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Pittayanon R, Khongka W, Linlawan S, Thungsuk R, Aumkaew S, Teeratorn N, Maytapa J, Kimtrakool S, Pakvisal P, Kongtub N, Rerknimitr R, Barkun A. Hemostatic Powder vs Standard Endoscopic Treatment for Gastrointestinal Tumor Bleeding: A Multicenter Randomized Trial. Gastroenterology 2023; 165:762-772.e2. [PMID: 37277078 DOI: 10.1053/j.gastro.2023.05.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/14/2023] [Accepted: 05/09/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND & AIMS Current guidelines vary as to their recommendations addressing the role of hemostatic powders when managing patients with malignant gastrointestinal (GI) bleeding because these are based on very-low- to low-quality evidence, in large part due to a paucity of randomized trial data. METHODS This was a patient- and outcome assessor-blinded, multicenter, randomized controlled trial. Patients presenting with active bleeding from an upper or lower GI lesion suspected to be malignant at index endoscopy between June 2019 and January 2022 were randomly allocated to receive either TC-325 alone or standard endoscopic treatment (SET). The primary outcome was 30-day rebleeding, and secondary objectives included immediate hemostasis and other clinically relevant endpoints. RESULTS Overall, 106 patients made up the study population (55 TC-325 and 51 SET, after 1 exclusion in the TC-325 group and 5 in the SET group). Baseline characteristics and endoscopic findings did not differ between the groups. Thirty-day rebleeding was significantly lower in the TC-325 (2.1% TC-325 vs 21.3% SET; odds ratio, 0.09; 95% confidence interval [CI], 0.01-0.80; P = .003). Immediate hemostasis rates were 100% in the TC-325 group vs 68.6% in the SET group (odds ratio, 1.45; 95% CI, 0.93-2.29; P < .001). Other secondary outcomes did not differ between the 2 groups. Independent predictors of 6-month survival included the Charlson comorbidity index (hazard ratio, 1.17; 95% CI, 1.05-1.32; P = .007) and receiving an additional nonendoscopic hemostatic or oncologic treatment during 30 days after the index endoscopy (hazard ratio, 0.16; 95% CI, 0.06-0.43; P < .001) after adjustment for functional status, Glasgow-Blatchford score, and an upper GI source of bleeding. CONCLUSION The TC-325 hemostatic powder results in greater immediate hemostasis rates followed by lower 30-day rebleeding rates when compared to contemporary SET. (ClinicalTrials.gov, Number: NCT03855904).
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Affiliation(s)
- Rapat Pittayanon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand.
| | | | | | | | | | | | | | | | | | - Natanong Kongtub
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Alan Barkun
- Division of Gastroenterology, McGill University, Montreal, Quebec, Canada; McGill University Health Center, Montreal, Quebec, Canada
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Wang J, He S, Shang G, Lv N, Shu X, Zhu Z. Epinephrine injection monotherapy shows similar hemostatic efficacy to epinephrine injection combined therapy in high-risk patients (Forrest Ib) with bleeding ulcers. Surg Endosc 2023; 37:6954-6963. [PMID: 37336844 PMCID: PMC10462566 DOI: 10.1007/s00464-023-10152-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/20/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Whether combination therapy has higher hemostatic efficacy than epinephrine injection monotherapy in different Forrest classifications is not clear. This study aimed to compare hemostatic efficacy between epinephrine injection monotherapy (MT) and combination therapy (CT) based on different Forrest classifications. METHODS We retrospectively analyzed peptic ulcer bleeding (PUB) patients who underwent endoscopic epinephrine injections or epinephrine injections combined with a second therapy between March 2014 and June 2022 in our center, and the patients were divided into MT group or CT group. Subsequently, a propensity score matching analysis (PSM) was performed and rebleeding rates were calculated according to Forrest classifications via a stratified analysis. RESULTS Overall, 605 patients who met the inclusion criteria were included, and after PSM, 173 patients in each of the CT and MT groups were included. For PUB patients with nonbleeding visible vessels (FIIa), the rebleeding rates by Days 3, 7, 14, and 30 after PSM were 8.8%, 17.5%, 19.3%, and 19.3% in the MT group, respectively, and rates were 0%, 4.1%, 5.5%, and 5.5% in the CT group, respectively, with significant differences observed between the two groups by Days 3, 7, 14, and 30 (P = 0.015, P = 0.011, P = 0.014, and P = 0.014, respectively). However, for PUB patients with oozing bleeding (FIb), the rebleeding rates by Days 3, 7, 14, and 30 after PSM were 14.9%, 16.2%, 17.6%, and 17.6% in the MT group, respectively, and rates were 13.2%, 14.7%, 14.7%, and 16.2% in the CT group, respectively, with no significant differences observed between the two groups by Days 3, 7, 14, and 30 (P = 0.78, P = 0.804, P = 0.644 and P = 0.825). CONCLUSION Combined therapy has higher hemostatic efficacy than epinephrine injection monotherapy for PUB patients with visible blood vessel (FIIa) ulcers. However, epinephrine injection monotherapy is equally as effective as combined therapy for PUB patients with oozing blood (FIb) ulcers.
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Affiliation(s)
- Jingsong Wang
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Shan He
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Guanqun Shang
- Queen Mary School, Nanchang University, Nanchang, 330001 Jiangxi China
| | - Nonghua Lv
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Xu Shu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Zhenhua Zhu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
- Department of Gastroenterology, Gaoxin Branch, The First Affiliated Hospital of Nanchang University, Nanchang, 330096 Jiangxi China
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Orpen-Palmer J, Stanley AJ. Update on the management of upper gastrointestinal bleeding. BMJ MEDICINE 2022; 1:e000202. [PMID: 36936565 PMCID: PMC9951461 DOI: 10.1136/bmjmed-2022-000202] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/15/2022] [Indexed: 11/04/2022]
Abstract
Upper gastrointestinal bleeding is a common emergency presentation requiring prompt resuscitation and management. Peptic ulcers are the most common cause of the condition. Thorough initial management with a structured approach is vital with appropriate intravenous fluid resuscitation and use of a restrictive transfusion threshold of 7-8 g/dL. Pre-endoscopic scoring tools enable identification of patients at high risk and at very low risk who might benefit from specific management. Endoscopy should be carried out within 24 h of presentation for patients admitted to hospital, although optimal timing for patients at a higher risk within this period is less clear. Endoscopic treatment of high risk lesions and use of subsequent high dose proton pump inhibitors is a cornerstone of non-variceal bleeding management. Variceal haemorrhage results in higher mortality than non-variceal haemorrhage and, if suspected, antibiotics and vasopressors should be administered urgently, before endoscopy. Oesophageal variceal bleeding requires endoscopic band ligation, whereas bleeding from gastric varices requires thrombin or tissue glue injection. Recurrent bleeding is managed by repeat endoscopic treatment. If uncontrolled bleeding occurs, interventional radiological embolisation or surgery is required for non-variceal bleeding or transjugular intrahepatic portosystemic shunt placement for variceal bleeding.
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4
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Saffo S, Nagar A. Impact of epinephrine volume on further bleeding due to high-risk peptic ulcer disease in the combination therapy era. World J Gastrointest Pharmacol Ther 2022; 13:67-76. [PMID: 36157267 PMCID: PMC9453442 DOI: 10.4292/wjgpt.v13.i5.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/22/2022] [Accepted: 07/31/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND In monotherapy studies for bleeding peptic ulcers, large volumes of epinephrine were associated with a reduction in rebleeding. However, the impact of epinephrine volume in patients treated with combination endoscopic therapy remains unclear.
AIM To assess whether epinephrine volume was associated with bleeding outcomes in individuals who also received endoscopic thermal therapy and/or clipping.
METHODS Data from 132 patients with Forrest class Ia, Ib, and IIa peptic ulcers were reviewed. The primary outcome was further bleeding at 7 d; secondary outcomes included further bleeding at 30 d, need for additional therapeutic interventions, post-endoscopy blood transfusions, and 30-day mortality. Logistic and linear regression and Cox proportional hazards analyses were performed.
