Factors identifying the probability of further haemorrhage after acute upper gastrointestinal haemorrhage

Acute Gastrointestinal Bleeding

A greater understanding of the pathophysiology of gastrointestinal bleeding has been accompanied by a rapid advancement in therapeutic technology. Newer endoscopic and radiologic techniques are being tested to determine their appropriate uses, but pharmacologic therapy has yet to be proved beneficial. A discussion of the newer as well as some traditional therapies is presented.

Recurrent bleeding in acute upper gastrointestinal hemorrhage: transfusion confusion

OBJECTIVE

Acute upper gastrointestinal (UGI) hemorrhage is a common, often serious condition encountered in the emergency department (ED). Previous research has suggested that transfusion of blood products may interfere with the hypercoagulable state induced by significant blood loss. Our objective was to determine whether the frequency of rebleeding is higher in patients with UGI bleeding who have received early blood transfusion.

METHODS

The study was a retrospective chart review of patients admitted to hospital through the ED with a diagnosis of UGI hemorrhage. Inclusion criteria limited analysis to patients presenting with hematemesis, melena, or bloody nasogastric aspirate, in whom a UGI lesion was confirmed endoscopically during admission.

RESULTS

A total of 214 charts were analyzed. Baseline demographic characteristics were similar in transfused and non-transfused patients. Presenting hemoglobin level was lower in the transfused group (86.5 v. 119.2 g/L, p < 0.001). Recurrent bleeding occurred in 99 (46%) patients and was more common in transfused patients (67 [66%] v. 33 [29%], p < 0.001). Logistic regression analysis revealed that transfusion and presenting hemoglobin level were the only variables with a statistically significant independent association with bleeding recurrence (p < 0.001 and p < 0.05 respectively).

CONCLUSIONS

Our results support previous research suggesting that transfused UGI bleed patients have a higher rate of rebleeding. However, because of the retrospective design, causality cannot be inferred.

Effect of high-dose oral rabeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers

Background. The aim of this study was to compare the effect of high-dose oral rabeprazole versus high-dose IV PPI on rebleeding after endoscopic treatment of bleeding peptic ulcers. Methods. This was a two-center, prospective, randomized, controlled trial. Patients with a high-risk bleeding peptic ulcer had endoscopic hemostasis and were randomly assigned to the high-dose oral rabeprazole group (20 mg twice daily for 72 hours) or the high-dose IV omeprazole group (80 mg as a bolus injection followed by continuous infusion at 8 mg/h for 72 hours). Results. The study was stopped because of slow enrollment (total n = 106). The rebleeding rates within 3 days were 3.7% (2 of 54 patients) given oral rabeprazole and 1.9% (1 of 52 patients) given IV omeprazole (P = 1.000). The rebleeding rates after 3 days were 1.9% and 0% (P = 1.000), respectively. The surgical intervention rates were 3.7% and 0% (P = 0.495), and the mortality rates were 1.9% and 0% (P = 1.000), respectively. Conclusions. The effect of high-dose oral rabeprazole did not differ significantly from that of high-dose IV omeprazole on rebleeding, surgical intervention, or mortality after endoscopic treatment of bleeding peptic ulcers, but this requires further evaluation.

Clinical Risk Characteristics of Upper Gastrointestinal Hemorrhage Severity: A Multivariable Risk Analysis

Background

Upper gastrointestinal hemorrhage (UGIH) is one of the common clinical manifestations encountered in most emergency departments. Patient characteristics indicating UGIH severity in developing countries may be different from those in developed countries. The present study was designed to explore clinical prognostic indicators for UGIH severity.

Methods

A retrospective cohort study was conducted in a university affiliated tertiary hospital in Kamphaeng Phet, Thailand. Medical folders of patients with UGIH were reviewed. Patients were grouped into 3 severity levels, based on criteria proposed by The American College of Surgeon. Pre-defined prognostic indicators were compared. The prognostic indicators for UGIH severity were analyzed by a multivariable continuation ratio ordinal logistic regression and presented with odds ratios.

Results

From 1,043 eligible medical folders, 984 (94.3%) complete folders were used in analysis. There were 241, 631 and 112 patients in the mild, moderate and severe UGIH groups. Six independent indicators of severe UGIH were, hemoglobin < 100 g/dL (OR = 13.82, 95% CI = 9.40 to 20.33, P < 0.001), systolic blood pressure < 100 mmHg (OR = 11.01, 95% CI = 7.41 to 16.36, P < 0.001), presence of hepatic failure (OR = 5.50, 95% CI = 1.14 to26.64, P = 0.037), presence of cirrhosis (OR = 2.03, 95% CI = 1.32 to 3.11, P = 0.001), blood urea nitrogen ≥ 35 mmol/L (OR = 1.73, 95% CI = 1.25 to 2.40, P = 0.001), and pulse rate ≥ 100 per minute (OR = 1.72, 95% CI = 1.21 to 2.45, P = 0.003).

Conclusions

Pulse rate ≥ 100 per minute, systolic blood pressure < 100 mmHg, hemoglobin < 10 g/dL, blood urea nitrogen ≥ 35 mmol/L, presence of cirrhosis and presence of hepatic failure are prognostic indicators for an increase in UGIH severity levels. They are potentially useful in UGIH risk stratification.

Systematic review of the predictors of recurrent hemorrhage after endoscopic hemostatic therapy for bleeding peptic ulcers

BACKGROUND

An increased knowledge regarding the predictors of rebleeding after endoscopic therapy for bleeding ulcers should improve clinical management and outcomes. The aim of this systematic review was to identify the strongest and most consistent predictors of rebleeding to assist in the development of tools to stratify and appropriately manage patients after endoscopic therapy.

