Introduction

Acute gastrointestinal (GI) bleeding requiring emergency endoscopic intervention is a common high‐risk medical and surgical problem. Traditional apprentice‐type training for such GI events is often inadequate because of their unpredictable frequency, usual off‐hours occurrence, urgency to complete, and potential risks of poor outcomes or complications. Similar problems occur in other medical specialties such as cardiology or trauma surgery. The development of the Advanced Cardiac Life Support (ACLS) and Advanced Trauma Life Support (ATLS) programs has facilitated the training of health‐care professionals to better prepare for those infrequent events. Both programs allow trainees to rehearse resuscitation scenarios outside of the emergency clinical environment until proper management is learned. A similar program would be useful for training about the management of acute GI bleeding, but national or international programs to do this are needed but lacking.

When learning about the endoscopic management of GI bleeding during an emergency case, the number of different potential diseases and their acute management seems daunting. However, if the diagnoses are categorized by GI organ location, anatomy, lesion vascularity, and comorbidities and the hemodynamic condition of the patient are considered, similarities in patient medical treatment and endoscopic hemostasis become more manageable (Table 16.1). For endoscopic management of GI bleeding, the trainee should focus on a differential diagnosis of the potential lesions, the type of vascular supply, and what type of endoscopic management strategy to use for each type of lesion. For endoscopic treatment of GI bleeding, there are currently four major categories—topical, injection, thermal, and mechanical.

This chapter focuses on defining the processes and techniques of learning the skills required to successfully achieve endoscopic GI hemostasis. It does not explore indications and contraindications for the procedures or efficacy since that material is covered in a general textbook of gastroenterology. Instead, the chapter describes how one trains in endoscopic hemostatic techniques by outlining both the prerequisite and necessary knowledge and technical skills required to become proficient. The appropriate settings to learn hemostatic strategies are also discussed as are the benefits and limitations of simulators, current hemostasis guidelines, and use of additional learning tools and aids. Finally, assessment of competency in endoscopic hemostasis and maintenance of skills is reviewed.

Hemostasis as defined in this chapter is the cessation of active bleeding and prevention of rebleeding with an endoscopic intervention. It has an added dimension of going beyond visual endoscopic hemostasis to now include monitoring and obliterating underlying blood flow. With success in all these goals, clinical outcomes patients have been shown to improve. However, failure to achieve all of these goals often results in rebleeding and need for further intervention. Although they are critically important, neither the medical management nor the clinical outcomes of GI bleeding are the primary focus of this chapter.

Prerequisite cognitive knowledge required prior to learning GI endoscopic hemostatic techniques

The first step to becoming proficient in endoscopic hemostasis is to acquire a fundamental knowledge of the pathophysiology and clinical presentation of different GI bleeding lesions. This cognitive learning is gained through studying textbooks of gastroenterology, reviewing literature about GI hemorrhage, and participating in postgraduate training focused on diseases of the GI tract. Such knowledge is critical so that the endoscopist who is trying to learn GI hemostasis management at the bedside can discuss a focused differential diagnosis and the expected lesion vascular anatomy that will guide the therapeutic and endoscopic plans. The following examples illustrate the importance of accurate differential diagnoses and understanding lesion blood supply.

Example 1: A 55‐year‐old cirrhotic patient presents with hematemesis and melena.

A knowledgeable endoscopist should suspect this patient to have a lesion related to portal hypertension and venous blood flow such as esophageal or gastric varices or a Mallory–Weiss tear [1]. The trainee should know that bleeding from these lesions is venous and probably related to portal hypertension. The most likely treatments that should be anticipated and prepared for are band ligation, sclerotherapy, and injection of glue (cyanoacrylate) (Table 16.2). These endoscopic treatments are in addition to concomitant hemodynamic resuscitation, octreotide drip, treatment of coagulopathies, antibiotics, and management of comorbid conditions (1). Based upon the potential diagnoses, the GI team should be instructed to equip the emergency endoscopy cart with the proper supplies and be prepared to use them. Other important pre‐endoscopic decisions are about airway protection (in patients with altered mental or respiratory status and to prevent aspiration of blood) and methods to remove blood or clots and to improve visualization prior to and during the endoscopy. The timing of the procedure and also the type of anesthesia are important. It may be advisable to perform the procedure in the ICU either with tracheal intubation or with an anesthesiologist with MAC anesthesia. Other decisions to make prior to the emergency endoscopy are what types of endoscopes (therapeutic and diagnostic), irrigators, and accessory devices to bring to the bedside. Finally, once the procedure is underway, the endoscopist must communicate closely with the GI team to ensure proper monitoring of the patient, adequate sedation, and accurate application of hemostatic devices.