RESULTS There was no association between epinephrine volume and all primary and secondary outcomes in multivariable analyses. Increased odds for further bleeding at 7 d occurred in patients with elevated creatinine values (aOR 1.96, 95%CI 1.30-3.20; P < 0.01) or hypotension requiring vasopressors (aOR 6.34, 95%CI 1.87-25.52; P < 0.01). Both factors were also associated with all secondary outcomes.
CONCLUSION Epinephrine maintains an important role in the management of bleeding ulcers, but large volumes up to a range of 10-20 mL are not associated with improved bleeding outcomes among individuals receiving combination endoscopic therapy. Further bleeding is primarily associated with patient factors that likely cannot be overcome by increased volumes of epinephrine. However, in carefully-selected cases where ulcer location or size pose therapeutic challenges or when additional modalities are unavailable, it is conceivable that increased volumes of epinephrine may still be beneficial.
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Affiliation(s)
- Saad Saffo
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT 06520, United States
| | - Anil Nagar
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT 06520, United States
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5
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Kate V, Sureshkumar S, Gurushankari B, Kalayarasan R. Acute Upper Non-variceal and Lower Gastrointestinal Bleeding. J Gastrointest Surg 2022; 26:932-949. [PMID: 35083723 DOI: 10.1007/s11605-022-05258-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/17/2022] [Indexed: 01/31/2023]
Abstract
Acute gastrointestinal (GI) bleeding is a common surgical emergency requiring hospital admission and associated with high morbidity and mortality. Appropriate decision-making is essential to make a prompt diagnosis, accurate risk assessment, and proper resuscitation of patients with gastrointestinal bleeding. Despite multiple randomized trials and meta-analyses, there is still controversy on various management issues like appropriate risk stratification, the timing of endoscopy, choosing an appropriate endoscopic, and radiological intervention in these groups of patients. As the usage of nonsteroidal anti-inflammatory drugs, antiplatelet, and antithrombotic agents is common in patients with gastrointestinal bleeding, the physician is challenged with proper management of these drugs. The present review summarizes the current strategies for risk stratification, localization of bleeding source, endoscopic and radiological intervention in patients with acute nonvariceal upper GI, middle GI, and lower GI bleeding.
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Affiliation(s)
- Vikram Kate
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India.
| | - Sathasivam Sureshkumar
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Balakrishnan Gurushankari
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Raja Kalayarasan
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
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6
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Wangrattanapranee P, Khrucharoen U, Jensen DM, Wongpongsalee T, Jensen ME. Severe Upper Gastrointestinal Hemorrhage Caused by Reflux Esophagitis. Dig Dis Sci 2022; 67:159-169. [PMID: 33590404 DOI: 10.1007/s10620-021-06828-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 01/06/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND There are few reports about reflux esophagitis (RE) as a cause of severe upper gastrointestinal bleeding (UGIB). AIMS This study aims to evaluate (1) changes in its prevalence over the last three decades and (2) clinical and endoscopic characteristics and 30-day outcomes among RE patients with and without focal esophageal ulcers (EUs) and stigmata of recent hemorrhage (SRH). METHODS A retrospective study of prospectively collected data of esophagitis patients hospitalized with severe UGIB between 1992 and 2020. Descriptive analysis and statistical comparisons were performed. RESULTS Of 114 RE patients, the mean age was 61.1 years and 76.3% were males. 38.6% had prior gastroesophageal reflux disease (GERD) symptoms; overall 36% were on acid suppressants. Over three consecutive decades, the prevalence of RE as a cause of severe UGIB increased significantly from 3.8 to 16.7%. 30-day rebleeding and all-cause mortality rates were 11.4% and 6.1%. RE patients with focal EUs and SRH (n = 23) had worse esophagitis than those with diffuse RE (n = 91) (p = 0.012). There were no differences in 30-day outcomes between RE patients with and without EUs and SRH. CONCLUSIONS For patients with severe UGIB caused by RE, (1) the prevalence has increased significantly over the past three decades, (2) the reasons for this increase and preventive strategies warrant further study, (3) most patients lacked GERD symptoms and did not take acid suppressants, and (4) those with focal ulcers and SRH had more severe esophagitis and were treated endoscopically.
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Affiliation(s)
- Peerapol Wangrattanapranee
- CURE: Digestive Diseases Research Core Center (CURE: DDRCC), Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Gastroenterology Division, Department of Medicine, VA Greater Los Angeles Healthcare System, Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA
| | - Usah Khrucharoen
- CURE: Digestive Diseases Research Core Center (CURE: DDRCC), Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Gastroenterology Division, Department of Medicine, VA Greater Los Angeles Healthcare System, Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - Dennis M Jensen
- CURE: Digestive Diseases Research Core Center (CURE: DDRCC), Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA. .,Gastroenterology Division, Department of Medicine, VA Greater Los Angeles Healthcare System, Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA. .,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA.
| | - Thongsak Wongpongsalee
- CURE: Digestive Diseases Research Core Center (CURE: DDRCC), Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA.,Division of Trauma Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, 13th Floor, Syamindra Building, 2 Prannok Road, Bangkok, 10700, Thailand
| | - Mary Ellen Jensen
- CURE: Digestive Diseases Research Core Center (CURE: DDRCC), Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Gastroenterology Division, Department of Medicine, VA Greater Los Angeles Healthcare System, Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
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7
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Akay T, Leblebici M. Comparison of high and low-dose epinephrine & endoclip application in peptic ulcer bleeding: A case series analysis observational study. Medicine (Baltimore) 2021; 100:e28480. [PMID: 34967393 PMCID: PMC8718225 DOI: 10.1097/md.0000000000028480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/15/2021] [Indexed: 01/05/2023] Open
Abstract
Peptic ulcer disease accounts for 50% to 70% of acute upper gastrointestinal bleeding cases. There is no consensus on the treatment of peptic ulcer bleeding (PUB) using endoscopic techniques. This study aimed to compare endoscopic techniques for PUB.Patients with PUB who were hospitalized between January 2014 and June 2020 were included in this study. They were divided into 3 groups: endoclip and low-dose epinephrine injection (0-2 mg, Group 1, n = 62), endoclip and high-dose epinephrine injection (2-4 mg, Group 2, n = 54), and endoclip only (Group 3, n = 64).Early bleeding and permanent hemostasis were higher in Group 2 (P = .014, .035). When evaluated in terms of late hemostasis and urgent surgical need, there was no significant difference between the groups (P > .05). Group 2 received a higher amount of blood. Thirty-day mortality occurred in 16.5%, 22.2%, and 9.4% of patients in Groups 1, 2, and 3, respectively. Group 2 had a longer hospital stay than Groups 1 and 3 (P = .008). The endoscopic success rates were 80.6%, 72.2%, and 90.6% in Groups 1, 2, and 3, respectively.In PUB, if the patient's Rockall score is high and the ulcer size is larger than 2 cm, endoclip application can be used as the main treatment. Addition of epinephrine may be considered when necessary.
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Affiliation(s)
- Tamer Akay
- Bandirma Onyedi Eylül University Faculty of Medicine, Department of General Surgery, Balikesir, Turkey
| | - Metin Leblebici
- Istanbul Medeniyet University, Göztepe Training and Research Hospital, General Surgery Department, Istanbul, Turkey
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8
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Lau LHS, Sung JJY. Treatment of upper gastrointestinal bleeding in 2020: New techniques and outcomes. Dig Endosc 2021; 33:83-94. [PMID: 32216134 DOI: 10.1111/den.13674] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/15/2020] [Accepted: 03/19/2020] [Indexed: 02/08/2023]
Abstract
The clinical outcome of upper gastrointestinal bleeding has improved due to advances in endoscopic therapy and standardized peri-endoscopy care. Apart from validating clinical scores, artificial intelligence-assisted machine learning models may play an important role in risk stratification. While standard endoscopic treatments remain irreplaceable, novel endoscopic modalities have changed the landscape of management. Over-the-scope clips have high success rates as rescue or even first-line treatments in difficult-to-treat cases. Hemostatic powder is safe and easy to use, which can be useful as temporary control with its high immediate hemostatic ability. After endoscopic hemostasis, Doppler endoscopic probe can offer an objective measure to guide the treatment endpoint. In refractory bleeding, angiographic embolization should be considered before salvage surgery. In variceal hemorrhage, banding ligation and glue injection are first-line treatment options. Endoscopic ultrasound-guided therapy is gaining popularity due to its capability of precise localization for treatment targets. A self-expandable metal stent may be considered as an alternative option to balloon tamponade in refractory bleeding. Transjugular intrahepatic portosystemic shunting should be reserved as salvage therapy. In this article, we aim to provide an evidence-based comprehensive review of the major advancements in endoscopic hemostatic techniques and clinical outcomes.
