Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials

Advancements in endoscopic hemostasis for non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal (GI) bleeding is a significant cause of morbidity and mortality. Traditionally, through-the-scope (TTS) clips, thermal therapy, and injection therapies are used to treat GI bleeding. In this review, we provide an overview of novel endoscopic treatments that can be used to achieve hemostasis. Specifically, we discuss the efficacy and applicability of over-the-scope clips, hemostatic agents, TTS doppler ultrasound, and endoscopic ultrasound, each of which offer an effective method of reducing rates of GI rebleeding.

Ideal strategy for nonvariceal upper gastrointestinal bleeding

PURPOSE OF REVIEW

Over 300 000 hospital admissions in the United States each year are due to patients with upper gastrointestinal (GI) bleeding (UGIB). Common etiologies of nonvariceal UGIB include peptic ulcers, mucosal erosions of the esophagus, stomach or duodenum, Mallory-Weiss tears, Dieulafoy lesions, upper GI tract malignancy, or other etiology.

RECENT FINDINGS

Peptic ulcers classified as Forrest Ia, Ib, or IIa require endoscopic hemostasis, while IIb ulcers may be considered for endoscopic clot removal with endoscopic treatment of any underlying major stigmata. Endoscopic hemostasis for ulcers classified as Forrest IIc or III is not advised due to the low risk of recurrent bleeding. Endoscopic hemostasis in ulcer bleeding can be achieved using injection, thermal, and/or mechanical modalities.

SUMMARY

This review focuses on the currently recommended endoscopic therapies of patients presenting with acute nonvariceal upper gastrointestinal hemorrhage.

Emergency medicine updates: Upper gastrointestinal bleeding

INTRODUCTION

Upper gastrointestinal bleeding (UGIB) is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease.

OBJECTIVE

This paper evaluates key evidence-based updates concerning UGIB for the emergency clinician.

DISCUSSION

UGIB most frequently presents with hematemesis. There are numerous causes, with the most common peptic ulcer disease, though variceal bleeding in particular can be severe. Nasogastric tube lavage for diagnosis is not recommended based on the current evidence. A hemoglobin transfusion threshold of 7 g/dL is recommended (8 g/dL in those with myocardial ischemia), but patients with severe bleeding and hemodynamic instability require emergent transfusion regardless of their level. Medications that may be used in UGIB include proton pump inhibitors, prokinetic agents, and vasoactive medications. Antibiotics are recommended for those with cirrhosis and suspected variceal bleeding. Endoscopy is the diagnostic and therapeutic modality of choice and should be performed within 24 h of presentation in non-variceal bleeding after resuscitation, though patients with variceal bleeding may require endoscopy within 12 h. Transcatheter arterial embolization or surgical intervention may be necessary. Intubation should be avoided if possible. If intubation is necessary, several considerations are required, including resuscitation prior to induction, utilizing preoxygenation and appropriate suction, and administering a prokinetic agent. There are a variety of tools available for risk stratification, including the Glasgow Blatchford Score.

CONCLUSIONS

An understanding of literature updates can improve the ED care of patients with UGIB.

Systematic review and meta-analysis of endoscopic versus medical management of peptic ulcers with adherent clots

Peptic ulcer disease is an important cause of upper gastrointestinal bleeding. Current guidelines recommend endoscopic treatment for ulcers with active bleeding or non-bleeding visible vessels, but the optimal management of ulcers with adherent clots is unclear. We performed a systematic review of the efficacy of endoscopic versus medical management of peptic ulcers with adherent clots. A systematic literature search was performed through September 2022 (MEDLINE, Embase, and CENTRAL). Randomized controlled trials (RCTs) comparing the effect of endoscopic versus medical management alone for peptic ulcers with adherent clots on the outcome of recurrent bleeding were incuded. A random-effects meta-analysis was performed to estimate the overall treatment effect. We included seven RCTs reporting on the endoscopic versus medical management of peptic ulcers with adherent clots. The pooled cohort comprised 268 patients with a mean age of 62.8 years and a mean follow up of 20 days. There was a significant reduction in the risk of recurrent bleeding with endoscopic hemostatic treatment for peptic ulcers with adherent clots, compared with medical management alone (risk ratio [RR] = 0.40, 95% confidence interval [CI] 0.16-0.95, 268 participants). However, there was no difference in mortality (RR = 0.90, 95% CI 0.23-3.59, 52 participants) or need for ulcer surgery (RR = 0.48, 95% CI 0.10-2.28, 52 participants) between endoscopic and medical management groups. In summary, there was evidence for a reduction in recurrent bleeding from peptic ulcers with adherent clots treated with endoscopic hemostatic techniques compared with medical management alone but no difference in rates of mortality or need for surgery.

Review article: Upper gastrointestinal bleeding - review of current evidence and implications for management

BACKGROUND

Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital-based care. Advances in care across pre-endoscopic, endoscopic and post-endoscopic phases have led to improvements in clinical outcomes.

AIMS

To provide a detailed, evidence-based update on major aspects of care across pre-endoscopic, endoscopic and post-endoscopic phases.

METHODS

We performed a structured bibliographic database search for each topic. If a recent high-quality meta-analysis was not available, we performed a meta-analysis with random effects methods and odds ratios with 95% confidence intervals.

RESULTS

Pre-endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high-risk stigmata, endoscopic therapy, including over-the-scope clips (OTSCs) and TC-325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post-endoscopic management includes early enteral feeding for all UGIB patients. For high-risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high-risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered.

CONCLUSIONS

Management of acute UGIB should include treatment plans for pre-endoscopic, endoscopic and post-endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding.

A systematic review and meta-analysis assessing the use of tranexamic acid (TXA) in acute gastrointestinal bleeding

INTRODUCTION

Gastrointestinal bleeding results in significant morbidity, cost and mortality. TXA, an antifibrinolytic agent, has been proposed to reduce mortality; however, many studies report conflicting results.

METHODS

The aim of the study was to perform the first systematic review and meta-analysis of RCTs to evaluate the efficacy TXA for both upper and lower gastrointestinal bleeding. This was performed per PRISMA guidelines. PubMed, EMBASE, Cochrane and Scopus databases were searched for RCTs. Dichotomous variables were pooled as risk ratios (RR) with 95% confidence intervals (CI) using the MH method with random effects modelling.

RESULTS

Fourteen RCTs were identified with 14,338 patients and mean age of 58.4 years. 34.9% (n = 5008) were female and 65.1% (n = 9330) male. There was no significant difference in mortality between TXA and placebo (RR 0.86 95% CI (0.74 to 1.00), P: 0.05). The secondary outcomes, similarly, did not yield significant results. These included rebleeding, need for surgical intervention (RR: 0.75 95% CI (0.53, 1.07)), endoscopic intervention (RR: 0.92 95% CI (0.70, 1.22)), transfusion requirement (RR: 1.01 95% CI (0.94, 10.7)) and length of stay (RR: 0.03 95% CI (- 0.03, 0.08)). There was no increased risk of VTE, RR: 1.29 95% CI (0.53, 3.16). One trial (n = 12,009) reported an increased risk of seizure in the TXA group, RR: 1.73 95% CI (1.03-2.93).

