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Tan VP, Yan BP, Kiernan TJ, Ajani AE. Risk and management of upper gastrointestinal bleeding associated with prolonged dual-antiplatelet therapy after percutaneous coronary intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2009; 10:36-44. [PMID: 19159853 DOI: 10.1016/j.carrev.2008.11.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Revised: 11/02/2008] [Accepted: 11/03/2008] [Indexed: 12/30/2022]
Abstract
Prolonged dual-antiplatelet therapy with aspirin and clopidogrel is mandatory after drug-eluting stent implantation because of the potential increased risk of late stent thrombosis. The concern regarding prolonged antiplatelet therapy is the increased risk of bleeding. Gastrointestinal bleeding is the most common site of bleeding and presents a serious threat to patients due to the competing risks of gastrointestinal hemorrhage and stent thrombosis. Currently, there are no guidelines and little evidence on how best to manage these patients who are at high risk of morbidity and mortality from both the bleeding itself and the consequences of achieving optimum hemostasis by interruption of antiplatelet therapy. Managing gastrointestinal bleeding in a patient who has undergone recent percutaneous coronary intervention requires balancing the risk of stent thrombosis against further catastrophic bleeding. Close combined management between gastroenterologist and cardiologist is advocated to optimize patient outcomes.
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Affiliation(s)
- Victoria P Tan
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Australia
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102
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Chiu PWY, Ng EKW, Cheung FKY, Chan FKL, Leung WK, Wu JCY, Wong VWS, Yung MY, Tsoi K, Lau JYW, Sung JJY, Chung SSC. Predicting mortality in patients with bleeding peptic ulcers after therapeutic endoscopy. Clin Gastroenterol Hepatol 2009; 7:311-6; quiz 253. [PMID: 18955161 DOI: 10.1016/j.cgh.2008.08.044] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Revised: 08/07/2008] [Accepted: 08/30/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Despite advances in management of patients with bleeding peptic ulcers, mortality is still 10%. This study aimed to identify predictive factors and to develop a prediction model for mortality among patients with bleeding peptic ulcers. METHODS Consecutive patients with endoscopic stigmata of active bleeding, visible vessels, or adherent clots were recruited, and risk factors for mortality were identified in this deprivation cohort by using multiple stepwise logistic regression. A prediction model was then built on the basis of these factors and validated in the evaluation cohort. RESULTS From 1993 to 2003, 3220 patients with bleeding peptic ulcers were treated. Two hundred eighty-four of the patients developed rebleeding (8.8%); emergency surgery was performed on 47 of these patients, whereas others were managed with endoscopic retreatment. Two hundred twenty-nine of these sustained in-hospital death (7.1%). In patients older than 70 years, presence of comorbidity, more than 1 listed comorbidity, hematemesis on presentation, systolic blood pressure below 100 mm Hg, in-hospital bleeding, rebleeding, and need for surgery were significant predictors for mortality. Helicobacter pylori-related ulcers had lower risk of mortality. The receiver operating characteristic curve comparing the prediction of mortality with actual mortality showed an area under the curve of 0.842. From 2004 to 2006, data were collected prospectively from a second cohort of patients with bleeding peptic ulcers, and mortality was predicted by using the model developed. The receiver operating characteristic curve showed an area under the curve of 0.729. CONCLUSIONS Among patients with bleeding peptic ulcers after endoscopic hemostasis, advanced age, presence of listed comorbidity, multiple comorbidities, hypovolemic shock, in-hospital bleeding, rebleeding, and need for surgery successfully predicted in-hospital mortality.
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Affiliation(s)
- Philip W Y Chiu
- Department of Surgery, Institute of Digestive Disease, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong.
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103
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Rácz I, Kárász T, Saleh H. Endoscopic hemostasis of bleeding gastric ulcer with a combination of multiple hemoclips and endoloops. Gastrointest Endosc 2009; 69:580-3. [PMID: 18684454 DOI: 10.1016/j.gie.2008.04.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2007] [Accepted: 04/26/2008] [Indexed: 02/08/2023]
Affiliation(s)
- István Rácz
- 1st Department of Medicine and Gastroenterology, Petz Aladár County and Teaching Hospital, Gyor, Hungary
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104
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105
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Tsai JJ, Hsu YC, Perng CL, Lin HJ. Oral or intravenous proton pump inhibitor in patients with peptic ulcer bleeding after successful endoscopic epinephrine injection. Br J Clin Pharmacol 2008; 67:326-32. [PMID: 19523014 DOI: 10.1111/j.1365-2125.2008.03359.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
AIMS We aimed to assess the clinical effectiveness of oral vs. intravenous (i.v.) regular-dose proton pump inhibitor (PPI) after endoscopic injection of epinephrine in patients with peptic ulcer bleeding. METHODS Peptic ulcer patients with active bleeding, nonbleeding visible vessels, or adherent clots were enrolled after successful endoscopic haemostasis achieved by epinephrine injection. They were randomized to receive either oral rabeprazole (RAB group, 20 mg twice daily for 3 days) or i.v. omeprazole (OME group, 40 mg i.v. infusion every 12 h for 3 days). Subsequently, the enrolled patients receive oral PPI for 2 months (rabeprazole 20 mg or esomeprazole 40 mg once daily). The primary end-point was recurrent bleeding up to 14 days. The hospital stay, blood transfusion, surgery and mortality within 14 days were compared as well. RESULTS A total of 156 patients were enrolled, with 78 patients randomly allocated in each group. The two groups were well matched for factors affecting the clinical outcomes. Primary end-points (recurrent bleeding up to 14 days) were reached in 12 patients (15.4%) in the OME group and 13 patients (16.7%) in the RAB group [95% confidence interval (CI) of difference -12.82, 10.22]. All the rebleeding events occurred within 3 days of enrolment. The two groups were not different in hospital stay, volume of blood transfusion, surgery or mortality rate (1.3% of the OME group and 2.6% of the RAB group died, 95% CI of difference -5.6, 3.0). CONCLUSIONS Oral rabeprazole and i.v. regular-dose omeprazole are equally effective in preventing rebleeding in patients with high-risk bleeding peptic ulcers after successful endoscopic injection with epinephrine.
