Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial

MRI scoring system including dynamic motility evaluation in assessing the activity of Crohn's disease of the terminal ileum

RATIONALE AND OBJECTIVES

We sought to investigate the value of a MRI scoring system including dynamic motility evaluation in the assessment of small bowel Crohn's disease activity.

MATERIALS AND METHODS

From March 2005 to December 2006, 52 patients with suspected Crohn's disease onset or relapse underwent MRI on a 1.5-T magnet. Bowel distention was achieved orally assuming a mean of 1.6 L of a polyethyleneglycol (PEG) preparation. Per-patient assessment of disease activity was based on a scoring system including evaluation of morphology and motility of the small bowel and perivisceral structures (true-FISP, cine-true-FISP, and HASTE T2W sequences) and dynamic assessment of parietal contrast enhancement (FLASH T1W sequence). Patients were included in three categories, using endoscopic biopsy as the standard reference: no activity/quiescent disease, mild activity, or moderate-to-severe activity. Patients without terminal ileum involvement were excluded from data analysis.

RESULTS

MRI allowed a detailed and panoramic evaluation of the small bowel in all subjects examined. MRI properly assessed 14 of 16 (87.5%) cases of no activity/quiescent disease, 12 of 14 (85.7%) cases of mild activity, and 15 of 15 (100%) cases of severe activity. Overall, activity score led to a per-patient misdiagnosis of disease activity in a nonsignificant proportion of subjects (4 of 45; 8.8%) (P > .05), determining two false-positive and two false-negative results of mild disease activity. Sensitivity, specificity, PPV, NPV, and overall accuracy in assessing disease activity were 93.1%, 87.5%, 93.1%, 87.5%, and 91.1%, respectively.

CONCLUSION

Accurate assessment of Crohn's disease activity is achieved by using an activity score providing an overall interpretation of MRI findings.

Current endoscopic and pharmacological therapy of peptic ulcer bleeding

Peptic ulcer bleeding is the most significant complication of ulcer disease, remaining the most important reason for upper gastrointestinal bleeding even in the era of Helicobacter eradication. Endoscopic triage and management plays a vital role in the handling of these patients, albeit in close collaboration with radiological and surgical expertise. Injection therapy, preferably with large volume epinephrine remains a core technology. Histoacryl and fibrin glue are more costly and less widely adopted alternatives. Mechanical measures are attractive and clips offer an excellent solution, particularly in soft tissues, and in combination with initial injection. Thermal methods with coagulation and coaptive axial force have similar performance characteristics. Increasingly, the combination of injection therapy with either a mechanical or thermal method appears the best option to achieve permanent haemostasis. PPIs for potent acid inhibition improves the clotting regardless of other treatment modalities. In the setting of rebleeding, patient and ulcer factors determine whether repeat endoscopy should be attempted, but the surgeon should be close at hand in this situation.

Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage: a cost-effectiveness analysis

BACKGROUND

Erythromycin is a potent stimulator of gastrointestinal motility. Recent studies have examined the use of intravenous erythromycin to clear the stomach of blood before oesophago-gastroduodenoscopy (EGD) for acute upper gastrointestinal haemorrhage (UGIH). These studies have shown clinical effectiveness.

AIM

To evaluate the cost-effectiveness of this intervention.

METHODS

We sought to determine the cost-effectiveness of erythromycin before EGD from the payer's perspective. We found three relevant studies of erythromycin and used these data for the analysis. We obtained costs for intravenous erythromycin and charges for peptic ulcer hospitalization, EGD, surgery, and angiographic embolization. Complication rates were also incorporated from the literature. We implemented a model of health-related quality of life to measure the impact of the intervention. We created a decision-analysis tree and performed a probabilistic sensitivity analysis.

RESULTS

A strategy of erythromycin prior to EGD resulted in a cost-effective outcome in a majority of trials using willingness-to-pay figures of USD 0, USD 50,000 and USD 100,000 per quality-adjusted life-year (QALY).

CONCLUSION

Because of the implications for cost saving and increase in QALY, we would recommend giving erythromycin prior to EGD for UGIH.

The role of rapid endoscopy for high-risk patients with acute nonvariceal upper gastrointestinal bleeding

BACKGROUND

Performance of endoscopy within 24 h is recommended for patients with acute nonvariceal upper gastrointestinal bleeding (ANVUGIB). It is unknown whether performing endoscopy early within this 24 h window is beneficial for clinically high-risk patients.