METHODS

Bibliographic database searches for prospective studies assessing rebleeding after endoscopic therapy for bleeding ulcers were performed. Relevant studies were identified, and data were abstracted in a duplicate and independent fashion. The primary outcomes sought were significant independent predictors of rebleeding by multivariable analyses in > or =2 studies.

RESULTS

Ten articles met the prespecified inclusion criteria. The pooled rate of rebleeding after endoscopic therapy was 16.4%. The independent pre-endoscopic predictors of rebleeding were hemodynamic instability (significant in 5 of 5 studies; summary odds ratio [OR] 2.75, 95% confidence interval [CI] 1.99-3.51) and comorbid illness (significant in 2 of 7 studies; insufficient data to calculate summary OR or report OR range). The independent endoscopic predictors of rebleeding were active bleeding at endoscopy (significant in 5 of 8 studies; summary OR 1.93, 95% CI 1.30-2.55), large ulcer size (significant in 4 of 5 studies; summary OR 2.01, 95% CI 1.21-2.80), posterior duodenal ulcer (significant in 2 of 3 studies; insufficient data to calculate summary OR or report OR range), and lesser gastric curvature ulcer (significant in 2 of 2 studies; insufficient data to calculate summary OR or report OR range).

CONCLUSIONS

The independent predictors of recurrent hemorrhage after endoscopic therapy, particularly those that are the strongest and most consistent in the literature, may be used to select patients who are most likely to benefit from aggressive post-hemostasis care, including intensive care unit (ICU) observation and second-look endoscopy. Prospective studies designed to formally assess the relative utilities of these factors in predicting rebleeding and dictating management are needed.

Gastrointestinal bleeding in the elderly

Gastrointestinal bleeding affects a substantial number of elderly people and is a frequent indication for hospitalization. Bleeding can originate from either the upper or lower gastrointestinal tract, and patients with gastrointestinal bleeding present with a range of symptoms. In the elderly, the nature, severity, and outcome of bleeding are influenced by the presence of medical comorbidities and the use of antiplatelet medication. This Review discusses trends in the epidemiology and outcome of gastrointestinal bleeding in elderly patients. Specific causes of upper and lower gastrointestinal bleeding are discussed, and recommendations for approaches to endoscopic diagnosis and therapy are given.

When and why do ulcers bleed and what can be done about it?

This article reviews the pathophysiology and management of bleeding peptic ulcer. Ulcers bleed when and because they erode into a blood vessel, and bleed massively when they erode into a medium- or large-sized artery. Focal pathology at the bleeding point (such as arteritis, aneurysmal dilatation or recanalized thrombus) contributes to the timing and clinical pattern of ulcer bleeding. Big bleeds are probably associated with erosion into big arteries. The identification of a visible vessel in the floor of an ulcer that has recently bled is predictive of further bleeding, while the absence of a visible vessel or stigmata of recent haemorrhage is strongly predictive that further bleeding will not occur. Unfortunately, no conventional method of managing gastrointestinal bleeding from ulcers has been convincingly shown to be better than placebo in controlled clinical trials. The value of transfusion and surgery has never been tested in controlled trials, while many small studies of drug therapy, especially of H2-receptor blocking agents, and a few small studies of early surgery afford generally negative or equivocal results. There is some evidence that new physical methods such as lasers or bipolar probes applied at endoscopy are superior to placebo though negative trials have also been reported. Studies randomizing larger numbers of patients with bleeding ulcers are required if therapeutic benefit of any aspect of management is to be demonstrated or refuted.

A risk score system for identification of patients with upper-GI bleeding suitable for outpatient management

BACKGROUND

The aim of this study was to develop a risk score system for identification of patients with upper-GI hemorrhage who are suitable for outpatient management.

METHODS

From a prospective cohort of 983 consecutive patients with upper-GI hemorrhage not associated with portal hypertension, 581 cases that did not meet pre-established criteria for admission were selected, and a logistic regression analysis was performed to identify factors associated with two adverse outcomes: recurrent bleeding and/or the need for emergency surgery. The risk score system was developed by using the beta coefficients of the logistic model, and its performance was evaluated. The results of this model were combined with pre-established criteria for admission to build a simplified scoring system for identification of patients who can be managed safely on an outpatient basis.

RESULTS

Chronic alcoholism, active malignancy, prior upper digestive tract surgery, wasting syndrome, hemodynamic compromise, duodenal ulcer as the cause of upper-GI hemorrhage, and hemorrhage of unknown cause were independently associated with a greater risk of unfavorable outcomes in the group that did not meet pre-established criteria for admission. The logistic model showed a high capacity for discrimination (C statistic: 0.87) and good calibration (p value for Hosmer-Lemeshow goodness-of-fit test, 0.62), with a sensitivity of 100% and specificity of 64%. The simplified score had a sensitivity of 100% and specificity of 29% for adverse outcomes, and sensitivity of 78% and specificity of 38% for mortality.

CONCLUSIONS

The score system developed in this study may be helpful in deciding between hospitalization and outpatient management for patients with upper-GI hemorrhage, but it remains to be validated in patient groups other than those used for its development.

Endoscopic hemostasis: safe treatment for peptic ulcer patients aged 80 years or older?

BACKGROUND AND AIM

Recently, the number of peptic ulcer patients aged 80 years or older has been increasing. However, little information is available concerning therapeutic endoscopy for these patients. The objective of this study was to evaluate the efficacy of endoscopic hemostasis for peptic ulcer bleeding in patients aged 80 years or older.

METHODS

In this 7-year study, bleeding peptic ulcer patients were divided into group A (>/=80 years old) and group B (<80 years), for which prospective data, endoscopic findings and outcomes of endoscopic treatment were compared.