CONCLUSION

TXA does not reduce mortality in patients with acute upper or lower gastrointestinal bleeding and may confer an increased risk of seizures. The authors do not recommend the use of TXA in acute gastrointestinal bleeding.

Medical therapy has similar hemostatic efficacy with endoscopic treatment for PUB patients with adherent clot (FIIb ulcers)

BACKGROUND

Currently, there is no clear consensus on whether medical treatment or endoscopic treatment should be used for peptic ulcer bleeding patients with adherent clot. The aim of this study is to investigate the hemostatic effects of medical treatment, single endoscopic treatment, and combination endoscopic treatment for peptic ulcer bleeding (PUB) patients with adherent clot.

METHODS

We retrospectively analyzed PUB patients with adherent clot who underwent endoscopic examination or treatment in our center from March 2014 to January 2023 and received intravenous administration of proton pump inhibitors. Patients were divided into medical treatment (MT) group, single endoscopic treatment (ST) group, and combined endoscopic treatment (CT) group. Subsequently, inverse probability of treatment weighting (IPTW) was performed to calculate the rebleeding rate.

RESULTS

A total of 605 eligible patients were included in this study. After IPTW, the rebleeding rate in the MT group on days 3, 7, 14, and 30 were 13.3 (7.3), 14.2 (7.8), 14.5 (7.9), and 14.5 (7.9), respectively; the rebleeding rates in the ST group were 17.4 (5.1), 20.8 (6.1), 20.8 (6.1), and 20.8 (6.1), respectively; the rebleeding rates in the CT group were 0.4 (0.9), 1.7 (3.3), 2.3 (4.5), and 2.3 (4.5), respectively. Although the rebleeding rate in the medical treatment group was higher, there was no significant difference among the three groups on days 3, 7, 14, and 30 (P = 0.132, 0.442, 0.552, and 0.552).

CONCLUSIONS

Medical therapy has similar hemostatic efficacy with endoscopic treatment for PUB patients with adherent clot (FIIb ulcers). However, for patients with more risk factors and access to well-equipped endoscopy centers, endoscopic treatment may be considered. The choice of treatment approach should be based on the individual conditions of the patient, as well as other factors such as medical resources available.

Endoscopic Diagnosis, Grading, and Treatment of Bleeding Peptic Ulcer Disease

Peptic ulcer bleeding is a major cause for hospital admissions and has a significant mortality. Endoscopic interventions reduce the risk of rebleeding in high-risk patients and several options are available including injection therapies, thermal therapies, mechanical clips, hemostatic sprays, and endoscopic suturing. Proton-pump inhibitors and Helicobacter pylori treatment are important adjuncts to endoscopic therapy. Endoscopic therapy is indicated in Forrest 1a, 1b, and 2a lesions. Patients with Forrest 2b lesions may do well with proton-pump inhibitor therapy alone but can also be managed by removal of the clot and targeting endoscopic therapy to the underlying lesion.

Endoscopic Management of Post-Sleeve Gastrectomy Complications

Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.

Three Simple Parameters on Admission to the Emergency Department are Predictors for Endoscopic Intervention in Patients with Suspected Nonvariceal Upper Gastrointestinal Bleeding

BACKGROUND

A considerable number of patients with nonvariceal upper gastrointestinal bleeding (UGIB) need endoscopic intervention.

OBJECTIVE

The aim of this study was to determine factors that predict the need for endoscopic intervention at the time of admission to the emergency department.

METHODS

Consecutive patients with International Classification of Diseases, Tenth Revision diagnosis code K92.2 (gastrointestinal hemorrhage) who underwent upper endoscopy between February 2019 and February 2022, including patients diagnosed with nonvariceal UGIB in the emergency department in the study were reviewed retrospectively. The patients were divided into two groups: those treated endoscopically and those not treated endoscopically. These two groups were compared according to clinical and laboratory findings at admission and independent predictors for endoscopic intervention were determined using multivariate regression analysis.

RESULTS

Although 123 patients (30.3%) were treated endoscopically, endoscopic treatment was not required in 283 (69.7%) patients. Syncope, mean arterial pressure (MAP), and blood urea nitrogen (BUN) at admission were independent predictors for endoscopic intervention in the multivariate analysis, after adjusting for endoscopy time. The area under the curve of the syncope+MAP+BUN combination for endoscopic intervention was 0.648 (95% CI 0.588-0.708). Although the syncope+MAP+BUN combination predicted the need for intervention significantly better than pre-endoscopy Rockall and AIMS65 scores (p = 0.010 and p < 0.001, respectively), there was no significant difference in its comparison with the Glasgow-Blatchford score (p = 0.103).

CONCLUSIONS

Syncope, MAP, and BUN at admission were independent predictors for endoscopic therapy in patients with nonvariceal UGIB. Rather than using complicated scores, it would be more practical and easier to predict the need for endoscopic intervention with these three simple parameters, which are included in the Glasgow-Blatchford score.

Endoscopic and surgical treatment of non-neoplastic proximal duodenal ulceration in dogs, and anatomical study of proximal duodenal vascularisation

OBJECTIVES

Proximal duodenal ulceration is often characterised by continuous bleeding, and treatment is challenging. The aims of this study were to investigate the role of vascularisation in proximal duodenal ulceration and describe clinical aspects, endoscopic features and treatment in dogs.

MATERIAL AND METHODS

Polyurethane foam casts of gastroduodenal vessels were obtained from five dogs which had died from disorders unrelated to the digestive system. In addition, 12 dogs having proximal duodenal ulcers diagnosed by endoscopic examination were enrolled in a treatment trial. After the endoscopic diagnosis of a duodenal ulcer, all the dogs were treated medically and, in the absence of resolution, were subsequently treated by endoscopic electrocauterisation or by surgery.

RESULTS

A submucosal vascular network was evident in all the casts, with a prominent venous plexus seen exclusively in the first half inch of the duodenum. In clinical cases, on endoscopic examination, the duodenal ulcer was located at the proximal part of the duodenum, involving the mesenteric portion of the wall. The dogs not responding to medical treatment (6/12) were treated with endoscopic electrocauterisation, surgical coagulation or resection of the proximal duodenal portion. All the dogs survived until discharge, and the median survival time following discharge was 107.5 days.

CLINICAL SIGNIFICANCE

Based on the anatomical details highlighted in this study, the continuous bleeding observed in our patients may have been due to the prominent venous plexus evidenced at the level of the proximal duodenum. Surgical and endoscopic treatments in six patients resolved the ulcer bleeding with no recurrences noted during follow-up.

Adverse events associated with the gold probe and the injection gold probe devices used for endoscopic hemostasis: A MAUDE database analysis

BACKGROUND

Gastrointestinal (GI) bleeding accounts for over half a million admissions annually and is the most common GI diagnosis requiring hospitalization in the United States. Bipolar electrocoagulation devices are used for the management of gastrointestinal bleeding. There is no data on device-related adverse events for gold probe (GP) and injection gold probe (IGP).

