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Tassone D, Kazi S, Lee T, Gilmore R, Ding N. Systematic review and meta-analysis of endoscopic versus medical management of peptic ulcers with adherent clots. J Gastroenterol Hepatol 2024; 39:2031-2042. [PMID: 38818853 DOI: 10.1111/jgh.16611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/28/2024] [Accepted: 05/01/2024] [Indexed: 06/01/2024]
Abstract
Peptic ulcer disease is an important cause of upper gastrointestinal bleeding. Current guidelines recommend endoscopic treatment for ulcers with active bleeding or non-bleeding visible vessels, but the optimal management of ulcers with adherent clots is unclear. We performed a systematic review of the efficacy of endoscopic versus medical management of peptic ulcers with adherent clots. A systematic literature search was performed through September 2022 (MEDLINE, Embase, and CENTRAL). Randomized controlled trials (RCTs) comparing the effect of endoscopic versus medical management alone for peptic ulcers with adherent clots on the outcome of recurrent bleeding were incuded. A random-effects meta-analysis was performed to estimate the overall treatment effect. We included seven RCTs reporting on the endoscopic versus medical management of peptic ulcers with adherent clots. The pooled cohort comprised 268 patients with a mean age of 62.8 years and a mean follow up of 20 days. There was a significant reduction in the risk of recurrent bleeding with endoscopic hemostatic treatment for peptic ulcers with adherent clots, compared with medical management alone (risk ratio [RR] = 0.40, 95% confidence interval [CI] 0.16-0.95, 268 participants). However, there was no difference in mortality (RR = 0.90, 95% CI 0.23-3.59, 52 participants) or need for ulcer surgery (RR = 0.48, 95% CI 0.10-2.28, 52 participants) between endoscopic and medical management groups. In summary, there was evidence for a reduction in recurrent bleeding from peptic ulcers with adherent clots treated with endoscopic hemostatic techniques compared with medical management alone but no difference in rates of mortality or need for surgery.
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Affiliation(s)
- Daniel Tassone
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Shamsul Kazi
- Department of Emergency Medicine, Toowoomba Hospital, Toowoomba, Queensland, Australia
| | - Tanya Lee
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Robert Gilmore
- Department of Gastroenterology and Hepatology, Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - Nik Ding
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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2
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Lu MH, Chiang HC. Turn over the new leaf of the treatment in peptic ulcer bleeding: a review of the literature. Therap Adv Gastroenterol 2024; 17:17562848241275318. [PMID: 39253108 PMCID: PMC11382247 DOI: 10.1177/17562848241275318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 07/26/2024] [Indexed: 09/11/2024] Open
Abstract
Peptic ulcer bleeding is the most common cause of upper gastrointestinal bleeding, which has a high mortality risk. The standard therapy for acute peptic ulcer bleeding combines medication administration and endoscopic therapies. Both pharmacologic and endoscopic therapies have developed continuously in the past few decades. Proton pump inhibitors (PPIs) already reached a high efficacy in ulcer healing and have been widely used in the past few decades. Endoscopic hemostasis, which includes local epinephrine injection, heater probe coagulation, use of hemostatic clips, and/or band ligation, is highly effective with an overall hemostatic success rate of 85%-90%. However, 10%-20% of patients could not be cured by the current standard combination treatment. Recurrent ulcer bleeding, despite an initial successful hemostasis, is also a big problem for longer hospitalization stays, higher mortality, and higher complication rates, especially for malignant ulcer bleeding. How to manage all types of peptic ulcer bleeding and how to prevent early recurrent peptic ulcer bleeding remain unresolved clinical problems. Recently, several novel medications and endoscopic methods have been developed. Potassium competitive acid blockers have shown a stronger and longer acid suppression than PPI. Hemostatic powder spray and hemostatic gel emulsion are novel hemostatic weapons with emerging evidence, which are potential missing pieces of the puzzle. This literature review will go through the development of endoscopic hemostasis to the prospects of novel endoscopic treatments.
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Affiliation(s)
- Meng-Hsuan Lu
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsueh-Chien Chiang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, Tainan 70428, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Soriani P, Biancheri P, Bonura GF, Gabbani T, Rodriguez de Santiago E, Dioscoridi L, Andrisani G, Luigiano C, Deiana S, Rainer J, Del Buono M, Amendolara R, Marino M, Hassan C, Repici A, Manno M. Over-the-scope clip as first-line treatment of peptic ulcer bleeding: a multicenter randomized controlled trial (TOP Study). Endoscopy 2024; 56:665-673. [PMID: 38599622 DOI: 10.1055/a-2303-4824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
BACKGROUND First-line over-the-scope (OTS) clip treatment has shown higher efficacy than standard endoscopic therapy in acute nonvariceal upper gastrointestinal bleeding (NVUGIB) from different causes. We compared OTS clips with through-the-scope (TTS) clips as first-line mechanical treatment in the specific setting of peptic ulcer bleeding. METHODS We conducted an international, multicenter randomized controlled trial on consecutive patients with suspected NVUGIB. Patients with Forrest Ia-IIb gastroduodenal peptic ulcer were randomized 1:1 to OTS clip or TTS clip treatment. The primary outcome was the rate of 30-day rebleeding after successful initial hemostasis. Secondary outcomes included the rates of successful initial hemostasis and overall clinical success, defined as the composite of successful initial hemostasis and no evidence of 30-day rebleeding. RESULTS 251 patients were screened and 112 patients were randomized to OTS (n = 61) or TTS (n = 51) clip treatment. The 30-day rebleeding rates were 1.6% (1/61) and 3.9% (2/51) in patients treated with OTS clips and TTS clips, respectively (Kaplan-Meier log-rank, P = 0.46). Successful initial hemostasis rates were 98.4% (60/61) in the OTS clip group and 78.4% (40/51) in the TTS clip group (P = 0.001). Overall clinical success rates were 96.7% (59/61) with OTS clips and 74.5% (38/51) with TTS clips (P = 0.001). CONCLUSIONS Low rates of 30-day rebleeding were observed after first-line endoscopic treatment of acute peptic ulcer bleeding with either OTS or TTS clips. However, OTS clips showed higher efficacy than TTS clips in achieving successful initial hemostasis and overall clinical success.
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Affiliation(s)
- Paola Soriani
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, Carpi, Italy
| | - Paolo Biancheri
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, Carpi, Italy
| | | | - Tommaso Gabbani
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, Carpi, Italy
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Lorenzo Dioscoridi
- Digestive and Interventional Endoscopy Unit, Niguarda Hospital, ASST Niguarda, Milan, Italy
| | - Gianluca Andrisani
- Digestive Endoscopy Unit, Campus Bio-Medico, University of Rome, Rome, Italy
| | - Carmelo Luigiano
- Digestive Endoscopy Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Simona Deiana
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, Carpi, Italy
| | - Joachim Rainer
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, Carpi, Italy
| | | | | | - Massimiliano Marino
- Clinical Governance Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Mauro Manno
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, Carpi, Italy
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Kavitt RT, Gralnek IM. Ideal strategy for nonvariceal upper gastrointestinal bleeding. Curr Opin Gastroenterol 2024; 40:342-347. [PMID: 38967918 DOI: 10.1097/mog.0000000000001043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
PURPOSE OF REVIEW Over 300 000 hospital admissions in the United States each year are due to patients with upper gastrointestinal (GI) bleeding (UGIB). Common etiologies of nonvariceal UGIB include peptic ulcers, mucosal erosions of the esophagus, stomach or duodenum, Mallory-Weiss tears, Dieulafoy lesions, upper GI tract malignancy, or other etiology. RECENT FINDINGS Peptic ulcers classified as Forrest Ia, Ib, or IIa require endoscopic hemostasis, while IIb ulcers may be considered for endoscopic clot removal with endoscopic treatment of any underlying major stigmata. Endoscopic hemostasis for ulcers classified as Forrest IIc or III is not advised due to the low risk of recurrent bleeding. Endoscopic hemostasis in ulcer bleeding can be achieved using injection, thermal, and/or mechanical modalities. SUMMARY This review focuses on the currently recommended endoscopic therapies of patients presenting with acute nonvariceal upper gastrointestinal hemorrhage.
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Affiliation(s)
- Robert T Kavitt
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, Illinois, USA
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Karna R, Hans B, Nasereddin T, Chaudhary D, Dhawan M. Comparison of mechanical and thermal therapy in upper gastrointestinal bleeding: an analysis of efficacy outcomes. Proc AMIA Symp 2024; 37:734-741. [PMID: 39165805 PMCID: PMC11332638 DOI: 10.1080/08998280.2024.2381180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 07/04/2024] [Accepted: 07/07/2024] [Indexed: 08/22/2024] Open
Abstract
Background Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a complication of dual antiplatelet therapy (DAPT) and direct oral anticoagulant therapy (DOAC). There is a lack of data comparing mechanical therapy (clips) with thermal therapy in this population. Methods We conducted a retrospective chart review of patients undergoing urgent/emergent endoscopy for NVUGIB while being on DAPT or DOAC. Patients who had DAPT/DOAC held as per American Society of Gastrointestinal Endoscopy guidelines were excluded from the study. Results A total of 122 patients were included in the study. There was no difference in primary hemostasis, rebleeding rate, rescue hemostatic procedure, and 30-day mortality between the mechanical and thermal therapy groups. The mechanical therapy group had a significantly higher rate of prolonged length of stay (61.2% vs 38.9%, P = 0.02), serious clinical outcomes (56% vs 37.5%, P = 0.04), and intensive care unit admissions (50% vs 20.8%, P = 0.001) than the thermal therapy group. Conclusion Patients on DAPT/DOAC presenting with NVUGIB can undergo mechanical or thermal endoscopic intervention without a significant difference in achieving primary hemostasis, rebleeding, requiring a secondary procedure, or mortality outcomes.
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Affiliation(s)
- Rahul Karna
- Division of Gastroenterology and Hepatology, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Bandhul Hans
- Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Thayer Nasereddin
- Indianapolis Gastroenterology and Hepatology, Indianapolis, Indiana, USA
| | - Dhruv Chaudhary
- Division of Gastroenterology and Hepatology, Columbus, Georgia, USA
| | - Manish Dhawan
- Division of Gastroenterology and Hepatology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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Li XJ, Fung BM. Advancements in endoscopic hemostasis for non-variceal upper gastrointestinal bleeding. World J Gastrointest Endosc 2024; 16:376-384. [PMID: 39072248 PMCID: PMC11271718 DOI: 10.4253/wjge.v16.i7.376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/06/2024] [Accepted: 06/26/2024] [Indexed: 07/08/2024] Open
Abstract
Non-variceal upper gastrointestinal (GI) bleeding is a significant cause of morbidity and mortality. Traditionally, through-the-scope (TTS) clips, thermal therapy, and injection therapies are used to treat GI bleeding. In this review, we provide an overview of novel endoscopic treatments that can be used to achieve hemostasis. Specifically, we discuss the efficacy and applicability of over-the-scope clips, hemostatic agents, TTS doppler ultrasound, and endoscopic ultrasound, each of which offer an effective method of reducing rates of GI rebleeding.