RESULTS

Of the 459 patients who underwent endoscopic hemostasis for peptic ulcer bleeding, the 42 patients (average age 84 +/- 3 years) in group A had a significantly higher incidence of concomitant disease, lower hemoglobin, transfusional requirement over 800 mL and lower serum albumin than the 417 patients (average age 55 +/- 13 years) in group B. Significantly more patients in group A had large gastric ulcers. More patients in group A had ulcers located at the proximal third of the stomach, which is technically difficult to treat endoscopically. Nevertheless, all patients in groups A and B underwent initial hemostasis successfully. The rebleeding rate was not significantly different between group A and B. Neither group had hospital deaths nor complications related to endoscopic procedures.

CONCLUSIONS

Endoscopic hemostasis for peptic ulcer bleeding in patients aged 80 years or older is effective and safe. Increasing age may no longer be a risk factor for rebleeding and hospital death after endoscopic hemostasis for peptic ulcer bleeding.

Three-year prospective validation of a pre-endoscopic risk stratification in patients with acute upper-gastrointestinal haemorrhage

OBJECTIVE

To assess the accuracy of a risk stratification that is used at initial assessment to identify groups with increased risk of mortality and requirement for urgent treatment intervention.

DESIGN

Prospective assessment of risk stratification in consecutive patients with acute upper-gastrointestinal haemorrhage.

METHODS

Over a 3-year period, 1349 consecutive patients with acute upper-gastrointestinal haemorrhage presenting to a single teaching hospital were prospectively risk stratified before endoscopy and followed up for outcome.

MAIN OUTCOME MEASURES

Two-week, all-cause mortality, re-bleeding, and need for urgent treatment intervention.

RESULTS

Stratification within the high-risk group predicted a significant increased risk of 2-week, all-cause mortality (P < 0.001) when compared with intermediate- and low-risk patients (11.8%, 3% and 0%, respectively), re-bleeding (P < 0.001) (44.1%, 2.3% and 0%, respectively), and need for urgent treatment intervention (P < 0.001) (71%, 40.6% and 2.6%, respectively).

CONCLUSIONS

Over a 3-year period, medical staff at this institution have routinely used this risk stratification, which identifies groups of patients at high and low risk of mortality, re-bleeding and need for urgent treatment intervention following acute upper-gastrointestinal haemorrhage. Use of this risk stratification should allow targeting of more intensive treatment where it might be of most benefit. Those patients at lowest risk from outpatient management are also identified.

Outpatient management of upper digestive hemorrhage not associated with portal hypertension: a large prospective cohort

OBJECTIVES

To evaluate the safety of outpatient management of upper GI hemorrhage (UGIH) not associated with portal hypertension.

METHODS

A prospective cohort of 983 subjects who went to the Accident & Emergency Department (A&ED) of a University hospital in Valencia (Spain), for UGIH not associated with portal hypertension during 1994 to 1997 were evaluated. After evaluation in the A&ED, 216 patients (22%) were discharged and referred for outpatient follow-up, but 15 patients could not be located thus, reducing the follow-up to 201 subjects. The main outcome measures were rebleeding within 10 days, emergency surgery within 15 days, and mortality for any cause during the 30 days after the initial hemorrhaging episode.

RESULTS

UGIH in subjects under outpatient care were less severe than those subjects in the hospitalized group. Hemorrhaging recurred in 7.3% of inpatients versus 0.5% of outpatients (p < 0.01); emergency surgery was required in 5.6% of the hospitalized patients and 0.5% of the outpatients (p < 0.01); a total of 20 deaths occurred in the hospitalized group (2.6%), while three (1.5%) occurred in outpatients (p = 0.26). After adjusting for several significant risk factors, outpatient management was not associated with outcomes that were worse.

CONCLUSIONS

Treatment under an outpatient regime is a safe alternative for a large percentage of selected patients with UGIH not associated with portal hypertension.

Clinical scoring systems for determining the prognosis of gastrointestinal bleeding

The prognosis of GI bleeding depends upon many factors. Patients should be evaluated carefully for risk factors. To avoid complications from GI bleeding, triage should be performed promptly after patient presentation. The history and physical examination should emphasize analysis of risk factors for severe GI bleeding and mortality. Factors that increase the morbidity and mortality include: age greater than 60 years; underlying comorbidity such as pulmonary diseases, liver diseases, renal diseases, encephalopathy, or cancer; physiologic stress from major surgery, trauma, or sepsis; coexisting disease in three organ systems; low hematocrit; melena or hematochezia; and prolonged prothrombin time. Hospitalized patients who require more than five units of packed erythrocytes transfusion or who develop hypotension or hypovolemic shock are more likely to need surgery. Patients with a high APACHE II score, the presence of esophageal varices, active bleeding, or other endoscopic stigmata of recent hemorrhage are more likely to rebleed and undergo surgery. The proliferation of multivariable prognostic scales, as described herein, provides ample evidence that the goal of developing a single comprehensive multivariable scale to accurately assess severity of disease and to determine prognosis of GI bleeding is still not achieved. Yet significant progress has occurred in this field, leading to the hope of developing a universally applicable multivariable scale.

The effect of endoscopic injection therapy on the clinical outcome of patients with benign peptic ulcer bleeding

BACKGROUND

Our aim was to investigate the effect of endoscopic injection therapy on the clinical outcome of patients with benign peptic ulcer bleeding.

METHODS

In this study 1203 patients admitted with peptic ulcer bleeding over a 5-year period (January 1987 to April 1991) before endoscopic therapy and 1028 patients admitted with peptic ulcer bleeding after introduction of endoscopic therapy (May 1991 to March 1996) were assessed. Endoscopic therapy was performed in all patients with active bleeding or non-bleeding visible vessels during emergency endoscopy with injection of adrenaline, 1:10,000 in 0.9% saline.