Example 2: A 65‐year‐old patient with multiple comorbidities (without cirrhosis) presents with painless melena, hypotension, and severe anemia while on chronic aspirin and clopidogrel for secondary prevention of cardiovascular events.

With this history, the most likely diagnosis is an aspirin‐induced ulcer with or without stigmata of recent hemorrhage (SRH). Furthermore the experienced clinician and endoscopist know that the method of hemostasis recommended as the standard of care and the risk stratification for rebleeding prior to endoscopic hemostasis depend upon major vs. minor SRH. For ulcers, the usual findings related to SRH (with their prevalence and risk of continued bleeding or rebleeding on medical management alone without endoscopic treatment) are major SRH [spurting arterial bleeding (5%/80–90%), a nonbleeding visible vessel (NBVV) (20%/40–50%), adherent clot (10%/25–35%)], lesser SRH [oozing bleeding without other SRH (10%/20–30%) or a flat spot (5%/20%)], and vs. no SRH [clean ulcer base (50%/<5%)] [2]. It is much less likely that this patient with severe acute bleeding and hemodynamic instability has an upper GI (UGI) neoplasm, varices, an angioma syndrome, or a diffuse lesion such as esophagitis. The endoscopist and GI team must be prepared to perform emergency endoscopy with a therapeutic panendoscope (with separate channel for target irrigation and a large suction port to remove blood and clots prior to focal endoscopic treatment). They should have concluded before the endoscopy that the most likely source of bleeding is arterial from an ulcer or Dieulafoy’s lesion. They should expect to use combination therapy with injection of dilute epinephrine (1:20,000 dilution in saline) followed by thermal coagulation, standard hemoclipping, or large over‐the‐scope clip (OTSC) as the most effective methods of definitive hemostasis (Table 16.2) [2–4]. With current endoscopic techniques using SRH and visually guided outcomes, the rebleeding rates are still 15–25% for major SRH. The rebleeding rates can be significantly decreased by Doppler endoscopic probe (DEP) monitoring of arterial blood flow and using this as a guide to definitive hemostasis [5]. (See later section on DEP.)

Example 3: A 70‐year‐old patient presents with severe hematochezia, hypotension, and anemia.

An experienced endoscopist knows that an urgent colonoscopy after purge is recommended as the best way to make the diagnosis and apply successful hemostasis to focal lesions such as a diverticula bleed, or post‐polypectomy induced ulcers, a rectal ulcer, or angiomas [5, 6]. An UGI source should be considered for patients with cirrhosis, a history of hematemesis or melena, and a positive nasogastric aspirate and for patients who develop severe hematochezia as inpatients [6, 7]. In contrast, for the elderly patient who develop hematochezia at home as an outpatient, the most likely location of the bleeding lesion is the colon. In such a patient, the differential diagnosis of lesions includes, in descending order of prevalence, a diverticular bleed, ischemia, internal hemorrhoids, rectal ulcers, colitis, delayed post‐polypectomy ulcer (if recent polypectomy), or an angioma syndrome [6–10]. After thorough cleansing of the colon with purge to remove all clots, blood, and stool, urgent colonoscopy and treatment of focal lesions are recommended. Lesions that are amenable to colonoscopic hemostasis include those with underlying arteries and SRH (definitive diverticular bleeds and ulcers of any type), angioma syndromes (radiation or angiodysplasia), or venous‐type bleeding (internal hemorrhoids). The three general types of endoscopic accessories that will be required for treatment of this spectrum of colon lesions are thermal probes, hemoclips with or without epinephrine injection, and banding (for bleeding internal hemorrhoids).

These examples illustrate the in‐depth knowledge that is required to formulate an accurate differential diagnosis for patients with GI bleeding; to plan for the timing, protection of the airway, and type of anesthesia for a safe emergency procedure; and to anticipate and bring to the bedside the necessary equipment and accessories for the procedure. Acquiring this knowledge is a prerequisite before the trainee attempts to learn about the technical aspects of endoscopic management of GI bleeding [1–10].