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Affiliation(s)
- Jai-Jen Tsai
- Division of Gastroenterology, Department of Medicine, Veterans General Hospital, Taipei, Taiwan
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106
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Abstract
Upper gastrointestinal bleeding secondary to ulcer disease is common and results in substantial patient morbidity and medical expense. After initial resuscitation to stabilize the patient, carefully performed endoscopy provides an accurate diagnosis and identifies high-risk ulcer patients who are likely to rebleed with medical therapy alone and will benefit most from endoscopic hemostasis. For patients with major stigmata of ulcer hemorrhage--active arterial bleeding, nonbleeding visible vessel, and adherent clot--combination therapy with epinephrine injection and either thermal coagulation (multipolar or heater probe) or endoclips is recommended. High-dose intravenous proton pump inhibitors are recommended as concomitant therapy after successful endoscopic hemostasis. Patients with minor stigmata or clean-based ulcers will not benefit from endoscopic treatment and should receive high-dose oral proton pump inhibitor therapy. Effective medical and endoscopic management of ulcer hemorrhage can significantly improve outcomes and decrease the cost of medical care by reducing rebleeding, transfusion requirements, and the need for surgery.
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Affiliation(s)
- Thomas O G Kovacs
- CURE/Digestive Disease Research Center, VA Greater Los Angeles Healthcare System, Building 115, Room 212, 11301 Wilshire Boulevard, Los Angeles, CA 90073-1003, USA.
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107
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Chong CC, Chiu PW, Ng EK. Multibend Endoscope Facilitates Endoscopic Hemostasis for Bleeding Gastric Ulcer at High Lesser Curvature. J Laparoendosc Adv Surg Tech A 2008; 18:837-9. [PMID: 18922060 DOI: 10.1089/lap.2008.0063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Charing C.N. Chong
- Department of Surgery, Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Philip W.Y. Chiu
- Department of Surgery, Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Enders K.W. Ng
- Department of Surgery, Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
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108
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Abstract
Endoscopic haemostasis should be attempted as the initial approach in most cases of gastrointestinal (GI) bleeding, although cross-disciplinary collaboration is a prerequisite. For variceal bleeding, band ligation is the method of choice in the elective setting, although injection therapy still has a role in acute bleeding. Histoacryl remains preferable for fundic varices in most parts of the world. For peptic ulcer bleeds, injection therapy should be combined with at least one 'mechanical' modality, thermal treatment or clipping. In rebleeding, a single endoscopic retreatment can be attempted, but alternative approaches must be considered. Acute lower GI bleeding is primarily a diagnostic challenge but, if the focus is found, the regular techniques for haemostasis can usually be applied. If small bowel haemorrhage is suspected after upper and lower endoscopy, capsule endoscopy and balloon enteroscopy offer make it possible to address even small bowel foci.
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109
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Elmunzer BJ, Young SD, Inadomi JM, Schoenfeld P, Laine L. Systematic review of the predictors of recurrent hemorrhage after endoscopic hemostatic therapy for bleeding peptic ulcers. Am J Gastroenterol 2008; 103:2625-32; quiz 2633. [PMID: 18684171 DOI: 10.1111/j.1572-0241.2008.02070.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND An increased knowledge regarding the predictors of rebleeding after endoscopic therapy for bleeding ulcers should improve clinical management and outcomes. The aim of this systematic review was to identify the strongest and most consistent predictors of rebleeding to assist in the development of tools to stratify and appropriately manage patients after endoscopic therapy. METHODS Bibliographic database searches for prospective studies assessing rebleeding after endoscopic therapy for bleeding ulcers were performed. Relevant studies were identified, and data were abstracted in a duplicate and independent fashion. The primary outcomes sought were significant independent predictors of rebleeding by multivariable analyses in > or =2 studies. RESULTS Ten articles met the prespecified inclusion criteria. The pooled rate of rebleeding after endoscopic therapy was 16.4%. The independent pre-endoscopic predictors of rebleeding were hemodynamic instability (significant in 5 of 5 studies; summary odds ratio [OR] 2.75, 95% confidence interval [CI] 1.99-3.51) and comorbid illness (significant in 2 of 7 studies; insufficient data to calculate summary OR or report OR range). The independent endoscopic predictors of rebleeding were active bleeding at endoscopy (significant in 5 of 8 studies; summary OR 1.93, 95% CI 1.30-2.55), large ulcer size (significant in 4 of 5 studies; summary OR 2.01, 95% CI 1.21-2.80), posterior duodenal ulcer (significant in 2 of 3 studies; insufficient data to calculate summary OR or report OR range), and lesser gastric curvature ulcer (significant in 2 of 2 studies; insufficient data to calculate summary OR or report OR range). CONCLUSIONS The independent predictors of recurrent hemorrhage after endoscopic therapy, particularly those that are the strongest and most consistent in the literature, may be used to select patients who are most likely to benefit from aggressive post-hemostasis care, including intensive care unit (ICU) observation and second-look endoscopy. Prospective studies designed to formally assess the relative utilities of these factors in predicting rebleeding and dictating management are needed.