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Affiliation(s)
- Xue Jing Li
- Department of Gastroenterology and Hepatology, Banner-University Medical Center Phoenix, Phoenix, AZ 85006, United States
| | - Brian M Fung
- Department of Gastroenterology, Arizona Digestive Health, Mesa, AZ 85210, United States
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7
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Long B, Gottlieb M. Emergency medicine updates: Upper gastrointestinal bleeding. Am J Emerg Med 2024; 81:116-123. [PMID: 38723362 DOI: 10.1016/j.ajem.2024.04.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/20/2024] [Accepted: 04/27/2024] [Indexed: 06/07/2024] Open
Abstract
INTRODUCTION Upper gastrointestinal bleeding (UGIB) is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning UGIB for the emergency clinician. DISCUSSION UGIB most frequently presents with hematemesis. There are numerous causes, with the most common peptic ulcer disease, though variceal bleeding in particular can be severe. Nasogastric tube lavage for diagnosis is not recommended based on the current evidence. A hemoglobin transfusion threshold of 7 g/dL is recommended (8 g/dL in those with myocardial ischemia), but patients with severe bleeding and hemodynamic instability require emergent transfusion regardless of their level. Medications that may be used in UGIB include proton pump inhibitors, prokinetic agents, and vasoactive medications. Antibiotics are recommended for those with cirrhosis and suspected variceal bleeding. Endoscopy is the diagnostic and therapeutic modality of choice and should be performed within 24 h of presentation in non-variceal bleeding after resuscitation, though patients with variceal bleeding may require endoscopy within 12 h. Transcatheter arterial embolization or surgical intervention may be necessary. Intubation should be avoided if possible. If intubation is necessary, several considerations are required, including resuscitation prior to induction, utilizing preoxygenation and appropriate suction, and administering a prokinetic agent. There are a variety of tools available for risk stratification, including the Glasgow Blatchford Score. CONCLUSIONS An understanding of literature updates can improve the ED care of patients with UGIB.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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8
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Shung DL, Laine L. Review article: Upper gastrointestinal bleeding - review of current evidence and implications for management. Aliment Pharmacol Ther 2024; 59:1062-1081. [PMID: 38517201 DOI: 10.1111/apt.17949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/27/2023] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital-based care. Advances in care across pre-endoscopic, endoscopic and post-endoscopic phases have led to improvements in clinical outcomes. AIMS To provide a detailed, evidence-based update on major aspects of care across pre-endoscopic, endoscopic and post-endoscopic phases. METHODS We performed a structured bibliographic database search for each topic. If a recent high-quality meta-analysis was not available, we performed a meta-analysis with random effects methods and odds ratios with 95% confidence intervals. RESULTS Pre-endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high-risk stigmata, endoscopic therapy, including over-the-scope clips (OTSCs) and TC-325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post-endoscopic management includes early enteral feeding for all UGIB patients. For high-risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high-risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered. CONCLUSIONS Management of acute UGIB should include treatment plans for pre-endoscopic, endoscopic and post-endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding.
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Affiliation(s)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA
- West Haven Veterans Affairs Medical Center, West Haven, Connecticut, USA
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O'Donnell O, Gallagher C, Davey MG, Coulter J, Regan M. A systematic review and meta-analysis assessing the use of tranexamic acid (TXA) in acute gastrointestinal bleeding. Ir J Med Sci 2024; 193:705-719. [PMID: 37794272 PMCID: PMC10961292 DOI: 10.1007/s11845-023-03517-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/04/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Gastrointestinal bleeding results in significant morbidity, cost and mortality. TXA, an antifibrinolytic agent, has been proposed to reduce mortality; however, many studies report conflicting results. METHODS The aim of the study was to perform the first systematic review and meta-analysis of RCTs to evaluate the efficacy TXA for both upper and lower gastrointestinal bleeding. This was performed per PRISMA guidelines. PubMed, EMBASE, Cochrane and Scopus databases were searched for RCTs. Dichotomous variables were pooled as risk ratios (RR) with 95% confidence intervals (CI) using the MH method with random effects modelling. RESULTS Fourteen RCTs were identified with 14,338 patients and mean age of 58.4 years. 34.9% (n = 5008) were female and 65.1% (n = 9330) male. There was no significant difference in mortality between TXA and placebo (RR 0.86 95% CI (0.74 to 1.00), P: 0.05). The secondary outcomes, similarly, did not yield significant results. These included rebleeding, need for surgical intervention (RR: 0.75 95% CI (0.53, 1.07)), endoscopic intervention (RR: 0.92 95% CI (0.70, 1.22)), transfusion requirement (RR: 1.01 95% CI (0.94, 10.7)) and length of stay (RR: 0.03 95% CI (- 0.03, 0.08)). There was no increased risk of VTE, RR: 1.29 95% CI (0.53, 3.16). One trial (n = 12,009) reported an increased risk of seizure in the TXA group, RR: 1.73 95% CI (1.03-2.93). CONCLUSION TXA does not reduce mortality in patients with acute upper or lower gastrointestinal bleeding and may confer an increased risk of seizures. The authors do not recommend the use of TXA in acute gastrointestinal bleeding.
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Affiliation(s)
- Oisín O'Donnell
- Department of General and Colorectal Surgery, Galway University Hospitals, Saolta University Health Care Group, Newcastle Road, Galway, H91YR71, Ireland.
- School of Postgraduate Studies, Royal College of Surgeon in Ireland, Dublin, D02YN77, Ireland.
| | - Clodagh Gallagher
- University of Limerick, Sreelane, Castletroy, Co., Limerick, V94 T9PX, Ireland
| | - Matthew G Davey
- Department of General and Colorectal Surgery, Galway University Hospitals, Saolta University Health Care Group, Newcastle Road, Galway, H91YR71, Ireland
- The National University of Ireland Galway, University Rd, Galway, H91TK33, Ireland
| | - Jonathan Coulter
- Department of General and Colorectal Surgery, Galway University Hospitals, Saolta University Health Care Group, Newcastle Road, Galway, H91YR71, Ireland
| | - Mark Regan
- Department of General and Colorectal Surgery, Galway University Hospitals, Saolta University Health Care Group, Newcastle Road, Galway, H91YR71, Ireland
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Lui TKL. Response. Gastrointest Endosc 2024; 99:664-665. [PMID: 38508814 DOI: 10.1016/j.gie.2023.11.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 03/22/2024]
Affiliation(s)
- Thomas K L Lui
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
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11
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Wang J, Peng X, Ye Z, He S, Liu L, Luo Y, Lv N, Shu X, Zhu Z. Medical therapy has similar hemostatic efficacy with endoscopic treatment for PUB patients with adherent clot (FIIb ulcers). Surg Endosc 2024; 38:1791-1806. [PMID: 38291159 DOI: 10.1007/s00464-024-10679-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 12/30/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Currently, there is no clear consensus on whether medical treatment or endoscopic treatment should be used for peptic ulcer bleeding patients with adherent clot. The aim of this study is to investigate the hemostatic effects of medical treatment, single endoscopic treatment, and combination endoscopic treatment for peptic ulcer bleeding (PUB) patients with adherent clot. METHODS We retrospectively analyzed PUB patients with adherent clot who underwent endoscopic examination or treatment in our center from March 2014 to January 2023 and received intravenous administration of proton pump inhibitors. Patients were divided into medical treatment (MT) group, single endoscopic treatment (ST) group, and combined endoscopic treatment (CT) group. Subsequently, inverse probability of treatment weighting (IPTW) was performed to calculate the rebleeding rate. RESULTS A total of 605 eligible patients were included in this study. After IPTW, the rebleeding rate in the MT group on days 3, 7, 14, and 30 were 13.3 (7.3), 14.2 (7.8), 14.5 (7.9), and 14.5 (7.9), respectively; the rebleeding rates in the ST group were 17.4 (5.1), 20.8 (6.1), 20.8 (6.1), and 20.8 (6.1), respectively; the rebleeding rates in the CT group were 0.4 (0.9), 1.7 (3.3), 2.3 (4.5), and 2.3 (4.5), respectively. Although the rebleeding rate in the medical treatment group was higher, there was no significant difference among the three groups on days 3, 7, 14, and 30 (P = 0.132, 0.442, 0.552, and 0.552). CONCLUSIONS Medical therapy has similar hemostatic efficacy with endoscopic treatment for PUB patients with adherent clot (FIIb ulcers). However, for patients with more risk factors and access to well-equipped endoscopy centers, endoscopic treatment may be considered. The choice of treatment approach should be based on the individual conditions of the patient, as well as other factors such as medical resources available.
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Affiliation(s)
- Jingsong Wang
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Xiang Peng
- Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhen Ye
- Department of Postgraduate, Jiangxi University of Traditional Chinese Medicine, Nanchang, 330004, Jiangxi, China
| | - Shan He
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Linlin Liu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Yixing Luo
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Nonghua Lv
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Xu Shu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Zhenhua Zhu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China.
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Gaoxin Branch, Nanchang, 330096, Jiangxi, China.
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Vakil N. Endoscopic Diagnosis, Grading, and Treatment of Bleeding Peptic Ulcer Disease. Gastrointest Endosc Clin N Am 2024; 34:217-229. [PMID: 38395480 DOI: 10.1016/j.giec.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Peptic ulcer bleeding is a major cause for hospital admissions and has a significant mortality. Endoscopic interventions reduce the risk of rebleeding in high-risk patients and several options are available including injection therapies, thermal therapies, mechanical clips, hemostatic sprays, and endoscopic suturing. Proton-pump inhibitors and Helicobacter pylori treatment are important adjuncts to endoscopic therapy. Endoscopic therapy is indicated in Forrest 1a, 1b, and 2a lesions. Patients with Forrest 2b lesions may do well with proton-pump inhibitor therapy alone but can also be managed by removal of the clot and targeting endoscopic therapy to the underlying lesion.
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Affiliation(s)
- Nimish Vakil
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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13
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Masood M, Low DE, Deal SB, Kozarek RA. Endoscopic Management of Post-Sleeve Gastrectomy Complications. J Clin Med 2024; 13:2011. [PMID: 38610776 PMCID: PMC11012813 DOI: 10.3390/jcm13072011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.
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Affiliation(s)
- Muaaz Masood
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
| | - Donald E. Low
- Division of Thoracic Surgery, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA;
| | - Shanley B. Deal
- Division of General and Bariatric Surgery, Center for Weight Management, Virginia Mason Franciscan Health, Seattle, WA 98101, USA;
| | - Richard A. Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
- Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
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14
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Acehan F, Karsavuranoğlu B, Kalkan C, Aslan M, Altiparmak E, Ates I. Three Simple Parameters on Admission to the Emergency Department are Predictors for Endoscopic Intervention in Patients with Suspected Nonvariceal Upper Gastrointestinal Bleeding. J Emerg Med 2024; 66:64-73. [PMID: 38267298 DOI: 10.1016/j.jemermed.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 07/31/2023] [Accepted: 08/31/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND A considerable number of patients with nonvariceal upper gastrointestinal bleeding (UGIB) need endoscopic intervention. OBJECTIVE The aim of this study was to determine factors that predict the need for endoscopic intervention at the time of admission to the emergency department. METHODS Consecutive patients with International Classification of Diseases, Tenth Revision diagnosis code K92.2 (gastrointestinal hemorrhage) who underwent upper endoscopy between February 2019 and February 2022, including patients diagnosed with nonvariceal UGIB in the emergency department in the study were reviewed retrospectively. The patients were divided into two groups: those treated endoscopically and those not treated endoscopically. These two groups were compared according to clinical and laboratory findings at admission and independent predictors for endoscopic intervention were determined using multivariate regression analysis. RESULTS Although 123 patients (30.3%) were treated endoscopically, endoscopic treatment was not required in 283 (69.7%) patients. Syncope, mean arterial pressure (MAP), and blood urea nitrogen (BUN) at admission were independent predictors for endoscopic intervention in the multivariate analysis, after adjusting for endoscopy time. The area under the curve of the syncope+MAP+BUN combination for endoscopic intervention was 0.648 (95% CI 0.588-0.708). Although the syncope+MAP+BUN combination predicted the need for intervention significantly better than pre-endoscopy Rockall and AIMS65 scores (p = 0.010 and p < 0.001, respectively), there was no significant difference in its comparison with the Glasgow-Blatchford score (p = 0.103). CONCLUSIONS Syncope, MAP, and BUN at admission were independent predictors for endoscopic therapy in patients with nonvariceal UGIB. Rather than using complicated scores, it would be more practical and easier to predict the need for endoscopic intervention with these three simple parameters, which are included in the Glasgow-Blatchford score.