RESULTS

The introduction of injection therapy was associated with a reduction in transfusion requirements (from 5.1 +/- 2.6 to 3.4 +/- 1.8 units), hospitalization days (from 10.8 +/- 6.5 to 7.8 +/- 5.1 days), surgical interventions (from 50.6% to 23.6%), and mortality (from 12.9% to 4.6%) in patients with active bleeding or non-bleeding visible vessels (P < 0.05) but remained unchanged in the rest. Patients with gastric ulcer had a more pronounced reduction in emergency surgical haemostasis and mortality than patients with duodenal ulcer. There were no deaths or procedure-related complications.

CONCLUSION

Endoscopic injection therapy with adrenaline/saline is a simple, low-cost, and safe method that improves the clinical outcome and reduces the mortality in patients with peptic ulcer bleeding.

Natural history of bleeding peptic ulcers with a tightly adherent blood clot: a prospective observation

BACKGROUND

The natural history of a bleeding peptic ulcer with a tightly adherent blood clot remains uncertain. Controversy exists concerning removal of such blood clots at the bleeding ulcer base. This article presents the natural history of a bleeding peptic ulcer with a tightly adherent clot and defines the characteristics of those requiring aggressive management.

METHODS

Clinical parameters were analyzed to determine the independent predictors of rebleeding in these patients. One hundred one patients with bleeding peptic ulcers and tightly adherent blood clots were enrolled during a period of 12 months.

RESULTS

Twenty-five patients (25%) rebled within 1 month. With a multivariate analysis, we found comorbid illness (odds ratio, 3.41), shock (odds ratio, 3.65), and initial hemoglobin at or below 10 gm/dL (odds ratio, 2.99) to be independent predictors of rebleeding.

CONCLUSIONS

Most patients with a tightly adherent clot in an ulcer have an uneventful course. However, endoscopic therapy may prove to be beneficial in the subset of patients with independent predictors of rebleeding.

A cost-effective approach to the patient with peptic ulcer bleeding

The average hospital cost to manage patients hospitalized at Virginia Mason Hospital who bleed from a peptic ulcer is approximately $5000 per patient in our series of 30 patients. Because there are 150,000 admissions per year in the United States for peptic ulcer bleeding, the total hospital cost can be estimated to be $750 million. The actual cost may be higher because our 30 patients had minimal complications and were discharged on average in less than 4 days. The majority of hospital cost is incurred by the intensive care unit or the hospital nursing floor. There is a close to linear relation between the length of stay and the total hospital cost. Upper gastrointestinal endoscopy is a major advance in the treatment of peptic ulcer bleeding. It can provide significant cost savings by identifying some patients with bleeding peptic ulcers who have clean bases on endoscopy who are then eligible for prompt discharge from the hospital. In addition, endoscopic thermal therapy (with multipolar electrocautery or heater probe) and injection therapy cost less than $50 in incremental cost and can reduce further bleeding by 43%, reduce the need for urgent surgery by 63%, and reduce the mortality rate by 60%. Some patients still require urgent surgical intervention, which is substantially more costly than endoscopic hemostasis but is highly effective. Preliminary studies show promise in predicting further bleeding, with clinical scoring systems such as the Baylor Bleeding Score and with the use of Doppler ultrasonography. Better prediction of further bleeding should guide the choice of durable hemostasis early in the hospitalization. Additional studies should clarify the role of NSAID avoidance and H. pylori eradication in the long-term prevention of recurrent peptic ulcer bleeding.

Age-related mortality in patients treated endoscopically for bleeding peptic ulcer

Before the widespread use of endoscopic therapy, mortality from peptic ulcer hemorrhage was highest in elderly patients, and many deaths in this group were a consequence of postoperative complications. Endoscopic intervention greatly reduces the need for an emergency surgical operation, and consequently increasing age may no longer be a risk factor for death from bleeding ulcer. To examine this hypothesis, the outcome of 326 patients undergoing endoscopic therapy for bleeding peptic ulcer was related to age. One hundred two patients were less than 60 years of age (group I), 116 were 61 to 74 years of age (group II), and 108 were older than 75 years (group III). More group III patients were women (p < .0001) and were receiving nonsteroidal anti-inflammatory drugs (p < .0001). Associated concomitant diseases were significantly more common in group II and group III patients (p < .001). Forty-nine (45%) group III patients bled from gastric ulcers. More of group II patients were receiving anticoagulant drugs (p < .005). A previous history of peptic ulcer was most common in group I (p < .005), and duodenal ulcer was usually the cause of bleeding in this group. The three groups were well matched in terms of endoscopic stigmata (active bleeding and nonbleeding vessel), admission hemoglobin concentration, the presence of shock, and total transfusion requirements. Endoscopic therapy (injection or heater probe) was possible in 95% of all patients. The need for surgical intervention tended to be lowest in group I (11%, 19%, and 18%), whereas hospital mortality (3%, 6%, and 5%) was very similar. In this large group of unselected patients with major peptic ulcer bleeding, age did not significantly influence response to endoscopic therapy or hospital mortality.

Prospective validation of the Baylor bleeding score for predicting the likelihood of rebleeding after endoscopic hemostasis of peptic ulcers

Endoscopic therapy is effective in securing hemostasis for bleeding ulcers, but bleeding recurs in 10% to 30% of patients. Prospective identification of patients at increased risk for rebleeding is requisite to reducing rebleeding rates. We previously developed a three-component scoring system that identifies patients at increased risk for rebleeding. In the present study, we prospectively validated our scoring system. Forty-seven men ranging in age from 23 to 95 years in whom endoscopic therapy for bleeding ulcers was successful were studied. Patients with pre-endoscopy scores greater than 5 or postendoscopy scores greater than 10 were stratified as high-risk, and patients with pre-endoscopy scores of 5 or less and post-endoscopy scores of 10 or less as low-risk. Twenty-six patients were categorized as high-risk and 19 as low-risk. All patients were followed until discharged from the hospital. The rebleeding rate for high-risk patients was 31% (8 of 26), compared with 0 for low-risk patients (p < .05). We conclude that our scoring system accurately predicts patients at increased risk for rebleeding after successful endoscopic therapy of bleeding ulcers.