AIM

To analyze this using the Food and Drug Administration (FDA's) Manufacturer and User Facility Device Experience (MAUDE) database from 2013 to 2023.

METHODS

We examined post-marketing surveillance data on GP and IGP from the FDA MAUDE database to report devicerelated and patient-related adverse events between 2013-2023. The MAUDE database is a publicly available resource providing over 4 million records relating to medical device safety. Statistical analyses were performed using IBM SPSS Statistics V.27.0 (IBM Corp., Armonk, NY, United States).

RESULTS

Our search elicited 140 reports for GP and 202 reports for IGP, respectively, during the study period from January 2013 to August 2023. Malfunctions reportedly occurred in 130 cases for GP, and actual patient injury or event occurred in 10 patients. A total of 149 patients (74%) reported with Injection GP events suffered no significant consequences due to the device failure, but 53 patients (26%) were affected by an event.

CONCLUSION

GP and IGP are critical in managing gastrointestinal bleeding. This study of the FDA MAUDE database revealed the type, number, and trends of reported device-related adverse events. The endoscopist and support staff must be aware of these device-related events and be equipped to manage them if they occur.

Role of endoscopic ultrasound in non-variceal upper gastrointestinal bleeding management

Non-variceal upper gastrointestinal bleeding (NVUGIB) is one of the challenging situations in clinical practice. Despite that gastric ulcer and duodenal ulcer are still the main causes of acute NVUGIB, there are other causes of bleeding which might not always be detected through the standard endoscopic evaluation. Standard endoscopic management of UGIB consists of injection, thermal coagulation, hemoclips, and combination therapy. However, these methods are not always successful for rebleeding prevention. Endoscopic ultrasound (EUS) has been used recently for portal hypertension management, especially in managing acute variceal bleeding. EUS has been considered a better tool to visualize the bleeding vessel in gastroesophageal variceal bleeding. There have been studies looking at the role of EUS for managing NVUGIB; however, most of them are case reports. Therefore, it is important to review back to see the evolution and innovation of endoscopic treatment for NVUGIB and the role of EUS for possibility to replace the standard endoscopic haemostasis management in daily practice.

Comparison Between Pantoprazole Intermittent Dosing and Continuous Infusion in Suspected Upper Gastrointestinal Bleeding Prior to Endoscopy: Impact of a Pharmacist-Driven Protocol to Reduce Utilization of Pantoprazole Continuous Infusion

BACKGROUND

Current practice for patients with suspected or confirmed upper gastrointestinal bleeding (GIB) is to utilize a proton pump inhibitor (PPI) bolus followed by a continuous infusion for 72 hours. Literature has shown similar outcomes with intermittent bolus dosing compared to continuous infusion. Substitution would lead to reduced costs and utilization of resources.

METHODS

This was a retrospective case-control study conducted via chart review. Utilizing electronic healthcare record reports, patients in the control arm were screened for inclusion if they received a pantoprazole continuous infusion from December 1, 2020, to March 31, 2021. A total of 38 patients were included in the control arm. Patients in the experimental arm were screened for inclusion with pantoprazole intermittent therapy from January 1, 2022, to June 30, 2022. A total of 60 patients were included in the experimental arm. The primary outcome was a 30-day GIB recurrence. Secondary outcomes included 30-day hospital readmission, 30-day Clostridioides difficile (C. difficile), hospital length of stay (LOS), and number of pantoprazole vials utilized.

RESULTS

There was a 65% reduction in the 30-day GIB recurrence in the intermittent bolus arm compared to the continuous infusion arm. Thirty-day hospital readmission was 57% lower in the intermittent bolus arm compared to the continuous infusion arm. The LOS between the two arms was almost identical with the median being five days for the intermittent bolus arm and the median being four days for the continuous infusion arm. The 30-day C. difficile infection rate had 5% of patients acquiring C. difficile in the intermittent bolus arm and 2.5% in the continuous infusion arm. The intermittent bolus arm used 55% fewer pantoprazole vials than the continuous infusion arm.

CONCLUSION

In hospitalized patients, the utilization of pantoprazole intermittent bolus is not only comparably efficacious but potentially represents a safer and economically advantageous alternative compared to the current guideline recommendation of a 72-hour pantoprazole continuous infusion. Further studies could provide more robust data to support our findings and challenge the current recommendation for patients who meet the indication criteria.

Endoscopic Versus Conservative Therapy for Bleeding Peptic Ulcer with Adherent Clot: A Comprehensive Systematic Review and Meta-Analysis

INTRODUCTION

Peptic ulcers with adherent clots are associated with a high-risk of rebleeding and mortality. However, the optimal management of bleeding ulcers with adherent clots remains unclear. We conducted this systematic review and meta-analysis to compare endoscopic therapy and conservative therapy to manage bleeding ulcers with adherent clots.

METHODS

We systematically searched PubMed, Embase, and Web of Science databases through October 2022 to include all studies comparing the endoscopic and conservative therapeutic approaches for bleeding ulcers with adherent clots. Our primary outcome was rebleeding (overall and 30-day). The secondary outcomes were mortality (overall and 30-day), need for surgery, and length of hospital stay (LOS). The random-effects model was used to calculate the pooled odds ratios (OR) and mean differences (MD) with the corresponding confidence intervals (CI) for proportional and continuous variables, respectively.

RESULTS

Eleven studies (9 RCTs) with 833 patients (431 received endoscopic therapy vs. 402 received conservative therapy) were included. Overall, endoscopic therapy was associated with lower overall rebleeding (OR 0.41, 95% CI 0.22-0.79, P = 0.007), 30-day rebleeding (OR 0.43, 95% CI 0.21-0.89, P = 0.002), overall mortality (OR 0.47, 95% CI 0.23-0.95, P = 0.04), 30-day mortality (OR 0.43, 95% CI 0.21-0.89, P = 0.002), need for surgery (OR 0.44, 95% CI 0.21-0.95, P = 0.04), and LOS (MD - 3.17 days, 95% CI - 4.14, - 2.19, P < 0.00001). However, subgroup analysis of randomized controlled trials (RCTs) showed no significant difference in overall mortality (OR 0.78, 95% CI 0.24-2.52, P = 0.68) between the two strategies, with numerically lower but statistically non-significant rates of overall rebleeding (7.2% vs. 18.5%, respectively; OR 0.42, 95% CI 0.17-1.05, P = 0.06), statistically lower rate of need for surgery (OR 0.28, 95% CI 0.08-0.96, P = 0.04) with endoscopic therapy compared to conservative therapy.

CONCLUSIONS

Our meta-analysis demonstrates that endoscopic therapy was overall associated with lower rates of rebleeding (overall and 30-day), mortality (overall and 30-day), need for surgery, and LOS, compared to conservative therapy for the management of bleeding ulcers with adherent clots. However, subgroup analysis of RCTs showed that endoscopic therapy was associated with numerically lower but statistically non-significant rates of overall rebleeding and a statistically lower rate of need for surgery compared to conservative therapy with similar overall mortality rates. Combined treatment with thermal therapy and injection therapy was the most effective treatment modality in reducing rebleeding risk. Further large-scale RCTs are needed to validate our findings.

