[TREATMENT MODALITIES OF THE FOREGUT HEMORRHAGES WHILE PERFORMING ENDOSCOPIC MONITORING]

Complex clinical examination was done in 107 patients, in whom gastrointestinal hemorrhage (GIH) of various etiology, have had occurred. Special attention was drawn toward early conduction of esophagogastroduodenofibroscopy, as a leading instrumental method, permitting to reveal a GIH source, its character and degree of hemostasis in accordance to J. Forrest scale. The patients state severity while hemorrhage from the foregut presence was estimated in accordance to routine principles, depending on the circulating blood volume deficiency. The structure algorithm for the patients' management, in accordance to which treatment tactic must be selected individually, permitting to improve the quality of the medical help delivery for the patients, was elaborated.

Successful treatment of life-threatening bleeding from a duodenal posterior bulb peptic ulcer by an over-the-scope-clip

Bleeding of peptic ulcer at the posterior duodenal bulb still is a particular endoscopic challenge with increased risk of treatment failure and worse outcome. In this article, we report successful treatment of an actively bleeding peptic ulcer located at the posterior duodenal wall, using an over-the-scope-clip in the case of a 54-year-old male patient with hemorrhagic shock. Incident primary hemostasis was achieved and no adverse events occurred during a follow-up of 60 d.

[BIOLOGICAL RESERVOIRS AS A THE RESPONSE OF THE ORGANISM TO INJURY AND PROOF FOR METABOLIC CORRECTION IN GASTRODUODENAL HEMORRHAGE IN PATIENTS WITH HIGH OPERATING-ANESTHETIC RISK]

In the authors opinion in the process of self-regulation the human body creates some biological reservoirs in response to damage (disturbance of homeostasis) for constant internal environment In cases of decompensation and depletion of these pools metabolic correction is necessary. This opinion was based on the results of the endoscopic metabolic hemostasis in ulcer gastroduodenal bleeding in patients with high operational and anesthetic risk.

Upper-gastrointestinal bleeding secondary to peptic ulcer disease: Incidence and outcomes

AIM: To evaluate the incidence, surgery, mortality, and readmission of upper gastrointestinal bleeding (UGIB) secondary to peptic ulcer disease (PUD).

METHODS: Administrative databases identified all hospitalizations for UGIB secondary to PUD in Alberta, Canada from 2004 to 2010 (n = 7079) using the International Classification of Diseases Codes (ICD-10). A subset of the data was validated using endoscopy reports. Positive predictive value and sensitivity with 95% confidence intervals (CI) were calculated. Incidence of UGIB secondary to PUD was calculated. Logistic regression was used to evaluate surgery, in-hospital mortality, and 30-d readmission to hospital with recurrent UGIB secondary to PUD. Co-variants accounted for in our logistic regression model included: age, sex, area of residence (i.e., urban vs rural), number of Charlson comorbidities, presence of perforated PUD, undergoing upper endoscopy, year of admission, and interventional radiological attempt at controlling bleeding. A subgroup analysis (n = 6356) compared outcomes of patients with gastric ulcers to those with duodenal ulcers. Adjusted estimates are presented as odds ratios (OR) with 95%CI.

RESULTS: The positive predictive value and sensitivity of ICD-10 coding for UGIB secondary to PUD were 85.2% (95%CI: 80.2%-90.2%) and 77.1% (95%CI: 69.1%-85.2%), respectively. The annual incidence between 2004 and 2010 ranged from 35.4 to 41.2 per 100000. Overall risk of surgery, in-hospital mortality, and 30-d readmission to hospital for UGIB secondary to PUD were 4.3%, 8.5%, and 4.7%, respectively. Interventional radiology to control bleeding was performed in 0.6% of patients and 76% of these patients avoided surgical intervention. Thirty-day readmission significantly increased from 3.1% in 2004 to 5.2% in 2010 (OR = 1.07; 95%CI: 1.01-1.14). Rural residents (OR rural vs urban: 2.35; 95%CI: 1.83-3.01) and older individuals (OR ≥ 65 vs < 65: 1.57; 95%CI: 1.21-2.04) were at higher odds of being readmitted to hospital. Patients with duodenal ulcers had higher odds of dying (OR = 1.27; 95%CI: 1.05-1.53), requiring surgery (OR = 1.73; 95%CI: 1.34-2.23), and being readmitted to hospital (OR = 1.54; 95%CI: 1.19-1.99) when compared to gastric ulcers.