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Affiliation(s)
- Fatih Acehan
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey.
| | | | - Cagdas Kalkan
- Department of Gastroenterology, Ankara City Hospital, Ankara, Turkey
| | - Meryem Aslan
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | - Emin Altiparmak
- Department of Gastroenterology, Ankara City Hospital, Ankara, Turkey
| | - Ihsan Ates
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
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15
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Sabetti MC, Cola V, Foglia A, Stanzani D, Galiazzo G, Perfetti S, Tagliavia C, Pisoni L, Pietra M. Endoscopic and surgical treatment of non-neoplastic proximal duodenal ulceration in dogs, and anatomical study of proximal duodenal vascularisation. J Small Anim Pract 2024; 65:113-122. [PMID: 37960926 DOI: 10.1111/jsap.13680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 09/13/2023] [Accepted: 10/01/2023] [Indexed: 11/15/2023]
Abstract
OBJECTIVES Proximal duodenal ulceration is often characterised by continuous bleeding, and treatment is challenging. The aims of this study were to investigate the role of vascularisation in proximal duodenal ulceration and describe clinical aspects, endoscopic features and treatment in dogs. MATERIAL AND METHODS Polyurethane foam casts of gastroduodenal vessels were obtained from five dogs which had died from disorders unrelated to the digestive system. In addition, 12 dogs having proximal duodenal ulcers diagnosed by endoscopic examination were enrolled in a treatment trial. After the endoscopic diagnosis of a duodenal ulcer, all the dogs were treated medically and, in the absence of resolution, were subsequently treated by endoscopic electrocauterisation or by surgery. RESULTS A submucosal vascular network was evident in all the casts, with a prominent venous plexus seen exclusively in the first half inch of the duodenum. In clinical cases, on endoscopic examination, the duodenal ulcer was located at the proximal part of the duodenum, involving the mesenteric portion of the wall. The dogs not responding to medical treatment (6/12) were treated with endoscopic electrocauterisation, surgical coagulation or resection of the proximal duodenal portion. All the dogs survived until discharge, and the median survival time following discharge was 107.5 days. CLINICAL SIGNIFICANCE Based on the anatomical details highlighted in this study, the continuous bleeding observed in our patients may have been due to the prominent venous plexus evidenced at the level of the proximal duodenum. Surgical and endoscopic treatments in six patients resolved the ulcer bleeding with no recurrences noted during follow-up.
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Affiliation(s)
- M C Sabetti
- Department of Veterinary Sciences, University of Parma, Via Taglio 8, 43100, Parma, Italy
| | - V Cola
- Department of Veterinary Medical Sciences, University of Bologna, via Tolara di Sopra 50, 40064 Ozzano Emilia (B0), Italy
| | - A Foglia
- Department of Veterinary Medical Sciences, University of Bologna, via Tolara di Sopra 50, 40064 Ozzano Emilia (B0), Italy
| | - D Stanzani
- Self Employed Veterinarian, 40050, Bologna, Italy
| | - G Galiazzo
- Self Employed Veterinarian, 45100, Rovigo, Italy
| | - S Perfetti
- Department of Veterinary Medical Sciences, University of Bologna, via Tolara di Sopra 50, 40064 Ozzano Emilia (B0), Italy
| | - C Tagliavia
- Department of Veterinary Medicine, University of Teramo, Località Piano D'Accio, 64100, Teramo, Italy
| | - L Pisoni
- Department of Veterinary Medical Sciences, University of Bologna, via Tolara di Sopra 50, 40064 Ozzano Emilia (B0), Italy
| | - M Pietra
- Department of Veterinary Medical Sciences, University of Bologna, via Tolara di Sopra 50, 40064 Ozzano Emilia (B0), Italy
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16
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Kumar VCS, Aloysius M, Aswath G. Adverse events associated with the gold probe and the injection gold probe devices used for endoscopic hemostasis: A MAUDE database analysis. World J Gastrointest Endosc 2024; 16:37-43. [PMID: 38313458 PMCID: PMC10835479 DOI: 10.4253/wjge.v16.i1.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/22/2023] [Accepted: 12/05/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Gastrointestinal (GI) bleeding accounts for over half a million admissions annually and is the most common GI diagnosis requiring hospitalization in the United States. Bipolar electrocoagulation devices are used for the management of gastrointestinal bleeding. There is no data on device-related adverse events for gold probe (GP) and injection gold probe (IGP). AIM To analyze this using the Food and Drug Administration (FDA's) Manufacturer and User Facility Device Experience (MAUDE) database from 2013 to 2023. METHODS We examined post-marketing surveillance data on GP and IGP from the FDA MAUDE database to report devicerelated and patient-related adverse events between 2013-2023. The MAUDE database is a publicly available resource providing over 4 million records relating to medical device safety. Statistical analyses were performed using IBM SPSS Statistics V.27.0 (IBM Corp., Armonk, NY, United States). RESULTS Our search elicited 140 reports for GP and 202 reports for IGP, respectively, during the study period from January 2013 to August 2023. Malfunctions reportedly occurred in 130 cases for GP, and actual patient injury or event occurred in 10 patients. A total of 149 patients (74%) reported with Injection GP events suffered no significant consequences due to the device failure, but 53 patients (26%) were affected by an event. CONCLUSION GP and IGP are critical in managing gastrointestinal bleeding. This study of the FDA MAUDE database revealed the type, number, and trends of reported device-related adverse events. The endoscopist and support staff must be aware of these device-related events and be equipped to manage them if they occur.
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Affiliation(s)
- Vishnu Charan Suresh Kumar
- Division of Gastroenterology and Hepatology, SUNY Upstate Medical University, Syracuse, NY 13202, United States
| | - Mark Aloysius
- Division of Gastroenterology and Hepatology, SUNY Upstate Medical University, Syracuse, NY 13202, United States
| | - Ganesh Aswath
- Division of Gastroenterology and Hepatology, SUNY Upstate Medical University, Syracuse, NY 13202, United States
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17
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Lesmana CRA. Role of endoscopic ultrasound in non-variceal upper gastrointestinal bleeding management. Artif Intell Gastrointest Endosc 2023; 4:12-17. [DOI: 10.37126/aige.v4.i2.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/14/2023] [Accepted: 12/04/2023] [Indexed: 12/07/2023] Open
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is one of the challenging situations in clinical practice. Despite that gastric ulcer and duodenal ulcer are still the main causes of acute NVUGIB, there are other causes of bleeding which might not always be detected through the standard endoscopic evaluation. Standard endoscopic management of UGIB consists of injection, thermal coagulation, hemoclips, and combination therapy. However, these methods are not always successful for rebleeding prevention. Endoscopic ultrasound (EUS) has been used recently for portal hypertension management, especially in managing acute variceal bleeding. EUS has been considered a better tool to visualize the bleeding vessel in gastroesophageal variceal bleeding. There have been studies looking at the role of EUS for managing NVUGIB; however, most of them are case reports. Therefore, it is important to review back to see the evolution and innovation of endoscopic treatment for NVUGIB and the role of EUS for possibility to replace the standard endoscopic haemostasis management in daily practice.
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Affiliation(s)
- Cosmas Rinaldi Adithya Lesmana
- Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta 10430, DKI, Indonesia
- Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta 12950, Indonesia
- Gastrointestinal Cancer Center, MRCCC Siloam Semanggi Hospital, Jakarta 12930, Indonesia
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18
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Hernandez IA, Morell J, Mulcahy L, Luzardo D. Comparison Between Pantoprazole Intermittent Dosing and Continuous Infusion in Suspected Upper Gastrointestinal Bleeding Prior to Endoscopy: Impact of a Pharmacist-Driven Protocol to Reduce Utilization of Pantoprazole Continuous Infusion. Cureus 2023; 15:e48056. [PMID: 38046478 PMCID: PMC10688605 DOI: 10.7759/cureus.48056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND Current practice for patients with suspected or confirmed upper gastrointestinal bleeding (GIB) is to utilize a proton pump inhibitor (PPI) bolus followed by a continuous infusion for 72 hours. Literature has shown similar outcomes with intermittent bolus dosing compared to continuous infusion. Substitution would lead to reduced costs and utilization of resources. METHODS This was a retrospective case-control study conducted via chart review. Utilizing electronic healthcare record reports, patients in the control arm were screened for inclusion if they received a pantoprazole continuous infusion from December 1, 2020, to March 31, 2021. A total of 38 patients were included in the control arm. Patients in the experimental arm were screened for inclusion with pantoprazole intermittent therapy from January 1, 2022, to June 30, 2022. A total of 60 patients were included in the experimental arm. The primary outcome was a 30-day GIB recurrence. Secondary outcomes included 30-day hospital readmission, 30-day Clostridioides difficile (C. difficile), hospital length of stay (LOS), and number of pantoprazole vials utilized. RESULTS There was a 65% reduction in the 30-day GIB recurrence in the intermittent bolus arm compared to the continuous infusion arm. Thirty-day hospital readmission was 57% lower in the intermittent bolus arm compared to the continuous infusion arm. The LOS between the two arms was almost identical with the median being five days for the intermittent bolus arm and the median being four days for the continuous infusion arm. The 30-day C. difficile infection rate had 5% of patients acquiring C. difficile in the intermittent bolus arm and 2.5% in the continuous infusion arm. The intermittent bolus arm used 55% fewer pantoprazole vials than the continuous infusion arm. CONCLUSION In hospitalized patients, the utilization of pantoprazole intermittent bolus is not only comparably efficacious but potentially represents a safer and economically advantageous alternative compared to the current guideline recommendation of a 72-hour pantoprazole continuous infusion. Further studies could provide more robust data to support our findings and challenge the current recommendation for patients who meet the indication criteria.
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Affiliation(s)
| | - Jason Morell
- Pharmacy, Baptist Health South Florida, Miami, USA
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19
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Beran A, Al-Abboodi Y, Majzoub AM, Ghazaleh S, Sayeh W, Mohamed MFH, Elfert K, Mhanna M, Montalvan-Sanchez E, Musallam R, Jaber F, Bhatti U, Abdeljawad K, Al-Haddad M. Endoscopic Versus Conservative Therapy for Bleeding Peptic Ulcer with Adherent Clot: A Comprehensive Systematic Review and Meta-Analysis. Dig Dis Sci 2023; 68:3921-3934. [PMID: 37634184 DOI: 10.1007/s10620-023-08078-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 08/04/2023] [Indexed: 08/29/2023]
Abstract
INTRODUCTION Peptic ulcers with adherent clots are associated with a high-risk of rebleeding and mortality. However, the optimal management of bleeding ulcers with adherent clots remains unclear. We conducted this systematic review and meta-analysis to compare endoscopic therapy and conservative therapy to manage bleeding ulcers with adherent clots. METHODS We systematically searched PubMed, Embase, and Web of Science databases through October 2022 to include all studies comparing the endoscopic and conservative therapeutic approaches for bleeding ulcers with adherent clots. Our primary outcome was rebleeding (overall and 30-day). The secondary outcomes were mortality (overall and 30-day), need for surgery, and length of hospital stay (LOS). The random-effects model was used to calculate the pooled odds ratios (OR) and mean differences (MD) with the corresponding confidence intervals (CI) for proportional and continuous variables, respectively. RESULTS Eleven studies (9 RCTs) with 833 patients (431 received endoscopic therapy vs. 402 received conservative therapy) were included. Overall, endoscopic therapy was associated with lower overall rebleeding (OR 0.41, 95% CI 0.22-0.79, P = 0.007), 30-day rebleeding (OR 0.43, 95% CI 0.21-0.89, P = 0.002), overall mortality (OR 0.47, 95% CI 0.23-0.95, P = 0.04), 30-day mortality (OR 0.43, 95% CI 0.21-0.89, P = 0.002), need for surgery (OR 0.44, 95% CI 0.21-0.95, P = 0.04), and LOS (MD - 3.17 days, 95% CI - 4.14, - 2.19, P < 0.00001). However, subgroup analysis of randomized controlled trials (RCTs) showed no significant difference in overall mortality (OR 0.78, 95% CI 0.24-2.52, P = 0.68) between the two strategies, with numerically lower but statistically non-significant rates of overall rebleeding (7.2% vs. 18.5%, respectively; OR 0.42, 95% CI 0.17-1.05, P = 0.06), statistically lower rate of need for surgery (OR 0.28, 95% CI 0.08-0.96, P = 0.04) with endoscopic therapy compared to conservative therapy. CONCLUSIONS Our meta-analysis demonstrates that endoscopic therapy was overall associated with lower rates of rebleeding (overall and 30-day), mortality (overall and 30-day), need for surgery, and LOS, compared to conservative therapy for the management of bleeding ulcers with adherent clots. However, subgroup analysis of RCTs showed that endoscopic therapy was associated with numerically lower but statistically non-significant rates of overall rebleeding and a statistically lower rate of need for surgery compared to conservative therapy with similar overall mortality rates. Combined treatment with thermal therapy and injection therapy was the most effective treatment modality in reducing rebleeding risk. Further large-scale RCTs are needed to validate our findings.
