What is Emergency Hemostasis?
Bleeding can occur in the oesophagus, stomach and intestine; this is called bleeding gastrointestinal tract. The causes of bleeding include:
- Diverticular disease
- Esophageal or gastric varices
- Abnormal blood vessel
- Traumatic tear
- Procedure related complications – e.g. post ERCP, polypectomy and endoscopic submucosal resection.
- Medication related: this is commonly known as blood thinner
Severe bleeding GIT can be life threatening and requires immediate treatment. Symptoms of severe bleeding include vomiting blood, passing black stool or passing fresh blood, low blood pressure and high heart rate.
Treatment includes stabilisation, medication, endoscopic procedure and occasionally, radiological procedure and surgery.
Some of the endoscopic procedures used to stop bleeding include:
- Injection of epinephrine, glue or sclerosant
- Use of mechanical devices like clips or rubber band
- Argon plasma coagulation or electrocoagulation
These procedures can be used for both upper and lower gastrointestinal tract.
Radiological intervention is often used for severe lower gastrointestinal bleeding.
Surgery is reserved for failure of endoscopy intervention and radiological intervention.
Endoscopic procedure is indicated within 24 hours for all severe upper gastrointestinal bleeding.
It is indicated in some lower gastrointestinal bleeding especially when radiological intervention is contraindicated or not available. Very distal bleeding can be easily treated with endoscopy intervention.
Fasting of 6 hours is required before endoscopic procedure to prevent complications of aspiration so you should stop eating immediately.
You should get to the hospital as soon as possible. Call for an ambulance would be appropriate if you feel unwell. If you have a regular gastroenterologist, you should contact him or her immediately.
Be prepared to stay in the hospital for a few days for monitoring after the procedure.
The hemostasis team, consisting of gastroenterologist anaesthetist and endoscopic nurse will be activated. The endoscopic procedure is expected to be carried out as soon as possible.
Supportive treatment including intravenous fluid resuscitation, infusion of blood products and stabilisation of vital signs should be done prior to endoscopy as much as possible. Sometimes stabilisation may not be possible without endoscopic procedure. Clinical judgement is crucial in these circumstances.
Treatment with medications to lower stomach acid, lower portal pressure, treat infection and reverse bleeding tendency are instituted when appropriate before the procedure.
Patient is put under moderate sedation or general anaesthesia before the procedure. The choice depends on the severity of bleeding and the risk of aspiration (blood going into the lung).
The gastroscope is then inserted through the mouth to examine the oesophagus, stomach and small intestine. Usually, a lot of washing is needed to clear as much blood as possible and try to identify the exact place of bleeding. Typical procedure time is about one hour.
Once identified, the bleeding is arrested with a combination of injection, mechanical devices and coagulation.
Sometimes, the bleeding spot cannot be identified and the procedure may need to be repeated at a later time.
Similar process can be done for lower gastrointestinal bleed for selected cases.
After the hemostasis procedure, the patient needs to be monitored closely. This is usually done at the high dependency unit or the intensive care unit.
Selective patient may be kept intubated (using a tube to help breathing and protect airway).
Some cases of severe bleeding require additional radiological intervention like TIPSS.
Most patients are discharged after 2-3 days if their bleeding is well controlled.
The risk of emergency haemostasis procedure include aspiration, perforation and failure to arrest bleeding.
Severe bleeding itself can lead to multiorgan failure and death.
Quality of hemostasis procedure depends largely on the skill and experience of the endoscopist.
Some quality indicators include early and late rebleeding rate, mortality rate and rate of complication. This is usually measured only in major hospitals.
Cost of emergency hemostasis procedure varies widely and it is difficult to predict at the time of admission.
This is because of additional charges of expensive medications, intensive care and often after hour surcharges.