Combination therapy using adrenaline and heater probe to reduce rebleeding in patients with peptic ulcer haemorrhage: a prospective randomized trial

A prospective randomized trial was performed to assess the efficacy of the combined therapy of endoscopic injection of adrenaline and heater probe application in the management of patients with major peptic ulcer haemorrhage. Some 153 consecutive patients were randomized to receive either local injection of adrenaline (1:10,000) followed by heater probe thermocoagulation (74 patients) or no endoscopic treatment (79 patients). The two groups were well matched with regard to age, haemoglobin concentration on admission, non-steroidal anti-inflammatory drug usage and endoscopic findings. More patients in the treatment group were in shock on admission (21 versus 13). Initial haemostasis was achieved in all patients randomized to endoscopic therapy. Rebleeding occurred in fewer treated than control patients (five versus 16, P = 0.01). The treated group also had fewer deaths (zero versus two) and requirement for operation (two versus six). The results show that the combination of sclerotherapy with adrenaline and subsequent thermocoagulation reduces the rate of rebleeding in peptic ulcer haemorrhage.

Intravenous omeprazole/amoxicillin and omeprazole pretreatment in Helicobacter pylori-positive acute peptide ulcer bleeding. A pilot study

BACKGROUND

The aims of this study were to evaluate a Helicobacter pylori eradication schedule for H. pylori-positive gastroduodenal ulcer bleeding, which could be commenced intravenously after endoscopic diagnosis, and to assess the effect of omeprazole pretreatment on bacterial eradication.

METHODS

In a prospective study 20 consecutive patients with H. pylori-positive acute peptide ulcer bleeding, who were managed conservatively including endoscopic injection therapy, were treated with a 2-week regimen consisting of either 40 mg omeprazole three times daily (with the exception of the loading dose of 80 mg) and 2 g amoxicillin three times daily intravenously for 3 days and 20 mg omeprazole twice daily and 1 g amoxicillin twice daily orally for 11 days (n = 10) or only with 40 mg omeprazole three times daily (with the exception of the loading dose of 80 mg) intravenously for 3 days and 20 mg omeprazole twice daily and 1 g amoxicillin twice daily orally for 11 days (n = 10). Subsequently, both groups received 20 mg omeprazole twice daily orally for 4 weeks.

RESULTS

H. pylori eradication, defined as negative bacterial findings in urease test, culture and histology, or 13C-urea breath test at least 4 weeks after cessation of omeprazole medication, was achieved in 100% (10/10) of patients in the first group but only in 30% (3/10) of patients in the second group (p < 0.01). Ulcer healing was endoscopically confirmed in all but one patient in the second group.

CONCLUSIONS

For the first time a promising concept for H. pylori eradication in H. pylori-positive ulcer bleeding is available by using a combined intravenous and oral omeprazole/amoxicillin therapy, which can be started intravenously immediately after an emergency upper GI endoscopy. In addition, these data imply that omeprazole pretreatment may not be wise when H. pylori eradication is attempted.

The natural history (fading time) of stigmata of recent hemorrhage in peptic ulcer disease

From October 1991 to December 1992, 144 patients with bleeding peptic ulcer and stigmata of recent hemorrhage were included in a study designed to investigate, by means of endoscopic examinations repeated at 2-day intervals, the evolutionary development of stigmata of recent hemorrhage, such as visible vessels, and to determine the time required for each type of stigma to fade. Eighty-five patients underwent endoscopic follow-up until the stigmata had disappeared. A visible vessel takes about 4.1 +/- 2.1 days to disappear, requiring significantly more time than an adherent clot or an old stigma, which take 2.4 +/- 0.8 days and 2.4 +/- 1.3 days, respectively (p < .05). Bleeding does not recur after stigmata disappear. Time required for stigmata to fade is not affected by age, sex, smoking, history of peptic ulcer, ulcer location, severe bleeding, underlying systemic disease, or endoscopic local therapy. While healing, stigmata of recent hemorrhage evolve through a sequence of phases: a visible vessel may or may not appear as an adherent clot and then as a red or black flat spot before disappearing.

Randomized trial of adrenaline injection and laser photocoagulation in the control of haemorrhage from peptic ulcer

Forty-nine consecutive patients with bleeding from peptic ulcers that would conventionally have required surgical intervention were randomized to receive endoscopic injection of adrenaline (1:10,000) or laser photocoagulation. Patients were included only if they had a visible vessel at endoscopic examination. Five patients proceeded directly to surgery and, of the remaining 44, 21 received laser photocoagulation and 23 injection therapy. Haemostasis was achieved initially in all patients. There was one rebleed in the group of patients who received laser treatment and four in those treated by injection. All five patients underwent further endoscopic haemostasis according to the initial randomization. Haemostasis was again achieved in all cases, but the patient who had undergone laser treatment suffered recurrent haemorrhage after a further 48 h and subsequently died. Overall, one of the 21 patients receiving laser treatment died compared with none of the 23 injected with adrenaline. Injection of adrenaline achieves similar results to laser photocoagulation for bleeding peptic ulcer.