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Affiliation(s)
- Louis H S Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong
| | - Joseph J Y Sung
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong
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Surek A, Gemici E, Bozkurt MA, Karabulut M. UPPER GASTROINTESTINAL BLEEDING:IS ONLY AN INJECTION OF EPINEPHRINE SUFFICIENT? SUCCES RATES BY FORREST CLASSIFICATION. SANAMED 2020. [DOI: 10.24125/sanamed.v15i3.457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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10
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Kanno T, Moayyedi P. Who Needs Gastroprotection in 2020? CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2020; 18:557-573. [PMID: 33199955 PMCID: PMC7656506 DOI: 10.1007/s11938-020-00316-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 10/23/2020] [Indexed: 02/07/2023]
Abstract
Purpose of review Peptic ulcer disease (PUD) is a recognized complication of non-steroidal anti-inflammatory drugs (NSAIDs). Stress ulcers are a concern for intensive care unit (ICU) patients; PUD is also an issue for patients taking anticoagulation. Helicobacter pylori test and treat is an option for patients starting NSAID therapy, and proton pump inhibitors (PPIs) may reduce PUD in NSAID patients and other high-risk groups. Recent findings There are a large number of trials that demonstrate that Helicobacter pylori eradication reduces PUD in NSAID patients. PPI is also effective at reducing PUD in this group and is also effective in ICU patients and those on anticoagulants. The effect is too modest for PPI to be recommended in everyone, and more research is needed as to which groups would benefit the most. Increasing age, past history of PUD, and comorbidity are the most important risk factors. Summary H. pylori test and treat should be offered to older patients starting NSAIDS, while PPIs should be prescribed to patients that are at high risk of developing PUD and at risk of dying from PUD complications.
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Affiliation(s)
- Takeshi Kanno
- Division of Gastroenterology, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575 Japan
- Farncombe Family Digestive Health Institute, McMaster University, Hamilton, Ontario Canada
| | - Paul Moayyedi
- Farncombe Family Digestive Health Institute, McMaster University, Hamilton, Ontario Canada
- Audrey Campbell Chair of Ulcerative Colitis Research, Division of Gastroenterology, Department of Medicine, McMaster University, 1280 Main St. W. HSC 3V3, Hamilton, ON L8S 4K1 Canada
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Mujtaba S, Chawla S, Massaad JF. Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives. J Clin Med 2020; 9:jcm9020402. [PMID: 32024301 PMCID: PMC7074258 DOI: 10.3390/jcm9020402] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 01/30/2023] Open
Abstract
Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.
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12
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Naseer M, Lambert K, Hamed A, Ali E. Endoscopic advances in the management of non-variceal upper gastrointestinal bleeding: A review. World J Gastrointest Endosc 2020; 12:1-16. [PMID: 31942229 PMCID: PMC6939122 DOI: 10.4253/wjge.v12.i1.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 08/28/2019] [Accepted: 10/19/2019] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal bleeding is defined as the bleeding originating from the esophagus to the ligament of Treitz and further classified into variceal and non-variceal gastrointestinal bleeding. Non-variceal upper gastrointestinal bleeding remains a common clinical problem globally. It is associated with high mortality, morbidity, and cost of the health care system. Despite the continuous improvement of therapeutic endoscopy, the 30-d readmission rate secondary to rebleeding and associated mortality is an ongoing issue. Available Food and Drug Administration approved traditional or conventional therapeutic endoscopic modalities includes epinephrine injection, argon plasma coagulation, heater probe, and placement of through the scope clip, which can be used alone or in combination to decrease the risk of rebleeding. Recently, more attention has been paid to the novel advanced endoscopic devices for primary treatment of the bleeding lesion and as a secondary measure when conventional therapies fail to achieve hemostasis. This review highlights emerging endoscopic modalities used in the management of non-variceal upper gastrointestinal related bleeding such as over-the-scope clip, Coagrasper, hemostatic sprays, radiofrequency ablation, cryotherapy, endoscopic suturing devices, and endoscopic ultrasound-guided angiotherapy. In this review article, we will also discuss the technical aspects of the common procedures, outcomes in terms of safety and efficacy, and their advantages and limitations in the setting of non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Maliha Naseer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Karissa Lambert
- Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Ahmed Hamed
- Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Eslam Ali
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
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13
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Tarasconi A, Coccolini F, Biffl WL, Tomasoni M, Ansaloni L, Picetti E, Molfino S, Shelat V, Cimbanassi S, Weber DG, Abu-Zidan FM, Campanile FC, Di Saverio S, Baiocchi GL, Casella C, Kelly MD, Kirkpatrick AW, Leppaniemi A, Moore EE, Peitzman A, Fraga GP, Ceresoli M, Maier RV, Wani I, Pattonieri V, Perrone G, Velmahos G, Sugrue M, Sartelli M, Kluger Y, Catena F. Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg Surg 2020; 15:3. [PMID: 31921329 PMCID: PMC6947898 DOI: 10.1186/s13017-019-0283-9] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 12/18/2019] [Indexed: 02/08/2023] Open
Abstract
Background Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment. Methods The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached. Conclusions The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
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Affiliation(s)
- Antonio Tarasconi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | | | - Matteo Tomasoni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Sarah Molfino
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Dieter G. Weber
- Royal Perth Hospital, Perth, Australia & The University of Western Australia, Crawley, Australia
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Fabio C. Campanile
- Division of Surgery, ASL VT - Ospedale “Andosilla”, Civita Castellana, Italy
| | - Salomone Di Saverio
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Claudio Casella
- Department of Molecular and Translational Medicine, Surgical Clinic, University of Brescia, Brescia, Italy
| | - Michael D. Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Andrew W. Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta Canada
| | | | - Ernest E. Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO USA
| | - Andrew Peitzman
- University of Pittsburgh, School of Medicine, UPMC – Presbyterian, Pittsburgh, PA USA
| | - Gustavo Pereira Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | - Marco Ceresoli
- Department of General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Ronald V. Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Imtaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | | | - Gennaro Perrone
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - George Velmahos
- Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, USA
| | - Michael Sugrue
- Letterkenny University Hospital, Donegal Clinical Research Academy Centre for Personalized Medicine, Donegal, Ireland
| | | | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fausto Catena
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
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14
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Yu JX, Russell WA, Asokkumar R, Kaltenbach T, Soetikno R. Clipping Over the Scope for Recurrent Peptic Ulcer Bleeding is Cost-Effective as Compared to Standard Therapy: An Initial Assessment. Gastrointest Endosc Clin N Am 2020; 30:91-97. [PMID: 31739969 DOI: 10.1016/j.giec.2019.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Clipping over the scope (C-OTS) is a novel closure technique used for the treatment of nonvariceal gastrointestinal bleeding, especially for high-risk lesions. C-OTS devices cost more than clipping through the scope and thermal devices. The high upfront cost of C-OTS may pose a barrier to its use and the cost-effectiveness of C-OTS for peptic ulcer disease bleeding is unknown. Cost-effectiveness studies of C-OTS for peptic ulcer bleeding as both first-line and second-line therapy can provide the current estimate of the conditions in which the use of C-OTS is cost-effective and give insights of the determinants to the cost-effectiveness of C-OTS.