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Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology, Department of Medicine, University of Michigan Medical Center, Ann Arbor, Michigan, USA
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110
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Affiliation(s)
- Ian M Gralnek
- Department of Gastroenterology and Gastrointestinal Outcomes Unit, Rambam Health Care Campus and Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel.
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111
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Yuan Y, Wang C, Hunt RH. Endoscopic clipping for acute nonvariceal upper-GI bleeding: a meta-analysis and critical appraisal of randomized controlled trials. Gastrointest Endosc 2008; 68:339-51. [PMID: 18656600 DOI: 10.1016/j.gie.2008.03.1122] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Accepted: 03/31/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Acute nonvariceal upper-GI bleeding (NVUGIB) is common, with a high rate of recurrent bleeding and substantial mortality rate. Endoscopic clipping has the theoretical advantage of minimizing tissue injury and is increasingly used. OBJECTIVE We conducted a systematic review and meta-analysis to investigate any potential benefits of clipping over other endoscopic techniques for NVUGIB. DESIGN Randomized controlled trials (RCT) that compared clipping with other endoscopic hemostatic methods to treat NVUGIB were included. Summary effect size was estimated by odds ratio (OR) with a random-effects model. RESULTS Twelve RCTs met inclusion criteria. For peptic ulcer bleeding (PUB), the hemoclip (n = 351 patients) was compared with the heat probe alone, thermal therapy plus injection, and injection alone in 2, 2, and 5 studies, respectively (n = 348 patients). The rate of the initial hemostasis was nonsignificantly increased in the control group compared with the hemoclip group (92% vs 96%, OR 0.58 [95% CI, 0.19-1.75]). The rebleeding rate was nonsignificantly decreased with hemoclips compared with controls (8.5% vs 15.5%, OR 0.56 [95% CI, 0.30-1.05]). Emergency surgery and the mortality rate were not significantly different between the hemoclip and controls. Subgroup analysis conducted in studies that compared hemoclips with injection alone show similar results. Two studies and one study reported outcomes of interest for Dieulafoy's lesions and Mallory-Weiss syndrome, respectively. CONCLUSIONS RCTs that compared clipping alone with other endoscopic hemostatic techniques for NVUGIB were limited. Current evidence suggests that the hemoclip is not superior to other endoscopic modalities in terms of initial hemostasis, rebleeding rate, emergency surgery, and the mortality rate for treatment of PUB.
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Affiliation(s)
- Yuhong Yuan
- Division of Gastroenterology, McMaster University Health Science Centre, Hamilton, Ontario, Canada
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112
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Ramón Foruny Olcina J, Vázquez-Sequeiros E. Endoscopia. Ante un paciente que presenta una hemorragia digestiva alta por ulcus gástrico o duodenal de origen péptico tipo Forrest Ia-IIb, ¿cuál es el tratamiento endoscópico de elección? GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 31:398-9. [DOI: 10.1157/13123611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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113
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Giordano-Nappi J, Maluf Filho F. Aspectos endoscópicos no manejo da úlcera péptica gastroduodenal. Rev Col Bras Cir 2008. [DOI: 10.1590/s0100-69912008000200010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
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114
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Fernández-Esparrach G, Bordas JM, Pellisé M, Gimeno-García AZ, Lacy A, Delgado S, Cárdenas A, Ginès A, Sendino O, Momblán D, Zabalza M, Llach J. Endoscopic management of early GI hemorrhage after laparoscopic gastric bypass. Gastrointest Endosc 2008; 67:552-5. [PMID: 18294521 DOI: 10.1016/j.gie.2007.10.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Accepted: 10/08/2007] [Indexed: 12/11/2022]
Abstract
BACKGROUND Early upper GI hemorrhage (UGH) is a potential complication after laparoscopic Roux-en-Y gastric bypass (RYGBP), and early reoperative intervention is the most accepted treatment. Experience with endoscopic treatment is limited. OBJECTIVE Our purpose was to describe the role of endoscopy and injection therapy in the management of early UGH after laparoscopic RYGBP. DESIGN Case series study. SETTING Endoscopy Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain. PATIENTS We describe the endoscopic treatment of 6 patients with early UGH within 24 hours after a RYGBP. INSTRUMENTATION Upper endoscopy was performed in all 6 cases. The origin of the bleeding was identified at the staple line in all cases, and epinephrine alone or combined with polidocanol was successfully injected in 5 of 6 patients. RESULTS Endoscopic therapy arrested active bleeding without any complications in all cases without the need for further surgery or endoscopic treatments. LIMITATION Our experience is limited to 6 cases. CONCLUSION Early postoperative UGH after RYGBP may be adequately controlled with endoscopic treatment and may obviate the need for surgery. Further data are necessary to evaluate the safety and the efficacy of this approach.