METHODS

A retrospective review was performed to identify patients presenting to two tertiary care centres with ANVUGIB and either systolic blood pressure lower than 100 mmHg or heart rate greater than 100 beats/min on presentation between 1999 and 2004. Patients receiving endoscopy within 6 h (rapid endoscopy [RE]) were compared with patients undergoing endoscopy between 6 h and 24 h (early endoscopy [EE]). The primary outcome measure was the development of any adverse bleeding outcome (rebleeding, surgery for control of bleeding, in-hospital mortality or readmission within 30 days for ANVUGIB).

RESULTS

There were 169 patients who met the entry criteria (77 RE patients and 92 EE patients). There was no significant difference in the development of any adverse bleeding outcomes between RE and EE patients (25% RE versus 23% EE, difference between groups 2%, 95% CI --9% to 13%). Transfusion requirements and length of hospital stay also did not differ between the comparator groups. RE was not associated with fewer adverse outcomes, even after adjusting for confounders.

CONCLUSION

For clinically high-risk ANVUGIB patients, performing endoscopy within 6 h of presentation is no more effective than performing endoscopy between 6 h and 24 h after presentation. The role of RE in high-risk ANVUGIB patients requires further delineation in a prospective fashion.

"You wanna do what?!" Modern indications for nasogastric intubation

Through the years, patients have asked their physicians why they needed nasogastric inbutation (NGI), a painful test. Some recent studies have also questioned the utility of NGI for several indications, enabling physicians to use judgment in offering it to patients. This article reviews the use of NGI for its traditional indications: gastrointestinal bleeding, presenting with or without hematemesis; gastric decompression; and the administration of treatment. It concludes with suggestions for limiting the pain of the procedure for patients who need it.

High-risk ED patients with nonvariceal upper gastrointestinal hemorrhage undergoing emergency or urgent endoscopy: a retrospective analysis

OBJECTIVES

The optimal timing of interventional endoscopy within the initial 24 hours remains controversial. We designed a retrospective study to compare the outcomes between emergency endoscopy (EE) and urgent endoscopy (UE) for high-risk patients with nonvariceal upper gastrointestinal hemorrhage presenting to the emergency department (ED).

METHODS

The medical records of 189 patients with nonvariceal upper gastrointestinal hemorrhage who underwent endoscopy within 24 hours of admission to the ED were reviewed. Patients were divided into 2 groups: EE group (<8 hours) or UE group (8-24 hours). We compared the endoscopic findings, hemostatic procedures, rate of hemostasis, rebleeding, need for transfusion, length of hospitalization, and mortality between the 2 groups.

RESULTS

There were 88 patients (47%) in the EE group and 101 patients (53%) in the UE group. Ulcers with active bleeding or exposed vessel were found more frequently in the EE group than in the UE group (19% vs 8%, P = .03; 34% vs 12%, P < .001). Fifty patients had blood retention in the stomach, especially in the EE group (40% vs 15%, P < .001). Forty-four (50%) patients in the EE group and 21 (21%) patients in the UE group received endoscopic interventions. Combination modalities of endoscopic hemostasis were more commonly used in the EE group than in the UE group (40% vs 15%, P < .001). Primary hemostasis was achieved at a rate of 95% in both groups. There was no statistical difference regarding the rate of recurrent bleeding, total amount of transfusion, length of hospital stay, and mortality rate in both groups.

CONCLUSIONS

Although more active lesions were detected and more therapeutic attempts were performed in the EE group, the outcome showed no difference in both groups. Emergency endoscopy performed less than 8 hours after arrival to the ED showed no definite benefit in comparison with UE performed within 8 to 24 hours.

ENDOSCOPIC MANAGEMENT OF NON-VARICEAL UPPER GASTROINTESTINAL HAEMORRHAGE

Endoscopy plays a central role in the diagnosis and treatment of non-variceal upper gastrointestinal haemorrhage. Advances in endoscopic techniques, supported by an increasing body of high quality data, have rendered endoscopy the first-line diagnostic and therapeutic intervention for the patient presenting with an upper gastrointestinal haemorrhage. However, endoscopic intervention must be considered in the context of the overall management of the bleeding patient, often with significant comorbidities. Although parameters such as hospitalization duration, transfusion requirements and surgery rates have improved with advances in endoscopic therapy, mortality rates remain relatively static. This review addresses the current status of endoscopic intervention for non-variceal upper gastrointestinal haemorrhage. Additionally, an overview of important periprocedural management issues is presented.