Prognostic factors in upper gastrointestinal bleeding

In this study we examined factors of possible prognostic value about outcome in a consecutive series of 2217 patients with hematemesis and melena. Death occurred in 189 (8.5%) patients, and 243 (11%) patients experienced rebleeding. Death was significantly associated with rebleeding, age over 60 years, and the finding of blood in the stomach at endoscopy. Rebleeding was significantly associated with melena, identification of a gastric or duodenal ulcer, endoscopic stigmata of hemorrhage such as blood, clot, and active bleeding, and the finding of shock at admission. However, female gender, previous history of ulceration, or indigestion of ulcerogenic drugs, especially nonsteroidal antiinflammatory drugs, were poor predictors of either death or rebleeding. We conclude that the identification of patients at a high risk could contribute to improved management of patients with gastrointestinal bleeding, including early therapeutic intervention.

Emergency surgical treatment for bleeding duodenal ulcer: oversewing plus vagotomy versus gastric resection, a controlled randomized trial. French Associations for Surgical Research

The best surgical procedure to treat bleeding bulbar peptic ulcer is unknown. The rates of postoperative bleeding recurrence, duodenal leakage, and mortality were compared in patients undergoing oversewing plus vagotomy (O+V) or gastric resection (GR) with ulcer excision. Of 202 patients undergoing emergency surgery for massive, persistent, or recurrent bleeding from bulbar peptic ulcer, 120 patients were enrolled in a prospective randomized trial. Fifty-nine were assigned to O+V and 61 to GR. One patient in each group was excluded after randomization. The two groups were well matched with respect to clinical and prognostic factors. The rate of postoperative bleeding recurrence was 17% after O+V and 3% after GR (p < 0.05). The duodenal leak rate was higher after GR than after O+V (13% vs. 3%) (p < 0.10) but was not different when the morbidity of reoperations for bleeding recurrence after O+V was considered on an "intention to treat" basis (12% vs. 13%). Overall postoperative mortality was similar: 22% (O+V) versus 23% (GR). Sixteen deaths were unrelated to the surgical procedure itself. Of 82 nonrandomized patients, 10 were not analyzed. In the 72 other nonrandomized patients, bleeding recurrence, duodenal leakage, and postoperative mortality rates were consistent with the results of the controlled trial, as they were 29% (O+V 32%; GR 0.7%), 16% (O+V 0.7%; GR 26%) and 27% (O+V 18%; GR 33.3%), respectively. We conclude that GR with ulcer excision is the procedure of choice for the emergency surgical treatment of bleeding duodenal ulcer because postoperative bleeding recurrence is lower, and the overall rates of mortality and duodenal leakage are the same as with O+V.

The non-bleeding visible vessel versus the sentinel clot: natural history and risk of rebleeding

Non-bleeding visible vessel and sentinel clot are terms used interchangeably to describe protuberances in the base of ulcers that have recently bled, but a consensus as to their definition or natural history does not exist. In patients with severe ulcer hemorrhage, non-bleeding protuberances were classified as vessels, with or without a small attached clot, or as sentinel clots, according to a schema based on the appearance of the protuberance at endoscopy but not subjected to pathologic correlation. Endoscopic therapy was not performed at the index endoscopic evaluation, and natural evolution was prospectively documented with daily videoendoscopy. Eleven (46%) of 24 patients with non-bleeding protuberances had rebleeding. Independent classification by three authors concurred in 18 (75%) of 24 lesions. Ten (91%) of 11 vessels with or without attached clot rebled versus 0 (0%) of 7 sentinel clots and 1 (17%) of 6 lesions without unanimous classification (p < 0.01, vessels versus other groups). Rebleeding occurred in 5 (71%) of 7 nonpigmented (pale or white), 6 (38%) of 16 red or purple, and 0 (0%) of 1 black protuberances. In general, vessels persisted until rebleeding, whereas sentinel clots disappeared within 1 to 3 days. We conclude that nonbleeding protuberances in ulcer bases can be separated into vessels, which have a high risk of rebleeding, and sentinel clots, which have a low risk of rebleeding.

Association of fibrinolytic tests with outcome of acute upper-gastrointestinal-tract bleeding

Endogenous fibrinolysis may play a part in acute upper-gastrointestinal-tract bleeding by causing digestion of haemostatic plugs. We assessed the predictive value of fibrinolytic tests for hospital outcome in a prospective study of 122 patients with acute upper-gastrointestinal-tract bleeding who underwent endoscopy. Serum fibrin degradation products (FDP) were above the normal range in 32% (95% CI 21-44%) of patients who survived and did not require transfusion or surgery, in 53% (37-69%) of patients who survived without surgery but required transfusion, and in 100% (82-100%) of patients who required surgery or died. Multivariate analysis showed that after adjustment for the effects of established risk factors (age, pulse rate, blood pressure, haemoglobin, site of bleeding, and stigmata of active bleeding at endoscopy), serum FDP was a powerful independent predictor of outcome (p = 0.003). Doubling of serum FDP was associated with a 59% increase in the risk of a poor outcome (95% CI 14-120%). These findings are consistent with roles for endogenous fibrinolysis in gastrointestinal-tract bleeding, for fibrinolytic tests in prediction of adverse outcome, and for fibrinolytic inhibitors in treatment.

Endoscopic management of nonvariceal gastrointestinal bleeding

Endoscopic management of upper gastrointestinal bleeding has been expanded from a purely diagnostic role to a therapeutic role in many patients. In addition to controlling active bleeding, it is an option in a patient who is clinically at a high risk of rebleeding, or in patients who have peptic ulcers with visible vessels or stigmata indicating high risk. Several methods have been studied, and currently the most useful include thermal cautery with the heater probe or bipolar electrocoagulation, and injection using epinephrine and/or sclerosants. Endoscopic hemostasis can effect permanent control of bleeding in many patients, but should be considered complementary to conventional surgical control in other patients, where temporary control to stabilize the patient is a desired end.