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Affiliation(s)
- Azizullah Beran
- Divison of Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, Ste 225, Indianapolis, IN, 46202, USA.
| | - Yasir Al-Abboodi
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Abdul Mounaem Majzoub
- Divison of Gastroenterology and Hepatology, University of Missouri, Columbia, MO, USA
| | - Sami Ghazaleh
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Wasef Sayeh
- Department of Medicine, University of Toledo, Toledo, OH, USA
| | - Mouhand F H Mohamed
- Department of Medicine, Warren Alpert Medical School Brown University, Providence, RI, USA
| | - Khaled Elfert
- Department of Medicine, St. Barnabas Hospital Health System, Bronx, NY, USA
| | - Mohammed Mhanna
- Division of Cardiology, University of Iowa, Iowa City, IA, USA
| | | | - Rami Musallam
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Fouad Jaber
- Department of Medicine, University of MO - Kansas City, Kansas City, MO, USA
| | - Umer Bhatti
- Divison of Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, Ste 225, Indianapolis, IN, 46202, USA
| | - Khaled Abdeljawad
- Divison of Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, Ste 225, Indianapolis, IN, 46202, USA
| | - Mohammad Al-Haddad
- Divison of Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, Ste 225, Indianapolis, IN, 46202, USA
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20
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Hung KW. Is Adherence to Guidelines Helpful? Endoscopic Hemostasis of Bleeding Peptic Ulcers with Adherent Clots. Dig Dis Sci 2023; 68:3843-3845. [PMID: 37634183 DOI: 10.1007/s10620-023-08082-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Kenneth W Hung
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208019, New Haven, CT, 06520, USA.
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21
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Wang J, He S, Shang G, Lv N, Shu X, Zhu Z. Epinephrine injection monotherapy shows similar hemostatic efficacy to epinephrine injection combined therapy in high-risk patients (Forrest Ib) with bleeding ulcers. Surg Endosc 2023; 37:6954-6963. [PMID: 37336844 PMCID: PMC10462566 DOI: 10.1007/s00464-023-10152-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/20/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Whether combination therapy has higher hemostatic efficacy than epinephrine injection monotherapy in different Forrest classifications is not clear. This study aimed to compare hemostatic efficacy between epinephrine injection monotherapy (MT) and combination therapy (CT) based on different Forrest classifications. METHODS We retrospectively analyzed peptic ulcer bleeding (PUB) patients who underwent endoscopic epinephrine injections or epinephrine injections combined with a second therapy between March 2014 and June 2022 in our center, and the patients were divided into MT group or CT group. Subsequently, a propensity score matching analysis (PSM) was performed and rebleeding rates were calculated according to Forrest classifications via a stratified analysis. RESULTS Overall, 605 patients who met the inclusion criteria were included, and after PSM, 173 patients in each of the CT and MT groups were included. For PUB patients with nonbleeding visible vessels (FIIa), the rebleeding rates by Days 3, 7, 14, and 30 after PSM were 8.8%, 17.5%, 19.3%, and 19.3% in the MT group, respectively, and rates were 0%, 4.1%, 5.5%, and 5.5% in the CT group, respectively, with significant differences observed between the two groups by Days 3, 7, 14, and 30 (P = 0.015, P = 0.011, P = 0.014, and P = 0.014, respectively). However, for PUB patients with oozing bleeding (FIb), the rebleeding rates by Days 3, 7, 14, and 30 after PSM were 14.9%, 16.2%, 17.6%, and 17.6% in the MT group, respectively, and rates were 13.2%, 14.7%, 14.7%, and 16.2% in the CT group, respectively, with no significant differences observed between the two groups by Days 3, 7, 14, and 30 (P = 0.78, P = 0.804, P = 0.644 and P = 0.825). CONCLUSION Combined therapy has higher hemostatic efficacy than epinephrine injection monotherapy for PUB patients with visible blood vessel (FIIa) ulcers. However, epinephrine injection monotherapy is equally as effective as combined therapy for PUB patients with oozing blood (FIb) ulcers.
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Affiliation(s)
- Jingsong Wang
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Shan He
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Guanqun Shang
- Queen Mary School, Nanchang University, Nanchang, 330001 Jiangxi China
| | - Nonghua Lv
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Xu Shu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Zhenhua Zhu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
- Department of Gastroenterology, Gaoxin Branch, The First Affiliated Hospital of Nanchang University, Nanchang, 330096 Jiangxi China
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22
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Hollenbach M, Wedi E. Response. Gastrointest Endosc 2023; 98:269-270. [PMID: 37455060 DOI: 10.1016/j.gie.2023.04.2065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Marcus Hollenbach
- Division of Gastroenterology, Medical Department II, University of Leipr, Leipzig, Germany
| | - Edris Wedi
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Offenbach, Germany; Clinic for Gastroenterology, Gastrointestinal Oncology and Endocrinology, University of Göttingen, Göttingen, Germany
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23
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Lei Y, Halasz J, Novak KL, Congly SE. Intermittent Proton Pump Inhibitor Therapy in Low-Risk Non-Variceal Upper Gastrointestinal Bleeding May Be Significantly Cost-Saving. MEDICINES (BASEL, SWITZERLAND) 2023; 10:44. [PMID: 37505065 PMCID: PMC10384205 DOI: 10.3390/medicines10070044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/09/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND High-dose proton pump inhibitor (PPI) therapy, given either intermittently or continuously for non-variceal upper gastrointestinal bleeding (NV-UGIB), is efficacious. Using intermittent PPI for low-risk patients may be cost-saving. Our objective was to estimate the annual cost savings if all low-risk NV-UGIB patients received intermittent PPI therapy. METHODS Patients who presented to hospital in Calgary, Alberta, who received a PPI for NV-UGIB from July 2015 to March 2017 were identified using ICD-10 codes. Patients were stratified into no endoscopy, high-risk, and low-risk lesion groups and further subdivided into no PPI, oral PPI, intermittent intravenous (IV), and continuous IV subgroups. Average length of stay (LOS) in each subgroup and costs were calculated. RESULTS We identified 4141 patients with NV-UGIBs, (median age 61, 57.4% male). One-thousand two-hundred and thirty-one low-risk patients received continuous IV PPI, with an average LOS of 6.8 days (95% CI 6.2-7.3) versus 4.9 days (95% CI 3.9-5.9) for intermittent IV patients. If continuous IV PPI patients instead received intermittent IV PPI, 3852 patient days and CAD 11,714,390 (2017 CAD)/year could be saved. CONCLUSIONS Using real-world administrative data, we demonstrate that a sizable portion of low-risk patients with NV-UGIB who were given continuous IV PPI if switched to intermittent IV therapy could generate significant potential cost savings.
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Affiliation(s)
- Yang Lei
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Jennifer Halasz
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB T2N 4Z6, Canada
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Laudani C, Capodanno D, Angiolillo DJ. Bleeding in acute coronary syndrome: from definitions, incidence, and prognosis to prevention and management. Expert Opin Drug Saf 2023; 22:1193-1212. [PMID: 38048099 DOI: 10.1080/14740338.2023.2291865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 11/22/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION In patients with acute coronary syndrome (ACS), the ischemic benefit of antithrombotic treatment is counterbalanced by the risk of bleeding. The recognition that bleeding events have prognostic implications (i.e. mortality) similar to recurrent ischemic events led to the development of treatment regimens aimed at balancing both ischemic and bleeding risks. AREAS COVERED This review aims at describing definitions, incidence, and prognosis related to bleeding events in ACS patients as well as bleeding-avoidance strategies for their prevention and management of bleeding complications. EXPERT OPINION Management of ACS patients has witnessed remarkable progress after the shift in focusing on the trade-off between ischemia and bleeding. Efforts in standardizing bleeding definitions will allow for better defining the prognostic impact of different types of bleeding events and enable to identify the high-bleeding risk patient. Such efforts will allow to balance the trade-off between the thrombotic and bleeding risk of the individual patient translating into better downward diagnostic and therapeutic decision-making. Novel strategies aiming at maximizing the safety and efficacy of antithrombotic regimens as well as the development of novel antithrombotic drugs and reversal agents and technological advances will allow for optimization of bleeding-avoidance strategies and management of bleeding complications.
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Affiliation(s)
- Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
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Orpen-Palmer J, Stanley AJ. A Review of Risk Scores within Upper Gastrointestinal Bleeding. J Clin Med 2023; 12:jcm12113678. [PMID: 37297873 DOI: 10.3390/jcm12113678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Upper gastrointestinal bleeding is a common medical emergency. Thorough initial assessment and appropriate resuscitation are essential to stabilise the patient. Risk scores provide an important tool to discriminate between lower- and higher-risk patients. Very low-risk patients can be safely discharged for out-patient management, while higher-risk patients can receive appropriate in-patient care. The Glasgow Blatchford Score, with a score of 0-1, performs best in the identification of very low-risk patients who will not require hospital based intervention or die, and is recommended by most guidelines to facilitate safe out-patient management. The performance of risk scores in the identification of specific adverse events to define high-risk patients is less accurate, with no individual score performing consistently well. Ongoing developments in the use of machine learning models and artificial intelligence in predicting poor outcomes in UGIB appear promising and will likely form the basis of dynamic risk assessment in the future.
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Affiliation(s)
- Josh Orpen-Palmer
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow G4 0SF, UK
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow G4 0SF, UK
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Chesta F, Buttar NS. Reply. Clin Gastroenterol Hepatol 2023; 21:1375-1376. [PMID: 35944831 DOI: 10.1016/j.cgh.2022.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/24/2022] [Accepted: 07/25/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Fnu Chesta
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, Hawaii; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Navtej S Buttar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Adão D, Gois AF, Pacheco RL, Pimentel CF, Riera R. Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage. Cochrane Database Syst Rev 2023; 2:CD013176. [PMID: 36723439 PMCID: PMC9891197 DOI: 10.1002/14651858.cd013176.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Upper endoscopy is the definitive treatment for upper gastrointestinal haemorrhage (UGIH). However, up to 13% of people who undergo upper endoscopy will have incomplete visualisation of the gastric mucosa at presentation. Erythromycin acts as a motilin receptor agonist in the upper gastrointestinal (GI) tract and increases gastric emptying, which may lead to better quality of visualisation and improved treatment effectiveness. However, there is uncertainty about the benefits and harms of erythromycin in UGIH. OBJECTIVES To evaluate the benefits and harms of erythromycin before endoscopy in adults with acute upper gastrointestinal haemorrhage, compared with any other treatment or no treatment/placebo. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 15 October 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) that investigated erythromycin before endoscopy compared to any other treatment or no treatment/placebo before endoscopy in adults with acute UGIH. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. UGIH-related mortality and 2. serious adverse events. Our secondary outcomes were 1. all-cause mortality, 2. visualisation of gastric mucosa, 3. non-serious adverse events, 4. rebleeding, 5. blood transfusion, and 5. rescue invasive intervention. We used GRADE criteria to assess the certainty of the evidence for each outcome. MAIN RESULTS: We included 11 RCTs with 878 participants. The mean age ranged from 53.13 years to 64.5 years, and most participants were men (72.3%). One RCT included only non-variceal haemorrhage, one included only variceal haemorrhage, and eight included both aetiologies. We defined short-term outcomes as those occurring within one week of initial endoscopy. Erythromycin versus placebo Three RCTs (255 participants) compared erythromycin with placebo. There were no UGIH-related deaths. The evidence is very uncertain about the short-term effects of erythromycin compared with placebo on serious adverse events (risk difference (RD) -0.01, 95% confidence interval (CI) -0.04 to 0.02; 3 studies, 255 participants; very low certainty), all-cause mortality (RD 0.00, 95% CI -0.03 to 0.03; 3 studies, 255 participants; very low certainty), non-serious adverse events (RD 0.01, 95% CI -0.03 to 0.05; 3 studies, 255 participants; very low certainty), and rebleeding (risk ratio (RR) 0.63, 95% CI 0.13 to 2.90; 2 studies, 195 participants; very low certainty). Erythromycin may improve gastric mucosa visualisation (mean difference (MD) 3.63 points on 16-point ordinal scale, 95% CI 2.20 to 5.05; higher MD means better visualisation; 2 studies, 195 participants; low certainty). Erythromycin may also result in a slight reduction in blood transfusion (MD -0.44 standard units of blood, 95% CI -0.86 to -0.01; 3 studies, 255 participants; low certainty). Erythromycin plus nasogastric tube lavage versus no intervention/placebo plus nasogastric tube lavage Six RCTs (408 participants) compared erythromycin plus nasogastric tube lavage with no intervention/placebo plus nasogastric tube lavage. There were no UGIH-related deaths and no serious adverse events. The evidence is very uncertain about the short-term effects of erythromycin plus nasogastric tube lavage compared with no intervention/placebo plus nasogastric tube lavage on all-cause mortality (RD -0.02, 95% CI -0.08 to 0.03; 3 studies, 238 participants; very low certainty), visualisation of the gastric mucosa (standardised mean difference (SMD) 0.48 points on 10-point ordinal scale, 95% CI 0.10 to 0.85; higher SMD means better visualisation; 3 studies, 170 participants; very low certainty), non-serious adverse events (RD 0.00, 95% CI -0.05 to 0.05; 6 studies, 408 participants; very low certainty), rebleeding (RR 1.13, 95% CI 0.63 to 2.02; 1 study, 169 participants; very low certainty), and blood transfusion (MD -1.85 standard units of blood, 95% CI -4.34 to 0.64; 3 studies, 180 participants; very low certainty). Erythromycin versus nasogastric tube lavage Four RCTs (287 participants) compared erythromycin with nasogastric tube lavage. There were no UGIH-related deaths and no serious adverse events. The evidence is very uncertain about the short-term effects of erythromycin compared with nasogastric tube lavage on all-cause mortality (RD 0.02, 95% CI -0.05 to 0.08; 3 studies, 213 participants; very low certainty), visualisation of the gastric mucosa (RR 1.19, 95% CI 0.79 to 1.79; 2 studies, 198 participants; very low certainty), non-serious adverse events (RD -0.10, 95% CI -0.34 to 0.13; 3 studies, 213 participants; very low certainty), rebleeding (RR 0.77, 95% CI 0.40 to 1.49; 1 study, 169 participants; very low certainty), and blood transfusion (median 2 standard units of blood, interquartile range 0 to 4 in both groups; 1 study, 169 participants; very low certainty). Erythromycin plus nasogastric tube lavage versus metoclopramide plus nasogastric tube lavage One RCT (30 participants) compared erythromycin plus nasogastric tube lavage with metoclopramide plus nasogastric tube lavage. The evidence is very uncertain about the effects of erythromycin plus nasogastric tube lavage on all the reported outcomes (serious adverse events, visualisation of gastric mucosa, non-serious adverse events, and blood transfusion). AUTHORS' CONCLUSIONS We are unsure if erythromycin before endoscopy in people with UGIH has any clinical benefits or harms. However, erythromycin compared with placebo may improve gastric mucosa visualisation and result in a slight reduction in blood transfusion.