Nonvariceal upper gastrointestinal bleeding

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is an important condition facing gastroenterologists. The focus of this article is the management of NVUGIB, with a particular emphasis on the endoscopic modalities and techniques that are most effective for various bleeding etiologies. Attention also is given to medical management, risk assessment, and issues pertaining to the timing of endoscopy and need for scheduled second-look endoscopy.

Management of acute bleeding from portal hypertension

Gastrointestinal bleeding is a frequent and severe complication of portal hypertension. The most frequent cause of the bleeding is variceal rupture. Despite improvements in prognosis after variceal bleeding over the past two decades, the 6-week mortality rate remains high, ranging from 15 to 30%. Patients die from uncontrolled bleeding, early rebleeding, infection, or renal failure within the first weeks of a bleeding episode. Poor hepatic function, severe portal hypertension with a hepatic venous pressure gradient (HVPG) >20 mmHg, and active bleeding at endoscopy are independently associated with poor prognosis. First-line treatment includes resuscitation, prophylactic antibiotic therapy, the combined use of vasoactive drugs (started as soon as possible), and an endoscopic procedure. Reconstitution of blood volume should be done cautiously to maintain the haematocrit between 25 and 30%. Terlipressin, somatostatin, or octreotide can be used, and drug therapy is maintained from 48 h to 5 days. Ligation is the endoscopic treatment of choice in bleeding oesophageal varices; in gastric varices, obturation with cyanoacrylate is preferable. Uncontrolled bleeding should be an indication for a salvage transjugular portosystemic shunt (TIPS). In patients with Child-Pugh score A, shunt surgery might be an alternative to TIPS. Trials are currently ongoing into the precise indications of early TIPS in selected patients with an HVPG >20 mmHg, and into the usefulness of administration of recombinant activated factor VII when there is an active bleeding at endoscopy.

Upper gastrointestinal bleeding

PURPOSE OF REVIEW

This review provides an update on the management of upper gastrointestinal bleeding with special attention to patient preparation, sedation, hemostatic techniques, and postprocedure care.

RECENT FINDINGS

In a large multicenter clinical trial, nurse-administered propofol sedation had a complication rate of less than 0.2%. The optimal management for an ulcer with adherent clot was confirmed by a meta-analysis to be clot removal and endoscopic treatment of the underlying lesion. A number of prospective studies have demonstrated that capsule endoscopy is the most sensitive imaging modality for identifying lesions in the small bowel and that double-balloon enteroscopy is the least invasive modality available for the management of these lesions.

SUMMARY

This update describes many recent advances in the diagnosis and management of upper gastrointestinal bleeding. However, clearly, much work needs to be done in this field. Since propofol is not available for use in all endoscopy units, is there a better alternative for deep sedation? Rebleeding occurs in 20% of patients after endoscopic therapy, and so can we provide better outcomes with newer technologies (endoscopic suturing devices)? Finally, what is the best management for Helicobacter pylori-negative, nonsteroidal antiinflammatory drug-negative ulcer patients?

Dose adjustment in patients with liver disease

Unfortunately, there is no endogenous marker for hepatic clearance that can be used as a guide for drug dosing. In order to predict the kinetic behaviour of drugs in cirrhotic patients, agents can be grouped according to their extent of hepatic extraction. For drugs with a high hepatic extraction (low bioavailability in healthy subjects), bioavailability increases and hepatic clearance decreases in cirrhotic patients. If such drugs are administered orally to cirrhotic patients, their initial dose has to be reduced according to hepatic extraction. Furthermore, their maintenance dose has to be adapted irrespective of the route of administration, if possible, according to kinetic studies in cirrhotic patients. For drugs with a low hepatic extraction, bioavailability is not affected by liver disease, but hepatic clearance may be affected. For such drugs, only the maintenance dose has to be reduced, according to the estimated decrease in hepatic drug metabolism. For drugs with an intermediate hepatic extraction, initial oral doses should be chosen in the low range of normal in cirrhotic patients and maintenance doses should be reduced as for high extraction drugs. In cholestatic patients, the clearance of drugs with predominant biliary elimination may be impaired. Guidelines for dose reduction in cholestasis exist for many antineoplastic drugs, but are mostly lacking for other drugs with biliary elimination. Dose adaptation of such drugs in cholestatic patients is, therefore, difficult and has to be performed according to pharmacological effect and/or toxicity. Importantly, the dose of drugs with predominant renal elimination may also have to be adapted in patients with liver disease. Cirrhotic patients often have impaired renal function, despite a normal serum creatinine level. In cirrhotic patients, creatinine clearance should, therefore, be measured or estimated to gain a guideline for the dosing of drugs with predominant renal elimination. Since the creatinine clearance tends to overestimate glomerular filtration in cirrhotic patients, the dose of a given drug may still be too high after adaptation to creatinine clearance. Therefore, the clinical monitoring of pharmacological effects and toxicity of such drugs is important. Besides the mentioned kinetic changes, the dynamics of some drugs is also altered in cirrhotic patients. Examples include opiates, benzodiazepines, NSAIDs and diuretics. Such drugs may exhibit unusual adverse effects that clinicians should be aware of for their safe use. However, it is important to realise that the recommendations for dose adaptation remain general and cannot replace accurate clinical monitoring of patients with liver disease treated with critical drugs.