Endoscopic interventional management of bleeding duodenal and gastric ulcers

Bleeding duodenal and gastric ulcers continue to be a common and serious problem. Definition of the precise appearance and location of the ulcer by endoscopy gives important information about the source of bleeding and additional information about the risk of rebleeding and the indications for surgery. Several endoscopic hemostatic methods are available. The nonerosive contact probes (heater and BICAP) are preferred. Injection therapy with vasoconstrictors or sclerosing agents can also be recommended as a safe, efficacious, and economical means of treatment. Several hemostatic modalities should be available for use depending on the anatomic location and type of bleeding ulcers. The collaboration of skilled interventional endoscopists with their traditional surgical colleagues offers the patient with bleeding peptic ulcer disease the optimum probability of a successful outcome, with minimum treatment-associated morbidity.

Hypotension and endoscopic stigmata of recent haemorrhage in bleeding peptic ulcer: risk models for rebleeding and mortality

Clinical and endoscopic data were collected prospectively in 1050 patients with bleeding peptic ulcer admitted between September 1985 and July 1989 to the care of one surgical team. Seventy-nine patients underwent therapeutic endoscopy soon after admission and in 129 patients either immediate or early elective surgery was performed. Eight hundred and forty-two patients, in whom therapeutic endoscopy was not performed at any stage, underwent initial conservative management and data from this latter group are now presented. Shock on admission was defined as systolic blood pressure (BP) less than or equal to 100 mmHg on presentation. There were 10 deaths of 147 shocked patients (6.8%) compared with only 25 deaths of 695 patients (3.6%) not in shock (P less than 0.08). Bleeding recurred in 30 patients (20.4%) shocked on presentation but in only 96 (13.8%) with a BP greater than 100 mmHg (P less than 0.05). Twenty-one of 358 patients (5.9%) with endoscopic stigmata of recent haemorrhage (ESRH) died, but only 14 of 484 patients (2.9%) without such stigmata (P less than 0.05) died. In shocked patients rebleeding was evident in 21 of 73 (28.8%) cases with ESRH but in only 9 of 74 (12.2%) patients in whom ESRH were absent (P less than 0.02). In the absence of fresh blood at endoscopy rebleeding occurred in 22 of 124 (17.8%) shocked patients and only 74 of 629 (11.8%) of those not shocked on presentation (P less than 0.07). When ulcer size was documented rebleeding rates for ulcers less than or equal to 1 cm, less than or equal to 2 cm and greater than 2 cm in size were 54 of 485 (11.1%), 30 of 142 (21.2%) and 12 of 44 (27.3%) respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Endoscopic injection sclerosis: effective treatment for bleeding peptic ulcer

One hundred and nine patients presenting with severe haemorrhage from benign peptic ulcers were randomised to either endoscopic injection sclerotherapy using a combination of 1:100,000 adrenaline and 5% ethanolamine or to conservative treatment. Only high risk patients with active bleeding or endoscopic stigmata of recent haemorrhage and accessible ulcers were considered. The two groups were well matched for age, shock, haemoglobin concentration, endoscopic findings, and consumption of non-steroidal anti-inflammatory drugs. The group treated endoscopically had a significantly reduced rebleeding rate (12.5% v 47%, p less than 0.001). Rebleeding was successfully treated in some patients by injection sclerotherapy, other patients underwent urgent surgery. While there was a tendency towards a lower operation rate and lower transfusion requirements in the treated group, this failed to achieve statistical significance. The use of injection sclerotherapy in the conservatively treated group after rebleeding undoubtedly reduced the number of surgical operations. Endoscopic injection sclerotherapy is effective in the prevention of rebleeding in these patients.

Management of bleeding ulcers

Hemorrhage is a common complication of peptic ulcer disease and is increased in frequency and severity with aspirin and NSAID use. A variety of clinical and endoscopic factors associated with an increased mortality rate from ulcer bleeding have been identified, the most important of which are presentation in shock and ongoing or recurrent bleeding after routine resuscitative measures. After hemodynamic stabilization, the goal of therapy is to diminish the chance that an ulcer will continue to bleed or will rebleed. Currently, this is best achieved by one of several endoscopic interventions in carefully selected patients. The most effective endoscopic techniques for decreasing the risk of ulcer rebleeding are multipolar electrocoagulation, heater probe thermal coagulation, and injection therapy in patients with active bleeding or a visible vessel in the ulcer base. Injection therapy may be used alone or in combination with either of the other two techniques. The major impact of therapeutic endoscopy appears to be a reduction in the number of emergent operations necessary to control hemorrhage. The mortality of emergent surgery for bleeding ulcer is prohibitive, and any means of reducing the need for surgery is likely to have a beneficial effect on survival.

Heat probe thermocoagulation and pure alcohol injection in massive peptic ulcer haemorrhage: a prospective, randomised controlled trial

We conducted a prospective randomised controlled trial of 137 patients with massive peptic ulcer haemorrhage over a period of 12 months to compare the haemostatic effects of endoscopic heat probe thermocoagulation and pure alcohol injection. Seventy eight patients (56.9%) were in shock at the time of randomisation to the trial. The age, sex, number of patients in shock, haemoglobin value at the time of entry to the trial, number of patients with severe medical illness, location of bleeders, and stigmata of recent haemorrhage were comparable among the heat probe, pure alcohol, and control groups. The initial haemostatic effect of the heat probe was better than that of the pure alcohol injection (44 of 45 v 31 of 46, p = 0.0004). The ultimate haemostasis achieved by the heat probe group (41 of 45) was better than that of the pure alcohol group (31 of 46, p = 0.012) and of controls (24 of 46, p = 0.0001). The duration of hospital stay was shorter for patients in the heat probe group than for the control group (6.2 days v 13.8 days, p less than 0.05). The incidence of emergency surgery was less for the heat probe than the control group (three of 45 v 12 of 46, p = 0.027). The mortality rate was less in the heat probe than in the control group (one of 45 v seven of 46, p = 0.031). We suggest that heat probe thermocoagulation should be the first treatment of choice for arrest of massive peptic ulcer haemorrhage.