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115
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Maiss J, Hochberger J, Schwab D. Hemoclips: which is the pick of the bunch? Gastrointest Endosc 2008; 67:40-3. [PMID: 18155423 DOI: 10.1016/j.gie.2007.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Accepted: 07/05/2007] [Indexed: 02/08/2023]
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116
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Glasgow RE, Rollins MD. Stomach and Duodenum. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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117
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Adler DG. Is dual therapy superior to monotherapy for the endoscopic treatment of patients with high-risk peptic ulcer bleeding? NATURE CLINICAL PRACTICE. GASTROENTEROLOGY & HEPATOLOGY 2007; 4:480-1. [PMID: 17646855 DOI: 10.1038/ncpgasthep0900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2007] [Accepted: 05/16/2007] [Indexed: 05/16/2023]
Affiliation(s)
- Douglas G Adler
- University of Utah School of Medicine, Huntsman Cancer Center, Salt Lake City, UT, USA.
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118
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Barrioz T, Lesur G. [Endoscopic hemostatic methods]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2007; 31:698-707. [PMID: 17925770 DOI: 10.1016/s0399-8320(07)91920-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Thierry Barrioz
- Service d'endoscopie digestive, CHU de Poitiers, Hôpital de la Milétrie, 2, rue de la Milétrie, 86021 Poitiers Cedex
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119
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Calvet X, Vergara M, Gisbert JP, Brullet E. Dual versus endoscopic monotherapy in bleeding peptic ulcers. Am J Gastroenterol 2007; 102:1826-7; author reply 1827-8. [PMID: 17686075 DOI: 10.1111/j.1572-0241.2007.01266.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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120
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Park WG, Yeh RW, Triadafilopoulos G. Injection therapies for nonvariceal bleeding disorders of the GI tract. Gastrointest Endosc 2007; 66:343-54. [PMID: 17643711 DOI: 10.1016/j.gie.2006.11.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Accepted: 11/09/2006] [Indexed: 02/08/2023]
Affiliation(s)
- Walter G Park
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California 94305, USA
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121
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Abstract
The evaluation and management of acute gastrointestinal bleeding in infants, children, and adolescents is a reason for emergency consultation frequently cited by pediatric gastroenterologists. After stabilization of the patient's condition, endoscopic evaluation remains the most rapid and accurate method to identify the origin of acute bleeding in the majority of lesions in the pediatric age group. Several endoscopic techniques may be applied to bleeding lesions to achieve hemostasis. Familiarity with the various techniques and with the specifics of their use is essential for the pediatric endoscopist. This review focuses on the endoscopic management of acute nonvariceal bleeding in infants and children.
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Affiliation(s)
- Marsha H Kay
- Department of Pediatric Gastroenterology and Nutrition, The Children's Hospital, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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122
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Iacopini F, Petruzziello L, Marchese M, Larghi A, Spada C, Familiari P, Tringali A, Riccioni ME, Gabbrielli A, Costamagna G. Hemostasis of Dieulafoy's lesions by argon plasma coagulation (with video). Gastrointest Endosc 2007; 66:20-6. [PMID: 17591469 DOI: 10.1016/j.gie.2006.11.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2006] [Accepted: 11/10/2006] [Indexed: 02/06/2023]
Abstract
BACKGROUND A Dieulafoy's lesion is a submucosal artery that may erode the epithelium and lead to severe hemorrhages. The safety and efficacy of argon plasma coagulation (APC) for the hemostasis of these lesions has not been studied. OBJECTIVE To evaluate efficacy of APC alone in the hemostasis of Dieulafoy's lesions. DESIGN A retrospective analysis of hemostasis by chart review, with long-term follow-up by outpatient visit or phone interview. SETTING An academic hospital with 24-hour endoscopic service availability. PATIENTS All patients with acute bleeding from a Dieulafoy's lesion treated with APC. INTERVENTIONS Hemostasis was attempted with 2.3-mm APC probes, with settings varying from 40 W to 60 W, according to lesion location. MAIN OUTCOME MEASUREMENTS Initial hemostasis, recurrent bleeding, and 30-day mortality rates. RESULTS Twenty-three Dieulafoy's lesions were treated with APC, which represented 85% of all such lesions observed. Severe comorbidities and abnormal coagulation were present in 39% and 22%, respectively. Dieulafoy's lesions were located in the upper-GI tract in 20 patients (87%). Active bleeding was found in 20 patients (87%), a nonbleeding visible vessel was found in 2 patients (9%), and a minute mucosal defect below an adherent clot was found in 1 (4%). Initial hemostasis was achieved in all patients, without complications. An injection of an average volume of 3 mL of 1:10,000 epinephrine solution preceded APC in 3 cases for the identification of the bleeding lesion. Recurrent bleeding occurred in a patient after 48 hours; no bleeding-related deaths were observed during a median follow-up of 29 months. LIMITATIONS Retrospective study. CONCLUSIONS Dieulafoy's lesions can be successfully managed by APC alone.