Epinephrine injection monotherapy shows similar hemostatic efficacy to epinephrine injection combined therapy in high-risk patients (Forrest Ib) with bleeding ulcers

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.

Intermittent Proton Pump Inhibitor Therapy in Low-Risk Non-Variceal Upper Gastrointestinal Bleeding May Be Significantly Cost-Saving

BACKGROUND

High-dose proton pump inhibitor (PPI) therapy, given either intermittently or continuously for non-variceal upper gastrointestinal bleeding (NV-UGIB), is efficacious. Using intermittent PPI for low-risk patients may be cost-saving. Our objective was to estimate the annual cost savings if all low-risk NV-UGIB patients received intermittent PPI therapy.

METHODS

Patients who presented to hospital in Calgary, Alberta, who received a PPI for NV-UGIB from July 2015 to March 2017 were identified using ICD-10 codes. Patients were stratified into no endoscopy, high-risk, and low-risk lesion groups and further subdivided into no PPI, oral PPI, intermittent intravenous (IV), and continuous IV subgroups. Average length of stay (LOS) in each subgroup and costs were calculated.

RESULTS

We identified 4141 patients with NV-UGIBs, (median age 61, 57.4% male). One-thousand two-hundred and thirty-one low-risk patients received continuous IV PPI, with an average LOS of 6.8 days (95% CI 6.2-7.3) versus 4.9 days (95% CI 3.9-5.9) for intermittent IV patients. If continuous IV PPI patients instead received intermittent IV PPI, 3852 patient days and CAD 11,714,390 (2017 CAD)/year could be saved.

CONCLUSIONS

Using real-world administrative data, we demonstrate that a sizable portion of low-risk patients with NV-UGIB who were given continuous IV PPI if switched to intermittent IV therapy could generate significant potential cost savings.

Bleeding in acute coronary syndrome: from definitions, incidence, and prognosis to prevention and management

INTRODUCTION

In patients with acute coronary syndrome (ACS), the ischemic benefit of antithrombotic treatment is counterbalanced by the risk of bleeding. The recognition that bleeding events have prognostic implications (i.e. mortality) similar to recurrent ischemic events led to the development of treatment regimens aimed at balancing both ischemic and bleeding risks.

AREAS COVERED

This review aims at describing definitions, incidence, and prognosis related to bleeding events in ACS patients as well as bleeding-avoidance strategies for their prevention and management of bleeding complications.

EXPERT OPINION

Management of ACS patients has witnessed remarkable progress after the shift in focusing on the trade-off between ischemia and bleeding. Efforts in standardizing bleeding definitions will allow for better defining the prognostic impact of different types of bleeding events and enable to identify the high-bleeding risk patient. Such efforts will allow to balance the trade-off between the thrombotic and bleeding risk of the individual patient translating into better downward diagnostic and therapeutic decision-making. Novel strategies aiming at maximizing the safety and efficacy of antithrombotic regimens as well as the development of novel antithrombotic drugs and reversal agents and technological advances will allow for optimization of bleeding-avoidance strategies and management of bleeding complications.

A Review of Risk Scores within Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding is a common medical emergency. Thorough initial assessment and appropriate resuscitation are essential to stabilise the patient. Risk scores provide an important tool to discriminate between lower- and higher-risk patients. Very low-risk patients can be safely discharged for out-patient management, while higher-risk patients can receive appropriate in-patient care. The Glasgow Blatchford Score, with a score of 0-1, performs best in the identification of very low-risk patients who will not require hospital based intervention or die, and is recommended by most guidelines to facilitate safe out-patient management. The performance of risk scores in the identification of specific adverse events to define high-risk patients is less accurate, with no individual score performing consistently well. Ongoing developments in the use of machine learning models and artificial intelligence in predicting poor outcomes in UGIB appear promising and will likely form the basis of dynamic risk assessment in the future.

Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage

BACKGROUND

Upper endoscopy is the definitive treatment for upper gastrointestinal haemorrhage (UGIH). However, up to 13% of people who undergo upper endoscopy will have incomplete visualisation of the gastric mucosa at presentation. Erythromycin acts as a motilin receptor agonist in the upper gastrointestinal (GI) tract and increases gastric emptying, which may lead to better quality of visualisation and improved treatment effectiveness. However, there is uncertainty about the benefits and harms of erythromycin in UGIH.

OBJECTIVES

To evaluate the benefits and harms of erythromycin before endoscopy in adults with acute upper gastrointestinal haemorrhage, compared with any other treatment or no treatment/placebo.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 15 October 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that investigated erythromycin before endoscopy compared to any other treatment or no treatment/placebo before endoscopy in adults with acute UGIH.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. UGIH-related mortality and 2. serious adverse events. Our secondary outcomes were 1. all-cause mortality, 2. visualisation of gastric mucosa, 3. non-serious adverse events, 4. rebleeding, 5. blood transfusion, and 5. rescue invasive intervention. We used GRADE criteria to assess the certainty of the evidence for each outcome.  MAIN RESULTS: We included 11 RCTs with 878 participants. The mean age ranged from 53.13 years to 64.5 years, and most participants were men (72.3%). One RCT included only non-variceal haemorrhage, one included only variceal haemorrhage, and eight included both aetiologies. We defined short-term outcomes as those occurring within one week of initial endoscopy. Erythromycin versus placebo Three RCTs (255 participants) compared erythromycin with placebo. There were no UGIH-related deaths. The evidence is very uncertain about the short-term effects of erythromycin compared with placebo on serious adverse events (risk difference (RD) -0.01, 95% confidence interval (CI) -0.04 to 0.02; 3 studies, 255 participants; very low certainty), all-cause mortality (RD 0.00, 95% CI -0.03 to 0.03; 3 studies, 255 participants; very low certainty), non-serious adverse events (RD 0.01, 95% CI -0.03 to 0.05; 3 studies, 255 participants; very low certainty), and rebleeding (risk ratio (RR) 0.63, 95% CI 0.13 to 2.90; 2 studies, 195 participants; very low certainty). Erythromycin may improve gastric mucosa visualisation (mean difference (MD) 3.63 points on 16-point ordinal scale, 95% CI 2.20 to 5.05; higher MD means better visualisation; 2 studies, 195 participants; low certainty). Erythromycin may also result in a slight reduction in blood transfusion (MD -0.44 standard units of blood, 95% CI -0.86 to -0.01; 3 studies, 255 participants; low certainty). Erythromycin plus nasogastric tube lavage versus no intervention/placebo plus nasogastric tube lavage Six RCTs (408 participants) compared erythromycin plus nasogastric tube lavage with no intervention/placebo plus nasogastric tube lavage. There were no UGIH-related deaths and no serious adverse events. The evidence is very uncertain about the short-term effects of erythromycin plus nasogastric tube lavage compared with no intervention/placebo plus nasogastric tube lavage on all-cause mortality (RD -0.02, 95% CI -0.08 to 0.03; 3 studies, 238 participants; very low certainty), visualisation of the gastric mucosa (standardised mean difference (SMD) 0.48 points on 10-point ordinal scale, 95% CI 0.10 to 0.85; higher SMD means better visualisation; 3 studies, 170 participants; very low certainty), non-serious adverse events (RD 0.00, 95% CI -0.05 to 0.05; 6 studies, 408 participants; very low certainty), rebleeding (RR 1.13, 95% CI 0.63 to 2.02; 1 study, 169 participants; very low certainty), and blood transfusion (MD -1.85 standard units of blood, 95% CI -4.34 to 0.64; 3 studies, 180 participants; very low certainty). Erythromycin versus nasogastric tube lavage Four RCTs (287 participants) compared erythromycin with nasogastric tube lavage. There were no UGIH-related deaths and no serious adverse events. The evidence is very uncertain about the short-term effects of erythromycin compared with nasogastric tube lavage on all-cause mortality (RD 0.02, 95% CI -0.05 to 0.08; 3 studies, 213 participants; very low certainty), visualisation of the gastric mucosa (RR 1.19, 95% CI 0.79 to 1.79; 2 studies, 198 participants; very low certainty), non-serious adverse events (RD -0.10, 95% CI -0.34 to 0.13; 3 studies, 213 participants; very low certainty), rebleeding (RR 0.77, 95% CI 0.40 to 1.49; 1 study, 169 participants; very low certainty), and blood transfusion (median 2 standard units of blood, interquartile range 0 to 4 in both groups; 1 study, 169 participants; very low certainty). Erythromycin plus nasogastric tube lavage versus metoclopramide plus nasogastric tube lavage One RCT (30 participants) compared erythromycin plus nasogastric tube lavage with metoclopramide plus nasogastric tube lavage. The evidence is very uncertain about the effects of erythromycin plus nasogastric tube lavage on all the reported outcomes (serious adverse events, visualisation of gastric mucosa, non-serious adverse events, and blood transfusion).