CONCLUSION: UGIB secondary to PUD, particularly duodenal ulcers, was associated with significant morbidity and mortality. Early readmissions increased over time and occurred more commonly in rural areas.

Monopolar soft-mode coagulation using hemostatic forceps for peptic ulcer bleeding

BACKGROUND/AIMS

Upper gastrointestinal hemorrhage from bleeding peptic ulcer is sometimes difficult to treat by conventional endoscopic methods. Recently, monopolar electrocoagulation using a soft-coagulation system and hemostatic forceps (soft coagulation) has been used to prevent bleeding during endoscopic submucosal dissection. The aim of this study was to assess the safety and efficacy of soft coagulation in the treatment of bleeding peptic ulcer.

METHODOLOGY

A total of 39 patients with peptic ulcers were treated using soft coagulation at our hospital between January 2005 and March 2010. Emergency treatment employed an ERBE soft-mode coagulation system using hemostatic forceps. Second-look endoscopy was performed to evaluate the efficacy of prior therapy. Initial hemostasis was defined as accomplished by soft coagulation, with or without other endoscopic therapy prior to soft coagulation. The rate of initial hemostasis, rebleeding, and ultimate hemostasis were retrospectively analyzed.

RESULTS

The study subjects were 31 men and 8 women with a mean age of 68.3±13.7 years, with 29 gastric ulcers and 10 duodenal ulcers. Initial hemostasis was achieved in 37 patients (95%). During follow-up, bleeding recurred in two patients, who were retreated with soft coagulation.

CONCLUSIONS

The monopolar soft coagulation is feasible and safe for treating bleeding peptic ulcers.

[Mucosal changes in the periulcer zone and endocrine system in patients with gastroduodenal ulcer, complicated by hemorrhage]

Examination of patients, suffering gastroduodenal ulcer, complicated by hemorrhage, was conducted, using clinical, microbiological, immunohistochemical methods and chromatomassspectrography. Enhanced activity of inducible NO-synthase, contamination of periulcer zone with microorganisms Klebsiella pneumoniae, Streptococcus beta-haemoliticus, enhancement of contents of catecholamines and serotonin in the blood serum were revealed. These changes are most expressed in severe blood loss, unstable local endoscopic hemostasis, high risk of a recurrent hemorrhage occurrence. The data obtained permit to prognosticate severity of a pathologic process course and to improve the treatment programe.

Methods of emergency surgery in high-risk stigmata peptic ulcer hemorrhage

AIM

The choice of emergency operative methods in management of peptic ulcer hemorrhage (PUH) is controversial. The aim of this study was to analyze the patient characteristics, surgical methods and treatment outcome of patients with PUH during 10 years.

METHODS

Of the 953 admitted PUH patients all 67 (7.0%) operated cases had high-risk stigmata PUH (Forrest classification). These patients were grouped and their data were compared under two 5-year periods: period I - 32 patients (2003-2007) and period II - 35 patients (2008-2012).

RESULTS

The majority of the patients had giant ulcer (diameter ≥ 2 cm) hemorrhage at 75.0% (24/32) and 94.3% (33/35) during study periods I and II, respectively (P=0.04). Giant duodenal and gastric ulcers for PUH were operated in 16 and 8 vs 27 and 6 during periods I and II, respectively. Ulcer exclusion or ulcerectomy combined with definitive acid reducing surgery was applied in 68.7% (22/32) and 71.4% (25/35) of the patients, respectively, without early recurrent hemorrhage. Postoperative in hospital mortality in the 10-year study period was 6.0% (4/67); 2.1% (1/48) of the patients died after definitive operations and 15.8% (3/19) (P=0.04) died after non-definitive operations.