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Affiliation(s)
- Jessica X Yu
- Division of Gastroenterology and Hepatology, University of Michigan, 1301 Catherine Street, Ann Arbor, MI 48109, USA.
| | - W Alton Russell
- Department of Management Sciences and Engineering, Stanford University, 475 Via Ortega, Stanford, CA 94305, USA
| | - Ravishankar Asokkumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Tonya Kaltenbach
- Division of Gastroenterology and Hepatology, University of California San Francisco, 513 Parnassus Avenue, San Francisco, CA 94143, USA; Department of Gastroenterology, Veterans Affairs Medical Center; Advanced Gastrointestinal Endoscopy, Mountain View, CA, USA
| | - Roy Soetikno
- Advanced Gastrointestinal Endoscopy, Mountain View, CA, USA
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15
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Barkun AN, Almadi M, Kuipers EJ, Laine L, Sung J, Tse F, Leontiadis GI, Abraham NS, Calvet X, Chan FKL, Douketis J, Enns R, Gralnek IM, Jairath V, Jensen D, Lau J, Lip GYH, Loffroy R, Maluf-Filho F, Meltzer AC, Reddy N, Saltzman JR, Marshall JK, Bardou M. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med 2019; 171:805-822. [PMID: 31634917 PMCID: PMC7233308 DOI: 10.7326/m19-1795] [Citation(s) in RCA: 281] [Impact Index Per Article: 56.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
DESCRIPTION This update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and presents new clinically relevant recommendations. METHODS An international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional. RECOMMENDATIONS Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.
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Affiliation(s)
- Alan N Barkun
- McGill University, Montreal, Quebec, Canada (A.N.B.)
| | - Majid Almadi
- McGill University, Montreal, Quebec, Canada, and King Saud University, Riyadh, Saudi Arabia (M.A.)
| | - Ernst J Kuipers
- Erasmus University Medical Center, Rotterdam, the Netherlands (E.J.K.)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, and VA Connecticut Healthcare System, West Haven, Connecticut (L.L.)
| | - Joseph Sung
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - Frances Tse
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | | | | | - Xavier Calvet
- Hospital Parc Taulí de Sabadell, University of Barcelona, Sabadell, Spain, and CiberEHD (Instituto de Salud Carlos III), Madrid, Spain (X.C.)
| | - Francis K L Chan
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - James Douketis
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | - Robert Enns
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada (R.E.)
| | - Ian M Gralnek
- Technion-Israel Institute of Technology, Emek Medical Center, Afula, Israel (I.M.G.)
| | | | - Dennis Jensen
- University of California, Los Angeles, Los Angeles, California (D.J.)
| | - James Lau
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - Gregory Y H Lip
- University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom, and Aalborg University, Aalborg, Denmark (G.Y.L.)
| | - Romaric Loffroy
- Dijon-Bourgogne University Hospital, Dijon, France (R.L., M.B.)
| | | | | | - Nageshwar Reddy
- Asian Institute of Gastroenterology, Hyderabad, India (N.R.)
| | - John R Saltzman
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (J.R.S.)
| | - John K Marshall
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | - Marc Bardou
- Dijon-Bourgogne University Hospital, Dijon, France (R.L., M.B.)
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16
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Stofkova A, Murakami M. Neural activity regulates autoimmune diseases through the gateway reflex. Bioelectron Med 2019; 5:14. [PMID: 32232103 PMCID: PMC7098223 DOI: 10.1186/s42234-019-0030-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/18/2019] [Indexed: 12/15/2022] Open
Abstract
The brain, spinal cord and retina are protected from blood-borne compounds by the blood-brain barrier (BBB), blood-spinal cord barrier (BSCB) and blood-retina barrier (BRB) respectively, which create a physical interface that tightly controls molecular and cellular transport. The mechanical and functional integrity of these unique structures between blood vessels and nervous tissues is critical for maintaining organ homeostasis. To preserve the stability of these barriers, interplay between constituent barrier cells, such as vascular endothelial cells, pericytes, glial cells and neurons, is required. When any of these cells are defective, the barrier can fail, allowing blood-borne compounds to encroach neural tissues and cause neuropathologies. Autoimmune diseases of the central nervous system (CNS) and retina are characterized by barrier disruption and the infiltration of activated immune cells. Here we review our recent findings on the role of neural activity in the regulation of these barriers at the vascular endothelial cell level in the promotion of or protection against the development of autoimmune diseases. We suggest nervous system reflexes, which we named gateway reflexes, are fundamentally involved in these diseases. Although their reflex arcs are not completely understood, we identified the activation of specific sensory neurons or receptor cells to which barrier endothelial cells respond as effectors that regulate gateways for immune cells to enter the nervous tissue. We explain this novel mechanism and describe its role in neuroinflammatory conditions, including models of multiple sclerosis and posterior autoimmune uveitis.
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Affiliation(s)
- Andrea Stofkova
- 1Department of Physiology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
- 2Division of Molecular Psychoimmunology, Institute for Genetic Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-0815 Japan
| | - Masaaki Murakami
- 2Division of Molecular Psychoimmunology, Institute for Genetic Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-0815 Japan
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17
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Parsi MA, Schulman AR, Aslanian HR, Bhutani MS, Krishnan K, Lichtenstein DR, Melson J, Navaneethan U, Pannala R, Sethi A, Trikudanathan G, Trindade AJ, Watson RR, Maple JT. Devices for endoscopic hemostasis of nonvariceal GI bleeding (with videos). VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2019; 4:285-299. [PMID: 31334417 PMCID: PMC6616320 DOI: 10.1016/j.vgie.2019.02.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Endoscopic intervention is often the first line of therapy for GI nonvariceal bleeding. Although some of the devices and techniques used for this purpose have been well studied, others are relatively new, with few available outcomes data. METHODS In this document, we review devices and techniques for endoscopic treatment of nonvariceal GI bleeding, the evidence regarding their efficacy and safety, and financial considerations for their use. RESULTS Devices used for endoscopic hemostasis in the GI tract can be classified into injection devices (needles), thermal devices (multipolar/bipolar probes, hemostatic forceps, heater probe, argon plasma coagulation, radiofrequency ablation, and cryotherapy), mechanical devices (clips, suturing devices, banding devices, stents), and topical devices (hemostatic sprays). CONCLUSIONS Endoscopic evaluation and treatment remains a cornerstone in the management of nonvariceal upper- and lower-GI bleeding. A variety of devices is available for hemostasis of bleeding lesions in the GI tract. Other than injection therapy, which should not be used as monotherapy, there are few compelling data that strongly favor any one device over another. For endoscopists, the choice of a hemostatic device should depend on the type and location of the bleeding lesion, the availability of equipment and expertise, and the cost of the device.
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Key Words
- ABS, Ankaferd blood stopper
- APC, argon plasma coagulation
- ASGE, American Society for Gastrointestinal Endoscopy
- CPT, Current Procedural Terminology
- CSEMS, covered self-expandable metallic stent
- EBL, endoscopic band ligation
- EDP, endoscopic Doppler probe
- GAVE, gastric antral vascular ectasia
- HP, heater probe
- LGIB, lower GI bleeding
- MPEC, multipolar electrocoagulation
- OTSC, over-the-scope clip
- PTFE, polytetrafluoroethylene
- RCT, randomized controlled trial
- TTS, through-the-scope
- U.S. FDA, United States Food and Drug Administration
- UGIB, upper GI bleeding
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Affiliation(s)
| | - Mansour A. Parsi
- Section for Gastroenterology & Hepatology, Tulane University Health Sciences Center, New Orleans, LA
| | - Allison R. Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Harry R. Aslanian
- Section of Digestive Diseases, Department of Internal Medicine, Yale University, New Haven, CT
| | - Manoop S. Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Kuman Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - David R. Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, IL
| | | | - Rahul Pannala
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, New York-Presbyterian/Columbia University Medical Center, New York, NY
| | | | - Arvind J. Trindade
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, NY
| | - Rabindra R. Watson
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, CA
| | - John T. Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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18
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Jung K, Moon W. Role of endoscopy in acute gastrointestinal bleeding in real clinical practice: An evidence-based review. World J Gastrointest Endosc 2019; 11:68-83. [PMID: 30788026 PMCID: PMC6379746 DOI: 10.4253/wjge.v11.i2.68] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 02/02/2019] [Accepted: 02/13/2019] [Indexed: 02/06/2023] Open
Abstract
Although upper gastrointestinal bleeding is usually segregated from lower gastrointestinal bleeding, and guidelines for gastrointestinal bleeding are divided into two separate sections, they may not be distinguished from each other in clinical practice. Most patients are first observed with signs of bleeding such as hematemesis, melena, and hematochezia. When a patient with these symptoms presents to the emergency room, endoscopic diagnosis and treatment are considered together with appropriate initial resuscitation. Especially, in cases of variceal bleeding, it is important for the prognosis that the endoscopy is performed immediately after the patient stabilizes. In cases of suspected lower gastrointestinal bleeding, full colonoscopy after bowel preparation is effective in distinguishing the cause of the bleeding and treating with hemostasis. The therapeutic aspect of endoscopy, using the mechanical method alone or injection with a certain modality rather than injection alone, can increase the success rate of bleeding control. Therefore, it is important to consider the origin of bleeding and how to approach it. In this article, we aim to review the role of endoscopy in diagnosis, treatment, and prognosis in patients with acute gastrointestinal bleeding in a real clinical setting.