AUTHORS' CONCLUSIONS

We are unsure if erythromycin before endoscopy in people with UGIH has any clinical benefits or harms. However, erythromycin compared with placebo may improve gastric mucosa visualisation and result in a slight reduction in blood transfusion.

Application of endoscopic purse-string sutures in high-risk peptic ulcer hemorrhage: preliminary experience of 38 cases

OBJECTIVE

This study is a prospective study to explore the therapeutic effect of endoscopic purse-string sutures in high-risk peptic ulcer hemorrhage.

PATIENTS AND METHODS

We prospectively collected and analyzed data from July 2018 to December 2020 from patients in Jinshan hospital, Fudan University, who underwent emergency endoscopy for acute severe high-risk non-variceal upper gastrointestinal hemorrhage (NVUGIB) and were treated with endoscopic purse-string sutures.

RESULTS

We included 38 patients whose median age was 64 years (interquartile range: 57.2 - 71.2 years). All patients were high risk gastric ulcer larger than 1 cm, including Forrest Ia (n = 4, 10.5%), Forrest Ib (n = 13, 34.2%) and Forrest IIa (n = 21, 55.3%). All patients were treated with endoscopic purse-string sutures. The clinical success rate reached 89.5%. Three patients suffered from rebleeding within seven days, and were treated with surgery or arterial embolization, respectively, all of which successfully stopped bleeding. One patient died of myocardial infarction. All other patients were followed up for 30 days without bleeding.

CONCLUSIONS

We conclude that endoscopic purse-string sutures seem to be safe and effective in the treatment of patients at high risk of ulcer bleeding.

Hemostatic Powders in Non-Variceal Upper Gastrointestinal Bleeding: The Open Questions

Hemostatic powder (HP) is a relatively recent addition to the arsenal of hemostatic endoscopic procedures (HEPs) for gastrointestinal bleeding (GIB) due to benign and malignant lesions. Five types of HP are currently available: TC-325 (Hemospray™), EndoClot™, Ankaferd Blood Stopper^®, and, more recently, UI-EWD (Nexpowder^TM) and CEGP-003 (CGBio™). HP acts as a mechanical barrier and/or promotes platelet activation and coagulation cascade. HP may be used in combination with or as rescue therapy in case of failure of conventional HEPs (CHEPs) and also as monotherapy in large, poorly accessible lesions with multiple bleeding sources. Although the literature on HP is abundant, randomized controlled trials are scant, and some questions remain open. While HP is highly effective in inducing immediate hemostasis in GIB, the rates of rebleeding reported in different studies are very variable, and conditions affecting the stability of hemostasis have not yet been fully elucidated. It is not established whether HP as monotherapy is appropriate in severe GIB, such as spurting peptic ulcers, or should be used only as rescue or adjunctive therapy. Finally, as it can be sprayed on large areas, HP could become the gold standard in malignancy-related GIB, which is often nonresponsive or not amenable to treatment with CHEPs as a result of multiple bleeding points and friable surfaces. This is a narrative review that provides an overview of currently available data and the open questions regarding the use of HP in the management of non-variceal upper GIB due to benign and malignant diseases.

Nomogram for predicting rebleeding after initial endoscopic epinephrine injection monotherapy hemostasis in patients with peptic ulcer bleeding: a retrospective cohort study

Background

Although the current guidelines recommend endoscopic combination therapy, endoscopic epinephrine injection (EI) monotherapy is still a simple, common and effective modality for treating peptic ulcer bleeding (PUB). However, the rebleeding risk after EI monotherapy is still high, and identifying rebleeding patients after EI monotherapy is unclear, which is highly important in clinical practice. This study aimed to identify risk factors and constructed a predictive nomogram related to rebleeding after EI monotherapy.

Methods

We consecutively and retrospectively analyzed 360 PUB patients who underwent EI monotherapy between March 2014 and July 2021 in our center. Then we identified independent risk factors associated with rebleeding after initial endoscopic EI monotherapy by multivariate logistic regression. A predictive nomogram was developed and validated based on the above predictors.

Results

Among all PUB patients enrolled, 51 (14.2%) had recurrent hemorrhage within 30 days after endoscopic EI monotherapy. After multivariate logistic regression, shock [odds ratio (OR) = 12.691, 95% confidence interval (CI) 5.129–31.399, p < 0.001], Rockall score (OR = 1.877, 95% CI 1.250–2.820, p = 0.002), tachycardia (heart rate > 100 beats/min) (OR = 2.610, 95% CI 1.098–6.203, p = 0.030), prolonged prothrombin time (PT > 13 s) (OR = 2.387, 95% CI 1.019–5.588, p = 0.045) and gastric ulcer (OR = 2.258, 95% CI 1.003–5.084, p = 0.049) were associated with an increased risk of rebleeding after an initial EI monotherapy treatment. A nomogram incorporating these independent high-risk factors showed good discrimination, with an area under the receiver operating characteristic curve (AUROC) of 0.876 (95% CI 0.817–0.934) (p < 0.001).

