Forrest 11 bleeding: indications for treatment and results of laser therapy

Ulcers with stigmata of recent hemorrhage (SRH) but without evidence of active bleeding (Forrest 11 bleeding) are a common endoscopic finding in patients with upper gastrointestinal bleeding. This study considers the problem of identifying patients in this group at risk of further bleeding and death. The high incidence of rebleeding in patients with visible vessel and the low incidence in patients with other SRH or no SRH suggest that endoscopic therapy in the absence of active bleeding is best limited to patients with visible vessels in ulcers that have recently bled. Evidence from controlled trials of laser therapy is presented which suggests that laser therapy can reduce the incidence of rebleeding in such patients with visible vessel.

Nature of the bleeding vessel in recurrently bleeding gastric ulcers

An unselected consecutive series of 826 patients admitted for acute upper gastrointestinal bleeding underwent urgent endoscopy. Peptic ulcers were found in 402 (49%). Of the 329 ulcer craters that could be fully examined, visible vessels were identified in 156 (47%), other stigmata of recent hemorrhage in 66, and no stigmata of recent hemorrhage in 107. One hundred twenty-nine patients with stigmata of recent hemorrhage (93 of whom had visible vessels) randomly allocated to no endoscopic treatment were observed for evidence of further bleeding. Fifty-four of the 93 patients (58%) with visible vessels rebled, compared with 2 of 36 (6%) with other stigmata of recent hemorrhage. No patient without stigmata of recent hemorrhage rebled. Twenty-seven patients in whom a visible vessel in a gastric ulcer was identified at endoscopy underwent urgent partial gastrectomy because of recurrent bleeding. The vessel identified at endoscopy was found in 26 of 27 resection specimens (96%). The arterial vessel wall protruded above the surface of the ulcer crater in 10 specimens, and clot in continuity with a breach in the vessel wall protruded in a further 10 specimens. Postoperative angiography, when technically possible, showed that the breached artery ran across the base of the ulcer in all of these specimens. Pathological changes were common in the bleeding artery and included arteritis in 24 of 29 (83%) eroded arteries found in these specimens, with aneurysmal dilatation in 14 of 27 (52%) bleeding points that could be fully examined. The ulcer had penetrated to serosa in 13 specimens (45%). The bleeding artery had a mean external diameter of 0.7 mm with a range of 0.1-1.8 mm. This study provides new information about the nature of the bleeding vessel in gastric ulcers, and some of this information is relevant in planning studies of endoscopic therapy for bleeding peptic ulcers. It validates the endoscopic identification of a visible vessel, and confirms that such identification has a high predictive value for the development of recurrent hemorrhage.

Controlled trial of small bipolar probe in bleeding peptic ulcers

204 of 460 patients with upper gastrointestinal bleeding admitted to a busy district hospital were found to be bleeding from peptic ulcers or to have signs of recent haemorrhage at endoscopy within 24 h of admission. To determine if the small bipolar probe could stop bleeding or rebleeding, patients were allocated to electrocoagulation (101) or not (103); other aspects of treatment were identical. Groups were stratified by ulcer site to give similar numbers in each. To allow for differences in sex, age, initial haemoglobin, presence of other diseases, and shock, data were analysed by logistic regression. Fewer patients in the treated group (17) continued to bleed or rebled compared with controls (34). Rebleeding and mortality rates in the treated group were higher early in the trial, suggesting the need for experience in application of the probe. Further improvements in technology and technique may result in significant reductions in mortality.

