Endoscopic management of nonvariceal gastrointestinal bleeding

Application of endoscopic hemoclips for nonvariceal bleeding in the upper gastrointestinal tract

AIM: To investigate acute nonvariceal bleeding in the upper gastrointestinal (GI) tract and evaluate the effects of endoscopic hemoclipping.

METHODS: Sixty-eight cases of acute nonvariceal bleeding in the upper GI tract were given endoscopic treatment with hemoclip application. Clinical data, endoscopic findings, and the effects of the therapy were evaluated.

RESULTS: The 68 cases (male:female = 42:26, age from 9 to 70 years, average 54.4) presented with hematemesis in 26 cases (38.2%), melena in nine cases (13.3%), and both in 33 cases (48.5%). The causes of the bleeding included gastric ulcer (29 cases), duodenal ulcer (11 cases), Dieulafoy’s lesion (11 cases), Mallory-Weiss syndrome (six cases), post-operative (three cases), post-polypectomy bleeding (five cases), and post-sphincterotomy bleeding (three cases); 42 cases had active bleeding. The mean number of hemoclips applied was four. Permanent hemostasis was obtained by hemoclip application in 59 cases; 6 cases required emergent surgery (three cases had peptic ulcers, one had Dieulafoy’s lesion, and two were caused by sphincterotomy); three patients died (two had Dieulafoy’s lesion and one was caused by sphincterotomy); and one had recurrent bleeding with Dieulafoy’s lesion 10 mo later, but in a different location.

CONCLUSION: Endoscopic hemoclip application was an effective and safe method for acute nonvariceal bleeding in the upper GI tract with satisfactory outcomes.

Helicobacter pylori infection in patients with haemophilia in Poland: prevalence and risk of upper gastrointestinal bleeding

Infection with Helicobacter pylori is the main aetiological factor for erosive gastritis and duodenal or gastric peptic ulcers often complicated with life-threatening bleeding in patients with coagulation disorders. The aim of this prospective study was to evaluate the prevalence of Helicobacter pylori infection in haemophilia patients, and to assess the risk of gastrointestinal bleeding associated with this infection. From 2000 to 2002, 146 patients with haemophilia (129, haemophilia A; 13, haemophilia B), mean age, 39.9 years (+/-7.3), were investigated for H. pylori infection using IgG and IgA latex serological test. The control group included 100 men with no coagulation disorders, mean age, 40.9 years (+/-9.2). For 72 (49.3%) patients with haemophilia and 39 controls (39.0%) serological tests were positive indicating the presence of H. pylori infection (P =0.1112). A history of gastrointestinal bleeding was reported in 46 patients (31.5%) with haemophilia and in two control group patients (2.0%) (P < 0.0001). Gastrointestinal bleeding was significantly more frequent in patients with haemophilia infected with H. pylori (33/46; 71.7%) than in patients with no H. pylori infection (13/46; 28.3%; P = 0.0002). In conclusion, the prevalence of H. pylori infection in haemophilic patients in Poland is comparable with that in patients with no coagulation disorders. Helicobacter pylori infection is a risk factor for duodenal and gastric ulcer bleeding in haemophilia patients. In view of the high frequency of upper gastrointestinal bleeding associated with H. pylori infection, we believe that screening and eradication therapy are appropriate in haemophilia patients.

Can endoscopic injection of epinephrine prevent surgery in gastroduodenal ulcer bleeding? An analysis of 107 cases

BACKGROUND

Gastroduodenal ulcers are still a common cause of severe upper gastrointestinal bleeding. Endoscopy has gained popularity worldwide over conventional open surgery for the treatment of upper gastrointestinal bleeding. This study aims to assess the efficacy of endoscopic injection of epinephrine in the treatment of gastroduodenal ulcer bleeding.

METHODS

This study was conducted between March 2000 and March 2003. We analyzed 107 consecutive patients admitted to our department of trauma and emergency surgery with upper gastrointestinal bleeding. Endoscopy was performed on all 107 patients and bleeding ulcers were treated with injection of diluted epinephrine.

