Upper Gastrointestinal Bleeding Management An Issue Of Gastrointestinal Endoscopy Clinics

Upper gastrointestinal bleeding is the leading emergency leading to hospitalization and urgent endoscopy. The field of gastrointestinal bleeding is rapidly evolving. The epidemiology is changing with more complex older patients on anticoagulant and antithrombotic agents presenting with upper gastrointestinal bleeding. The initial management has rapidly evolved with new transfusion thresholds, the use of risk stratification scores and no more nasogastric tubes. There is new data and recommendations on optimal timing of endoscopy. Medical therapies have also evolved with changes in proton pump inhibitor administration and the use of prokinetics to improve endoscopic visualization. Many modifications in endoscopic therapy have recently been advanced including the use of endoscopic ultrasound guided angiotherapy, topical sprays (i.e. Hemospray) and over-the-scope clips. In order to give optimal care to patients, it is critical that practicing gastroenterologists are aware of the many recent advances in management of patients with upper gastrointestinal bleeding.

Dr. Gralnek is considered an authority on GI bleeding, and he has invited experts in their respective fields to contribute to this issue. The content is divided up between Acute Non-Variceal Upper GI Hemorrhage and Acute Lower Gastrointestinal Hemorrhage. Articles are devoted to the follow topics: Initial assessment, risk stratification and early management; Endotherapy of peptic ulcer bleeding; Endoscopic hemostasis of non-variceal, non-ulcer UGIH; Emerging endoscopic treatments for NVUGIH; The cutting edge: doppler ultrasound in guiding endoscopic hemostasis; The role of interventional radiology in NVUGIH; Managing antithrombotic agents in the setting of acute GI bleeding; Patient presentation, risk stratification and initial management; Colonoscopy: Diagnosis, timing and bowel preparation; The role of endoscopic hemostasis therapy; and Prevention of recurrent lower GI hemorrhage. Readers will come away with the most current clinical infomration on how to manage and prevent GI bleeding.

In this issue of Gastrointestinal Endoscopy Clinics of North America, guest editor Dr. Patrick Pfau brings his considerable expertise to the topic of Gastrointestinal Bleeding. Top experts in the field cover a broad range of topics on the diagnosis and treatment of both upper and lower gastrointestinal bleeding with a concentration on endoscopic intervention. This issue discusses the preparation of the patient with a GI bleed even before endoscopy is performed, and provides extensive coverage of the latest data and technology for variceal and non-variceal upper GI tract bleeding, small bowel/occult, and lower GI and colonic bleeding. Contains 12 relevant, practice-oriented topics including endoscopic diagnosis, grading, and treatment of bleeding peptic ulcer disease; variceal and non-variceal upper gastrointestinal bleeding refractory to endoscopic management: indications and role of interventional radiology; diagnosis of occult and obscure gastrointestinal bleeding; endoscopic treatment of small bowel bleeding; endoscopic diagnosis and treatment of colonic diverticular bleeding; and more. Provides in-depth clinical reviews on gastrointestinal bleeding, offering actionable insights for clinical practice. Presents the latest information on this timely, focused topic under the leadership of experienced editors in the field. Authors synthesize and distill the latest research and practice guidelines to create clinically significant, topic-based reviews.