Endoscopic management of the bleeding ulcer. A survey

The study was performed to evaluate the prognostic and therapeutic value of endoscopy in patients with bleeding ulcer. Before endoscopic control of ulcer bleeding was introduced 373 patients with bleeding ulcer and a median age of 67 years were studied retrospectively. Emergency surgery was required in 155 patients. The surgical mortality was 11% in 37 low risk patients, but 36% in 118 poor risk patients. There was a trend to improved outcome after introduction of diagnostic endoscopy but only in patients with hemorrhage managed conservatively. Surgical mortality remained unchanged. Ranked in order of prognostic importance, a complicating disorder, postoperative complications, overtransfusion, and absent past history of ulcer dyspepsia were identified as the most important determinants of fatal outcome. Age, onset of hemorrhage at home or in hospital, previous ulcer surgery, previous bleeds, ulcer site, and sex had comparatively less bearing on outcome. It was concluded that although surgery was efficient in preventing exsanguination, it was poorly tolerated in poor surgical risks who constituted 76% of the patients in need of emergency control of ulcer bleeding. The results indicate that the search for non-surgical methods is justified. In a pilot study, endoscopic electrocoagulation was applied to control ulcer bleeding in 60 patients. The experience from the study served as basis for a prospective study in an attempt to assess the prognostic and therapeutic potential of endoscopy in the management of bleeding ulcer and to define indications for emergency endoscopy. The histomorphologic effect of electrocoagulation employed to stop bleeding from acute gastric ulcers in rabbits suggested that intravascular occlusive fibrin thrombosis is the probable mechanism of hemostasis. In the prospective study, 539 consecutive patients admitted with hematemesis and melena underwent emergency endoscopy. Peptic ulcer, identified as the bleeding source in 51% of these patients, was the predominant lesion most liable to hemorrhage assessed as requiring emergency surgery. Black hematemesis with melena, occurring in 13% of the patients, was the best predictor of ulcer bleeding. Red hematemesis with melena (26%) was the most important predictor of major bleeding. Black hematemesis with melena was found to be as important as red hematemesis without melena (22%) in predicting major ulcer bleeding. In contrast, melena (18%) and, in particular, black hematemesis without melena (20%) were poor predictors of ulcer bleeding as well as of major bleeding.(ABSTRACT TRUNCATED AT 400 WORDS)

Bleeding ulcer: timing and technique in surgical management

The individual surgeon's training, experience and flexibility are decisive factors in the successful recovery of patients after surgery for acute bleeding peptic ulcer. With planned management, careful preparation for surgery should be considered as of equal importance to surgical skill. Early diagnosis and exact resuscitation are the two most important aspects of a plan of treatment which anticipates the need for early surgery. In the past, patients were often referred late for surgery after significant blood loss and transfusion. Surgeons have endeavoured to define the cases that are likely to rebleed and prepare them promptly for surgery. Probably the best indications for early surgery are severe haemorrhage, reflected by shock on admission, an age of over 50 and active bleeding from the ulcer seen at diagnostic endoscopy. Prospective studies have shown a reduction in mortality from bleeding ulcer where policy requires early endoscopic diagnosis, exact resuscitation in the intensive care unit and early surgery in high risk cases.

[Therapy failures in ulcer drug therapy--what should be done?]

In cases of ulcer relapses during drug therapy of duodenal ulcers the therapy has primarily to be checked and, if necessary, rearranged, and a gastrinoma has to be excluded. In case of ulcer complications the indication for operation is given: in cases of uncomplicated recurrences of ulcers the drug therapy may be adapted or reinforced, at least for the first or perhaps a second recurrence. In case of further recurrences, especially after cessation of medication, the operation has several advantages (no lethality of the elective proximal selective vagotomy, short treatment period, less costly) as compared to a life-long drug therapy.

[Nonresecting technic in uncomplicated and complicated gastroduodenal ulcer]

The technique of the nonresective surgical treatment of peptic ulcer disease is based on the recognition of the autonomous innervation of the stomach and of its musculature, especially in the pyloric region. A correct performance is of very high relevance. The tactics are a combination of a neurosurgical and plastic restorative procedure. This is contrary to the technique of the resective methods. A prospective study pointed out the following healing rates: lethality: phi, healing: 94% objective, 98% subjective; dumping: healing 86%, medium 13%, bad 1% - risk of recurrency: 4%, for the total number of ulcers.