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Affiliation(s)
- Diego Adão
- Department of Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Aecio Ft Gois
- Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
| | - Rafael L Pacheco
- Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
| | | | - Rachel Riera
- Cochrane Brazil Rio de Janeiro, Cochrane Brazil, Petrópolis, Brazil
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Hu J, Jiang M, Liu H, Zhou H, Wang Y. Application of endoscopic purse-string sutures in high-risk peptic ulcer hemorrhage: preliminary experience of 38 cases. Scand J Gastroenterol 2023; 58:216-221. [PMID: 36039564 DOI: 10.1080/00365521.2022.2116291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study is a prospective study to explore the therapeutic effect of endoscopic purse-string sutures in high-risk peptic ulcer hemorrhage. PATIENTS AND METHODS We prospectively collected and analyzed data from July 2018 to December 2020 from patients in Jinshan hospital, Fudan University, who underwent emergency endoscopy for acute severe high-risk non-variceal upper gastrointestinal hemorrhage (NVUGIB) and were treated with endoscopic purse-string sutures. RESULTS We included 38 patients whose median age was 64 years (interquartile range: 57.2 - 71.2 years). All patients were high risk gastric ulcer larger than 1 cm, including Forrest Ia (n = 4, 10.5%), Forrest Ib (n = 13, 34.2%) and Forrest IIa (n = 21, 55.3%). All patients were treated with endoscopic purse-string sutures. The clinical success rate reached 89.5%. Three patients suffered from rebleeding within seven days, and were treated with surgery or arterial embolization, respectively, all of which successfully stopped bleeding. One patient died of myocardial infarction. All other patients were followed up for 30 days without bleeding. CONCLUSIONS We conclude that endoscopic purse-string sutures seem to be safe and effective in the treatment of patients at high risk of ulcer bleeding.
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Affiliation(s)
- Jingxian Hu
- Department of Gastroenterology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Miao Jiang
- Department of Gastroenterology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Hongyan Liu
- Department of Gastroenterology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Hao Zhou
- Department of Gastroenterology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Yajie Wang
- Department of Gastroenterology, Jinshan Hospital, Fudan University, Shanghai, China
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Hemostatic Powders in Non-Variceal Upper Gastrointestinal Bleeding: The Open Questions. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010143. [PMID: 36676767 PMCID: PMC9863809 DOI: 10.3390/medicina59010143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
Hemostatic powder (HP) is a relatively recent addition to the arsenal of hemostatic endoscopic procedures (HEPs) for gastrointestinal bleeding (GIB) due to benign and malignant lesions. Five types of HP are currently available: TC-325 (Hemospray™), EndoClot™, Ankaferd Blood Stopper®, and, more recently, UI-EWD (NexpowderTM) and CEGP-003 (CGBio™). HP acts as a mechanical barrier and/or promotes platelet activation and coagulation cascade. HP may be used in combination with or as rescue therapy in case of failure of conventional HEPs (CHEPs) and also as monotherapy in large, poorly accessible lesions with multiple bleeding sources. Although the literature on HP is abundant, randomized controlled trials are scant, and some questions remain open. While HP is highly effective in inducing immediate hemostasis in GIB, the rates of rebleeding reported in different studies are very variable, and conditions affecting the stability of hemostasis have not yet been fully elucidated. It is not established whether HP as monotherapy is appropriate in severe GIB, such as spurting peptic ulcers, or should be used only as rescue or adjunctive therapy. Finally, as it can be sprayed on large areas, HP could become the gold standard in malignancy-related GIB, which is often nonresponsive or not amenable to treatment with CHEPs as a result of multiple bleeding points and friable surfaces. This is a narrative review that provides an overview of currently available data and the open questions regarding the use of HP in the management of non-variceal upper GIB due to benign and malignant diseases.
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He S, Liu L, Ouyang L, Wang J, Lv N, Chen Y, Shu X, Zhu Z. Nomogram for predicting rebleeding after initial endoscopic epinephrine injection monotherapy hemostasis in patients with peptic ulcer bleeding: a retrospective cohort study. BMC Gastroenterol 2022; 22:368. [PMID: 35909111 PMCID: PMC9341049 DOI: 10.1186/s12876-022-02448-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/22/2022] [Indexed: 11/28/2022] Open
Abstract
Background Although the current guidelines recommend endoscopic combination therapy, endoscopic epinephrine injection (EI) monotherapy is still a simple, common and effective modality for treating peptic ulcer bleeding (PUB). However, the rebleeding risk after EI monotherapy is still high, and identifying rebleeding patients after EI monotherapy is unclear, which is highly important in clinical practice. This study aimed to identify risk factors and constructed a predictive nomogram related to rebleeding after EI monotherapy. Methods We consecutively and retrospectively analyzed 360 PUB patients who underwent EI monotherapy between March 2014 and July 2021 in our center. Then we identified independent risk factors associated with rebleeding after initial endoscopic EI monotherapy by multivariate logistic regression. A predictive nomogram was developed and validated based on the above predictors. Results Among all PUB patients enrolled, 51 (14.2%) had recurrent hemorrhage within 30 days after endoscopic EI monotherapy. After multivariate logistic regression, shock [odds ratio (OR) = 12.691, 95% confidence interval (CI) 5.129–31.399, p < 0.001], Rockall score (OR = 1.877, 95% CI 1.250–2.820, p = 0.002), tachycardia (heart rate > 100 beats/min) (OR = 2.610, 95% CI 1.098–6.203, p = 0.030), prolonged prothrombin time (PT > 13 s) (OR = 2.387, 95% CI 1.019–5.588, p = 0.045) and gastric ulcer (OR = 2.258, 95% CI 1.003–5.084, p = 0.049) were associated with an increased risk of rebleeding after an initial EI monotherapy treatment. A nomogram incorporating these independent high-risk factors showed good discrimination, with an area under the receiver operating characteristic curve (AUROC) of 0.876 (95% CI 0.817–0.934) (p < 0.001). Conclusions We developed a predictive nomogram of rebleeding after EI monotherapy, which had excellent prediction accuracy. This predictive nomogram can be conveniently used to identify low-risk rebleeding patients after EI monotherapy, allowing for decision-making in a clinical setting.
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Orpen-Palmer J, Stanley AJ. Update on the management of upper gastrointestinal bleeding. BMJ MEDICINE 2022; 1:e000202. [PMID: 36936565 PMCID: PMC9951461 DOI: 10.1136/bmjmed-2022-000202] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/15/2022] [Indexed: 11/04/2022]
Abstract
Upper gastrointestinal bleeding is a common emergency presentation requiring prompt resuscitation and management. Peptic ulcers are the most common cause of the condition. Thorough initial management with a structured approach is vital with appropriate intravenous fluid resuscitation and use of a restrictive transfusion threshold of 7-8 g/dL. Pre-endoscopic scoring tools enable identification of patients at high risk and at very low risk who might benefit from specific management. Endoscopy should be carried out within 24 h of presentation for patients admitted to hospital, although optimal timing for patients at a higher risk within this period is less clear. Endoscopic treatment of high risk lesions and use of subsequent high dose proton pump inhibitors is a cornerstone of non-variceal bleeding management. Variceal haemorrhage results in higher mortality than non-variceal haemorrhage and, if suspected, antibiotics and vasopressors should be administered urgently, before endoscopy. Oesophageal variceal bleeding requires endoscopic band ligation, whereas bleeding from gastric varices requires thrombin or tissue glue injection. Recurrent bleeding is managed by repeat endoscopic treatment. If uncontrolled bleeding occurs, interventional radiological embolisation or surgery is required for non-variceal bleeding or transjugular intrahepatic portosystemic shunt placement for variceal bleeding.
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Shin CM. Acid Suppressive Drugs. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2022. [DOI: 10.7704/kjhugr.2022.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Histamine H<sub>2</sub> receptor antagonists (H<sub>2</sub>RAs) suppress gastric acid production by blocking H<sub>2</sub> receptors in parietal cells. Studies have shown that proton pump inhibitors (PPIs) are superior to H<sub>2</sub>RAs as a treatment for acid-related disorders, such as peptic ulcer disease (PUD) and gastroesophageal reflux disease (GERD). PPIs reduce gastric acid production by irreversibly inhibiting the H<sup>+</sup>/K<sup>+</sup> ATPase pump, and they also increase gastric emptying. Although PPIs have differing pharmacokinetic properties, each PPI is effective in managing GERD and PUDs. However, PPIs have some limitations, including short plasma half-lives, breakthrough symptoms (especially at night), meal-associated dosing, and concerns associated with long-term PPI use. Potassium-competitive acid blockers (P-CABs) provide more rapid and profound suppression of intragastric acidity than PPIs. P-CABs are non-inferior to lansoprazole in healing erosive esophagitis and peptic ulcers, and may also be effective in improving symptoms in patients with non-erosive reflux disease. Acid suppressive drugs are the most commonly used drugs in clinical practice, and it is necessary to understand the pharmacological properties and adverse effects of each drug.
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Timing of endoscopy in patients with upper gastrointestinal bleeding. Sci Rep 2022; 12:6833. [PMID: 35477727 PMCID: PMC9046398 DOI: 10.1038/s41598-022-10897-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 04/11/2022] [Indexed: 11/08/2022] Open
Abstract
The optimal timing of endoscopy in patients with acute upper gastrointestinal bleeding (UGIB) remains controversial. In this study, we investigated the clinical outcomes of urgent endoscopy in patients with UGIB compared with elective endoscopy. From January 2016 to December 2018, consecutive patients who visited the emergency department and underwent endoscopy for clinical manifestations of acute UGIB, including variceal bleeding, were eligible. Urgent endoscopy (within 6 h) and elective endoscopy (after 6 h) were defined as the time taken to perform endoscopy after presentation to the emergency department. The primary outcome was mortality rate within 30 days. A total of 572 patients were included in the analysis. Urgent endoscopy was performed in 490 patients (85.7%). The 30-day mortality rate did not differ between the urgent and elective endoscopy groups (5.3% and 6.1%, p = 0.791). There was no difference regarding the recurrent bleeding rate, total amount of transfusion, or length of hospital between the groups. In multivariate analysis, age and the amount of transfusion were associated with mortality. Urgent endoscopy was not associated with a lower 30-day mortality rate compared with elective endoscopy in patients with acute UGIB.