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Affiliation(s)
- Federico Iacopini
- Digestive Endoscopy Unit, Department of Surgery, Catholic University, Rome, Italy
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123
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Simon-Rudler M, Massard J, Bernard-Chabert B, DI Martino V, Ratziu V, Poynard T, Thabut D. Continuous infusion of high-dose omeprazole is more effective than standard-dose omeprazole in patients with high-risk peptic ulcer bleeding: a retrospective study. Aliment Pharmacol Ther 2007; 25:949-54. [PMID: 17402999 DOI: 10.1111/j.1365-2036.2007.03286.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
UNLABELLED High-dose omeprazole reduces the rate of recurrent bleeding after endoscopic treatment of peptic ulcer bleeding. However, the effectiveness of high-dose vs. standard-dose omeprazole in peptic ulcer bleeding has never been shown. AIM To compare the benefits of high-dose vs. standard-dose omeprazole in peptic ulcer bleeding. METHODS We reviewed the medical files of patients admitted between 1997 and 2004 for high-risk peptic ulcer bleeding who had undergone successful endoscopic treatment. We distinguished 2 periods: before 2001, standard-dose omeprazole (40 mg/day intravenously until alimentation was possible, then 40 mg/day orally for 1 week); after 2001, high-dose omeprazole (80 mg bolus injection, then 8 mg/h continuous infusion for 72 h, then 40 mg/day orally for 1 week). During both periods, patients subsequently received omeprazole, 20 mg/day, orally for 3 weeks. RESULTS We enrolled 114 patients (period 1, n = 45, period 2, n = 69). Therapy with high-dose omeprazole significantly decreased the occurrence of poor outcome (27 vs. 12%, P = 0.04), rebleeding (24 vs. 7%, P = 0.01), mortality due to haemorrhagic shock (11 vs. 0%, P < 0.001) and need for surgery (9 vs. 1%, P = 0.05). CONCLUSIONS In this retrospective study, high-dose omeprazole reduced the occurrence of rebleeding, need for surgery and mortality due to hemorrhagic shock in patients with high-risk peptic ulcer bleeding, as compared with standard-dose omeprazole.
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Affiliation(s)
- M Simon-Rudler
- Service d'Hépatologie et de Gastroentérologie, Hôpital Pitié-Salpêtrière AP-HP, Paris, France
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124
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Abstract
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.
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Affiliation(s)
- Vu Kwan
- Department of Gastroenterology, Concord Hospital, Sydney, New South Wales, Australia
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125
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Abstract
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.
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Affiliation(s)
- Christopher J DiMaio
- Division of Digestive & Liver Diseases, Columbia University Medical Center, 630 West 168th Street, Box 83, New York, NY 10032, USA
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126
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Marmo R, Rotondano G, Piscopo R, Bianco MA, D'Angella R, Cipolletta L. Dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers: a meta-analysis of controlled trials. Am J Gastroenterol 2007; 102:279-89; quiz 469. [PMID: 17311650 DOI: 10.1111/j.1572-0241.2006.01023.x] [Citation(s) in RCA: 185] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is no definite recommendation on the use of dual endoscopic therapy in patients with severe peptic ulcer bleeding. A systematic review and meta-analysis were performed to determine whether the use of two endoscopic hemostatic procedures improved patient outcomes compared with monotherapy. METHODS A search for randomized trials comparing dual therapy (i.e., epinephrine injection plus other injection or thermal or mechanical method) versus monotherapy (injection, thermal, or mechanical alone) was performed between 1990 and 2006. Heterogeneity between studies was tested with chi(2) and explained by metaregression analysis. RESULTS Twenty studies (2,472 patients) met inclusion criteria. Compared with controls, dual endoscopic therapy reduces the risk of recurrent bleeding (OR [odds ratio] 0.59 [0.44-0.80], P= 0.0001) and the risk of emergency surgery (OR 0.66 [0.49-0.89], P= 0.03) and showed a trend toward a reduction in the risk of death (OR 0.68 [0.46-1.02], P= 0.06). Subcategory analysis showed that dual therapy was significantly superior to injection therapy alone for all the outcomes considered, but failed to demonstrate that any combination of treatments is better than either mechanical therapy alone (OR 1.04 [0.45-2.45] for rebleeding, 0.49 [0.50-4.87] for surgery, and 1.28 [0.34-4.86] for death) or thermal therapy alone (OR 0.67 [0.40-1.20] for rebleeding, 0.89 [0.45-1.76] for surgery, and 0.51 [0.24-1.10] for death). CONCLUSIONS Dual endoscopic therapy proved significantly superior to epinephrine injection alone, but had no advantage over thermal or mechanical monotherapy in improving the outcome of patients with high-risk peptic ulcer bleeding.
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Affiliation(s)
- Riccardo Marmo
- Department of Medicine, Division of Gastroenterology, Hospital L. Curto, Polla, Italy
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127
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Abstract
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?
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Affiliation(s)
- Noel B Martins
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
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128
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Abstract
Hemorrhage from stress ulceration in acutely ill children is seen in association with acute respiratory failure, coagulopathy and Pediatric Risk of Mortality Score of 10 or higher. We report an unusual association of clinically significant hemorrhagic stress ulcer with appendicitis in a pediatric patient.
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Affiliation(s)
- Hemant Shyam Agarwal
- Department of Pediatrics, Division of Pediatric Critical Care, Vanderbilt University School of Medicine, Nashville, TN 37232-9075, USA.
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129
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Abstract
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.
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Affiliation(s)
- M-A Ortner
- Department Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, Lausanne, Schweiz.