[Emergency fibrogastroduodenoscopy in the diagnosis and treatment of peptic gastroduodenal hemorrhages in the middle-aged and elderly]

Urgent fibrogastroduodenoscopy was performed in 145 of 178 elderly and senile patients with bleedings from upper portions of the digestive tract, ulcerous bleedings being revealed in 92 of them. Surgery is thought to be the best method in cases with persistent bleedings and in the revealed during examination thrombosed vessels in the ulcer without active bleeding. In 33 patients not subjected to endoscopy the latter could have given better results of treatment.

[Hemorrhaging peptic ulcer--Therapy? When? Which?]

The influence of frequency of surgical interventions and the time of operation on the overall mortality is still a matter of considerable controversy. A close correlation between the risk and incidence of recurrent bleeding and the primary bleeding status during emergency endoscopy let us to design a new concept of a more aggressive surgical strategy. The dominating criteria for choice of treatment based on instant endoscopical classification of bleeding type and activity. The overall mortality was 5.4%. 59 patients (53%) underwent surgery with only two hospital deaths (3.4%). Among the group with conservative treatment there were four additional deaths (7.5%), all patients being above 70 years of age. The results suggest that mortality rates in patients with bleeding gastroduodenal ulcers can be reduced by a more aggressive surgical approach.

Endoscopic treatment of suture line bleeding ulcer caused by nonabsorbable suture material in postvagotomy patients

Two postvagotomy patients with upper gastrointestinal bleeding, which appeared several months after operation, are reported. Endoscopy showed the pyloroplasty suture line to be ulcerated and bleeding, with a few strands of silk protruding from edematous mucosa. The history of suture line ulceration and the contribution of endoscopy to its diagnosis and treatment are reviewed.

[Symptomless and complicated peptic ulcer as an extreme clinical form of ulcer disease: consequences for choice between conservative and surgical therapy]

Asymptomatic recurrent ulcers following drugs and surgical therapy are true failures of treatment (Visick IV). Several types of bias at present do not allow any conclusion whether medical treatment and maintenance increase the rate of ulcer complications. The mechanisms of action for medical treatment with cimetidine and operative treatment with SPV are similar, but not identical. Bad compliance and incomplete vagotomies mainly account for success of mutual exchange between the two types of therapy. Using a decision tree with mortality as outcome recommendations are developed for a step-wise therapeutic concept in peptic ulcer patients.

Controlled trial of liquid monopolar electrocoagulation in bleeding peptic ulcers

The aim of this study was to evaluate the efficacy and the safety of liquid monopolar electrocoagulation in the endoscopic control of major haemorrhage from peptic ulcers. During the 24-month period of the trial, emergency endoscopy was performed on 480 patients consecutively admitted with acute upper gastrointestinal tract hemorrhage. Ulcers were seen in 168 cases (35%). Seventy-eight of these were included in the trial. Active bleeding was present in 21 cases and stigmata of recent bleeding were observed in 57. Immediate hemostasis was achieved in nine of 11 patients with active bleeding ulcers. However, active bleeding can stop spontaneously (as in four of 10 control patients), which reemphasizes the importance of randomized studies. There was a trend toward hemostatic benefit for the electrocoagulation-treated patients with actively bleeding ulcers. In the group of 31 patients with visible vessels, the electrocoagulation treatment reduced significantly both the rate of rebleeding and the emergency surgery. In the group of 26 patients with other stigmata of recent bleeding (fresh or altered clot, or black spots), only in two cases allocated to placebo treatment occurred rebleeding. These patients are at minimal risk of further bleeding. The results offer support to the contention that liquid monopolar electrocoagulation is a safe and effective method of reducing the incidence of further bleeding and emergency surgery. This new technique has the advantages of low cost, easy maintenance, durability, and portability.