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Affiliation(s)
- Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan 49267, South Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Busan 49267, South Korea
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19
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Alzoubaidi D, Lovat LB, Haidry R. Management of non-variceal upper gastrointestinal bleeding: where are we in 2018? Frontline Gastroenterol 2019; 10:35-42. [PMID: 30651955 PMCID: PMC6319149 DOI: 10.1136/flgastro-2017-100901] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/10/2018] [Accepted: 01/21/2018] [Indexed: 02/04/2023] Open
Abstract
Acute upper gastrointestinal bleeding (AUGIB) is one of the most common medical emergencies in the UK. Despite advancement in technology the management of AUGIB remains a challenge. The clinical community recognise the need for improvement in the treatment of these patients. AUGIB has a significant impact on resources. Endoscopic therapy is the gold standard treatment. The mortality in AUGIB is rarely related to the presenting bleed but significantly associated with concurrent comorbidities. The cost of blood transfusion in the management of patients with AUGIB is significant and misuse of blood products has been documented nationally. Risk stratification tools such as Glasgow-Blatchford Score, Rockall Score and the AIMS65 score have allowed clinicians to triage patients appropriately in order to deliver endoscopic therapy within a suitable time frame. Endoscopic therapeutic modalities such as epinephrine injection, heat thermocoagulation and mechanical clips have had a positive impact on patient's management. However, in order to continue to improve patient's outcomes, further developments are needed.
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Affiliation(s)
- Durayd Alzoubaidi
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Laurence B Lovat
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Rehan Haidry
- Division of Surgery and Interventional Science, University College London, London, UK
- GI Services, University College London Hospital, London, UK
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20
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Cipolletta L, Cipolletta F, Granata A, Ligresti D, Barresi L, Tarantino I, Traina M. What Is the Best Endoscopic Strategy in Acute Non-variceal Gastrointestinal Bleeding? ACTA ACUST UNITED AC 2018; 16:363-375. [PMID: 30229463 DOI: 10.1007/s11938-018-0192-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OPINION STATEMENT PURPOSE OF REVIEW: Upper non-variceal gastrointestinal bleeding (UNVGIB) remains an important clinical challenge for endoscopists, requiring skill and expertise for correct management. In this paper, we suggest the best strategy for an effective treatment of this complex category of patients. RECENT FINDINGS Early endoscopic examination, the increasingly widespread use of endoscopic hemostasis methods, and the most powerful antisecretory agents that induce clot stabilization have radically modified the clinical scenario for treating this pathology. While hospitalization for digestive hemorrhage is decreasing, the incidence of bleeding seems to be increasing, especially in the elderly for whom a greater use of gastrolesive drugs and the presence of comorbidities are more common. A multidisciplinary approach for initial patient evaluation and hemodynamic resuscitation prior to endoscopic treatment is crucial for correct management, prevention of rebleeding, and reduction of morbidity and mortality rates and hospital stays. Appropriate operator technical expertise, together with the availability of a wide range of endoscopes and devices, is mandatory. Newer endoscopic techniques may improve patient outcomes for difficult-to-treat lesions. Today, endoscopic hemostasis can be achieved in over 95% of patients.
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Affiliation(s)
- Livio Cipolletta
- Endoscopy Unit, Ruesch Clinic, Via San Domenico, 24, 80127, Naples, Italy.
| | - Fabio Cipolletta
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Antonino Granata
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
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21
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Abstract
Peptic ulcer bleeding is common and associated with significant morbidity and mortality. We discuss the endoscopic assessment of peptic ulcers and the rationale for treatment. We also review the evidence for the available endoscopic therapies, both individually and in combination, to draw conclusions on the optimum endoscopic management of peptic ulcer bleeding.
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22
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Ghassemi KA, Jensen DM. The Cutting Edge: Doppler Probe in Guiding Endoscopic Hemostasis. Gastrointest Endosc Clin N Am 2018; 28:321-330. [PMID: 29933778 DOI: 10.1016/j.giec.2018.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This article examines use of the Doppler endoscopic probe (DEP) for risk stratification and as a guide to definitive hemostasis of nonvariceal upper gastrointestinal (NVUGI) bleeding and colonic diverticular hemorrhage. Studies report that lesions with high-risk stigmata of recent hemorrhage (SRH) have a higher rate of a positive DEP signal compared with those without such SRH. Lesions with a persistently positive DEP signal after endoscopic hemostasis have a higher 30-day rebleeding rate. Studies document arterial blood flow underneath stigmata of recent hemorrhage as a risk factor for rebleeding of focal nonvariceal gastrointestinal lesions. With DEP probe as a guide, rates of definitive endoscopic hemostasis and clinical outcomes are improved compared with standard visually guided treatment.
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Affiliation(s)
- Kevin A Ghassemi
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 100 Medical Plaza Driveway, Los Angeles, CA 90095, USA; CURE: Digestive Diseases Research Center, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA.
| | - Dennis M Jensen
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 100 Medical Plaza Driveway, Los Angeles, CA 90095, USA; CURE: Digestive Diseases Research Center, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA; Department of Medicine, VA West Los Angeles Medical Center, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA
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23
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Song IJ, Kim HJ, Lee JA, Park JC, Shin SK, Lee SK, Lee YC, Chung H. Clinical Outcomes of Endoscopic Hemostasis for Bleeding in Patients with Unresectable Advanced Gastric Cancer. J Gastric Cancer 2017; 17:374-383. [PMID: 29302377 PMCID: PMC5746658 DOI: 10.5230/jgc.2017.17.e42] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 12/22/2017] [Accepted: 12/22/2017] [Indexed: 12/16/2022] Open
Abstract
Purpose Bleeding is one of the most serious complications of advanced gastric cancer (AGC) and is associated with a poor prognosis. This study aimed to evaluate the clinical outcomes of endoscopic hemostasis for bleeding in patients with unresectable AGC. Materials and Methods This study included 106 patients with bleeding associated with gastric cancer who had undergone endoscopic hemostasis between January 2010 and December 2013. Clinical characteristics, treatment outcomes, including rates of successful endoscopic hemostasis and rebleeding, risk factors for rebleeding, and overall survival (OS) were investigated. Results Successful initial hemostasis was achieved in 83% of patients. Rebleeding occurred in 28.3% of patients within 30 days. The median OS after initial hemostasis was lower in patients with rebleeding than in those without rebleeding (2.7 and 3.9 months, respectively, P=0.02). There were no significant differences in disease status and rebleeding rates among patients with partial response or stable disease (n=4), progressive disease (n=64), and first diagnosis of disease (n=38). Univariate and multivariate analyses (P=0.038 and 0.034, respectively) revealed that transfusion of ≥5 units of RBCs was a significant risk factor for rebleeding. Conclusions Despite favorable success rates of endoscopic hemostasis for bleeding associated with gastric cancer, the 30-day rebleeding rate was 28.3% and the median OS was significantly lower in patients with rebleeding than in those without rebleeding. Massive transfusion (≥5 units of RBCs) was the only significant risk factor for rebleeding. Patients with bleeding associated with AGC who have undergone massive transfusion should be observed closely following endoscopic hemostasis. Further research on approaches to reduce rebleeding rate and prevent death is needed.