Conclusions

We developed a predictive nomogram of rebleeding after EI monotherapy, which had excellent prediction accuracy. This predictive nomogram can be conveniently used to identify low-risk rebleeding patients after EI monotherapy, allowing for decision-making in a clinical setting.

Acid Suppressive Drugs

Histamine H₂ receptor antagonists (H₂RAs) suppress gastric acid production by blocking H₂ receptors in parietal cells. Studies have shown that proton pump inhibitors (PPIs) are superior to H₂RAs as a treatment for acid-related disorders, such as peptic ulcer disease (PUD) and gastroesophageal reflux disease (GERD). PPIs reduce gastric acid production by irreversibly inhibiting the H⁺/K⁺ ATPase pump, and they also increase gastric emptying. Although PPIs have differing pharmacokinetic properties, each PPI is effective in managing GERD and PUDs. However, PPIs have some limitations, including short plasma half-lives, breakthrough symptoms (especially at night), meal-associated dosing, and concerns associated with long-term PPI use. Potassium-competitive acid blockers (P-CABs) provide more rapid and profound suppression of intragastric acidity than PPIs. P-CABs are non-inferior to lansoprazole in healing erosive esophagitis and peptic ulcers, and may also be effective in improving symptoms in patients with non-erosive reflux disease. Acid suppressive drugs are the most commonly used drugs in clinical practice, and it is necessary to understand the pharmacological properties and adverse effects of each drug.

Timing of endoscopy in patients with upper gastrointestinal bleeding

The optimal timing of endoscopy in patients with acute upper gastrointestinal bleeding (UGIB) remains controversial. In this study, we investigated the clinical outcomes of urgent endoscopy in patients with UGIB compared with elective endoscopy. From January 2016 to December 2018, consecutive patients who visited the emergency department and underwent endoscopy for clinical manifestations of acute UGIB, including variceal bleeding, were eligible. Urgent endoscopy (within 6 h) and elective endoscopy (after 6 h) were defined as the time taken to perform endoscopy after presentation to the emergency department. The primary outcome was mortality rate within 30 days. A total of 572 patients were included in the analysis. Urgent endoscopy was performed in 490 patients (85.7%). The 30-day mortality rate did not differ between the urgent and elective endoscopy groups (5.3% and 6.1%, p = 0.791). There was no difference regarding the recurrent bleeding rate, total amount of transfusion, or length of hospital between the groups. In multivariate analysis, age and the amount of transfusion were associated with mortality. Urgent endoscopy was not associated with a lower 30-day mortality rate compared with elective endoscopy in patients with acute UGIB.

Effects of high-dose versus low-dose proton pump inhibitors for treatment of gastrointestinal ulcer bleeding: a meta-analysis of randomized controlled trials

Background

We performed a meta-analysis to compare the effects of high-dose (80 mg/day) versus low-dose (40 mg/day) proton pump inhibitors (PPIs) on gastrointestinal ulcer bleeding.

Methods

We retrieved studies of randomized controlled trials of PPIs administered according to different schedules for the treatment of gastrointestinal ulcer bleeding from Medline, Embase, Web of Science, Clinical Trials, and the Cochrane Database in April 2020.

Results

Nine randomized controlled trials including 2329 patients were included in this meta-analysis. There were no significant differences in the incidences of re-bleeding, operation intervention, postoperative mortality, and length of hospital stay between the low-dose and high-dose groups. However, the blood transfusion volume was significantly higher in the high-dose group.

Conclusion

Compared with low-does PPIs, high-dose PPIs had no effect on the incidence of re-bleeding, operation intervention, or postoperative mortality, and did not reduce hospital stay in patients treated with endoscopic hemostasis for gastrointestinal bleeding.

Acute Upper Non-variceal and Lower Gastrointestinal Bleeding

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.

The global burden of peptic ulcer disease in 204 countries and territories from 1990 to 2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Peptic ulcer disease is one of the most common diseases in gastroenterology clinics. However, reported data about the global burden of peptic ulcer disease are still scarce.

METHODS

This was a secondary data analysis on the prevalence, mortality and disability-adjusted life years (DALYs) due to peptic ulcer disease by sex, age group and socio-demographic index (SDI) at the global level in 21 regions and 204 countries and territories between 1990 and 2019 using the Global Burden of Diseases, Injuries, and Risk Factors Study 2019.

RESULTS

Globally, the prevalence cases of peptic ulcer disease increased from 6 434 103 (95% uncertainty interval 5 405 963 to 7 627 971) in 1990 to 8 090 476 (6 794 576 to 9 584 000) in 2019. However, the age-standardized prevalence rate decreased from 143.4 (120.5 to 170.2) per 100 000 population in 1990 to 99.4 (83.9 to 117.5) per 100 000 population in 2019. Moreover, the age-standardized mortality rate decreased by 59.4% (55.3 to 63.1) and the DALYs rate fell by 60.6% (56.8 to 63.9) from 1990 to 2019. Across SDI quintiles, low-middle and low SDI quintiles had the highest age-standardized prevalence, mortality and DALYs rates from 1990 to 2019.

CONCLUSION

The age-standardized prevalence, mortality and DALYs estimates of peptic ulcer disease decreased from 1990 to 2019 globally, but more efforts are needed for the prevention, early diagnosis and treatment of peptic ulcer disease in low SDI and low-middle SDI groups of countries.

Intermittent Versus Continuous Infusion Dosing of Intravenous Proton Pump Inhibitors for Upper Gastrointestinal Bleeding

BACKGROUND

Proton pump inhibitor (PPI) continuous infusions or intermittent boluses are used for the treatment of upper gastrointestinal bleeding (UGIB). Intermittent boluses are easier to give and are of lower cost without affecting clinical outcomes.

OBJECTIVE

To compare the rate of rebleeding between intermittent bolus and continuous infusion PPI therapy.

METHODS

We performed a retrospective, multicenter review of patients with UGIB receiving either continuous or intermittent PPI therapy. During the study period, due to drug and supply shortages, each institution implemented policies preferring intermittent PPI bolus therapy. We performed bivariate and multivariable comparisons of the 2 treatment strategies, with the primary outcome of interest being incidence of rebleeding. Additional variables of interest included intensive care unit (ICU) and hospital lengths of stay, discharge disposition, and in-hospital mortality.

RESULTS

Compared with intermittent bolus dosing (n = 209), patients receiving continuous infusion PPI (n = 237) were associated with a higher rate of rebleeding (33.8% vs 23.0%; P = 0.012); however, no difference was detected in multivariable analysis: adjusted odds ratio, 1.50 (95% confidence interval, 0.91-2.50). There was no difference in median hospital or ICU length of stay, discharge disposition, or in-hospital mortality. Correlatively, patients receiving continuous infusion therapy were more likely to have liver disease (29.1% vs 20.1%; P = 0.028), alcohol use disorder (28.3% vs 16.3.%; P = 0.003), history of lower gastrointestinal bleeding (6.4% vs 1.9%; P = 0.021), variceal bleeding (6.3 vs 2.4%, P = 0.045), and be admitted to the ICU (65.0% vs 32.5%, P = 0.00).