RESULTS

Recurrent bleeding was seen in 21 patients (19.6%), all of whom underwent a second endoscopy. Four patients (3.7%) required a third endoscopy session and nine patients (8.5%) needed surgery after endoscopy failed. There were two mortalities (1.9%). The nine patients who required surgery and the two patients who died were all in the Forrest Ia and Ib groups of acute UGI hemorrhage.

DISCUSSION

Endoscopic injection therapy with epinephrine reduces operation rates and can be used safely in adequate hemostasis of gastroduodenal ulcers.

Current therapy for nonvariceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding continues to plague physicians despite the discovery of Helicobacter pylori and advances in medical therapy for peptic ulcer disease. Medical therapy with new nonsteroidal anti-inflammatory medications and somatostatin/octreotide and intravenous proton pump inhibitors provides hope for reducing the incidence of and treating bleeding peptic ulcer disease. Endoscopic therapy remains the mainstay for diagnosis and treatment of upper gastrointestinal bleeding. Many methods of endoscopic hemostasis have proven useful in upper gastrointestinal hemorrhage. Currently, combination therapy with epinephrine injection and bicap or heater probe therapy is most commonly employed in the United States. Angiography and embolization play a role primarily when endoscopic therapy is unsuccessful.

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.

Endoscopic hemoclip treatment for bleeding peptic ulcer

AIM: To evaluate the efficacy of endoscopic hemoclip in the t reatment of bleeding peptic ulcer.

METHODS: Totally, 40 patients with F1a and F1b hemorrhagic activity of peptic ulcers were enrolled in this uncontrolled prospective study for e ndoscopic hemoclip treatment. We used a newly developed rotatable clip-device for the application of hemoclip (MD850) to stop bleeding. Endoscopy was repeated if there was any sign or suspicion of rebleeding, and re-clipping was performed if necessary and feasible.

RESULTS: Initial hemostatic rate by clipping was 95%, and rebl eeding rate was only 8%. Ultimate hemostatic rates were 87%, 96%, and 93% in the F1a and F1b subgroups, and total cases, respectively. In patients with shock on admission, hemoclipping achieved ultimate hemostasis of 71% and 83% in F1a and F1b subgroups, respectively. Hemostasis reached 100% in patients without shock regardless of hemorrhagic activity being F1a or F1b. The average number of clips used per case was 3.0 (range 2-5). Spurting bleeders required more clips on av erage than did oozing bleeders (3.4 versus 2.8). We observed no obvious co mplications, no tissue injury, or impairment of ulcer healing related to hemocli pping.

CONCLUSION: Endoscopic hemoclip placement is an effective and safe method. With the improvement of the clip and application device, the procedu re has become easier and much more efficient. Endoscopic hemoclipping deserves further study in the treatment of bleeding peptic ulcers.

Management of haematemesis and melaena

Upper gastrointestinal bleeding remains a common medical emergency with high morbidity and mortality. High risk patients are best managed in specialised units. Endoscopy is the procedure of choice for diagnosis and haemostatic therapy of peptic ulcers, reducing deaths and the probability of rebleeding, as well as the need for surgery; for acute variceal bleeding, pharmacotherapy followed by endoscopic ligation is recommended.

Combined use of laparoscopy and endoscopy in diagnosing and treating Dieulafoy's vascular malformations of the stomach

We present the case of a 70-year-old female successfully treated for a bleeding Dieulafoy's gastric lesion with a combined laparoscopic/endoscopic approach. An increasing percentage of surgery is now being performed laparoscopically and the authors feel that combined laparoscopic/endoscopic surgery offers advantages to the patient over either of these methods individually and over open surgery. This report demonstrates that a bleeding point anywhere on the gastric wall is amenable to laparoscopic intervention if the localization techniques we describe are utilized.