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130
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Abstract
Bleeding peptic ulcers are responsible for about half of all upper gastrointestinal hemorrhages, one of the most frequent gastroenterological emergencies. In its pathogenesis, infection with Helicobacter pylori and the use of ulcerogenic drugs play a dominant role. Endoscopy has to be performed urgently when a decline in hemoglobin and/or hemodynamic instability occurs. The indications for local endoscopic therapy depend on the Forrest criteria, which include bleeding and the presence or absence of a blood clot or visible vessel. Local endoscopic therapy comprises injections and mechanical or thermal procedures. The efficacy of these procedures has been demonstrated. Additionally, proton pump inhibitors are administered. The prognosis for bleeding ulcers depends on the endoscopic findings as well as the age and comorbidity of the patients.
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Affiliation(s)
- U Weickert
- Medizinische Klinik C, Klinikum der Stadt Ludwigshafen gGmbH, Bremserstrasse 79, 67 063 Ludwigshafen, Germany.
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131
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132
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Sung J. Best endoscopic hemostasis for ulcer bleeding: is there such a treatment? Gastrointest Endosc 2006; 63:774-5. [PMID: 16650536 DOI: 10.1016/j.gie.2005.12.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2005] [Accepted: 12/28/2005] [Indexed: 12/10/2022]
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133
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Lo CC, Hsu PI, Lo GH, Lin CK, Chan HH, Tsai WL, Chen WC, Wu CJ, Yu HC, Cheng JS, Lai KH. Comparison of hemostatic efficacy for epinephrine injection alone and injection combined with hemoclip therapy in treating high-risk bleeding ulcers. Gastrointest Endosc 2006; 63:767-73. [PMID: 16650535 DOI: 10.1016/j.gie.2005.11.048] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2005] [Accepted: 11/08/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND Rebleeding occurs in 10% to 30% of bleeding ulcer patients receiving endoscopic epinephrine injection therapy. It remains unclear whether addition of a secondary clip therapy following epinephrine injection may reduce the rebleeding rate of high-risk bleeding ulcers. OBJECTIVE To compare the efficacies of epinephrine injection alone and epinephrine injection combined with hemoclip therapy in treating high-risk bleeding ulcers. DESIGN Prospective randomized controlled trial. SETTING A medical center in Taiwan. PATIENTS One hundred five bleeding ulcer patients with active spurting, oozing, nonbleeding visible vessels or adherent clots in ulcer bases. INTERVENTIONS Endoscopic combination therapy (n = 52) or diluted epinephrine injection alone (n = 53). MAIN OUTCOME MEASUREMENTS Initial hemostasis rates and recurrent bleeding rates. RESULTS Initial hemostasis was achieved in 51 patients treated with combination therapy and 49 patients with epinephrine injection therapy (98% vs 92%, P = .18). Bleeding recurred in 2 patients in the combination therapy group and 11 patients in the epinephrine injection group (3.8% vs 21%, P = .008). Among the patients with rebleeding, repeated combination therapy was more effective than repeated injection therapy in achieving permanent hemostasis (100% vs 33%, P = .02). No patient required an emergency operation in the combination therapy group. However, 5 patients in the epinephrine injection group underwent emergency surgery to arrest bleeding (0% vs 9%, P = .023). LIMITATIONS Treatment outcome of endoscopic hemoclip therapy is related to the techniques of endoscopists. CONCLUSION Endoscopic combination therapy is superior to epinephrine injection alone in the treatment of high-risk bleeding ulcers.
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Affiliation(s)
- Ching-Chu Lo
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
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134
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Lin HJ, Lo WC, Cheng YC, Perng CL. Role of intravenous omeprazole in patients with high-risk peptic ulcer bleeding after successful endoscopic epinephrine injection: a prospective randomized comparative trial. Am J Gastroenterol 2006; 101:500-5. [PMID: 16542286 DOI: 10.1111/j.1572-0241.2006.00399.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Epinephrine injection is the most common endoscopic therapy for peptic ulcer bleeding. Controversy exists concerning the optimal dose of proton pump inhibitors (PPI) for patients with bleeding peptic ulcers after successful endoscopic therapy. The objective of this study was to determine the optimal dose of PPI after successful endoscopic epinephrine injection in patients with bleeding peptic ulcers. METHODS A total of 200 peptic ulcer patients with active bleeding or nonbleeding visible vessels (NBVV) who had obtained initial hemostasis with endoscopic injection of epinephrine were randomized to receive omeprazole 40 mg infusion every 6 h, omeprazole 40 mg infusion every 12 h or cimetidine (CIM) 400 mg infusion every 12 h. Outcomes were checked at 14 days after enrollment. RESULTS Rebleeding episodes were fewer in the group with omeprazole 40 mg infusion every 6 h (6/67, 9%) as compared with that of the CIM infusion group (22/67, 32.8%, p < 0.01). The volume of blood transfusion was less in the group with omeprazole 40 mg every 6 h than in those groups with omepraole 40 mg infusion every 12 h (p= 0.001) and CIM 400 mg infusion every 12 h (p < 0.001). The hospital stay, number of patients requiring urgent operation, and death rate were not statistically different among the three groups. CONCLUSION A combination of endoscopic epinephrine injection and a large dose of omeprazole infusion is superior to combined endoscopic epinephrine injection with CIM infusion for preventing recurrent bleeding from peptic ulcers with active bleeding or NBVV.