CONCLUSIONS

Introduction of intermittent PPI bolus UGIB treatment via change in hospital policy was not associated with higher rates of rebleeding. However, continuous PPI therapy may have been perceived as more effective as it was used more commonly in high-risk patients.

Treatment and outcome of gastrointestinal bleeding due to peptic ulcers and erosions - (BLUE study)

OBJECTIVES

Peptic ulcers and erosions are the most common causes of upper gastrointestinal bleeding. The aim of this study was to investigate the management and outcomes of these patients.

MATERIALS AND METHODS

A total of 543 patients with endoscopically confirmed bleeding from peptic ulcers and erosions were included from March 2015 to December 2017. The patient characteristics, endoscopic findings, Forrest classification and endoscopic treatment were recorded. Moreover, the rebleeding rates, repeated endoscopies and transcatheter angiographic embolization and surgery incidences were registered. A follow-up endoscopy after discharge from the hospital was scheduled.

RESULTS

Among the patients, high-risk stigmata ulcers were present in 36% (198/543) and low-risk stigmata ulcers and erosions in 60% (327/543) at first endoscopy. Endoscopic therapy was performed in 30% (165/543) of the patients, and hemostasis was achieved in 94% (155/165). The incidence of rebleeding was 9% (49/543) for the whole cohort and 14.8% (23/155) for those patients who had received successful endoscopic treatment. Moreover, rebleeding was significantly more frequent in duodenal ulcers than in gastric ulcers (11.9% vs 4.0%, p = .004). In a multivariable analysis, rebleeding was significantly related to comorbidity and Forrest classification. Transcatheter angiographic embolization and surgery were required in 6% (34/543) and 0.07% (4/543) of patients, respectively. Complete peptic ulcer healing was found at follow-up in 73.3% (270/368) of patients.

CONCLUSIONS

Endoscopic hemostasis was achieved in the majority of patients with high-risk ulceration, although the occurrence of rebleeding is a significant challenge, especially in patients with duodenal ulcers. Clinical trial registration: Bleeding Ulcer and Erosions Study (BLUE Study), ClinicalTrials.gov identifier: NCT03367897.

Update on the management of upper gastrointestinal bleeding

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.

Severe Upper Gastrointestinal Hemorrhage Caused by Reflux Esophagitis

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.

Superiority of urgent vs early endoscopic hemostasis in patients with upper gastrointestinal bleeding with high-risk stigmata

Background

Guidelines recommend that all patients with upper gastrointestinal bleeding (UGIB) undergo endoscopy within 24 h. It is unclear whether a subgroup may benefit from an urgent intervention. We aimed to evaluate the influence of endoscopic hemostasis and urgent endoscopy on mortality in UGIB patients with high-risk stigmata (HRS).

Methods

Consecutive patients with suspected UGIB were enrolled in three Japanese hospitals with a policy to perform endoscopy within 24 h. The primary outcome was 30-day mortality. Endoscopic hemostasis and endoscopy timing (urgent, ≤6 h; early, >6 h) were evaluated in a regression model adjusting for age, systolic pressure, heart rate, hemoglobin, creatinine, and variceal bleeding in multivariate analysis. A propensity score of 1:1 matched sensitivity analysis was also performed.

Results

HRS were present in 886 of 1966 patients, and 35 of 886 (3.95%) patients perished. Median urgent-endoscopy time (n = 769) was 3.0 h (interquartile range [IQR], 2.0–4.0 h) and early endoscopy (n = 117) was 12.0 h (IQR, 8.5–19.0 h). Successful endoscopic hemostasis and urgent endoscopy were significantly associated with reduced mortality in multivariable analysis (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.09–0.52; P = 0.0006, and OR, 0.37; 95% CI, 0.16–0.87; P = 0.023, respectively). In a propensity-score-matched analysis of 115 pairs, adjusted comparisons showed significantly lower mortality of urgent vs early endoscopy (2.61% vs 7.83%, P < 0.001).

Conclusions

A subgroup of UGIB patients, namely those harboring HRS, may benefit from endoscopic hemostasis and urgent endoscopy rather than early endoscopy in reducing mortality. Implementing triage scores that predict the presence of such lesions is important.

Acute gastrointestinal bleeding: proposed study outcomes for new randomised controlled trials

BACKGROUND

Acute gastrointestinal bleeding (GIB) remains a common cause of hospitalisation. However, interpretation and comparisons of published studies in GIB have been hampered by disparate study methodology.

AIMS

To make recommendations about outcome measures to be used in future randomised controlled trials (RCTs) of patients with acute bleeding from any GI source (nonvariceal UGI, variceal, small bowel, or colon) and suggest new RCTs in acute GIB for future peer-reviewed funding.

METHODS

As part of a National Institutes of Health conference entitled "Hemostatic Outcomes in Clinical Trials", a group of GIB experts performed targeted critical reviews of available evidence with the goal of proposing a bleeding outcome that could potentially be applied to different disciplines. In addition, the panel sought to develop a clinically meaningful primary endpoint specifically for acute GIB, potentially allowing a more contemporary regrouping of clinically relevant outcomes.

RESULTS

The primary endpoint proposed was a composite outcome of further bleeding within 30 days after randomisation leading to red blood cell transfusion, urgent intervention (repeat endoscopy; interventional radiology or surgery), or death. Secondary outcomes may include the individual components of the primary outcome, length of hospitalisation, serious adverse events, and health care resource utilisation.

CONCLUSION

The proposed endpoint may help move the GIB field forward by focusing on the most clinically relevant outcomes for patients with acute GIB of all types and informing study design and importance of sample size determination for future RCTs in GIB.

New Trends and Advances in Non-Variceal Gastrointestinal Bleeding-Series II

The gastrointestinal tract is a long tubular structure wherein any point in the mucosa along its entire length could be the source of a hemorrhage. Upper (esophagel and gastroduodenal) and lower (jejunum, ileum, and colon) gastrointestinal bleeding are common. Gastroduodenal and colonic bleeding are more frequent than bleeding from the small bowel, but nowadays the entire gastrointestinal tract can be explored endoscopically and bleeding lesions can be locally treated successfully to stop or prevent further bleeding. The extensive use of antiplatelet and anticoagulants drugs in cardiovascular patients is, at least in part, the cause of the increasing number of patients suffering from gastrointestinal bleeding. Patients with these conditions are usually older and more fragile because of their comorbidities. The correct management of antithrombotic drugs in cases of gastrointestinal bleeding is essential for a successful outcome for patients. The influence of the microbiome in the pathogenesis of small bowel bleeding is an example of the new data that are emerging as potential therapeutic target for bleeding prevention. This text summarizes the latest research and advances in all forms of acute gastrointestinal bleeding (i.e., upper, small bowel and lower). Diagnosis is approached, and medical, endoscopic or antithrombotic management are discussed in the text in an accessible and comprehensible way.