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Affiliation(s)
- In Ji Song
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Ju Kim
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea.,Departtment of Medicine, Yonsei University Graduate School, Seoul, Korea
| | - Ji Ae Lee
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kwan Shin
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Lee
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyunsoo Chung
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea.,Departtment of Medicine, Yonsei University Graduate School, Seoul, Korea
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Tse CS, Parikh ND. An uncommon source of upper gastrointestinal bleeding: epiphrenic esophageal diverticulum. Gastroenterol Rep (Oxf) 2017; 5:313-315. [PMID: 26304469 PMCID: PMC5691801 DOI: 10.1093/gastro/gov043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 06/29/2015] [Accepted: 07/09/2015] [Indexed: 12/12/2022] Open
Abstract
Esophageal diverticula are rare findings that have an estimated incidence of 1 per 500 000 people per year, even though acute upper gastrointestinal bleeding is a relatively common medical emergency with an incidence of up to 150 per 100 000 people per year and a mortality rate of 7-14%. An 83-year-old man presented with hematemesis and melena. Urgent upper endoscopy revealed an esophageal diverticulum, within which was an adherent clot. Removal of the clot identified a bleeding vessel within the diverticulum; this was successfully clipped and hemostasis was achieved. To the best of our knowledge, this is the first case report of a bleeding epiphrenic esophageal diverticulum that was successfully managed endoscopically with hemostatic clips alone. While rare, our case serves as a reminder that bleeding epiphrenic esophageal diverticula can present as massive upper gastrointestinal bleeding and urgent endoscopic therapy can be life-saving.
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Affiliation(s)
- Chung Sang Tse
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Neil D Parikh
- Division of Gastroenterology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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Shi K, Shen Z, Zhu G, Meng F, Gu M, Ji F. Systematic review with network meta-analysis: dual therapy for high-risk bleeding peptic ulcers. BMC Gastroenterol 2017; 17:55. [PMID: 28424073 PMCID: PMC5395769 DOI: 10.1186/s12876-017-0610-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 04/04/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Adding a second endoscopic therapy to epinephrine injection might improve hemostatic efficacy in patients with high-risk bleeding ulcers but the optimum modality remains unknown. We aimed to estimate the comparative efficacy of different dual endoscopic therapies for the management of bleeding peptic ulcers through random-effects Bayesian network meta-analysis. METHODS Different databases were searched for controlled trials comparing dual therapy versus epinephrine monotherapy or epinephrine combined with another second modality until September, 30 2016. We estimated the ORs for rebleeding, surgery and mortality among different treatments. Adverse events were also evaluated. RESULTS Seventeen eligible articles were included in the network meta-analysis. The addition of mechanical therapy (OR 0.19, 95% CrI 0.07-0.52 and OR 0.10, 95% CrI 0.01-0.50, respectively) after epinephrine injection significantly reduced the probability of rebleeding and surgery. Similarly, patients who received epinephrine plus thermal therapy showed a significantly decreased rebleeding rate (OR 0.30, 95% CrI 0.10-0.91), as well as a non-significant reduction in surgery (OR 0.47, 95% CrI 0.16-1.20). Although differing, epinephrine plus mechanical therapy did not provide a significant reduction in rebleeding (OR 0.62, 95% CrI 0.19-2.22) and surgery (OR 0.21, 95% CrI 0.03-1.73) compared to epinephrine plus thermal therapy. Sclerosant failed to confer further benefits and was ranked highest among the 5 treatments in relation to adverse events. CONCLUSIONS Mechanical therapy was the most appropriate modality to add to epinephrine injection. Epinephrine plus thermal coagulation was effective for controlling high risk bleeding ulcers. There was no further benefit with sclerosants with regard to rebleeding or surgery, and sclerosants were also associated with more adverse events than any other modality.
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Affiliation(s)
- Keda Shi
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, No. 79 Qingchun Rd, Hangzhou, 310000, Zhejiang, China
| | - Zeren Shen
- Eye Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Guiqi Zhu
- Department of Hepatology, Liver Research Center, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Fansheng Meng
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, No. 79 Qingchun Rd, Hangzhou, 310000, Zhejiang, China
| | - Mengli Gu
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, No. 79 Qingchun Rd, Hangzhou, 310000, Zhejiang, China
| | - Feng Ji
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, No. 79 Qingchun Rd, Hangzhou, 310000, Zhejiang, China.
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What Does Lesion Blood Flow Tell Us About Risk Stratification and Successful Management of Non-variceal UGI Bleeding? Curr Gastroenterol Rep 2017; 19:17. [PMID: 28374310 DOI: 10.1007/s11894-017-0556-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW There has been a decline in mortality associated with upper gastrointestinal (UGI) hemorrhage as the use of urgent endoscopy has increased. This review will examine endoscopic risk stratification of non-variceal UGI bleeding (e.g., ulcers, Dieulafoy lesions, and Mallory-Weiss tears), including the use of the Doppler endoscopic probe (DEP). RECENT FINDINGS Prospective studies evaluating the use of DEP in non-variceal UGI hemorrhage showed that lesions with high-risk stigmata of recent hemorrhage (SRH) have a higher rate of a positive DEP signal compared to those with intermediate-risk SRH. Additionally, lesions with a persistently positive DEP signal after endoscopic hemostasis were seen with high-risk SRH and had a higher 30-day rebleeding rate. Residual arterial blood flow underneath ulcers is a significant risk factor for rebleeding. However, if more endoscopic treatment is applied, clinical outcomes for patients with severe non-variceal UGI hemorrhage are improved, as documented by a recent CURE Hemostasis randomized controlled trial (RCT).
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Akin M, Alkan E, Tuna Y, Yalcinkaya T, Yildirim B. Comparison of heater probe coagulation and argon plasma coagulation in the management of Mallory–Weiss tears and high-risk ulcer bleeding. Arab J Gastroenterol 2017; 18:35-38. [DOI: 10.1016/j.ajg.2017.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 10/28/2016] [Accepted: 12/23/2016] [Indexed: 12/24/2022]
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The Application of Hemospray in Gastrointestinal Bleeding during Emergency Endoscopy. Gastroenterol Res Pract 2017; 2017:3083481. [PMID: 28232848 PMCID: PMC5292382 DOI: 10.1155/2017/3083481] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/17/2016] [Accepted: 12/14/2016] [Indexed: 02/07/2023] Open
Abstract
Introduction. Gastrointestinal bleeding represents the main indication for emergency endoscopy (EE). Lately, several hemostatic powders have been released to facilitate EE. Methods. We evaluated all EE in which Hemospray was used as primary or salvage therapy, with regard to short- and long-term hemostasis and complications. Results. We conducted 677 EE in 474 patients (488 examinations in 344 patients were upper GI endoscopies). Hemospray was applied during 35 examinations in 27 patients (19 males), 33 during upper and 2 during lower endoscopy. It was used after previous treatment in 21 examinations (60%) and in 14 (40%) as salvage therapy. Short-term success was reached in 34 of 35 applications (97.1%), while long-term success occurred in 23 applications (65.7%). Similar long-term results were found after primary application (64,3%) or salvage therapy (66,7%). Rebleeding was found in malignant and extended ulcers. One major adverse event (2.8%) occurred with gastric perforation after Hemospray application. Discussion. Hemospray achieved short-term hemostasis in virtually all cases. The long-term effect is mainly determined by the type of bleeding source, but not whether it was applied as first line or salvage therapy. But, even in the failures, patients had benefit from hemodynamic stabilization and consecutive interventions in optimized conditions.
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29
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Cheng HC, Wu CT, Chen WY, Yang EH, Chen PJ, Sheu BS. Risk factors determining the need for second-look endoscopy for peptic ulcer bleeding after endoscopic hemostasis and proton pump inhibitor infusion. Endosc Int Open 2016; 4:E255-62. [PMID: 27004241 PMCID: PMC4798837 DOI: 10.1055/s-0041-111499] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 12/14/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS The need for routine second-look endoscopy in cases of peptic ulcer bleeding remains uncertain. We investigated risk factors related to the need for second-look endoscopy after endoscopic hemostasis and proton pump inhibitor (PPI) infusion. PATIENTS AND METHODS We prospectively enrolled 316 patients with peptic ulcer bleeding after endoscopic hemostasis. Second-look endoscopy was scheduled after 72-hour PPI infusion (Day-3 subgroup) or one day early (Day-2 subgroup). If early rebleeding developed within 3 days, emergent second-look endoscopy was conducted. Risk factors for early rebleeding (use of E2(nd) score to predict the need for early second-look endoscopy) and persistent major stigmata in the Day-3 subgroup (use of R2(nd) score to predict the need for routine second-look endoscopy) were analyzed using univariable and multivariable regression. RESULTS Excluding 10 of 316 patients with early rebleeding, the rate of persistent major stigmata was lower in the Day-3 subgroup than in the Day-2 subgroup (4.8 % vs. 15.4 %, P = 0.002). Endoscopic epinephrine-injection monotherapy and hypoalbuminemia < 3.0 g/dL were two independent risk factors for early rebleeding (P ≤ 0.05). The Forrest Ia-Ib type and hypoalbuminemia < 3.5 g/dL were two independent risk factors for persistent major stigmata on the day-3 second-look endoscopy (P < 0.05). The E2(nd) score was highly accurate for prediction of early rebleeding (AUROC 0.86; 95 % CI, 0.73~0.99), and the R2(nd) score could predict persistent major stigmata at second-look endoscopy (AUROC 0.84; 95 % CI, 0.69~0.99). CONCLUSIONS For patients with peptic ulcer bleeding, E2(nd) and R2(nd) scores can indicate the need for early and routine second-look endoscopy, respectively (Trial registration identifier: NCT02197039).