CONCLUSION

The surgical treatment of high-risk stigmata PUH was mainly associated with giant, particularly giant duodenal ulcer. As a rule, ulcer exclusion or ulcerectomy as hemorrhage control, combined with definitive surgery, was applied in the majority of the cases with an in hospital mortality of 2.1%.

[The ways of prophylaxis of the gastro-intestinal hemorrhage recurrence]

Through three-years period 57 patients, suffering gastro-intestinal hemorrhage (GIH) of the ulcer genesis, were treated in the clinic. Among them were 37 (64.9%) men and 20 (35.1%) women. The patients have had (56.3 +/- 4.7) yrs old at average. The treatment programm for the patients have included a local arrest of GIH, medicinal therapy, directed on restoration of the circulating blood volume, gastric secretion inhibition, rising of the blood coagulation property. In cases of a middle and severe blood loss the blood preparations were transfused--the erythrocytic mass and freshly frozen plasm. Three patients were operated in the high period of GIH. The GIH recurrence was absent. In 7 - 8 days, if a persistent hemostasis was achieved, the patients were transferred to therapeutic department for the conservative therapy prolongation.

[Complex application of laparoscopic vagotomy in case of hard scarring ulcers after gastroduodenal bleeding]

654 patients with ulcerative gastroduodenal bleeding from duodenum were under observation. It was done the meta-analysis of treatment results of 111 patients with hard scarring duodenal ulcers. It was discovered high efficiency of organ-preserving operations such aslaparoscopic vagotomy and proton pump inhibitors in these observations.

[The combined endoscopic hemostasis in case of gastroduodenal ulcerative bleeding]

It was done the retrospective analysis of the endoscopic hemostasis effectiveness in 207 patients with gastroduodenal bleeding in the period from November 2011 to April 2013. The differential approach to the choice of hemostasis methods and consistency of their application were developed. It was done the comparative analysis of two- and three-stages combined hemostasis results. The analysis included the infiltration of the submucosal layer by 0.01% solution of adrenaline, argon-plasma coagulation and hemostatic glue applique.

[Endoscopic and roentgenovascular interventions in treatment of patients with bleeding from a gastroduodenal ulcer]

The authors analyzed the results of treatment of 965 patients with bleeding from gastroduodenal ulcers. The endoscopic hemostasis was carried out in 20.2% patients, however a recurrence of bleeding was noted in 12.8% cases. The combined endoscopic hemostasis was performed in 76.9% patients, though the relapse of bleeding had only 4.2% and 49 patients were safe. A surgery was required for 3.2% patients.

Comparison the efficacy of intermediate dose argon plasma coagulation versus hemoclip for upper gastrointestinal non-variceal bleeding

BACKGROUND/AIMS

Endoscopic argon plasma coagulation (APC) and hemoclip were used for the treatment of bleeding peptic ulcers. There are wide ranges of hemostatic doses (power and flow) of APC used in previous studies. The aim of our study was to assess the efficacy and safety of "intermediate dose" APC compared to hemoclips for hemostasis from bleeding peptic ulcer.

METHODOLOGY

The present study was designed as a retrospective study using historical controls. One hundred and ninety-four consecutive upper GI bleeding patients with bleeding visible vessel lesions were treated with either APC or hemoclips. There are 110 patients received APC treatment and 84 patients received hemoclip hemostasis. The main outcome measurements were one week rebleeding rate, one month rebleeding rate, surgery, morality, amount of blood transfusion and durations of hospital stay.

RESULTS

There were no significant differences between the two groups in 1 week rebleeding rate (1.8% vs. 2.4%, p = 1.0), 1 month rebleeding rate (0% vs. 1.2%, p = 0.433), mortality, surgery and amount of blood transfusion (2.67 +/- 3.27 vs. 3.04 +/- 2.75 units, p = 0.322). However, the hospital stay was longer in hemoclip group (5.38 +/- 6.76 vs. 8.49 +/- 11.19 days p = 0.011).