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Affiliation(s)
- Hwai-Jeng Lin
- Division of Gastroenterology, Department of Medicine, VGH-TAIPEI, Sec. 2 Shih-Pai Road, Taipei 11217, Taiwan
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135
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Abstract
Treatment for most patients with upper gastrointestinal bleeding has shifted from the operating room to the endoscopy suite. Endoscopic treatment has resulted in substantial benefit for patients with bleeding from peptic ulcer. Ulcers associated with high-risk stigmata of recent hemorrhage (SRH) not treated endoscopically have 40 per cent to 100 per cent risk of continued or recurrent bleeding and up to a 35 per cent chance of requiring surgical control of bleeding. Endoscopic therapy has reduced the risk of recurrent bleeding to 10 per cent to 20 per cent and the need for surgery to 5 per cent to 10 per cent. These improvements translate to shorter hospital stays, fewer transfusions, lower costs, and less morbidity. Similar progress has been made for patients bleeding from esophageal varices. Mortality for a first variceal bleed is now approximately 20 per cent as compared with 40 per cent to 60 per cent in past decades. Rebleeding after initially successful endoscopic hemostasis is often best treated by a second attempt at endoscopic control. The decision regarding management of recurrent bleeding should be made at the time initial endoscopic control is achieved. Local factors such as experience of the endoscopic team, availability of interventional radiologists, and individual patient characteristics should guide these decisions. Failures of endoscopic control and patients with massive hemorrhage still require operative intervention.
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Affiliation(s)
- Greg V. Stiegmann
- From Gastrointestinal, Tumor and Endocrine Surgery, University of Colorado Denver and Health Science Center, Denver, Colorado
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136
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Sung J. Current management of peptic ulcer bleeding. ACTA ACUST UNITED AC 2006; 3:24-32. [PMID: 16397609 DOI: 10.1038/ncpgasthep0388] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2005] [Accepted: 11/03/2005] [Indexed: 01/23/2023]
Abstract
Peptic ulcer bleeding is a common and potentially fatal condition. It is best managed using a multidisciplinary approach by a team with medical, endoscopic and surgical expertise. The management of peptic ulcer bleeding has been revolutionized in the past two decades with the advent of effective endoscopic hemostasis and potent acid-suppressing agents. A prompt initial clinical and endoscopic assessment should allow patients to be triaged effectively into those who require active therapy, versus those who require monitoring and preventative therapy. A combination of pharmacologic and endoscopic therapy (using a combination of injection and thermal coagulation) offers the best chance of hemostasis for those with active bleeding ulcers. Surgery, being the most effective way to control bleeding, should be considered for treatment failures. The choice between surgery and repeat endoscopic therapy should be based on the pre-existing comorbidities of the patient and the characteristics of the ulcer.
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Affiliation(s)
- Joseph Sung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong.
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137
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Güell M, Artigau E, Esteve V, Sánchez-Delgado J, Junquera F, Calvet X. Usefulness of a delayed test for the diagnosis of Helicobacter pylori infection in bleeding peptic ulcer. Aliment Pharmacol Ther 2006; 23:53-9. [PMID: 16393280 DOI: 10.1111/j.1365-2036.2006.02726.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM To evaluate (i) the diagnostic usefulness of a delayed test in initially negative patients; and (ii) the reliability of the rapid urease test, histology or a combination of the two to diagnose Helicobacter pylori during emergency endoscopy in a large clinical practice series. PATIENTS AND METHODS Records of patients with ulcer bleeding from 1995 to 2000 were reviewed. Patients with initially negative tests were retested 4-8 weeks after the bleeding episode. Sensitivity of urease, histology or a combination of the two to detect H. pylori at initial endoscopy and the efficacy of delayed Urea Breath Test in detecting missed infection was determined. RESULTS The study included 429 patients. A delayed second test detected H. pylori infection in 57 out of 72 (79%) of initially negative patients. The sensitivity for detecting H. pylori was 76%, 78% and 86% for urease, histology and their combination, respectively. The prevalence of H. pylori was 95% in duodenal and 88% in gastric ulcer. In addition, only one test was performed in 17 of the 32 patients who were considered negative. CONCLUSION Not even the combination of a negative urease and histology in the initial endoscopy is able to rule out infection in bleeding ulcer patients. A delayed test should be performed to rule out Helicobacter pylori infection completely.
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Affiliation(s)
- M Güell
- Unitat de Malalties Digestives, Corporacio Parc Tauli, Institut Universitari Parc Tauli, Parc Tauli s/n, Sabadell, Spain
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138
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Calvet X, Vergara M, Brullet E. [Endoscopic treatment of bleeding ulcers: has everything been said and done?]. GASTROENTEROLOGIA Y HEPATOLOGIA 2005; 28:347-53. [PMID: 15989817 DOI: 10.1157/13076353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Endoscopic treatment reduces bleeding recurrence, the need for surgery and mortality in patients with bleeding ulcers. However endoscopic treatment fails in 10-15% of patients, leading to high morbidity and mortality. The therapeutic measures with demonstrated effectiveness in reducing the risk of hemorrhagic recurrence and its complications are combined endoscopic treatment (adrenaline plus a second hemostatic intervention) and proton pump inhibitors. Also useful, although there is less evidence, are immediate resuscitation and <<second look>> endoscopy. Some studies suggest that activated recombinant factor VII infusion or supra-selective arterial embolization can be useful in severe hemorrhage. Further studies are required to determine optimal treatment according to the characteristics of each patient.
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Affiliation(s)
- X Calvet
- Unitat de Malalties Digestives, Hospital de Sabadell, Institut Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Barcelona, España.