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Zhu W, Chen L, Zhang J, Wang P. Effects of high-dose versus low-dose proton pump inhibitors for treatment of gastrointestinal ulcer bleeding: a meta-analysis of randomized controlled trials. J Int Med Res 2022; 50:3000605211067396. [PMID: 35414289 PMCID: PMC9014724 DOI: 10.1177/03000605211067396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background We performed a meta-analysis to compare the effects of high-dose (80 mg/day) versus low-dose (40 mg/day) proton pump inhibitors (PPIs) on gastrointestinal ulcer bleeding. Methods We retrieved studies of randomized controlled trials of PPIs administered according to different schedules for the treatment of gastrointestinal ulcer bleeding from Medline, Embase, Web of Science, Clinical Trials, and the Cochrane Database in April 2020. Results Nine randomized controlled trials including 2329 patients were included in this meta-analysis. There were no significant differences in the incidences of re-bleeding, operation intervention, postoperative mortality, and length of hospital stay between the low-dose and high-dose groups. However, the blood transfusion volume was significantly higher in the high-dose group. Conclusion Compared with low-does PPIs, high-dose PPIs had no effect on the incidence of re-bleeding, operation intervention, or postoperative mortality, and did not reduce hospital stay in patients treated with endoscopic hemostasis for gastrointestinal bleeding.
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Affiliation(s)
- Wei Zhu
- Department of Gastrointestinal Vascular Pediatric Surgery, Dongfeng General Hospital of National Medicine, Hubei University of Medicine, Shiyan, Hubei, P.R. China
| | - Liang Chen
- Department of Gastrointestinal Surgery, Affiliated Huadu Hospital of Southern Medical University (People's Hospital of Huadu District), Guangzhou, Guangdong, P.R. China
| | - Jian Zhang
- Department of Gastrointestinal Surgery, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, P.R. China
| | - Pei Wang
- Department of Gastrointestinal Surgery, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, P.R. China
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Kate V, Sureshkumar S, Gurushankari B, Kalayarasan R. Acute Upper Non-variceal and Lower Gastrointestinal Bleeding. J Gastrointest Surg 2022; 26:932-949. [PMID: 35083723 DOI: 10.1007/s11605-022-05258-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/17/2022] [Indexed: 01/31/2023]
Abstract
Acute gastrointestinal (GI) bleeding is a common surgical emergency requiring hospital admission and associated with high morbidity and mortality. Appropriate decision-making is essential to make a prompt diagnosis, accurate risk assessment, and proper resuscitation of patients with gastrointestinal bleeding. Despite multiple randomized trials and meta-analyses, there is still controversy on various management issues like appropriate risk stratification, the timing of endoscopy, choosing an appropriate endoscopic, and radiological intervention in these groups of patients. As the usage of nonsteroidal anti-inflammatory drugs, antiplatelet, and antithrombotic agents is common in patients with gastrointestinal bleeding, the physician is challenged with proper management of these drugs. The present review summarizes the current strategies for risk stratification, localization of bleeding source, endoscopic and radiological intervention in patients with acute nonvariceal upper GI, middle GI, and lower GI bleeding.
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Affiliation(s)
- Vikram Kate
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India.
| | - Sathasivam Sureshkumar
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Balakrishnan Gurushankari
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Raja Kalayarasan
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
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Ren J, Jin X, Li J, Li R, Gao Y, Zhang J, Wang X, Wang G. The global burden of peptic ulcer disease in 204 countries and territories from 1990 to 2019: a systematic analysis for the Global Burden of Disease Study 2019. Int J Epidemiol 2022; 51:1666-1676. [PMID: 35234893 DOI: 10.1093/ije/dyac033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 02/15/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Peptic ulcer disease is one of the most common diseases in gastroenterology clinics. However, reported data about the global burden of peptic ulcer disease are still scarce. METHODS This was a secondary data analysis on the prevalence, mortality and disability-adjusted life years (DALYs) due to peptic ulcer disease by sex, age group and socio-demographic index (SDI) at the global level in 21 regions and 204 countries and territories between 1990 and 2019 using the Global Burden of Diseases, Injuries, and Risk Factors Study 2019. RESULTS Globally, the prevalence cases of peptic ulcer disease increased from 6 434 103 (95% uncertainty interval 5 405 963 to 7 627 971) in 1990 to 8 090 476 (6 794 576 to 9 584 000) in 2019. However, the age-standardized prevalence rate decreased from 143.4 (120.5 to 170.2) per 100 000 population in 1990 to 99.4 (83.9 to 117.5) per 100 000 population in 2019. Moreover, the age-standardized mortality rate decreased by 59.4% (55.3 to 63.1) and the DALYs rate fell by 60.6% (56.8 to 63.9) from 1990 to 2019. Across SDI quintiles, low-middle and low SDI quintiles had the highest age-standardized prevalence, mortality and DALYs rates from 1990 to 2019. CONCLUSION The age-standardized prevalence, mortality and DALYs estimates of peptic ulcer disease decreased from 1990 to 2019 globally, but more efforts are needed for the prevention, early diagnosis and treatment of peptic ulcer disease in low SDI and low-middle SDI groups of countries.
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Affiliation(s)
- Jiajia Ren
- Department of Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xuting Jin
- Department of Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jiamei Li
- Department of Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ruohan Li
- Department of Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ya Gao
- Department of Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jingjing Zhang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiaochuang Wang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Gang Wang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Leung T, Kedzior S, Moore K, Bierman J, Coralic Z. Intermittent Versus Continuous Infusion Dosing of Intravenous Proton Pump Inhibitors for Upper Gastrointestinal Bleeding. Ann Pharmacother 2022; 56:1127-1132. [PMID: 35135340 DOI: 10.1177/10600280211073936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Proton pump inhibitor (PPI) continuous infusions or intermittent boluses are used for the treatment of upper gastrointestinal bleeding (UGIB). Intermittent boluses are easier to give and are of lower cost without affecting clinical outcomes. OBJECTIVE To compare the rate of rebleeding between intermittent bolus and continuous infusion PPI therapy. METHODS We performed a retrospective, multicenter review of patients with UGIB receiving either continuous or intermittent PPI therapy. During the study period, due to drug and supply shortages, each institution implemented policies preferring intermittent PPI bolus therapy. We performed bivariate and multivariable comparisons of the 2 treatment strategies, with the primary outcome of interest being incidence of rebleeding. Additional variables of interest included intensive care unit (ICU) and hospital lengths of stay, discharge disposition, and in-hospital mortality. RESULTS Compared with intermittent bolus dosing (n = 209), patients receiving continuous infusion PPI (n = 237) were associated with a higher rate of rebleeding (33.8% vs 23.0%; P = 0.012); however, no difference was detected in multivariable analysis: adjusted odds ratio, 1.50 (95% confidence interval, 0.91-2.50). There was no difference in median hospital or ICU length of stay, discharge disposition, or in-hospital mortality. Correlatively, patients receiving continuous infusion therapy were more likely to have liver disease (29.1% vs 20.1%; P = 0.028), alcohol use disorder (28.3% vs 16.3.%; P = 0.003), history of lower gastrointestinal bleeding (6.4% vs 1.9%; P = 0.021), variceal bleeding (6.3 vs 2.4%, P = 0.045), and be admitted to the ICU (65.0% vs 32.5%, P = 0.00). CONCLUSIONS Introduction of intermittent PPI bolus UGIB treatment via change in hospital policy was not associated with higher rates of rebleeding. However, continuous PPI therapy may have been perceived as more effective as it was used more commonly in high-risk patients.
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Affiliation(s)
| | - Sonya Kedzior
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kerry Moore
- Oregon Health & Science University, Portland, OR, USA
| | - Jesse Bierman
- Oregon Health & Science University, Portland, OR, USA
| | - Zlatan Coralic
- University of California San Francisco, San Francisco, CA, USA
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Romstad KK, Detlie TE, Søberg T, Thomas O, Ricanek P, Jahnsen ME, Lerang F, Jahnsen J. Treatment and outcome of gastrointestinal bleeding due to peptic ulcers and erosions - (BLUE study). Scand J Gastroenterol 2022; 57:8-15. [PMID: 34663154 DOI: 10.1080/00365521.2021.1988701] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Peptic ulcers and erosions are the most common causes of upper gastrointestinal bleeding. The aim of this study was to investigate the management and outcomes of these patients. MATERIALS AND METHODS A total of 543 patients with endoscopically confirmed bleeding from peptic ulcers and erosions were included from March 2015 to December 2017. The patient characteristics, endoscopic findings, Forrest classification and endoscopic treatment were recorded. Moreover, the rebleeding rates, repeated endoscopies and transcatheter angiographic embolization and surgery incidences were registered. A follow-up endoscopy after discharge from the hospital was scheduled. RESULTS Among the patients, high-risk stigmata ulcers were present in 36% (198/543) and low-risk stigmata ulcers and erosions in 60% (327/543) at first endoscopy. Endoscopic therapy was performed in 30% (165/543) of the patients, and hemostasis was achieved in 94% (155/165). The incidence of rebleeding was 9% (49/543) for the whole cohort and 14.8% (23/155) for those patients who had received successful endoscopic treatment. Moreover, rebleeding was significantly more frequent in duodenal ulcers than in gastric ulcers (11.9% vs 4.0%, p = .004). In a multivariable analysis, rebleeding was significantly related to comorbidity and Forrest classification. Transcatheter angiographic embolization and surgery were required in 6% (34/543) and 0.07% (4/543) of patients, respectively. Complete peptic ulcer healing was found at follow-up in 73.3% (270/368) of patients. CONCLUSIONS Endoscopic hemostasis was achieved in the majority of patients with high-risk ulceration, although the occurrence of rebleeding is a significant challenge, especially in patients with duodenal ulcers. Clinical trial registration: Bleeding Ulcer and Erosions Study (BLUE Study), ClinicalTrials.gov identifier: NCT03367897.
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Affiliation(s)
- Katrine Kauczynska Romstad
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Trond Espen Detlie
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Taran Søberg
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway
| | - Owen Thomas
- Division of Research and Innovation, Akershus University Hospital, Lørenskog, Norway
| | - Petr Ricanek
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Marte Eide Jahnsen
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Frode Lerang
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway
| | - Jørgen Jahnsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
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Wangrattanapranee P, Khrucharoen U, Jensen DM, Wongpongsalee T, Jensen ME. Severe Upper Gastrointestinal Hemorrhage Caused by Reflux Esophagitis. Dig Dis Sci 2022; 67:159-169. [PMID: 33590404 DOI: 10.1007/s10620-021-06828-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 01/06/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND There are few reports about reflux esophagitis (RE) as a cause of severe upper gastrointestinal bleeding (UGIB). AIMS This study aims to evaluate (1) changes in its prevalence over the last three decades and (2) clinical and endoscopic characteristics and 30-day outcomes among RE patients with and without focal esophageal ulcers (EUs) and stigmata of recent hemorrhage (SRH). METHODS A retrospective study of prospectively collected data of esophagitis patients hospitalized with severe UGIB between 1992 and 2020. Descriptive analysis and statistical comparisons were performed. RESULTS Of 114 RE patients, the mean age was 61.1 years and 76.3% were males. 38.6% had prior gastroesophageal reflux disease (GERD) symptoms; overall 36% were on acid suppressants. Over three consecutive decades, the prevalence of RE as a cause of severe UGIB increased significantly from 3.8 to 16.7%. 30-day rebleeding and all-cause mortality rates were 11.4% and 6.1%. RE patients with focal EUs and SRH (n = 23) had worse esophagitis than those with diffuse RE (n = 91) (p = 0.012). There were no differences in 30-day outcomes between RE patients with and without EUs and SRH. CONCLUSIONS For patients with severe UGIB caused by RE, (1) the prevalence has increased significantly over the past three decades, (2) the reasons for this increase and preventive strategies warrant further study, (3) most patients lacked GERD symptoms and did not take acid suppressants, and (4) those with focal ulcers and SRH had more severe esophagitis and were treated endoscopically.