[Endoscopic diagnosis and therapy for gastrointestinal bleeding]

Gastrointestinal bleeding is still one of the most frequent medical emergencies. Despite improvements in endoscopic diagnosis and therapy, mortality from bleeding is still high (15%). Since conclusive trials are lacking, the endoscopist often has to rely on personal experience in the selection of therapeutic options. Therefore this article gives an overview of new publications in this field and recommendations based on personal experience.

Erythromycin infusion prior to endoscopy for acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial

BACKGROUND/AIM

Presence of clots in the stomach makes emergency endoscopy difficult in patients with upper gastrointestinal bleeding. We investigated whether the association of erythromycin infusion to gastric lavage could improve stomach cleansing before endoscopy.

PATIENTS AND METHODS

One hundred patients admitted for upper gastrointestinal bleeding were randomly assigned to receive either gastric lavage plus intravenous erythromycin (250 mg) or gastric lavage plus placebo before endoscopy in a double-blind study. The primary end point was the efficacy of intravenous erythromycin to improve stomach cleansing before endoscopy, assessed by both subjective and objective criteria.

RESULTS

Characteristics of patients at admission were similar in both groups. Sixty-six patients had portal hypertension. The gastric mucosa was entirely visualized by the endoscopist in 65% of patients in the erythromycin group, versus 44% in the placebo group (p<0.05). The quality of examination of the upper gastrointestinal tract, assessed by using a 10-cm visual analog scale, was better in the erythromycin group (4.2+/-2 vs. 3.3+/-2.2, p<0.05). Clots were found in the stomach in 30% of patients in the erythromycin group, versus 52% in the placebo group (p<0.05). However, ability to identify the source of bleeding, mean duration of endoscopy, and need for a second-look endoscopy, did not differ between the two groups. Similar results were observed in the subgroup of cirrhotic patients. Erythromycin was well tolerated by all patients.

CONCLUSION

Intravenous erythromycin before endoscopy improves stomach cleansing and quality of endoscopic examination in patients with upper gastrointestinal bleeding, but the clinical benefit is limited.

Nonvariceal upper gastrointestinal bleeding: standard and new treatment

Nonvariceal upper gastrointestinal bleeding remains a challenging problem with a significant morbidity and mortality. In recent years endoscopic techniques have evolved, resulting in improved primary hemostasis and a reduction in the risk of rebleeding. Combination endoscopic therapy followed by high-dose proton pump inhibitor shows improved outcomes. Innovative endoscopic therapies hold promise but are as yet unproved. An aging population with significant medical comorbidities has a major influence on the overall outcome from upper gastrointestinal bleeding.

Basic and clinical pharmacology of new motility promoting agents

Recent research has provided new information about drugs that could be used to treat functional motility disorders. Promotility drugs accelerate gastric emptying or colonic transit and these properties may contribute to their efficacy in treating symptoms associated with gastroparesis, functional dyspepsia or constipation. 5-Hydroxytryptamine4 receptors are targets for drugs (tegaserod, renzapride) that treat symptoms in constipated irritable bowel syndrome patients and in gastroparesis. Drugs acting at motilin (erythromycin) and cholecystokinin-1 (dexloxiglumide) receptors accelerate gastric emptying. Dexloxiglumide might be useful in the treatment of functional dyspepsia particularly that associated with lipid intake. Alvimopan is a mu-opioid receptor antagonist that does not cross the blood brain barrier. Alvimopan is effective in treating postsurgical ileus and perhaps opiate-induced bowel dysfunction. Successes and failures of recent efforts to develop promotility agents revealed opportunities and challenges for developing new promotility drugs. The pharmacological properties of partial agonists might be exploited to develop effective promotility drugs. However, opposing actions of promotility agents on motility (increased contraction vs decreased accommodation) limit the clinical efficacy of drugs with these opposing actions. Selection of appropriate patient populations for evaluation of new drugs is also critical.