Prerequisite technical knowledge and skills required to learn endoscopic hemostasis

Emergency endoscopic hemostasis is an advanced procedure and should not be attempted by a novice, untrained endoscopist. Once the cognitive aspects about sources of bleeding as discussed above are mastered along with the knowledge of medical management and resuscitation, substantial technical knowledge and skill related to the procedure are necessary to be able to successfully manage patients with severe GI hemorrhage. Requisite knowledge includes understanding the proper setup and function of the endoscopic equipment, such as a standard gastroscope, therapeutic gastroscope (single and double channel), duodenoscope, enteroscopes (standard push and balloon enteroscopes), and colonoscope. Also needed are a thorough knowledge of anesthesia for emergency procedures (including IV moderate sedation or MAC anesthesia) and protection of the airway to prevent aspiration. Finally, a basic understanding of the principles of electrosurgery is necessary, although a more thorough review is critical to master successful and safe hemostatic techniques.

Prerequisite technical skills include the safe administration of moderate sedation, ability to minimize the risk of aspiration, and application of airway rescue management strategies if necessary (such as the use of oral airway adjuncts, bag ventilation, and endotracheal intubation). Mastery of basic endoscopic manipulation is also required. This can be better understood if the skill is deconstructed into component steps.

Both upper and lower endoscopy require a common skill set that includes the ability to provide scope traversal, four‐way tip deflection, and torque to deliver the endoscope to the desired location. Endoscopy also requires the correct use of insufflation and target irrigation to properly identify lesions and access various areas of the GI tract. Targeting is another critical skill that enables skilled endoscopists to deliver the endoscopic accessory onto the lesion of interest with proper orientations (see Video 16.1). Upper endoscopy requires the additional skill of being able to traverse the upper sphincter and pylorus. Finally, an endoscopist must be able to communicate well with the rest of the endoscopic team in order to make accurate diagnoses and to perform successful endoscopic therapies.

It is recommended that any practitioner who wants to learn endoscopic hemostasis skills should first have the cognitive and technical knowledge discussed above prior to starting their hemostasis training, including performing bedside cases.

Required technical knowledge and skills to be proficient in endoscopic hemostasis

In contrast to the breadth of knowledge required to understand the pathophysiology and current medical–surgical management of all causes of GI bleeding, the knowledge and skills required to actually perform endoscopic hemostatic maneuvers are less expansive. GI hemostasis can more easily be broken down into components with common strategies. Each of these strategies requires a specific fund of knowledge and technical skill to be successfully applied so that good clinical outcomes result.

Common knowledge and skills for all hemostatic strategies

Specific hemostatic strategies

Injection

Knowledge

Injection of a drug (e.g., vasoactive or sclerosant) with a needle is often useful to slow arterial bleeding or control spurting variceal bleeding (Figure 16.3). Understanding what substance to inject for different lesions, where to inject it (e.g., intravariceal or paravariceal for varices or around the SRH in the ulcer base), and the complications of injection are important. One example is epinephrine—the most common substance injected for nonvariceal bleeding. It is typically used at 1:10,000 or 1:20,000 concentrations but may be diluted more with saline if lower concentrations are desired. It is injected as 1–2‐cc aliquots into the submucosal layer, directly into the base of the ulcer or lesion around the SRH, typically in four quadrants. Common side effects are transient tachycardia and hypertension. Table 16.3 lists substances used for injection into bleeding lesions [12]. There is a major limitation of injection for bleeding ulcers. As monotherapy, injection therapies for ulcers with major SRH have been reported to have significantly higher rebleeding rates than thermal coagulation, hemoclips, or combination therapy with epinephrine and coagulation or hemoclipping [13].

Skill

One of the reasons injection therapy is so common is that it is technically easy to perform with little chance for an adverse event, at least with dilute epinephrine or other vasoactive injectants. The skills required to perform sclerotherapy include an ability to pass the device down the working channel, deliver it to the target, extrude the needle, and insert the needle into the lesion or near the SRH and into the desired tissue plane. Ongoing communication with the assistant during emergency endoscopy for deployment of the needle and injection of the sclerosant or epinephrine is critical (see Video 16.2).

	Nonvariceal lesions with SRH	Varices
Epinephrine (1:10,000 or more dilute)	Yes	No
Ethanol 99.5%	Yes	Yes
Hypertonic (50%) dextrose	Yes	No
Polidochanol 0.5–3%	Yes	Yes
Ethanolamine oleate 5%	No	Yes
Sodium morrhuate 5%	No	Yes
Sodium tetradecyl sulfate 1 or 3%	No	Yes

Thermal

Knowledge

Applying thermal energy to a bleeding lesion either alone or in combination with epinephrine injection therapy is also commonly used for endoscopic hemostasis [1, 2]. A thorough knowledge of the principles of electrosurgery is critical for this technique. A comprehensive review of this topic is beyond the scope of this chapter but is included in a separate chapter in this book (see Chapter 12). Some basic principles of electrosurgery and types of generators will be reviewed however.

