Should we use Doppler endoscopic probe for management of patients with severe non-variceal gastrointestinal hemorrhage? Yes.

This is half of a two-part debate — read the opposing argument.

Why use Doppler endoscopic probe (DEP) in the management of severe non-variceal gastrointestinal hemorrhage (NVUGIH)? The fundamental reason is that DEP gives endoscopists a new dimension to help them treat patients: the ability to monitor arterial blood flow underneath stigmata of recent hemorrhage (SRH).1 Goals of endoscopic treatment are to control active bleeding and prevent rebleeding. Visually guided, standard endoscopic treatment often fails in the second goal because it does not reliably obliterate blood flow underneath SRH.  DEP allows the endoscopist to quantitate rebleed risk, to gauge completeness of hemostasis, and to guide obliteration of lesion blood flow.1,2


Strong scientific evidence has now been reported: use of DEP improves routine management of patients with severe NVUGIH by improving clinical outcomes and reducing costs. DEP is an easy technique to learn how to use, is quick to apply, and is safe.


Strong scientific evidence has now been reported: use of DEP improves routine management of patients with severe NVUGIH  by improving clinical outcomes and reducing costs.1-3  DEP is an easy technique to learn how to use, is quick to apply, and is safe. I will elaborate on each of these points in this discussion.

How does DEP improve risk stratification in peptic ulcer bleeding (PUB)?   

For PUB, rates of detecting underlying arterial flow vary with the SRH — spurting arterial bleeding, 100 percent; non-bleeding visible vessels (NBVV), 91 percent; adherent clot, 68 percent; oozing bleeding, 47 percent; and flat spot, 41 percent. Whereas  visually classifying SRH often lacks agreement among endoscopists leading to misinterpretation of results, risk stratification for likelihood of rebleeding is more predictable using the combination of SRH and DEP.1,2 If there is  arterial blood flow underneath the SRH after endoscopic hemostasis, the risk of rebleeding is much higher than if no blood flow is detected by DEP.1,2

What is the compelling evidence that use of DEP improves clinical outcomes?

The strongest evidence that DEP monitoring of arterial blood flow as a guide to risk stratification and definitive endoscopic hemostasis is effective, safe and improves clinical outcomes has been reported by my CURE group.1,2,4 In an initial cohort study, all 163 patients had bleeding ulcers and DEP was used to monitor arterial blood flow before and after standard of care, visually guided treatment with MPEC or hemoclips (with or without pre-injection of epinephrine). For PUB’s with arterial blood flow prior to endoscopic hemostasis, those with major SRH (spurting bleeding, NBVV or adherent clot) had residual blood flow after the endoscopic treatment in 27 percent, indicating inadequate hemostasis to prevent rebleeding. Of interest were the subgroup of patients some PUBs thought leaders lump together as “active bleeding:” those with spurting bleeding and others with oozing bleeding without other SRH. At baseline, 100 percent of spurters had arterial blood flow detected versus only 47 percent of oozers. Of those with positive blood flow at baseline, 36 percent of the spurters had residual blood flow after visually guided standard endoscopic hemostasis and 80 percent rebled (four out of five with residual blood flow) within 30 days. In contrast, none of the oozers with positive arterial blood flow at baseline had residual blood flow after visually guided hemostasis and none rebled within 30 days of follow-up.  This striking difference between oozers and spurters is also confirmed  in a large international study.5

We also reported a new RCT of severe bleeders with NVUGI lesions: PUB’s, Dieulafoy’s lesions and Mallory Weiss tears.2 This was a DEP interventional trial with blinding of caregivers who made all the  decisions about clinical management after randomization. The endoscopic treatment was either with standard visually guided hemostasis (as described for the cohort study) or DEP monitoring of blood flow before and after hemostasis with application of more endoscopic treatment if the endoscopist deemed that to be feasible and safe.2 The rebleeding rate of the standard group was significantly higher than the DEP group: 26 percent versus 11 percent.3 The treatment was safe and there were arithmetically higher rates of severe complications and surgery in the standard group. In the DEP group, residual arterial blood flow after endoscopic treatment highly correlated with rebleeding: 0 percent of patients (0/8) with no residual flow rebled, whereas 89 percent of those with residual blood flow rebled (8/9).

Subsequently, we performed a multivariable analysis matching historical controls treated by the same investigators before DEP was available to NVUGI RTC patients.4 Matching was by multiple risk factors including age, gender, prognosis score, inpatient start of bleeding versus outpatient start,  lesion type, SRH, and endoscopic treatment. The results were significant improvements with DEP in reduced rates of rebleeding, surgery, and death compared to visually guided, standard-of-care hemostasis.4

A recent study by Barkun and Wong evaluated the cost effectiveness of DEP monitoring and reported significant cost savings when DEP was utilized.3 The practical take home messages of utilizing DEP for PUB management are not all intuitive but they include the low cost of the probes (about the same as a single use hemoclip), the reusable DEP control box (less than $2,500), and the fact that by using the DEP to map out the course and location of the underlying artery and to clip (or cauterize) it on either side of the SRH to obliterate blood flow, you can reduce the number of hemoclips used and significantly reduce rebleeding, which uses a lot of health care dollars.

Key takeaways

    1. DEP is a safe and effective endoscopic technique to apply during emergency endoscopic procedures in NVUGIB.
    2. Monitoring of blood flow gives the endoscopist another important dimension beyond visual cues alone and blood flow underneath SRH is extremely useful for risk stratification, completion of endoscopic treatment, and providing definitive hemostasis.
    3. Patients with residual blood flow after visually guided endoscopic hemostasis have a high risk of rebleeding.
    4. There is very strong and compelling scientific evidence that monitoring blood flow with DEP improves clinical outcomes, is safe, and cost-effective.

Disclosures: Dr. Jensen has been part of the BSC speaker’s bureau in the past. Dr. Jensen has received research support from VIT.


Dr. Gralnek describes why Dopler should not be used yet.


References

1.Jensen D.M., Ohning G.V., Kovacs T.O.G., Ghassemi K., et al. Doppler endoscopic probe as a guide to risk stratification and definitive hemostasis of peptic ulcer bleeding. Gastrointest Endosc. 2016;83:129-136.

2.Jensen D.M., Kovacs T.O.G, Ohning G.V., Ghassemi K., et al. Doppler endoscopic probe monitoring for blood flow improves risk stratification and outcomes of patients with severe non-variceal UGI hemorrhage. Gastrointest Endosc. 2017;152:1310-1318.

3.Barkun A.N., Adam V., Wong R.C.K. Use of Doppler probe in non-variceal upper gastrointestinal bleeding is less costly and more effective than standard of care. Clin Gasterenterol Hepatol. 2019; in press.

4.Jensen D.M., Jensen M.E., Markovic D., Gornbein J., et al. Is Hemostasis with Doppler endoscopic probe guidance an improvement compared to visually guided treatment of severe ulcer hemorrhage? Gasterenterol. 2017;152:S474.

5.Jensen D.M., Eklund S., Persson, T., Ahlbom H., et al. Reassessment of rebleeding risk of Forrest IB (oozing) peptic ulcer bleeding in a large international randomized trial. Am J Gastroenterol. 2017;112:441-446.

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