Effect of oral erythromycin on gastric and small bowel transit time of capsule endoscopy

AIM: To determine the effect of oral erythromycin on gastric and small bowel transit time of capsule endoscopy.

METHODS: Consecutive patients who underwent capsule endoscopy during the 16-mo study period were either given 250 mg oral erythromycin, 1 h prior to swallowing the capsule endoscope or nothing. The gastric and small bowel transit time, and the small bowel image quality were compared.

RESULTS: Twenty-four patients received oral erythromycin whereas 14 patients were not given any prokinetic agent. Patients who received erythromycin had a significantly lower gastric transit time than control (16 min vs 70 min, P = 0.005), whereas the small bowel transit time was comparable between the two groups (227 min vs 183 min, P = 0.18). Incomplete small bowel examination was found in three patients of the control group and in one patient of the erythromycin group. There was no significant difference in the overall quality of small bowel images between the two groups. A marked reduction in gastric transit time was noted in two patients who had repeat capsule endoscopy after oral erythromycin.

CONCLUSION: Use of oral erythromycin significantly reduces the gastric transit time of capsule endoscopy.

Management of bleeding peptic ulcer in France: a national inquiry

AIMS OF THE STUDY

To evaluate and compare management practices in France for bleeding peptic ulcers using a national inquiry of university and non-university hospitals.

METHOD

Responses to questionnaires sent to 812 gastroenterologists, 496 practicing in non-university hospitals and 316 in university hospitals, were compared.

RESULTS

An analysis was possible in 279 (34% response rate) of the questionnaires. Forrest classification was used more frequently in university hospitals (83% vs 60%, P<0.01). Endoscopic hemostatic therapy was used more frequently in university hospitals for Forrest Ib (92% vs 81%, P=0.02), IIa (93% vs 73%, P<0.001), and IIb (58% vs 29%, P<0.001) ulcers. Injection therapy, mainly epinephrine, was the first-intention treatment for 99% of the responding gastroenterologists. Proportions of clinicians employing hemoclips (27%) or argon plasma coagulation (21%) were similar in both types of practice. Anti-secretory treatment included mainly omeprazole (82%), given intravenously (76%), sometimes as bolus i.v. doses followed by i.v. high-dose continuous infusion (15%) with some variations according to the type of hospital. In the event of recurrent or persistent bleeding, surgery was more frequent in non-university hospitals. When rebleeding occurred, a second endoscopic treatment was performed in about one quarter of patients.

CONCLUSION

In France, management practices for bleeding peptic ulcer vary between university and non-university hospitals.

Upper gastrointestinal bleeding

PURPOSE OF REVIEW

This review discusses key issues in the management of upper gastrointestinal bleeding including patient preparation, sedation, hemostatic techniques, disposition, and recommended pharmacologic interventions.

RECENT FINDINGS

Optimal resuscitation before endoscopy and proper pharmacologic interventions after endoscopy seem to be as crucial to the management of patients with upper gastrointestinal bleeding as meticulous hemostatic techniques during the procedure. In a retrospective evaluation of patients with upper gastrointestinal bleeding, multivariate analysis demonstrated significantly reduced morbidity and mortality in those who underwent aggressive preendoscopic resuscitation. In a prospective, randomized clinical trial, patients who received intravenous proton pump inhibitor therapy after endoscopic intervention had a significantly reduced rebleeding rate compared with their placebo control group.

SUMMARY

The algorithms described in this review can be applied clinically today and should directly lead to improved outcome. Nevertheless, even with the latest care available, results are not optimal. This review points to two major areas where we can benefit from improvement: primary hemostasis and recurrent bleeding. By pointing to these limitations, it is hoped that this review can help stimulate research in the field by applying new technologies to solve these problems. Endoscopic ultrasound, for example, could be used to help identify feeding vessels that can be treated endoscopically, thus potentially decreasing the incidence of failed primary hemostasis. Endoscopic suturing, when more fully developed, may provide a better hemostatic technique that can reduce the incidence of recurrent bleeding. It is only through these reviews that our state of knowledge in the field can be constantly reevaluated to update today's clinician with the latest knowledge and stimulate tomorrow's researchers with challenging problems.