CONCLUSIONS

APC and hemoclip are with different hemostatic mechanisms, but the hemostatic outcomes were not significantly different between the two groups. APC is an effective, safe, and easily applicable endoscopic hemostatic modality as hemoclip for patients with non-variceal bleeding.

An upper gastrointestinal ulcer still bleeding after endoscopy: what comes next?

INTRODUCTION

Recurrent bleeding from an upper gastrointestinal ulcer when endoscopy fails is a reason for radiological or surgical treatment, both of which have their advantages and disadvantages.

CASE

Based on a patient with recurrent gastrointestinal bleeding, we reviewed the available evidence regarding the efficacy and safety of surgical treatment and embolisation, respectively.

DISCUSSION

Transarterial embolisation (TAE) and surgical treatment are both options for recurrent gastrointestinal bleeding when endoscopy fails. Both therapies have serious complications and a risk of rebleeding. Choosing the therapy depends on the capability of the patient to tolerate haemodynamic instability, resuscitation and hypotension.

CONCLUSION

Choosing between TAE and surgery depends a great deal on the case presented, haemodynamic stability and the skills and tools available at that moment.

[Modern approach to prognostication of the acute hemorrhage recurrence from duodenal ulcer]

There was 2223 of 2285 patients, treated in the Kyiv's municipal center of gastrointestinal hemorrhage in 1994-1996 yrs (the control group) and in 2004-2008 yrs (the main group) for an acute hemorrhage from duodenal ulcer. The integral prognostic index (IPI) was determined for the early recurrence risk (ERR) assessment. The point prognostication system, based on the step by step discriminant analysis, was transformed while its application. While in a control group of an acute hemorrhage early recurrence prognostication and its low risk (ERR was 5.6%) the IPI have had constituted 7-9 points, in the middle risk (ERR was 34%) the IPI have measured 10-16 points and in the conditions of a high risk (ERR have constituted 89.1%), the IPI was 17-22 points, vs in the main group in conditions of application of potent intravenous proton pump inhibitors and effective endoscopic hemostasis measures in a low risk group (the realized ERR was 1.2%) the IPI have measured 7-12 points, in middle ERR (realized ERR 7.15%) the IPI raised to 13-19 points and in a high ERR (realized ERR was 23.81%) 20-22 points.

[Remote results of conservative and operative treatment of patients with duodenal ulcer complicated by bleeding]

Analyzed long-term outcomes of 690 patients with duodenal ulcer, complicated by bleeding in Kyiv City Centre gastrointestinal bleeding for the periods 1994-1996 (control group) and 2004-2008 (main group). In the late period of patients who were found giperhlorgidry (moderate and severe), increased by 1.4 tImes, indicating a higher voltage continuous acid production In the main group. With the introduction of modern circuits Helicobacter therapy incidence of H. pylori reduced by half. Improving modern tactical approaches to conservative treatment helped to reduce the frequency of relapses in duodenal ulcer remote period by 2.2 times, acute bleeding--in 1.9 times, increase the frequency of excellent results--in 2.8 times.

[Prognosis of the hemorrhage recurrence in the patients suffering from acute gastroduodenal ulcer bleeding]

The prognostication method for the hemorrhage recurrence, permitting to estimate the risk of its occurrence and to prescribe an adequate antirecurrence treatment, was proposed. Among numerous predictors of recurrence the most significant clinical, endoscopic and laboratory factors were selected to raise the prognostication precision. Depending on therisk degree of a recurrent hemorrhage, different methods of treatment were prescribed to the patients. The proposed method was applied in 112 patients, suffering ulcer gastroduodenal hemorrhage. The hemorrhage recurrence have had occurred in 45 (43.3%) of them, in 5 (4.46%)--operative intervention was conducted, using organpreserving methods. General lethality have had constituted 0.89%, postoperative one in a control group--7.14%, and in the main all the patients were alive. The method proposed permits with a high precision to prognosticate and to determine effective tactics of treatment. Taking into account the additional factors of risk raises the prognosis precision and permits to prescribe antihelicobacter therapy and the proton pump inhibirors in a rational dosage soundly.