A controlled study of therapeutic endoscopy for peptic ulcer with non-bleeding visible vessel

In a period of 14 months, a prospective, randomized, controlled trial was undertaken in 61 patients who had bled from peptic ulcers in which, at endoscopy, non-bleeding vessels were visible in the ulcer crater. The control group consisted of 31 patients in whom the procedure was limited to observation alone; in 30 patients the ulcer base was coagulated by means of a heat probe. There were no statistically significant differences between the two groups in the rate of rebleeding, the assurance of ultimate hemostasis, the volume of blood transfusion required, the duration of hospitalization, or eventual mortality. However, the need for emergency surgical intervention was less frequent in the heat probe group (2 of 30) than among the controls (9 of 31) (p = 0.0243). Moreover, in the treatment group, those patients of advanced age (greater than 60 years), in shock, requiring blood transfusion of greater than 500 ml, and in whom blood or coffee ground material was seen in the stomach, thermocoagulation achieved statistically more effective hemostasis than that observed in the control group. For these high-risk subsets of patients with non-bleeding visible vessels, we recommend heat probe coagulation rather than mere observation.

Pancreatic pseudocyst haemorrhage presenting as a bleeding duodenal ulcer

We present a case of upper gastrointestinal haemorrhage where the preoperative endoscopic findings suggested a duodenal ulcer as the cause. Although at operation this proved to be the site of bleeding, the source was found to be the splenic artery in the base of a pancreatic pseudocyst.

Surgical management of bleeding gastric ulceration

In a nine-year period from 1977 to 1985 sixty-one patients underwent surgery for bleeding gastric ulceration in the Western Infirmary, Glasgow. Nineteen patients were treated by partial gastrectomy, twenty-two had undersewing of the ulcer plus vagotomy and drainage and twenty had undersewing alone. Mortality in the three groups was 26, 45 and 10 per cent respectively. All groups of patients were similar in terms of age, severity of haemorrhage, delay before surgery and grade of surgeon performing the procedure. Out-patient follow-up (mean: 37 months) of patients treated by undersewing alone revealed that 73 per cent were symptom free. Treatment of bleeding gastric ulceration by undersewing alone is effective and should be considered in patients who require surgery.

Endoscopic therapy of bleeding peptic ulcers: a cost-benefit analysis

Endoscopic hemostatic therapies have become increasingly popular and appear capable of controlling hemorrhage from peptic ulcers and reducing the need for surgery, but many physicians are unsure that the efficacy justifies the cost. In order to study this clinically and economically important issue, we developed a mathematical model to analyze the economics of endoscopic therapy of bleeding peptic ulcers. Endoscopic therapy appears capable of reducing direct hospital costs only when selectively applied to those patients with the highest risk of requiring surgery. Sensitivity analysis identifies efficacy, treatment cost, and the rebleeding rate in untreated patients as the most critical variables affecting the cost of interventional endoscopy. Using neodymium: YAG laser photocoagulation as an example, interventional endoscopy can be cost-effective for treating selected patients with bleeding peptic ulcers. Should other hemostatic devices such as the heater probe and bipolar electrocoagulator prove to be as effective as the laser, even greater cost savings could be achieved.

Tranexamic acid as an aid to reducing blood transfusion requirements in gastric and duodenal bleeding

A prospective randomised double blind study examined the effect of the antifibrinolytic drug tranexamic acid compared with placebo in 154 patients bleeding from verified benign lesions in the stomach or duodenum or both. Three out of 72 patients receiving tranexamic acid underwent emergency surgery compared with 15 out of 82 given placebo (p = 0.010). Nineteen patients receiving placebo rebled during their admission as compared with 10 in the active treatment group (p = 0.097). Blood transfusion requirements were significantly reduced by tranexamic acid (p = 0.018). Side effects occurred in six patients, of which an uncomplicated deep venous thrombosis was the most severe. Tranexamic acid reduces the blood transfusion requirement and need for emergency surgery in patients bleeding from a benign gastric or duodenal lesion.

Clinical factors in the prediction of further haemorrhage or mortality in acute upper gastrointestinal haemorrhage

Data collected prospectively from 326 admissions for acute upper gastrointestinal haemorrhage were examined to identify factors predicting further haemorrhage or mortality. Seven predictive factors were identified by univariate analysis for both further haemorrhage and/or mortality, but only age over 60 years, an admission haemoglobin less than 8 g/dl and the presence of endoscopic stigmata of recent haemorrhage were shown by stepwise logistic regression to have independent significance for further haemorrhage. An age over 60 years, the presence of clinical shock on admission and an episode of further haemorrhage following admission emerged as independently significant in the prediction of mortality.

Controlled trial of small bipolar probe in bleeding peptic ulcers

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

Bleeding ulcer: timing and technique in surgical management

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

Electrohydrothermoprobe--a simple alternative to laser therapy in the management of acute gastrointestinal haemorrhage

One hundred and twenty six consecutive patients presenting with upper alimentary bleeding were endoscoped. Seventeen gastric and 11 duodenal lesions with visible blood vessels were identified and cauterised with the electrohydrothermoprobe. One gastric and four duodenal vessels rebled, necessitating surgery. For the gastric vessels this represents about one tenth of the expected rebleeding rate, and is a significant reduction. The technique appears to have no effect on the rebleeding rate in duodenal vessels.