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Affiliation(s)
- Peerapol Wangrattanapranee
- CURE: Digestive Diseases Research Core Center (CURE: DDRCC), Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Gastroenterology Division, Department of Medicine, VA Greater Los Angeles Healthcare System, Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA
| | - Usah Khrucharoen
- CURE: Digestive Diseases Research Core Center (CURE: DDRCC), Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Gastroenterology Division, Department of Medicine, VA Greater Los Angeles Healthcare System, Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - Dennis M Jensen
- CURE: Digestive Diseases Research Core Center (CURE: DDRCC), Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA. .,Gastroenterology Division, Department of Medicine, VA Greater Los Angeles Healthcare System, Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA. .,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA.
| | - Thongsak Wongpongsalee
- CURE: Digestive Diseases Research Core Center (CURE: DDRCC), Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA.,Division of Trauma Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, 13th Floor, Syamindra Building, 2 Prannok Road, Bangkok, 10700, Thailand
| | - Mary Ellen Jensen
- CURE: Digestive Diseases Research Core Center (CURE: DDRCC), Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Gastroenterology Division, Department of Medicine, VA Greater Los Angeles Healthcare System, Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
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Horibe M, Iwasaki E, Matsuzaki J, Bazerbachi F, Kaneko T, Minami K, Fukuhara S, Masaoka T, Hosoe N, Ogura Y, Namiki S, Hosoda Y, Ogata H, Kanai T. Superiority of urgent vs early endoscopic hemostasis in patients with upper gastrointestinal bleeding with high-risk stigmata. Gastroenterol Rep (Oxf) 2021; 9:543-551. [PMID: 34925851 PMCID: PMC8677506 DOI: 10.1093/gastro/goab042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/26/2021] [Accepted: 08/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background Guidelines recommend that all patients with upper gastrointestinal bleeding (UGIB) undergo endoscopy within 24 h. It is unclear whether a subgroup may benefit from an urgent intervention. We aimed to evaluate the influence of endoscopic hemostasis and urgent endoscopy on mortality in UGIB patients with high-risk stigmata (HRS). Methods Consecutive patients with suspected UGIB were enrolled in three Japanese hospitals with a policy to perform endoscopy within 24 h. The primary outcome was 30-day mortality. Endoscopic hemostasis and endoscopy timing (urgent, ≤6 h; early, >6 h) were evaluated in a regression model adjusting for age, systolic pressure, heart rate, hemoglobin, creatinine, and variceal bleeding in multivariate analysis. A propensity score of 1:1 matched sensitivity analysis was also performed. Results HRS were present in 886 of 1966 patients, and 35 of 886 (3.95%) patients perished. Median urgent-endoscopy time (n = 769) was 3.0 h (interquartile range [IQR], 2.0–4.0 h) and early endoscopy (n = 117) was 12.0 h (IQR, 8.5–19.0 h). Successful endoscopic hemostasis and urgent endoscopy were significantly associated with reduced mortality in multivariable analysis (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.09–0.52; P = 0.0006, and OR, 0.37; 95% CI, 0.16–0.87; P = 0.023, respectively). In a propensity-score-matched analysis of 115 pairs, adjusted comparisons showed significantly lower mortality of urgent vs early endoscopy (2.61% vs 7.83%, P < 0.001). Conclusions A subgroup of UGIB patients, namely those harboring HRS, may benefit from endoscopic hemostasis and urgent endoscopy rather than early endoscopy in reducing mortality. Implementing triage scores that predict the presence of such lesions is important.
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Affiliation(s)
- Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Mayo Clinic, MN, USA
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Juntaro Matsuzaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Fateh Bazerbachi
- Interventional Endoscopy Program, CentraCare, St Cloud Hospital, MN, USA
| | - Tetsuji Kaneko
- Department of Clinical Trial, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Teikyo Academic Research Center, Teikyo University, Tokyo, Japan
| | - Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Tatsuhiro Masaoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Yuki Ogura
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Shin Namiki
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Yasuo Hosoda
- Division of Gastroenterology, Department of Internal Medicine, National Hospital Organization Saitama National Hospital, Saitama, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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41
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Jensen DM, Barkun A, Cave D, Gralnek IM, Jutabha R, Laine L, Lau JYW, Saltzman JR, Soetikno R, Sung JJ. Acute gastrointestinal bleeding: proposed study outcomes for new randomised controlled trials. Aliment Pharmacol Ther 2021; 54:616-626. [PMID: 34288017 PMCID: PMC9385213 DOI: 10.1111/apt.16483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/10/2021] [Accepted: 06/02/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute gastrointestinal bleeding (GIB) remains a common cause of hospitalisation. However, interpretation and comparisons of published studies in GIB have been hampered by disparate study methodology. AIMS To make recommendations about outcome measures to be used in future randomised controlled trials (RCTs) of patients with acute bleeding from any GI source (nonvariceal UGI, variceal, small bowel, or colon) and suggest new RCTs in acute GIB for future peer-reviewed funding. METHODS As part of a National Institutes of Health conference entitled "Hemostatic Outcomes in Clinical Trials", a group of GIB experts performed targeted critical reviews of available evidence with the goal of proposing a bleeding outcome that could potentially be applied to different disciplines. In addition, the panel sought to develop a clinically meaningful primary endpoint specifically for acute GIB, potentially allowing a more contemporary regrouping of clinically relevant outcomes. RESULTS The primary endpoint proposed was a composite outcome of further bleeding within 30 days after randomisation leading to red blood cell transfusion, urgent intervention (repeat endoscopy; interventional radiology or surgery), or death. Secondary outcomes may include the individual components of the primary outcome, length of hospitalisation, serious adverse events, and health care resource utilisation. CONCLUSION The proposed endpoint may help move the GIB field forward by focusing on the most clinically relevant outcomes for patients with acute GIB of all types and informing study design and importance of sample size determination for future RCTs in GIB.
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Affiliation(s)
- Dennis M. Jensen
- Division of Gastroenterology, Department of Medicine, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System Los Angeles, CA
| | - Alan Barkun
- Division of Gastroenterology, McGill University and the McGill University Health Centre Montréal, Québec, Canada
| | - David Cave
- UMass Memorial Medical Center, Worcester MA
| | - Ian M. Gralnek
- Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa Israel, Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology Emek Medical Center, Afula, Israel
| | - Rome Jutabha
- Division of Gastroenterology and Hepatology, Keck Hospital of University of Southern California, Los Angeles, CA
| | - Loren Laine
- Yale School of Medicine, New Haven CT; VA Connecticut Healthcare System, West Haven, CT
| | | | | | - Roy Soetikno
- University of California, San Francisco, Department of Medicine, San Francisco, CA
| | - Joseph J.Y. Sung
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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Cañamares-Orbís P, Lanas Arbeloa Á. New Trends and Advances in Non-Variceal Gastrointestinal Bleeding-Series II. J Clin Med 2021; 10:3045. [PMID: 34300211 PMCID: PMC8303152 DOI: 10.3390/jcm10143045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/03/2021] [Accepted: 07/05/2021] [Indexed: 12/12/2022] Open
Abstract
The gastrointestinal tract is a long tubular structure wherein any point in the mucosa along its entire length could be the source of a hemorrhage. Upper (esophagel and gastroduodenal) and lower (jejunum, ileum, and colon) gastrointestinal bleeding are common. Gastroduodenal and colonic bleeding are more frequent than bleeding from the small bowel, but nowadays the entire gastrointestinal tract can be explored endoscopically and bleeding lesions can be locally treated successfully to stop or prevent further bleeding. The extensive use of antiplatelet and anticoagulants drugs in cardiovascular patients is, at least in part, the cause of the increasing number of patients suffering from gastrointestinal bleeding. Patients with these conditions are usually older and more fragile because of their comorbidities. The correct management of antithrombotic drugs in cases of gastrointestinal bleeding is essential for a successful outcome for patients. The influence of the microbiome in the pathogenesis of small bowel bleeding is an example of the new data that are emerging as potential therapeutic target for bleeding prevention. This text summarizes the latest research and advances in all forms of acute gastrointestinal bleeding (i.e., upper, small bowel and lower). Diagnosis is approached, and medical, endoscopic or antithrombotic management are discussed in the text in an accessible and comprehensible way.
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Affiliation(s)
- Pablo Cañamares-Orbís
- Gastroenterology, Hepatology and Nutrition Unit, San Jorge University Hospital, 22004 Huesca, Spain
| | - Ángel Lanas Arbeloa
- IIS Aragón, CIBERehd, 50009 Zaragoza, Spain;
- Service of Digestive Diseases, University Clinic Hospital Lozano Blesa, 50009 Zaragoza, Spain
- University of Zaragoza, 500009 Zaragoza, Spain
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Bhurwal A, Patel A, Mutneja H, Goel A, Palomera-Tejeda E, Brahmbhatt B. The role of endoscopic doppler probe in the management of bleeding peptic ulcers: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2021; 15:835-843. [PMID: 33206568 DOI: 10.1080/17474124.2021.1850261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Forrest classification for ulceration has significant intra and inter-observer variability. The endoscopic doppler probe (DOP-US) identifies arterial blood flow at the base to direct therapy. We performed a systematic review and meta-analysis to evaluate the role of the DOP-US in bleeding peptic ulcers. METHODS Three independent reviewers performed a comprehensive review of all original articles published from inception to December 2019, evaluating the use of DOP-US in peptic ulcer bleeding. Primary outcomes were the comparison of rebleeding rate, mortality, and surgical intervention in patients with DOP-US signal-guided therapy versus standard visual evaluation guided therapy. RESULTS Eight studies were included after a thorough search was concluded using the key words. The use of DOP-US probe decreases rebleeding, mortality, and surgical intervention as compared to Forrest Classification. The risk of rebleeding is significantly higher if the signal persists despite endoscopic therapy (48.5% (95% CI 29.5-67.9%)). CONCLUSION The first systematic review and meta-analysis showed that the DOP-US is a beneficial tool in the management of bleeding ulcers and adds valuable information to visual evaluation.
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Affiliation(s)
- Abhishek Bhurwal
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, NJ
| | - Anish Patel
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, NJ
| | - Hemant Mutneja
- Division of Gastroenterology and Hepatology, John H. Stroger Cook County Hospital, Chicago, Illinois
| | - Akshay Goel
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Emanuel Palomera-Tejeda
- Division of Gastroenterology and Hepatology, John H. Stroger Cook County Hospital, Chicago, Illinois
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Kim JS, Kim BW, Kim DH, Park CH, Lee H, Joo MK, Jung DH, Chung JW, Choi HS, Baik GH, Lee JH, Song KY, Hur S. [Guidelines for Non-variceal Upper Gastrointestinal Bleeding]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 75:322-332. [PMID: 32581203 DOI: 10.4166/kjg.2020.75.6.322] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/03/2020] [Accepted: 02/19/2020] [Indexed: 02/06/2023]
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB is an important cause for visiting the hospital and is associated with significant morbidity and mortality. Although European and Asian-Pacific guidelines have been published, there has been no previous guidelines regarding management of NVUGIB in Korea. Korea is a country with a high prevalence of Helicobacter pylori infection and patients have easy accessibility to receive endoscopy. Therefore, we believe that guidelines regarding management of NVUGIB are mandatory. The Korean Society of Gastroenterology reviewed recent evidence and recommends practical management guidelines on NVUGIB in Korea.
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Affiliation(s)
- Joon Sung Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Byung-Wook Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Hyuk Lee
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon Kyung Joo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jun-Won Chung
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyuk Soon Choi
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Gwang Ho Baik
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyo Young Song
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Saebeom Hur
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
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Berner-Hansen V, Olsen AA, Brandstrup B. Endoscopic treatment of primary aorto-enteric fistulas: A case report and review of literature. World J Gastrointest Endosc 2021; 13:189-197. [PMID: 34163566 PMCID: PMC8209543 DOI: 10.4253/wjge.v13.i6.189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/12/2021] [Accepted: 05/21/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Primary aorto-enteric fistula (PAEF) is a rare condition, traditionally treated in the acute, bleeding phase with open surgery or endovascular repair. However, these approaches have high morbidity and mortality, indicating a need for new methods. With advances in endoscopic techniques and equipment, haemoclipping of fistulas has now become feasible. Therefore, we present a systematic review of the English literature and a rare case of a PAEF successfully treated by endoscopic haemoclipping.