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Affiliation(s)
- Hsiu-Chi Cheng
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung Univeristy, Tainan, Taiwan,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Tai Wu
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung Univeristy, Tainan, Taiwan,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ying Chen
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung Univeristy, Tainan, Taiwan,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Er-Hsiang Yang
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung Univeristy, Tainan, Taiwan,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Jun Chen
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung Univeristy, Tainan, Taiwan,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Bor-Shyang Sheu
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung Univeristy, Tainan, Taiwan,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Nojkov B, Cappell MS. Distinctive aspects of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss syndrome in patients with advanced alcoholic liver disease or cirrhosis. World J Gastroenterol 2016; 22:446-466. [PMID: 26755890 PMCID: PMC4698507 DOI: 10.3748/wjg.v22.i1.446] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/11/2015] [Accepted: 11/24/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To systematically review the data on distinctive aspects of peptic ulcer disease (PUD), Dieulafoy’s lesion (DL), and Mallory-Weiss syndrome (MWS) in patients with advanced alcoholic liver disease (aALD), including alcoholic hepatitis or alcoholic cirrhosis.
METHODS: Computerized literature search performed via PubMed using the following medical subject heading terms and keywords: “alcoholic liver disease”, “alcoholic hepatitis”,“ alcoholic cirrhosis”, “cirrhosis”, “liver disease”, “upper gastrointestinal bleeding”, “non-variceal upper gastrointestinal bleeding”, “PUD”, ‘‘DL’’, ‘‘Mallory-Weiss tear”, and “MWS’’.
RESULTS: While the majority of acute gastrointestinal (GI) bleeding with aALD is related to portal hypertension, about 30%-40% of acute GI bleeding in patients with aALD is unrelated to portal hypertension. Such bleeding constitutes an important complication of aALD because of its frequency, severity, and associated mortality. Patients with cirrhosis have a markedly increased risk of PUD, which further increases with the progression of cirrhosis. Patients with cirrhosis or aALD and peptic ulcer bleeding (PUB) have worse clinical outcomes than other patients with PUB, including uncontrolled bleeding, rebleeding, and mortality. Alcohol consumption, nonsteroidal anti-inflammatory drug use, and portal hypertension may have a pathogenic role in the development of PUD in patients with aALD. Limited data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic patients. The frequency of bleeding from DL appears to be increased in patients with aALD. DL may be associated with an especially high mortality in these patients. MWS is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism, and is associated with aALD. Patients with aALD have more severe MWS bleeding and are more likely to rebleed when compared to non-cirrhotics. Pre-endoscopic management of acute GI bleeding in patients with aALD unrelated to portal hypertension is similar to the management of aALD patients with GI bleeding from portal hypertension, because clinical distinction before endoscopy is difficult. Most patients require intensive care unit admission and attention to avoid over-transfusion, to correct electrolyte abnormalities and coagulopathies, and to administer antibiotic prophylaxis. Alcoholics should receive thiamine and be closely monitored for symptoms of alcohol withdrawal. Prompt endoscopy, after initial resuscitation, is essential to diagnose and appropriately treat these patients. Generally, the same endoscopic hemostatic techniques are used in patients bleeding from PUD, DL, or MWS in patients with aALD as in the general population.
CONCLUSION: Nonvariceal upper GI bleeding in patients with aALD has clinically important differences from that in the general population without aALD, including: more frequent and more severe bleeding from PUD, DL, or MWS.
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Ghassemi KA, Jensen DM. Evolving techniques for gastrointestinal endoscopic hemostasis treatment. Expert Rev Gastroenterol Hepatol 2016; 10:615-23. [PMID: 26651414 PMCID: PMC6063521 DOI: 10.1586/17474124.2016.1130623] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
With mortality due to gastrointestinal (GI) bleeding remaining stable, the focus on endoscopic hemostasis has been on improving other outcomes such as rebleeding rate, need for transfusions, and need for angiographic embolization or surgery. Over the past few years, a number of devices have emerged to help endoscopically assess and treat bleeding GI lesions. These include the Doppler endoscopic probe, hemostatic powder, and over-the-scope clip. Also, new applications have been described for radiofrequency ablation. In this article, we will discuss these evolving tools and techniques that have been developed, including an analysis of their efficacy and limitations.
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Affiliation(s)
- Kevin A. Ghassemi
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA,CURE Hemostasis Research Group
| | - Dennis M. Jensen
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA,CURE Hemostasis Research Group,Division of Gastroenterology, VA Greater Los Angeles Healthcare Center, Los Angeles, CA, USA
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32
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Kärkkäinen JM, Miilunpohja S, Rantanen T, Koskela JM, Jyrkkä J, Hartikainen J, Paajanen H. Alcohol Abuse Increases Rebleeding Risk and Mortality in Patients with Non-variceal Upper Gastrointestinal Bleeding. Dig Dis Sci 2015; 60:3707-15. [PMID: 26177705 DOI: 10.1007/s10620-015-3806-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 07/08/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND No current data are available on rebleeding and mortality risk in patients who use alcohol excessively and are admitted for non-variceal upper gastrointestinal bleeding (NVUGIB). This information could help in planning interventions and follow-up protocols for these patients. AIM This study provides contemporary data on the long-term outcome after first-time NVUGIB in alcohol abusers (AAs) compared to non-abusers (NAs). METHODS Consecutive patients hospitalized for their first acute gastrointestinal bleeding from 2009 through 2011 were retrospectively recorded and categorized as AA or NA. Risk factors for one-year mortality and rebleeding were identified, and patients were further monitored for long-term mortality until 2015. RESULTS Alcohol abuse was identified in 19.7% of patients with NVUGIB (n = 518). The one-year rebleeding rate was 16.7% in AAs versus 9.1% in NAs (P = 0.027). Alcohol abuse was associated with a twofold increase in rebleeding risk (P = 0.025); the risk especially increased 6 months after the initial bleeding. The study groups did not differ significantly in 30-day (6.0%) or one-year mortality rates (20.5%). However, there was a tendency for higher overall mortality in AAs than NAs after adjustment of comorbidities. CONCLUSION AAs with NVUGIB are at high risk of rebleeding, and mortality is increased in AA patients. A close follow-up strategy and long-term proton pump inhibitor therapy are recommended for AA patients with peptic ulcer or esophagitis.
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Affiliation(s)
- Jussi M Kärkkäinen
- Heart Center, Kuopio University Hospital, PL 100, 70029, Kuopio, KYS, Finland.
