From the Guidelines
Endoscopic therapies for treating hemorrhage in gastric adenocarcinoma include injection therapy, mechanical therapy (e.g., endoscopic clip placement), ablative therapy (e.g., argon plasma coagulation), or a combination of modalities, as recommended by the most recent guidelines 1.
Overview of Endoscopic Therapies
The management of bleeding in gastric cancer patients requires a multidisciplinary approach, with endoscopic assessment being crucial for diagnosis and treatment. According to the latest guidelines from 2022 1, endoscopic therapies can be effective as initial treatment, although the rate of recurrent bleeding is high.
Available Endoscopic Therapies
The following options are widely available for endoscopic therapies:
- Injection therapy
- Mechanical therapy (e.g., endoscopic clip placement)
- Ablative therapy (e.g., argon plasma coagulation or other laser therapy)
- Combination of modalities
Considerations for Treatment
The choice of endoscopic therapy depends on the bleeding pattern, tumor characteristics, and available expertise, with the goal of achieving immediate hemostasis to stabilize the patient before definitive cancer treatment can be initiated, as suggested by previous guidelines 1. In cases where endoscopy is not helpful, interventional radiology with angiographic embolization techniques may be useful 1. Additionally, external beam radiation therapy (EBRT) has been shown to effectively manage acute and chronic gastrointestinal bleeding 1.
Quality of Life and Mortality Considerations
Given the high rate of recurrent bleeding, it is essential to prioritize therapies that can provide immediate and effective hemostasis, thereby improving the patient's quality of life and reducing mortality risk. The most recent and highest quality study 1 supports the use of endoscopic therapies as the first-line approach for managing bleeding in gastric cancer patients.
From the Research
Endoscopic Therapies for Hemorrhage in Gastric Adenocarcinoma
- Endoscopic management of bleeding gastrointestinal tumors involves various therapeutic options, including contact and non-contact thermal therapy, radiofrequency ablation, endoloops, epinephrine and ethanol injection, and Hemospray 2.
- Endoscopic therapy has been highly successful in achieving initial hemostasis in patients with inoperable gastric cancer, with one or a combination of modalities such as injection therapy, mechanical therapy, or ablative therapy being used 3.
- Argon plasma coagulation (APC) is a feasible and safe option for managing bleeding GI tumors, with a high immediate hemostasis rate and low re-bleeding rate 4.
- Endoscopic management of tumor bleeding from gastrointestinal tumors is challenging, but endoscopic treatment may help reduce transfusion requirements, avoid surgery, and provide a temporary bridge to oncologic therapy 5.
- Endoscopic therapy for early gastric cancer is becoming increasingly popular, with innovations being made to improve technique and technology, including the use of new devices such as the Clutch Cutter and EndoLifter 6.
Specific Endoscopic Therapies
- Thermal/mechanical therapy in conjunction with injection therapy is a traditional approach for endoscopic management of bleeding gastrointestinal tumors 2.
- Argon plasma coagulation (APC) is preferred for the management of bleeding arterio-venous malformations and has been shown to be effective in achieving initial hemostasis in patients with bleeding GI tumors 4.
- Endoloops and epinephrine and ethanol injection are also used as endoscopic therapeutic options for managing tumor-related GI bleeding 2, 3.
- Hemospray is a newer topical agent that has been used in the endoscopic management of tumor bleeding from gastrointestinal tumors 2, 5.
Outcomes and Survival
- Immediate hemostasis was achieved in all patients treated with APC, with either APC performed alone or with adjuvant epinephrine 4.
- Re-bleeding occurred in 30% of patients during follow-up, and the 30-day mortality rate was 0% 4.
- Endoscopic therapy may help reduce transfusion requirements, avoid surgery, and provide a temporary bridge to oncologic therapy, allowing majority of patients to undergo cancer-specific therapy 3, 5.