CASE SUMMARY A 74-year-old man with an abdominal aortic aneurysm presented with symptoms of haemorrhagic shock and bloody stools. An oesophago-gastro-duodenoscopy was performed with haemoclipping of a suspected PAEF in the third part of the duodenum. Afterward, a computed tomography-angiography showed a contrast filled protrusion from the abdominal aortic aneurysm. Based on the clinical presentation and the combined endoscopic and radiographic findings, we argue that this is a case of a PAEF.
CONCLUSION Endoscopic therapy appears capable of achieving haemodynamic stabilisation in patients with bleeding PAEF, serving as a bridge to final therapy.
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Affiliation(s)
- Victoria Berner-Hansen
- Department of Surgery, Holbaek Hospital, Part of Copenhagen University Hospitals, Holbaek 4300, Denmark
| | - August A Olsen
- Institute for Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
| | - Birgitte Brandstrup
- Department of Surgery, Holbaek Hospital, Part of Copenhagen University Hospitals, Holbaek 4300, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen 2200, Denmark
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ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol 2021; 116:899-917. [PMID: 33929377 DOI: 10.14309/ajg.0000000000001245] [Citation(s) in RCA: 200] [Impact Index Per Article: 66.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/07/2021] [Indexed: 02/06/2023]
Abstract
We performed systematic reviews addressing predefined clinical questions to develop recommendations with the GRADE approach regarding management of patients with overt upper gastrointestinal bleeding. We suggest risk assessment in the emergency department to identify very-low-risk patients (e.g., Glasgow-Blatchford score = 0-1) who may be discharged with outpatient follow-up. For patients hospitalized with upper gastrointestinal bleeding, we suggest red blood cell transfusion at a threshold of 7 g/dL. Erythromycin infusion is suggested before endoscopy, and endoscopy is suggested within 24 hours after presentation. Endoscopic therapy is recommended for ulcers with active spurting or oozing and for nonbleeding visible vessels. Endoscopic therapy with bipolar electrocoagulation, heater probe, and absolute ethanol injection is recommended, and low- to very-low-quality evidence also supports clips, argon plasma coagulation, and soft monopolar electrocoagulation; hemostatic powder spray TC-325 is suggested for actively bleeding ulcers and over-the-scope clips for recurrent ulcer bleeding after previous successful hemostasis. After endoscopic hemostasis, high-dose proton pump inhibitor therapy is recommended continuously or intermittently for 3 days, followed by twice-daily oral proton pump inhibitor for the first 2 weeks of therapy after endoscopy. Repeat endoscopy is suggested for recurrent bleeding, and if endoscopic therapy fails, transcatheter embolization is suggested.
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Naga Y, Jayaraj M, Elmofti Y, Hong A, Ohning G. Intraluminal Endovascular Coil Migration: A Rare Complication Post-Embolization of the Gastroduodenal Artery for a Previously Bleeding Duodenal Ulcer. Cureus 2021; 13:e14615. [PMID: 34040915 PMCID: PMC8139854 DOI: 10.7759/cureus.14615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Transarterial angiographic embolization is a highly effective, safe treatment for non-variceal upper gastrointestinal bleeding refractory to endoscopic intervention. However, intraluminal coil migration is a possible complication. Coil migration, while usually a self-limiting process, can lead to significant rebleeding. In our case, a patient presented with a life-threatening duodenal ulcer hemorrhage, likely precipitated by intraluminal endovascular coil migration after a recent gastro-duodenal artery embolization. He was successfully managed without endoscopic coil removal and had no additional gastrointestinal bleeding. It is important for endoscopists to be aware of this complication and weigh the risks and benefits of coil removal.
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Affiliation(s)
- Yassin Naga
- Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, USA
| | - Mahendran Jayaraj
- Gastroenterology, University of Nevada Las Vegas School of Medicine, Las Vegas, USA
| | - Yousif Elmofti
- Gastroenterology, University of Nevada Las Vegas School of Medicine, Las Vegas, USA
| | - Annie Hong
- Gastroenterology, University of Nevada Las Vegas School of Medicine, Las Vegas, USA
| | - Gordon Ohning
- Gastroenterology, University of Nevada Las Vegas School of Medicine, Las Vegas, USA
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Zhang J, Diao P, Zhang L. Intravenous versus oral omeprazole on patients with high risk bleeding peptic ulcers: A prospective randomized clinical trial protocol. Medicine (Baltimore) 2021; 100:e25136. [PMID: 33832076 PMCID: PMC8036073 DOI: 10.1097/md.0000000000025136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 02/19/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Proton pump inhibitors (PPIs) decrease the rate of rebleeding following endoscopic hemostatic therapy in patients with bleeding peptic ulcers. This study compares the efficacy of oral omeprazole vs intravenous omeprazole in decrease of rebleeding of peptic ulcer patients. METHOD The present study was authorized by the local research ethics committee of Jiangjin District Central Hospital (2020120987) and informed consent was obtained from all patients. All adult patients who were admitted to medical emergency rooms of Jiangjin District Central Hospital due to upper gastrointestinal bleeding (as evidenced by hematemesis, melena or hematochezia) were considered for inclusion in the study. Endoscopy was performed within 24 hours after admission. Patients older than 18 years with successful endoscopic therapy of high risk ulcers [defined as active bleeding (Forrest IA, IB), non-bleeding visible vessel (NBVV, Forrest IIA) or adherent clots (Forrest IIB)] were enrolled. Patients with low risk ulcers (clean base, ulcers with a simple washable clot), suspicious malignant ulcer, bleeding tendency, uremia, liver cirrhosis, Mallory Weiss tear or already on PPI as an outpatient were excluded from study. All were managed endoscopically by injecting 5-30 ml of epinephrine (diluted 1:10000) around the ulcer crater. Cavitations or flattening of bleeding vessel and disappearance of NBVV was considered as established homeostasis. A biopsy was taken from antrum for evaluating Helicobacter pylori infection. Patient with unsuccessful endoscopic therapy were not enrolled and were referred to general surgeon. Information on demography, history of previous upper gastrointestinal bleeding, NSAID or ASA ingestion, ulcer location, bleeding stigmata and blood transfusion volume at entry were recorded in all patients. In the oral omeprazole group, the patients received 40 mg omeprazole orally twice daily for 72 hours. In intravenous omeprazole group, they received omeprazole 80 mg bolus and then 8 mg/hour infusion for 48-72 hours. Then, all patients received omeprazole 20 mg orally for 30 days. On the day of discharge Helicobacter pylori infected patients received standard regimens. RESULTS Figure 1 showed the primary and secondary end points. DISCUSSION Intravenous administration of PPIs has limitations. They are expensive, require a dedicated intravenous line, need nursing supervision and hospital admission. So, it would be reasonable to prescribe oral PPIs to patients with high risk bleeding ulcers provided that it is as effective as its intravenous counterpart. Oral PPIs have a high bioavailability. Its effect initiates one hour after ingestion and the maximal plasma concentration is achieved after 2-3 hours. However, there are few studies comparing oral and intravenous PPI in decreasing risk of rebleeding in peptic ulcer patients. More high quality randomized controlled trials are still necessary. REGISTRATION NUMBER researchregistry 6588.
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Razavilar N, Taleshi JM. Cost-Effectiveness Analysis of Transcatheter Arterial Embolization Techniques for the Treatment of Gastrointestinal Bleeding in the United States. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:477-485. [PMID: 33840425 DOI: 10.1016/j.jval.2020.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 09/04/2020] [Accepted: 10/30/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Gastrointestinal (GI) bleeding is a common medical emergency associated with significant mortality. Transcatheter arterial embolization first was introduced by Rosch et al as an alternative to surgery for upper GI bleeding. The clinical success in patients with GI bleeding treated with transcatheter arterial embolization previously has been reported. However, there are no cost-effectiveness analyses reported to date. Here we report cost-effectiveness analysis of N-butyl 2-cyanoacrylate glue (NBCA) and ethylene-vinyl alcohol copolymer (Onyx) versus coil (gold standard) for treatment of GI bleeding from a healthcare payer perspective. METHODS Fixed-effects modeling with a generalized linear mixed method was used in NBCA and coil intervention arms to determine the pooled probabilities of clinical success and mortality with complications with their confidence intervals, while the Clopper-Pearson model was used for Onyx to determine the same parameters. Models were provided by the "Meta-Analysis with R" software package. A decision tree was built for cost-effectiveness analysis, and Microsoft Excel was used for probabilistic sensitivity analysis. The cost-effective option was determined based on the incremental cost-effectiveness ratio and scatter plots of incremental cost versus incremental quality-adjusted life-years. RESULTS Comparing scatter plots and incremental cost-effectiveness ratio results, -$1024 and -$1349 per quality-adjusted life-year for Onyx and N-butyl 2-cyanoacrylate glue, respectively, Onyx was the least expensive and most effective intervention. CONCLUSION Onyx was the dominant strategy regardless of threshold values. Our analyses provide a framework for researchers to predict the target clinical effectiveness for early-stage TAE interventions and guide resource allocation decisions.
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Affiliation(s)
- Negin Razavilar
- RAZN Health Decision Modelling LTD, University of Alberta Health Accelerator, Edmonton, Canada; Faculty of Sciences, University of Alberta, Edmonton, Canada.
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50
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Lan T, Tong H, Qian S, Wei B, Huang Z, Wu H, Tan Q, Gao J, Bai S, Gong H, Jiang T, Yang J, Zhang Q, Hu B, Tang C. Prophylactic transcatheter angiographic embolization reduces Forrest IIa ulcer rebleeding: A retrospective study. Medicine (Baltimore) 2021; 100:e23855. [PMID: 33725926 PMCID: PMC7982249 DOI: 10.1097/md.0000000000023855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/31/2020] [Indexed: 02/07/2023] Open
Abstract
The application of transcatheter angiographic embolization (TAE) is controversial in the treatment of ulcer bleeding. This study aims to determine rebleeding risk factors and evaluate the efficacy of prophylactic TAE (p-TAE) following endoscopic hemostasis in rebleeding prevention of Forrest lla ulcers.The medical records of Forrest lla ulcer patients who underwent endoscopic hemostasis (E group) and endoscopic hemostasis plus p-TAE (E + p-TAE group) in West China Hospital from May 2009 to May 2018 were retrospectively reviewed. Baseline characteristics, clinical efficacy, and rebleeding risk factors were analyzed.As a result, a total of 102 patients were included, with 75 and 27 patients in E and E + p-TAE group, respectively. Most of the baseline data in E and E + p-TAE group were similar except for the proportion of protruded non-bleeding visible vessel (NBVV) (E group vs E + p-TAE group, 50.7% vs 74.1%, P = .035). The rebleeding rate of E + p-TAE group (3.7%) was significantly lower than E group (24.0%) (P = .02). The protruded NBVV (OR: 6.896, 95% confidence interval [CI]: 1.532-30.642, P = .01) and employment of p-TAE (OR: 0.038, 95% CI: 0.003-0.448, P = .009) were identified as independent risk factors for Forrest IIa ulcer rebleeding. Additionally, log-rank test indicated the rebleeding occurrence was greatly reduced by p-TAE in patients with protruded NBVVs (P = .006).In conclusion, the protruded NBVV and employment of p-TAE were the independent risk factors tightly associated with rebleeding of Forrest IIa ulcer. P-TAE following endoscopic hemostasis could effectively prevent Forrest IIa ulcer from rebleeding.
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Affiliation(s)
- Tian Lan
- Department of Gastroenterology
- Lab. of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital
| | | | - Shuaijie Qian
- West China School of Medicine, Sichuan University, Chengdu
| | - Bo Wei
- Department of Gastroenterology
| | | | - Hao Wu
- Department of Gastroenterology
| | | | - Jinhang Gao
- Lab. of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital
| | | | | | - Ting Jiang
- Department of Gastroenterology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jinhui Yang
- Department of Gastroenterology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | | | - Bing Hu
- Department of Gastroenterology
| | - Chengwei Tang
- Department of Gastroenterology
- Lab. of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital
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