- Department of Gastrointestinal Surgery, Kuopio University Hospital, Kuopio, Finland.
| | - Sami Miilunpohja
- Heart Center, Kuopio University Hospital, PL 100, 70029, Kuopio, KYS, Finland
- Emergency Department, Kuopio University Hospital, Kuopio, Finland
| | - Tuomo Rantanen
- Department of Gastrointestinal Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Jenni M Koskela
- School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Johanna Jyrkkä
- Assessment of Pharmacotherapies, Finnish Medicines Agency, Kuopio, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital, PL 100, 70029, Kuopio, KYS, Finland
- School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Hannu Paajanen
- Department of Gastrointestinal Surgery, Kuopio University Hospital, Kuopio, Finland
- School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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Biecker E. Diagnosis and therapy of non-variceal upper gastrointestinal bleeding. World J Gastrointest Pharmacol Ther 2015; 6:172-182. [PMID: 26558151 PMCID: PMC4635157 DOI: 10.4292/wjgpt.v6.i4.172] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 05/06/2015] [Accepted: 10/09/2015] [Indexed: 02/06/2023] Open
Abstract
Non-variceal upper gastrointestinal bleeding (UGIB) is defined as bleeding proximal to the ligament of Treitz in the absence of oesophageal, gastric or duodenal varices. The clinical presentation varies according to the intensity of bleeding from occult bleeding to melena or haematemesis and haemorrhagic shock. Causes of UGIB are peptic ulcers, Mallory-Weiss lesions, erosive gastritis, reflux oesophagitis, Dieulafoy lesions or angiodysplasia. After admission to the hospital a structured approach to the patient with acute UGIB that includes haemodynamic resuscitation and stabilization as well as pre-endoscopic risk stratification has to be done. Endoscopy offers not only the localisation of the bleeding site but also a variety of therapeutic measures like injection therapy, thermocoagulation or endoclips. Endoscopic therapy is facilitated by acid suppression with proton pump inhibitor (PPI) therapy. These drugs are highly effective but the best route of application (oral vs intravenous) and the adequate dosage are still subjects of discussion. Patients with ulcer disease are tested for Helicobacter pylori and eradication therapy should be given if it is present. Non-steroidal anti-inflammatory drugs have to be discontinued if possible. If discontinuation is not possible, cyclooxygenase-2 inhibitors in combination with PPI have the lowest bleeding risk but the incidence of cardiovascular events is increased.
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Baracat F, Moura E, Bernardo W, Pu LZ, Mendonça E, Moura D, Baracat R, Ide E. Endoscopic hemostasis for peptic ulcer bleeding: systematic review and meta-analyses of randomized controlled trials. Surg Endosc 2015; 30:2155-68. [PMID: 26487199 DOI: 10.1007/s00464-015-4542-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 09/01/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Peptic ulcer represents the most common cause of upper gastrointestinal bleeding. Endoscopic therapy can reduce the risks of rebleeding, continued bleeding, need for surgery, and mortality. The objective of this review is to compare the different modalities of endoscopic therapy. METHODS Studies were identified by searching electronic databases MEDLINE, Embase, Cochrane, LILACS, DARE, and CINAHL. We selected randomized clinical trials that assessed contemporary endoscopic hemostatic techniques. The outcomes evaluated were: initial hemostasis, rebleeding rate, need for surgery, and mortality. The possibility of publication bias was evaluated by funnel plots. An additional analysis was made, including only the higher-quality trials. RESULTS Twenty-eight trials involving 2988 patients were evaluated. Injection therapy alone was inferior to injection therapy with hemoclip and with thermal coagulation when evaluating rebleeding and the need for emergency surgery. Hemoclip was superior to injection therapy in terms of rebleeding; there were no statistically significant differences between hemoclip alone and hemoclip with injection therapy. There was considerable heterogeneity in the comparisons between hemoclip and thermal coagulation. There were no statistically significant differences between thermal coagulation and injection therapy, though their combination was superior, in terms of rebleeding, to thermal coagulation alone. CONCLUSIONS Injection therapy should not be used alone. Hemoclip is superior to injection therapy, and combining hemoclip with an injectate does not improve hemostatic efficacy above hemoclip alone. Thermal coagulation has similar efficacy as injection therapy; combining these appears to be superior to thermal coagulation alone. Therefore, we recommend the application of hemoclips or the combined use of injection therapy with thermal coagulation for the treatment of peptic ulcer bleeding.
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Affiliation(s)
- Felipe Baracat
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6° andar, São Paulo, SP, CEP 05403-900, Brazil. .,, Rua Martinico Prado, 241, apt 94, CEP 01224-010, São Paulo, SP, Brazil.
| | - Eduardo Moura
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6° andar, São Paulo, SP, CEP 05403-900, Brazil
| | - Wanderley Bernardo
- Thoracic Surgery Department, Instituto do Coraçao (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | - Leonardo Zorron Pu
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6° andar, São Paulo, SP, CEP 05403-900, Brazil
| | - Ernesto Mendonça
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6° andar, São Paulo, SP, CEP 05403-900, Brazil
| | - Diogo Moura
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6° andar, São Paulo, SP, CEP 05403-900, Brazil
| | - Renato Baracat
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6° andar, São Paulo, SP, CEP 05403-900, Brazil
| | - Edson Ide
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6° andar, São Paulo, SP, CEP 05403-900, Brazil
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Abstract
Upper gastrointestinal bleeding remains one of the most common challenges faced by gastroenterologists and endoscopists in daily clinical practice. Endoscopic management of nonvariceal bleeding has been shown to improve clinical outcomes, with significant reduction of recurrent bleeding, need for surgery, and mortality. Early upper gastrointestinal endoscopy is recommended in all patients presenting with upper gastrointestinal bleeding within 24 hours of presentation, although appropriate resuscitation, stabilization of hemodynamic parameters, and optimization of comorbidity before endoscopy are essential.
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Does Preendoscopy Rockall Score Safely Identify Low Risk Patients following Upper Gastrointestinal Haemorrhage? Gastroenterol Res Pract 2015; 2015:410702. [PMID: 26089867 PMCID: PMC4451575 DOI: 10.1155/2015/410702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 04/12/2015] [Accepted: 04/20/2015] [Indexed: 11/17/2022] Open
Abstract
Objective. To determine if preendoscopy Rockall score (PERS) enables safe outpatient management of New Zealanders with upper gastrointestinal haemorrhage (UGIH). Methods. Retrospective analysis of adults with UGIH over 59 consecutive months. PERS, diagnosis, demographics, need for endoscopic therapy, transfusion or surgery and 30-day mortality and 14-day rebleeding rate, and sensitivity and specificity of PERS for enabling safe discharge preendoscopy were calculated. Results. 424 admissions with UGIH. Median age was 74.3 years (range 19–93 years), with 55.1% being males. 30-day mortality was 4.6% and 14-day rebleeding rate was 6.0%. Intervention was required in 181 (46.6%): blood transfusion (147 : 37.9%), endoscopic intervention (75 : 19.3%), and surgery (8 : 2.1%). 42 (10.8%) had PERS = 0 with intervention required in 15 (35.7%). Females more frequently required intervention, OR 1.73 (CI: 1.12–2.69). PERS did not predict intervention but did predict 30-day mortality: each point increase equated to an increase in mortality of OR 1.46 (CI: 1.11–1.92). Taking NSAIDs/aspirin reduced 30-day mortality, OR 0.22 (CI: 0.08–0.60). Conclusion. PERS identifies 10.8% of those with UGIH as low risk but 35.7% required intervention or died. It has a limited role in assessing these patients and should not be used to identify those suitable for outpatient endoscopy.
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Kim YI, Choi IJ. Endoscopic management of tumor bleeding from inoperable gastric cancer. Clin Endosc 2015; 48:121-7. [PMID: 25844339 PMCID: PMC4381138 DOI: 10.5946/ce.2015.48.2.121] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 02/24/2015] [Accepted: 02/26/2015] [Indexed: 01/10/2023] Open
Abstract
Tumor bleeding is not a rare complication in patients with inoperable gastric cancer. Endoscopy has important roles in the diagnosis and primary treatment of tumor bleeding, similar to its roles in other non-variceal upper gastrointestinal bleeding cases. Although limited studies have been performed, endoscopic therapy has been highly successful in achieving initial hemostasis. One or a combination of endoscopic therapy modalities, such as injection therapy, mechanical therapy, or ablative therapy, can be used for hemostasis in patients with endoscopic stigmata of recent hemorrhage. However, rebleeding after successful hemostasis with endoscopic therapy frequently occurs. Endoscopic therapy may be a treatment option for successfully controlling this rebleeding. Transarterial embolization or palliative surgery should be considered when endoscopic therapy fails. For primary and secondary prevention of tumor bleeding, proton pump inhibitors can be prescribed, although their effectiveness to prevent bleeding remains to be investigated.
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Affiliation(s)
- Young-Il Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Il Ju Choi
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
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