Cauterizing a lesion with electromechanical energy (electrocautery) can be achieved by applying an alternating electrical current to the target tissue via an accessory such as a snare, probe, or forceps. Patients are not “shocked” by this energy the way they would be by coming into contact with a common wall outlet because it is delivered at a very high frequency in the radio wave spectrum (radiofrequency) and a grounding pad is used with monopolar coagulation. All electrocautery requires a complete circuit to be delivered to the target tissue. There are two ways to complete this circuit: monopolar or bipolar electrocoagulation. Monopolar electrocautery completes the circuit by the electrical current passing through the patient to a grounding pad or plate and back to the generator (Figure 16.4). The current in bipolar or multipolar electrocoagulation (MPEC) passes through the affected tissue only at the tip of the probe or accessory and does not require a grounding pad (Figure 16.5). Monopolar electrocautery can penetrate deeply into tissues and is effective for hemostasis, but the risks are deep thermal injury, transmural injury, and possible perforation in thin‐walled gut structures. Bipolar energy does not penetrate as deeply and can be less effective in endoscopic hemostasis, unless firm tamponade pressure is applied to achieve coaptive coagulation [1, 2]. A thorough knowledge of these principles along with proper energy settings on the generator used for electrocautery is critical for the safe application of this technology (see Tables 16.6–16.8).

Argon plasma coagulation (APC) is a special version of monopolar electrocautery that requires additional understanding. Argon gas, when “electrified,” converts to plasma that will conduct monopolar current. APC is useful when superficial tissue coagulation can be applied to a large surface area without touching the tissue. This prevents buildup of debris on the probe tip and allows for the expeditious “painting” of large areas, such as in watermelon stomach, radiation telangiectasia, or angiodysplasia (Figure 16.6). Understanding the unique energy settings and argon gas flow rates for operating an APC probe is essential. Being mindful to constantly aspirate the argon gas from the GI tract is also important. Limitations of APC for GI hemostasis must also be understood. For example, touching the electrode tip directly to the tissue results in monopolar coagulation, potentially transmural coagulation, and higher risk of perforation. In addition, coaptive coagulation (applying pressure with the electrocautery probe to collapse the walls of the bleeding vessel together for sealing) is not possible with APC, which limits its hemostasis application to superficial coagulation of AVMs or oozing bleeding from very small vessels [1, 2].

Another method of applying thermal energy to tissue in the GI tract is with a heater probe. This device heats up rapidly and transfers a preselected amount of heat across a Teflon‐tipped probe to the tissue. The heater probe does not apply electrocautery to the tissue, but cauterizes it by generating heat at its tip. Deep tissue injury is possible if repeated pulses are applied. Understanding the energy settings for different types of lesions, the size of probe to use, methods of irrigation, and conformity of the tip are all important for safe and successful application of heater probe for bleeding GI lesions (Table 16.6). Heater probe has been taken off the market in the United States but may still be available in some other countries.

Skill

Application of a heater probe, bipolar probe, or another contact electrocautery device by touching the probe tip to the tissue is called contact coagulation. When using these devices in the UGI tract for hemostasis, it is best to apply the principle of coaptive coagulation (Figure 16.7) (see Video 16.3). This technique requires applying the thermal probe directly on the actively bleeding site or SRH with enough pressure to stop the bleeding by interrupting blood flow in the underlying vessel and collapsing its walls against each other [2]. When the heat or electrocautery is applied, the vessel walls can be sealed together, and definitive hemostasis is achieved. Having the skill to deliver the thermal device to the target with the proper angle and force is a necessary skill for effective thermal hemostasis and coaptive coagulation [1, 2]. To do this requires the ability to keep the endoscope in a stable position with the probe tip close to the endoscope tip to maximize the ability to apply firm and steady pressure. Laboratory studies have reported that arteries as large as 2 mm in diameter can be sealed with heater probe or bipolar (or multipolar) probes using coaptive coagulation [14]. However, recent clinical studies of ulcers have reported that residual arterial blood flow is detectable in about 25% of patients with major SRH treated with visually guided coaptive coagulation at endoscopy [5, 15]. These patients have a high risk of rebleeding.

Mechanical

Skill

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