The Complete Guide to Endoscopic Management of Gastrointestinal (GI) Bleeding

Gastrointestinal (GI) bleeding is a serious condition that can occur anywhere along the digestive tract. It is often associated with conditions such as peptic ulcers, gastritis, inflammatory bowel disease (IBD), and colorectal cancer. This guide covers the several types of upper and lower GI bleeds and the challenges faced with diagnosis, risk assessment, and treatment.

The Critical Role of Endoscopy in GI Bleeding Management

GI bleeding can be classified by its severity. GI bleeding is often described as either acute or non-acute. Acute GI bleeding is known as a life-threatening bleed, and a non-acute GI bleed is labeled as a non-life-threatening bleed. Other types of GI bleeding include occult bleeding, which is bleeding that is not visible, and small bowel bleeding (formerly known as obscure bleeding), which is bleeding from the small bowel.

GI bleeds can be divided into two categories based on their anatomical location. Upper GI bleeding (UGIB) is anything above the ligament of Treitz, and lower GI bleeding (LGIB) is any bleeding detected below the ligament of Treitz. Approximately 15% of patients with presumed LGIB are found to have an upper GI source of bleeding.

Patients present with various signs and symptoms when they develop a GI bleed. They can experience any of the following: epigastric pain (lower abdomen), dyspepsia pain (upper abdomen), lightheadedness, and syncope. Patients with UGIB will present with either Hematemesis (red blood or coffee grounds vomiting), Melena (black, tarry stools), or Hematochezia (bright red bloody stools). LGIB patients will present with either Hematochezia, Melena, or Tenesmus, which is a constant feeling of needing to pass stool. Patients with either UGIB/LGIB may also have abnormal vital sign and hemodynamic instability.

Risk Assessment and Stratification in the Endoscopic Management of GI Bleeding

Effective endoscopic management of GI bleeding involves thorough pre-endoscopic assessment to evaluate the patient's condition and identify potential risks.¹ This assessment considers the severity and location of bleeding, the patient's age, overall health status, comorbidities, and lab values.

Guidelines from the American Society of Gastroenterological Endoscopy (ASGE) recommend using Risk Stratification scores to triage patients with UGIB to the appropriate level of care. The Glasgow-Blatchford Score (GBS) and the AIMS65 score can be calculated using only clinical data available on presentation, whereas the Rockall score is used to assess post-endoscopic treatment. The Rockall helps to predict rebleed rates, the need for further intervention, and mortality. Another assessment is the Forrest Classification. This is used to classify bleeds, stratify the risk of further bleeding, and to guide therapy, specifically in Peptic Ulcers.

GBS - scores patients BP, urea nitrogen, hemoglobin, and pulse

AIMS65 scores patients' Albumin, time of clotted blood ratio (INR), mental status, and age

Rockall scores (0-11 range) patients'
age, shock, comorbidity, endoscopic evidence of bleeding, and diagnosis

Forrest Classification of Ulcers

Endoscopic management plays a pivotal role in diagnosing and treating GI bleeding. Endoscopy, a minimally invasive procedure, allows healthcare professionals the ability to visualize the digestive tract, identify the bleeding source, and implement an appropriate treatment plan. STERIS has designed hemostasis devices to address a variety of clinical challenges. Our hemostasis products are designed to improve patient outcomes in instances of GI bleeding. Among other devices, we provide hemostatic through the scope clips for polypectomy defect closures and recurrent bleeds, over-the-scope clips for large defect closures that are acute GI perforations, anastomotic leaks, or fistulas. We also provide injection needles that are designed to perform in the most tortuous conditions. All of these devices improve procedural efficiency and contribute to effective endoscopic management of GI bleeding.

Diagnosis and Endoscopy: Crucial Steps in Managing GI Bleeding

Accurate and timely diagnosis is critical in the successful management of GI bleeding. Endoscopy has revolutionized GI bleeding diagnosis, offering a non-invasive yet comprehensive view of the gastrointestinal tract. The endoscopic procedures commonly employed for diagnosing GI bleeding include upper endoscopy (esophagogastroduodenoscopy (EGD)) and colonoscopy. Another endoscopic procedure, referred to as a double-balloon enteroscopy, may be needed for diagnosing a small bowel bleed. Double balloon enteroscopy is a special endoscope that uses a two-tube, two-balloon system to further advance by pleating the small intestine to diagnose and treat small bowel bleeds.