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139
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Abstract
Endoscopic therapy for nonvariceal bleeding should only be used if major stigmata of hemorrhage such as active bleeding and nonbleeding visible vessel are present. Treatment of peptic ulcers with adherent clots is currently controversial. Combination of epinephrine injection and coaptive coagulation is most effective in achieving endoscopic hemostasis. Hemoclips may be preferable for very deep ulcers and large visible blood vessels if coaptive coagulation is anticipated to have a high risk of perforation or bleeding. Adrenaline injection or hemoclip application should be used in bleeding Mallory-Weiss tears, as the safety of thermal methods is not well established. Argon plasma coagulation is the mainstay of endoscopic treatment for superficial lesions such as angiodysplasia and gastric antral vascular ectasia. Both sclerotherapy and band ligation are effective in acute hemostasis of bleeding esophageal varices. Variceal band ligation is preferred due to its superior safety profile and shorter procedure time. Due to the early recurrence of varices after banding ligation, there may be a role for metachronous combination therapy of ligation followed by sclerotherapy. Histoacryl glue is the preferred method of endoscopic hemostasis in gastric varices.
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Affiliation(s)
- Aric J Hui
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, N. T., Hong Kong SAR, China.
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140
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Hsu PI, Lo GH, Lo CC, Lin CK, Chan HH, Wu CJ, Shie CB, Tsai PM, Wu DC, Wang WM, Lai KH. Intravenous pantoprazole versus ranitidine for prevention of rebleeding after endoscopic hemostasis of bleeding peptic ulcers. World J Gastroenterol 2004; 10:3666-9. [PMID: 15534928 PMCID: PMC4612014 DOI: 10.3748/wjg.v10.i24.3666] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM: The role of intravenous pantoprazole in treatment of patients with high-risk bleeding peptic ulcers following endoscopic hemostasis remains uncertain. We therefore conducted the pilot prospective randomized study to assess whether intravenous pantoprazole could improve the efficacy of H2-antagonist as an adjunct treatment following endoscopic injection therapy for bleeding ulcers.
METHODS: Patients with active bleeding ulcers or ulcers with major signs of recent bleeding were treated with distilled water injection. After hemostasis was achieved, they were randomly assigned to receive intravenous pantoprazole or ranitidine.
RESULTS: One hundred and two patients were enrolled in this prospective trial. Bleeding recurred in 2 patients (4%) in the pantoprazole group (n = 52), as compared with 8 (16%) in the ranitidine group (n = 50). The rebleeding rate was significantly lower in the pantoprazole group (P = 0.04). There were no statistically significant differences between the groups with regard to the need for emergency surgery (0% vs 2%), transfusion requirements (4.9 ± 5.9 vs 5.7 ± 6.8 units), hospital days (5.9 ± 3.2 vs 7.5 ± 5.0 d) or mortality (2% vs 2%).
CONCLUSION: Pantoprozole is superior to ranitidine as an adjunct treatment to endoscopic injection therapy in high-risk bleeding ulcers.
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Affiliation(s)
- Ping-I Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386, Ta-Chung 1st Road, Kaohsiung 813, Taiwan, China
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141
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Bianco MA, Rotondano G, Marmo R, Piscopo R, Orsini L, Cipolletta L. Combined epinephrine and bipolar probe coagulation vs. bipolar probe coagulation alone for bleeding peptic ulcer: a randomized, controlled trial. Gastrointest Endosc 2004; 60:910-5. [PMID: 15605005 DOI: 10.1016/s0016-5107(04)02232-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Endoscopic treatment with combined modalities is considered standard of care for patients with high-risk peptic ulcer bleeding. This study compared epinephrine injection plus bipolar probe coagulation with bipolar probe coagulation alone in patients with high-risk peptic ulcer bleeding. METHODS Patients with endoscopically confirmed peptic ulcer bleeding (active or visible vessel) seen from January 2000 through December 2002 were prospectively randomized to two groups. The study group (n = 58) had epinephrine injection followed by bipolar coagulation; the control group (n = 56) was treated by bipolar coagulation alone. The primary outcomes assessed were the rate of initial hemostasis and the rate of recurrent bleeding. Secondary outcomes were the following: need for surgical intervention to control bleeding, transfusion requirements, length of hospital stay (in days), and 30-day mortality. RESULTS The rate of initial hemostasis was significantly higher in the combination therapy group ( p = 0.02; absolute risk reduction 31.6%: 95% CI [5.4, 57.7]). There was no significant difference between the two treatment groups with respect to all other outcomes measures, except that significantly fewer units of blood were transfused in the combination therapy group ( p = 0.006). CONCLUSIONS In patients with active peptic ulcer bleeding, epinephrine injection plus bipolar coagulation achieved significantly higher rate of initial hemostasis. All other outcome measures were similar with either treatment in patients with non-bleeding stigmata.
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142
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Affiliation(s)
- Richard C K Wong
- Division of Gastroenterology, University Hospitals of Cleveland, OH 44106-5066, USA
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143
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144
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Balanzó J, Villanueva C, Aracil C. Gastrointestinal and variceal bleeding: hemodynamic studies. Best Pract Res Clin Gastroenterol 2004; 18 Suppl:17-22. [PMID: 15588790 DOI: 10.1016/j.bpg.2004.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Joaquim Balanzó
- Gastroenterology Department, Hospital Santa Creu i Sant Pau, 8025 Barcelona, Spain.
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