This issue of Gastroenterology Clinics of North America is all about acute upper GI bleeding and is divided into two distinct sections: section I is devoted to nonvariceal upper GI bleeding and section II is devoted to variceal upper GI bleeding. Acute nonvariceal upper GI bleeding may originate from the esophagus, stomach, or duodenum, essentially anywhere proximal to the Ligament of Treitz. In Section I, Dr Gianluca Rotondano, Hospital Maresca, Torre del Greco, Italy, begins with a review of the epidemiology and diagnosis of acute nonvariceal upper GI bleeding. We then turn to patient presentation, risk stratification, and how to initially medically manage these bleeding patients. I am pleased to have one of our emergency medicine colleagues, Dr Andrew Meltzer, Department of Emergency Medicine, George Washington University, contribute this important article and provide a unique viewpoint from the emergency department where most of these patients initially present. As we all know, endoscopic hemostasis is the accepted standard of care for patients with acute nonvariceal upper GI bleeding. Moreover, peptic ulcer bleeding is the most common nonvariceal cause of acute upper GI bleeding; thus, Drs Yidan Lu, Yen-I Chen, and Alan Barkun from McGill University, Montreal, Canada, provide an in-depth review of the endoscopic management of peptic ulcer bleeding. Drs Eric Tjwa, I. Lisanne Holster, and Ernst Kuipers from the Erasmus Medical Center University Hospital, Rotterdam, The Netherlands, review the endoscopic management of all other causes of acute nonvariceal upper GI bleeding, and in addition, Drs Louis Wong Kee Song and Michael Levy from the Mayo Clinic, Rochester, Minnesota discuss emerging endoscopic hemostasis treatments, such as topical sprays and over-the-scope clipping devices. Although endoscopic hemostasis is very highly effective, there are unfortunately cases where bleeding is unable to be controlled or when significant rebleeding occurs that is not amenable to endoscopic therapy. Therefore, I have included two articles that provide insight into the question...what if endoscopic hemostasis fails? The first article, written by Drs Philip Wai Yan Chiu and James Yun Wong Lau, from Prince of Wales Hospital, The Chinese University of Hong Kong, focuses on tried and true surgical treatment options. The second article, by Dr Sujal Nanavati, University of California at San Francisco, Department of Radiology and Biomedical Imaging, addresses the alternative treatment strategy of angiographic embolization, which has now emerged as the often preferred salvage treatment strategy.

This group of international experts on gastrointestinal bleeding have written state-of-the art reviews on the overall approach to gastrointestinal bleeding. Endoscopists will find in this issue coverage of the endoscopic, surgical and pharmacologic therapies as well as competency and sedation issues. Other articles focus on the epidemiology, pathology, and the prevalence and incidence of H. Pylori in upper gastrointestinal bleeding.

Together with Consulting Editor Dr. Charles Lightdale, Dr. Qiang Cai has put together a comprehensive issue devoted to gastroparesis. Expert authors have contributed clinical review articles on the following topics: Epidemiology and Pathophysiology of Gastroparesis; Non-Diabetic Gastroparesis; Clinical Manifestations and Natural History of Patients with Gastroparesis; Evaluation of Patients with Suspected Gastroparesis; Symptomatic Management of Gastroparesis; Gastric Electrical Stimulator for treatment of Gastroparesis; Surgical Treatment for Gastroparesis; Botulinum Toxin Injection for Treatment of Gastroparesis; Stent Placement for Treatment for Gastroparesis; Technical Aspects of Per Oral Endoscopic Pyloromyotomy; Gastric Emptying Scintigraphy for Evaluation of Patients with Gastroparesis before Per Oral Endoscopic Myotomy; Outcomes of Per Oral Endoscopic Pyrolomyotomy in France; Outcomes of Per Oral Endoscopic Pyloromyotomy in China; Outcomes of Per Oral Endoscopic Pyloromyotomy in the United States.. Readers will come away with the information they need to improve endoscopic techniques and improve patient outcomes.

This book covers all aspects of bleeding in a systemic approach organized by the site of bleeding. It offers a step-by-step approach through appropriate diagnosis and management strategies including surgical, endoscopic, medical and angiographic techniques.

Endoscopic access to the small bowel has advanced significantly since the introduction of video capsule endoscopy and deep enteroscopy in early 2000. Other major advances have occurred in imaging modalities involving computed tomography and magnetic resonance studies. Due to these advances, the recent 2015 ACG guideline changed the terminology from “obscure to “small bowel bleeding because the majority of cases now can be found to have a small bowel source. The improvements in technology have advanced our ability to visualized vascular findings, inflammatory lesions, and small bowel neoplasms. Articles in this issue are devoted to these improvements in technology.