 18-25mm, length 95-140mm)
  • Stent indwelling time 1 – 14d

SX Ella Stent Danis

  • Published Data-

Hubmann, Endoscopy 2006

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Complementary treatment n 60-day- mortality TIPS 5 (28%) n = 0 Surgical shunt 5 (28%) n = 0 Band ligation 5 (28%) n = 1 Medical 2 (11%) n = 1

SX Ella Stent Danis

  • Published Data-
  • Immediate hemostasis in all patients
  • Stent removal in 18/20 pts (n=2 fatal liver failure)
  • No primary complications with explant

Hubmann, Endoscopy 2006

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Extended cohort (2008) 01/03-08/06 34 SEMS in eosphageal variceal bleeding (all SX-Ella)

  • Implantation without complications, n=7 distal dislocations (partial)
  • Stent indwelling time1 – 14d, median 5d

Complementary treatment n TIPS 8 (24%) Surgical shunt 5 (15%) Band ligation 11 (32%) Medical ?

  • No recurrent bleeding with indwelling stent
  • No recurrent bleeding 30d after SEMS removal
  • 60-day mortality n=10 (29%)

SX Ella Stent Danis

  • Published Data-

Zehetner, Surg Endoscopy 2006

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2010 10 SEMS in esophageal variceal hemorrhage (all SX-Ella) n=5 failure of primary endoscopic treatment n=3 unsuccessful balloon compression n=2 eophageal perforation on balloon compression

  • 9/10 successful implantation (1/10: dysfunction of positioning balloon)
  • 7/9 immediate hemostasis (2/9: bleeding source distally to esophagus)

SX Ella Stent Danis

  • Published Data-

Wright, Gastrointest Endoscopy 2010

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Follow up: 42d-survival 50% 4/10 sustained hemostasis (>60d), 2xTIPS 1/10 early recurrence (30d), successful EBL+TIPS 2/10 death by exsanguination (distal bleeding) 1/10 death by multi-organ failure with indwelling stent 2/10 death by multi-organ failure after stent removal

SX Ella Stent Danis

  • Published Data-

Wright, Gastrointest Endoscopy 2010

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8 pts. with esophageal variceal hemorrhage (08/07-08/09)

  • 5 male, 3 female, median age 62 years (1 pt. treated twice with SEMS)

Acute bleeding episodes, refractory to pharmacological treatment and EVL

SX Ella Stent Danis

  • Published Data from Essen, Germany-
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SX Ella Stent Danis

  • Published Data from Essen, Germany-

9/9: EV-hemorrhage and SEMS implant

3/9 Intervention directed at lowering portal pressure 6/9 only pharmacologic treatment to lower portal pressure 3/3 Stent removal after 10 ± 1,5 d (8-11d) 5/6 SEMS removal after 10 ± 3,6 d (6-12) 1/6 Death after 5d 4/5 SEMS removal after stabilization 1/5 Emergency SEMS removal (bronchus compression) 3/3 SEMS removal after intervention and stabilization No recurrent bleeding with indwelling SEMS

9/9: immediate hemostasis

Death 13 days after SEMS removal without further bleeding

Dechêne, Digestion 2012

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SX Ella Stent Danis

  • Published Data from Essen, Germany-

n=3 Intervention (PPG ) prior to SEMS removal n=4 Pharmacological therapy of portal pressure before SEMS removal 3/3 free of hemorrhage >3 months 3/4 recurrent bleeding within 10 days 1/3 EVL Death after 57 days 2/3 death from refractory bleeding 1/4 free of hemorrhage > 3months 2/3 death after 14 days

Dechêne, Digestion 2012

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SX Ella Stent Danis

  • Published Data from Essen, Germany-

Patient #. 4

  • 5d after SEMS placement: critical

impairment of mechanical ventilation

  • Compression of right main bronchus

by the SEMS

  • Emergency SEMS removal

Dechene Endoscopy. 2009

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SX Ella Stent Danis

  • Published Data-

Fierz, Case Rep Gastroenterol 2013

9 SEMS in 7 patients, 3/9 without prior endoscopic treatment attempt

  • Hemostasis in 8/9, SEMS removal 12h – 5 days after stent placement
  • 4/7 patients surviving >5 days, TIPS (3/4) or EBL (1/4)

Holster I, Endoscopy 2013

5 SEMS in 5 patients, failed attempts at EBL in all patients

  • Hemostasis in 5/5, SEMS removal in only 2/5 (after TIPS or liver transplantation)
  • 1/5 patients deceased 214 days after intervention with indwelling stent
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Survey 03

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De Franchis. J Hep 2010 Rosolowski M, Prz Gastroenterol 2014

„Another highly effective emergency procedure is endoscopic placement of removable, self-expanding metal stents (SX-Ella Danis stent).“ „Uncontrolled data suggest that self-expanding covered esophageal metal stents may be an

  • ption in refractory esophageal varicel

bleeding...“

SX-Ella Stent Danis Society Statements „Baveno V“

„Danis-Stent when endoscopy is not available or ineffective“

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SX Ella Stent Danis Clinical Case

57 y female, alcoholic liver cirrhosis

  • First episode of esophageal variceal bleeding treated successfully with EBL
  • Three months later: second variceal hemorrhage, refractory EBL + ethanol injection
  • Balloon compression (Senkstaken-Blakemore tube), referral to Essen University Hospital

Transjugular Intrahepatic Portosystemic Stent-Shunt

Sklerosing ulcers

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SX Ella Stent Danis Clinical Case

57 y female, alcoholic liver cirrhosis

  • 152 days after TIPS implantation: recurrent variceal bleeding, refractory to EBL
  • Immediate hemostasis after implantation of SX-Ella Stent Danis

Esophagus with SX-Ella Stent Danis After implant (d1) Before removal (d7) After removal (d7)

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SX Ella Stent Danis Clinical Case

57 y female, alcoholic liver cirrhosis

  • 152 days after TIPS implantation: recurrent variceal bleeding, refractory to EBL
  • Immediate hemostasis after implantation of SX-Ella Stent Danis
  • TIPS dilation and retrograde embolization of gastric veins

Before TIPS-Dilatation Arrows: Gastric veins After Dilation/Embolization Arrow: Coil in gastric vein

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SX Ella Stent Danis Clinical Case

57 y female, alcoholic liver cirrhosis

  • 341 days after TIPS implantation: recurrent variceal bleeding, refractory to EBL
  • Repeat deployment of SX-Ella Stent Danis with complete hemostasis
  • Surgical implantation of PTFE-covered splenorenal shunt
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Conclusions

Esophageal Variceal Bleeding

  • Primary and secondary prophylaxis regimes are well defined
  • Treatment of hemorrhage and secondary prophylaxis by endoscopic means
  • In refractory bleeding, self-expanding metal stents (SEMS) very effective
  • Low complication rate of SEMS treatment
  • Removal of stents via dedicated extraction device
  • Combination with complementary methods of decreasing portal pressure

mandatory

  • Stepwise repetition of therapeutic measures often necessary and successful
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Time for your questions