A randomized controlled trial of gastric lavage prior to endoscopy for acute upper gastrointestinal bleeding

GOALS

We hypothesized that large volume gastric lavage prior to endoscopy for acute upper gastrointestinal bleeding would improve the quality of endoscopic examination.

BACKGROUND

Blood retained in the stomach can impair visualization during esophagogastroduodenoscopy. Patients with acute upper gastrointestinal bleeding and a retained gastric fundic pool during endoscopy may have worse outcomes than patients without a retained fundic pool. No trials to date have evaluated if large volume gastric lavage prior to endoscopy improves visualization during acute upper gastrointestinal bleeding.

STUDY METHODS

Patients with acute upper gastrointestinal bleeding were randomized to esophagogastroduodenoscopy alone or large volume tap water gastric lavage prior to esophagogastroduodenoscopy. The quality of endoscopic visualization was assessed using a 5-point scale. Clinical outcomes were compared for lavaged and nonlavaged patients.

RESULTS

A total of 39 patients were randomized. In 1 patient, lavage was unsuccessful. The quality of visualization was not significantly different between groups for the esophagus, gastric antrum, or duodenum but was significantly better for the gastric fundus for patients randomized to lavage (P = 0.02). There was no significant difference between groups for ability to define a bleeding source, achieve hemostasis, recurrent bleeding, need for repeat endoscopy, and length of stay or death. There were no complications.

CONCLUSIONS

Large volume gastric lavage prior to esophagogastroduodenoscopy for acute upper gastrointestinal bleeding is safe and provides better visualization of the gastric fundus.

Endoscopic hemostatic treatment under irrigation for upper-GI hemorrhage: a comparison of one third and total circumference transparent end hoods

BACKGROUND

Endoscopic hemostasis for upper-GI hemorrhage often is difficult to achieve if the view of the bleeding lesion is poor because of the presence of mucus, blood, and clots. An end hood that facilitates endoscopic hemostatic procedures while simultaneously allowing irrigation of the bleeding site was designed by us. Based on this design, a one-third partial irrigating end hood was developed, and its usefulness for treatment of non-variceal hemorrhage was evaluated.

METHODS

The end hood was fabricated by drilling a side hole in the cap portion of a transparent end hood. An irrigation tube was glued to the exterior surface over the hole. A "total" (type 1) and a "one-third partial" (type 2) transparent end hood were fabricated. These differ with respect to the proportion of the endoscope circumference that is hooded by the device. The fabricated transparent end hood was placed on the tip of a standard endoscope. With the end hood in place, endoscopic hemostatic treatment under irrigation was performed in 35 patients (type 1 end hood, 18; type 2, 17) with non-variceal upper-GI hemorrhage.

OBSERVATIONS

Hemostatic treatment was enhanced by simultaneous irrigation beneath the end hood, and hemostasis was successfully achieved in 34 of 35 cases. The time required to achieve hemostasis was significantly shorter in the type 2 group than the type 1 group (median 11.8 vs. 16.9 minutes; p < 0.05).

CONCLUSIONS

The end hood was extremely useful for endoscopic hemostatic treatment under irrigation. The "one-third partial" end hood is superior to the total end hood in terms of duration of time required to achieve hemostasis.

Nonvariceal upper gastrointestinal bleeding

Nonvariceal UGI bleeding is one of the most common emergencies that gastroenterologists encounter, and continues to be a significant cause of morbidity and mortality. The keys to management are rapid resuscitation and stabilization; appropriate triage based on pre-endoscopic risk factors; early endoscopy to achieve prompt diagnosis and implement hemostatic therapy to high-risk lesions; and aggressive antisecretory therapy (in the case of peptic ulcer bleeding) to reduce the risk of continued or recurrent bleeding.

Interventional endoscopy

PURPOSE OF REVIEW

This review provides an updated summary of gastric interventional endoscopy. Relevant original articles and topic reviews are highlighted in the areas of infection control, light sedation, hemostasis, endoscopic mucosal resection, and endoscopic placement of enteric devices.

