Management of non-variceal upper gastrointestinal bleeding: role of endoscopic ultrasound-guided treatments

Abstract

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common type of upper gastrointestinal emergency with high risk of life-threatening conditions. Nowadays some standard guidelines for the treatments of NVUGIB have been established based on endoscopic therapies, including injection of glues or sclerosing agents, coiling, band ligation, and thermal therapies. Nevertheless, some patients are refractory to standard endoscopic treatments. We have noticed that endoscopic ultrasound (EUS)–guided treatments have been performed by some endoscopists in certain conditions. This review aims to evaluate the role of EUS-guided treatments in the management of NVUGIB. We performed a MEDLINE/PubMed search, and relevant studies were extracted and examined. According to the existing literature, the most common lesions were Dieulafoy’s lesion, pancreatic pseudoaneurysms, and gastrointestinal stromal tumors. EUS-guided treatments mainly include injection, mechanical therapies, and combined therapies, and seem to be a promising technique in the management of NVUGIB, especially for refractory bleeding.

Comparison of intermittent and continuous proton pump inhibitor infusions in patients with non-variceal upper gastrointestinal bleeding at King Abdulaziz University Hospital, Jeddah, Saudi Arabia

“… 2 The first step in managing NVUGIB is assessing the hemodynamic status and initiating resuscitative therapy. 3 Endoscopic therapy is considered for patients with ulcer bleeding. For patients at high risk of bleeding ulcers, an initial intravenous (IV) bolus dose followed by continuous proton pump inhibitors (PPI) infusion therapy is recommended after endoscopic therapy.…”

“…For patients at high risk of bleeding ulcers, an initial intravenous (IV) bolus dose followed by continuous proton pump inhibitors (PPI) infusion therapy is recommended after endoscopic therapy. 3 , 4 It is unclear whether substituting intermittent therapy for bolus plus continuous IV infusion PPI therapy would improve patient outcomes if it is as effective. Given the reduction in cost and resources, intermittent PPIs would be the preferred regimen if both achieve comparable efficacy.…”

Advancements in endoscopic hemostasis for non-variceal upper gastrointestinal bleeding

“…Under EUS-guidance, needles are used to target blood vessel or lesions responsible for bleeding. Cyanoacrylate, polidocanol, embolization coils, thrombin, or ethanol are then injected for hemostasis[ 49 ]. EUS has been reported to be an effective method for guiding hemostasis in patients with refractory GI bleeding from ulcers, Dieulafoy’s lesions, pancreatic pseudoaneurysms, and GI stromal tumors[ 50 ].…”

“…Advantages of this adjunctive technique include its ability to visualize small blood vessels not seen with radiologic or endoscopic exam, perform EUS-guided angiotherapy, and assess for procedural success real-time by looking for cessation of blood flow. Disadvantages include the need for training in endosonography, cost, lack of efficacy and safety data, limited portability and availability of EUS systems, as well as technical issues such as imaging artifacts from retained intraluminal blood[ 49 ].…”

Endoscopic ultrasound-guided vascular interventions: An expanding paradigm

“…Treatment of non-variceal bleed (NVB) entails the standard use of well-established therapies categorized into injection (epinephrine), mechanical (clip/EBL) or thermal (argon plasma coagulation) or hemostatic agents[ 80 - 82 ]. Despite this, 10%-24% of cases re-bleed or are refractory to the standard treatment modalities.…”