[The comparison of prognostic scales of the gastroduodenal bleeding recurrence]

229 patients with ulcerous gastroduodenal bleeding were included in the study. Prognostic scales of the bleeding recurrence by Rockall, Blatchford, Vinokurov and System of Prognosing of Bleeding Recurrence (SPBR) I and II were comparatively analyzed. The SPBR II proved to be statistically relevant and the most accurate in prognosing the bleeding recurrence, then other scales.

[Treatment strategy for ulcerative gastrointestinal bleeding from the upper gastrointestinal tract]

The deep statistical analysis of patients treatment with the ulcerous gastroduodenal bleeding set 2 years works of Center of the gastroduodenal bleeding of Dnepropetrovsk is conducted. It is exposed, that wide application of methods of endoscopic haemostasis and endoscopic monitoring allowed substantially to reduce the amount of operations at this category of patients and improve the results.

Mortality from nonulcer bleeding is similar to that of ulcer bleeding in high-risk patients with nonvariceal hemorrhage: a prospective database study in Italy

BACKGROUND

Nonulcer causes of bleeding are often regarded as minor, ie, associated with a lower risk of mortality.

OBJECTIVE

To assess the risk of death from nonulcer causes of upper GI bleeding (UGIB).

DESIGN

Secondary analysis of prospectively collected data from 3 national databases.

SETTINGS

Community and teaching hospitals.

PATIENTS

Consecutive patients admitted for acute nonvariceal UGIB.

INTERVENTIONS

Early endoscopy, medical and endoscopic treatment as appropriate.

MAIN OUTCOME MEASUREMENTS

Thirty-day mortality, recurrent bleeding, and need for surgery.

RESULTS

A total of 3207 patients (65.8% male), mean (standard deviation) age 68.3 (16.4) years, were analyzed. Overall mortality was 4.45% (143 patients). According to the source of bleeding, mortality was 9.8% for neoplasia, 4.8% for Mallory-Weiss tears, 4.8% for vascular lesions, 4.4% for gastroduodenal erosions, 4.4% for duodenal ulcer, and 3.1% for gastric ulcer. Frequency of death was not different among benign endoscopic diagnoses (overall P = .567). Risk of death was significantly higher in patients with neoplasia compared with benign conditions (odds ratio 2.50; 95% CI, 1.32-4.46; P < .0001). Gastric or duodenal ulcer significantly increased the risk of death, but this was not related to the presence of high-risk stigmata (P = .368). The strongest predictor of mortality for all causes of nonvariceal UGIB was the overall physical status of the patient measured with the American Society of Anesthesiologists score (1-2 vs 3-4, P < .001).

LIMITATIONS

No data on the American Society of Anesthesiologists class score in the Prometeo study.

CONCLUSIONS

Nonulcer causes of nonvariceal UGIB have a risk of death, similar to bleeding peptic ulcers in the clinical context of a high-risk patient.

Heater probe thermocoagulation for high-risk patients who show rebleeding from peptic ulcers

AIM

To investigate whether heater probe therapy is effective for patients showing rebleeding from peptic ulcers.

METHODS

We retrospectively reviewed the case profiles in our previous studies on endoscopic therapy for high-risk patients with peptic ulcer bleeding in the past two decades. We analysed the outcomes of 191 patients who showed rebleeding after initial endoscopic haemostasis and received endoscopic therapy with heater probe thermocoagulation. .

RESULTS

A total of 191 patients showing rebleeding received heater probe thermocoagulation. After re-therapy, 158 patients (82.7%) achieved ultimate haemostasis. Twenty-five of the 33 patients who failed to achieve haemostasis received surgical intervention. Ten patients (5.2%) died within 1 month after re-therapy.

CONCLUSION

Heater probe thermocoagulation can be used as the first choice for management of patients showing rebleeding after initial endoscopic therapy.

[Surgical treatment of gastroduodenal ulcers according to principles of a modern antirecurrence therapy with postoperative complications prophylaxis]

Modern approaches to surgical treatment of gastroduodenal ulcers in accordance with principles of antirecurrence therapy, directed on prophylaxis of postoperative complications occurrence, are enlighted.