RECENT FINDINGS

Several key findings are worth noting: the increased use of propofol by nonanesthesiologists for deep sedation with minimal adverse side effects, the adaptation of tissue adhesive agents for the treatment of bleeding gastric varices, the successful treatment of early gastric cancer by endoscopic mucosal resection, and the development of direct percutaneous endoscopic jejunostomy tubes for patients at high risk of aspiration.

SUMMARY

These recent developments in the field of interventional endoscopy have already made a great impact on clinical care. More advanced procedures can be performed safely while the patient is under deep sedation. Yet, these developments have not slowed down the need for improvement in interventional endoscopy. Researchers continue to look for smaller instruments, better optics, and more advanced accessories. This constant state of flux marks the field of interventional endoscopy and ensures its progress.

Plasma levels of motilin, cholecystokinin and somatostatin and gastric electrical activity in patients with liver cirrhosis

AIM

To investigate the mechanism of gastrointestinal dysfunction in patients with liver cirrhosis (LC) by determining the plasma levels of motilin (MTL), cholecystokinin (CCK) and somatostatin (SS) and gastric electrical activity.

METHODS

Plasma levels of MTL, CCK and SS were determined with radioimmunoassay in 38 LC patients and 30 healthy volunteers. Gastric electrical activities in all the 68 subjects were observed with the electrogastrograph (3 CPM, USA) before and after water load tests. The indexes of the gastric electrical activities included the percentage of frequency, the main frequency, the ratio of power of postprandial to preprandial, and the frequency spectrum analysis.

RESULTS

Compared with those in the control group, the levels of MTL and CCK in LC patients were increased (287±81 ng/L. 3.3±1.4 ng/L vs 131±27 ng/L. 1.1±0.5 ng/L. P<0.01, t = 11.150, n = 38; P<0.01, t = 9.146, n = 38). There was a significant difference between the levels of MTL and CCK with different liver functions (P<0.05, F = 87.570; P<0.05, F = 47.506). The levels of MTL and CCK tended to increase with the liver function from Child-Pugh A to B to C. The levels of SS in LC patients with Child-Pugh B and C liver function were increased, which showed a significant difference compared with those in the control groups (67±10 ng/L vs 28±13 ng/L.P <0.01, t =7.652, n =16; P <0.01, t =9.428, n =12). But the levels of SS in the patients with Child-Pugh A were not apparently increased. At the same time, the degree of disorder of gastric electrical activity in the patients with Child-Pugh B and C of liver function was higher than that in the control group (P<0.01, t = -8.088, n = 16; P<0.01, t = 7.697, n = 16; P<0.01, t = -10.178, n = 12; P<0.01, t = 9. 817, n = 12). The main frequency (P<0.01, t = -7.575, n = 16; P <0.01, t = -11.623, n =12) and the ratio of postprandial power to preprandial power (P<0.01. t = -3.987, n = 16; P<0.01. t = -4.330, n = 12) in patients with Child-Pugh B and C of liver function were lower than that in the control group

CONCLUSION

The percentage of disorder of gastric electrical activity in LC patients is increased compared with that in healthy volunteers. The variation of the levels of gastrointestinal hormone is one of the important causes of gastrointestinal dysfunction in patients with liver cirrhosis.

[Acute upper gastrointestinal hemorrhage. Diagnosis and management]

Upper gastrointestinal hemorrhage calls for a team approach. Early endotracheal intubation of unconscious patients helps to prevent aspiration. Erythromycin i.v. 20 min. before emergency endoscopy improves the diagnostic yield. Patients without increased risk of rebleeding may be treated on an outpatient basis. Band ligation is the gold standard for acute variceal bleeding. Terlipressin, somatostatin and octreotide are equally effective but require additional measures for prevention of late recurrence. Somatostatin and analogues used as adjunct to ligation slightly reduce the risk of rebleeding but not of death. Three to seven days of prophylactic antibiotics decrease the risk of uncontrolled or recurrent bleeding. Therapeutic failures are rescued by transjugular intrahepatic portosystemic shunting (TIPS). Patients with nonvaricose bleeding should only be treated when active hemorrhage or a "visible vessel" is found. First line treatment is endoscopic injection of diluted adrenalin or isotonic saline. Thermal coagulation is an alternative. Tissue-destructing sclerosants should be avoided. Clipping and injection of fibrin glue are second and third line measures. Proton pump inhibitors improve endoscopic hemostasis, however, it is unclear whether high i.v. doses are required. H. pylori must be eradicated to prevent late recurrence. Rebleeding is treated endoscopically with angiographic intervention or surgery as rescue measures.