While endoscopy is highly effective, it may have limitations in cases where the bleeding source is in the small intestine. Another procedure, referred to as a capsule endoscopy or double-balloon enteroscopy, may be needed for small intestine bleeding. A video capsule (for non-acute diagnosis) is given to a patient with water for oral consumption. For patients with difficulty swallowing, the capsule will be placed through the pyloric sphincter in the duodenum via an endoscope and a capsule delivery device. The capsule will pass through the small intestine over time while providing images to the recording device. Once the capsule passes through the small intestines, the images/recordings will be uploaded to a computer and reviewed. The findings can determine a bleed within the small intestine, which typical endoscopes cannot reach. Newer to the market are sensor capsules (for acute diagnosis), which can be given to a patient orally via water. The sensors will gather data based on wavelengths of light and report to the portable recording device a positive or negative diagnosis of a UGIB within minutes.

Therapeutic Interventions in Endoscopic Management of GI Bleeding

The endoscopic management of GI bleeding involves various therapeutic interventions. Treatments include thermal, injection, mechanical, and topical therapies. Thermal therapy uses contact and non-contact forms of heat and energy to coagulate tissue. Electrosurgery, monopolar, bipolar, and Argon Plasma Coagulation(APC) are to name a few. These treatments aim to control bleeding, prevent rebleeding, and promote healing.

Injection therapy causes vasoconstriction with the injection of epinephrine. It can also cause sclerosis when injecting Ethanol into the vessel, and when injecting glue, you can also cause embolization.³ When considering your injection needs, you have a variety of injection needles to choose from. Needles are available in various gauges to accommodate the media you inject and different needle lengths to address the injection depth.⁴

Teflon-coated stainless steel catheter

Stainless steel catheter

Plastic catheter

Examples of Mechanical therapy devices:

Band ligation devices have a specially designed transparent cap placed on the endoscope's tip and then introduced into the patient. As the endoscopist approaches the bleed site, the bleeding site is suctioned into the cap, and the band is deployed around the tissue surrounding the bleed. If deployed successfully, the band acts as a tourniquet, helping to stop the bleeding.

Through the scope, endoscopic clips can be introduced down the accessory channel of an endoscope if a bleed is found during a procedure.⁵ The clips will stay in place for an average of 10-14 days to allow healing of the bleed site and then pass harmlessly through the rest of the GI tract once they have fallen off.

Cap-based over-the-scope clips^5,6,7 are the newest mechanical therapy to be introduced. They are large defect closure devices.

The devices have been developed to help close acute GI perforations, anastomotic leaks, and chronic GI fistulae for which traditional clipping may not be suitable.

This large closure device grabs more tissue around the defect or ulcer and, when closed, provides more pressure to help the wound heal.

Diffuse bleeding treated with hemostatic powder.⁷

Topical Therapy^6,7 consists of liquids, aerosol powders, and solid polymers applied to the bleeding site.

Hemostatic powders are delivered through a catheter that can be inserted through the accessory channel of the endoscope to stop bleeding. Like thermal and mechanical therapies, Hemostatic sprays can deliver treatment without precision or direct visualization.

ASGE Report on Emerging Technology “Emerging technologies for endoscopic hemostasis. Volume 75, No. 5 : 2012 GIE
ASGE Editorial “Hemostatic powder spray for GI bleeding” Volume 77, No.3: 2013 GIE
Kim et al. 2019. ‘Management of Complications of Colorectal Submucosal Dissection’ Clinical Endoscopy. 52. 114-119. DOI:10.5946/ce.2019.063

Managing GI Bleeding in Critically Ill Patients

Endoscopic management of GI bleeding in critically ill patients requires special consideration before implementing a treatment plan. A thorough assessment of the patient's overall health, including comorbidities and underlying conditions, is essential.

Prognosis and Follow-Up after Endoscopic Management of GI Bleeding

Understanding the prognosis after GI bleeding and ensuring proper follow-up care is important in endoscopic management. Factors influencing the prognosis include the patient's age, comorbidities, severity of bleeding, and response to initial treatment.

Our innovative products are designed to enhance patient safety, improve procedural efficiency, and support positive clinical outcomes, making us your trusted partner in providing exceptional patient care.

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