The role of endoscopic doppler probe in the management of bleeding peptic ulcers: a systematic review and meta-analysis

OBJECTIVES

Forrest classification for ulceration has significant intra and inter-observer variability. The endoscopic doppler probe (DOP-US) identifies arterial blood flow at the base to direct therapy. We performed a systematic review and meta-analysis to evaluate the role of the DOP-US in bleeding peptic ulcers.

METHODS

Three independent reviewers performed a comprehensive review of all original articles published from inception to December 2019, evaluating the use of DOP-US in peptic ulcer bleeding. Primary outcomes were the comparison of rebleeding rate, mortality, and surgical intervention in patients with DOP-US signal-guided therapy versus standard visual evaluation guided therapy.

RESULTS

Eight studies were included after a thorough search was concluded using the key words. The use of DOP-US probe decreases rebleeding, mortality, and surgical intervention as compared to Forrest Classification. The risk of rebleeding is significantly higher if the signal persists despite endoscopic therapy (48.5% (95% CI 29.5-67.9%)).

CONCLUSION

The first systematic review and meta-analysis showed that the DOP-US is a beneficial tool in the management of bleeding ulcers and adds valuable information to visual evaluation.

[Guidelines for Non-variceal Upper Gastrointestinal Bleeding]

Non-variceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB is an important cause for visiting the hospital and is associated with significant morbidity and mortality. Although European and Asian-Pacific guidelines have been published, there has been no previous guidelines regarding management of NVUGIB in Korea. Korea is a country with a high prevalence of Helicobacter pylori infection and patients have easy accessibility to receive endoscopy. Therefore, we believe that guidelines regarding management of NVUGIB are mandatory. The Korean Society of Gastroenterology reviewed recent evidence and recommends practical management guidelines on NVUGIB in Korea.

Endoscopic treatment of primary aorto-enteric fistulas: A case report and review of literature

BACKGROUND

Primary aorto-enteric fistula (PAEF) is a rare condition, traditionally treated in the acute, bleeding phase with open surgery or endovascular repair. However, these approaches have high morbidity and mortality, indicating a need for new methods. With advances in endoscopic techniques and equipment, haemoclipping of fistulas has now become feasible. Therefore, we present a systematic review of the English literature and a rare case of a PAEF successfully treated by endoscopic haemoclipping.

CASE SUMMARY

A 74-year-old man with an abdominal aortic aneurysm presented with symptoms of haemorrhagic shock and bloody stools. An oesophago-gastro-duodenoscopy was performed with haemoclipping of a suspected PAEF in the third part of the duodenum. Afterward, a computed tomography-angiography showed a contrast filled protrusion from the abdominal aortic aneurysm. Based on the clinical presentation and the combined endoscopic and radiographic findings, we argue that this is a case of a PAEF.

CONCLUSION

Endoscopic therapy appears capable of achieving haemodynamic stabilisation in patients with bleeding PAEF, serving as a bridge to final therapy.

ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding

We performed systematic reviews addressing predefined clinical questions to develop recommendations with the GRADE approach regarding management of patients with overt upper gastrointestinal bleeding. We suggest risk assessment in the emergency department to identify very-low-risk patients (e.g., Glasgow-Blatchford score = 0-1) who may be discharged with outpatient follow-up. For patients hospitalized with upper gastrointestinal bleeding, we suggest red blood cell transfusion at a threshold of 7 g/dL. Erythromycin infusion is suggested before endoscopy, and endoscopy is suggested within 24 hours after presentation. Endoscopic therapy is recommended for ulcers with active spurting or oozing and for nonbleeding visible vessels. Endoscopic therapy with bipolar electrocoagulation, heater probe, and absolute ethanol injection is recommended, and low- to very-low-quality evidence also supports clips, argon plasma coagulation, and soft monopolar electrocoagulation; hemostatic powder spray TC-325 is suggested for actively bleeding ulcers and over-the-scope clips for recurrent ulcer bleeding after previous successful hemostasis. After endoscopic hemostasis, high-dose proton pump inhibitor therapy is recommended continuously or intermittently for 3 days, followed by twice-daily oral proton pump inhibitor for the first 2 weeks of therapy after endoscopy. Repeat endoscopy is suggested for recurrent bleeding, and if endoscopic therapy fails, transcatheter embolization is suggested.

Intraluminal Endovascular Coil Migration: A Rare Complication Post-Embolization of the Gastroduodenal Artery for a Previously Bleeding Duodenal Ulcer

Transarterial angiographic embolization is a highly effective, safe treatment for non-variceal upper gastrointestinal bleeding refractory to endoscopic intervention. However, intraluminal coil migration is a possible complication. Coil migration, while usually a self-limiting process, can lead to significant rebleeding. In our case, a patient presented with a life-threatening duodenal ulcer hemorrhage, likely precipitated by intraluminal endovascular coil migration after a recent gastro-duodenal artery embolization. He was successfully managed without endoscopic coil removal and had no additional gastrointestinal bleeding. It is important for endoscopists to be aware of this complication and weigh the risks and benefits of coil removal.

Intravenous versus oral omeprazole on patients with high risk bleeding peptic ulcers: A prospective randomized clinical trial protocol

BACKGROUND

Proton pump inhibitors (PPIs) decrease the rate of rebleeding following endoscopic hemostatic therapy in patients with bleeding peptic ulcers. This study compares the efficacy of oral omeprazole vs intravenous omeprazole in decrease of rebleeding of peptic ulcer patients.

METHOD

The present study was authorized by the local research ethics committee of Jiangjin District Central Hospital (2020120987) and informed consent was obtained from all patients. All adult patients who were admitted to medical emergency rooms of Jiangjin District Central Hospital due to upper gastrointestinal bleeding (as evidenced by hematemesis, melena or hematochezia) were considered for inclusion in the study. Endoscopy was performed within 24 hours after admission. Patients older than 18 years with successful endoscopic therapy of high risk ulcers [defined as active bleeding (Forrest IA, IB), non-bleeding visible vessel (NBVV, Forrest IIA) or adherent clots (Forrest IIB)] were enrolled. Patients with low risk ulcers (clean base, ulcers with a simple washable clot), suspicious malignant ulcer, bleeding tendency, uremia, liver cirrhosis, Mallory Weiss tear or already on PPI as an outpatient were excluded from study. All were managed endoscopically by injecting 5-30 ml of epinephrine (diluted 1:10000) around the ulcer crater. Cavitations or flattening of bleeding vessel and disappearance of NBVV was considered as established homeostasis. A biopsy was taken from antrum for evaluating Helicobacter pylori infection. Patient with unsuccessful endoscopic therapy were not enrolled and were referred to general surgeon. Information on demography, history of previous upper gastrointestinal bleeding, NSAID or ASA ingestion, ulcer location, bleeding stigmata and blood transfusion volume at entry were recorded in all patients. In the oral omeprazole group, the patients received 40 mg omeprazole orally twice daily for 72 hours. In intravenous omeprazole group, they received omeprazole 80 mg bolus and then 8 mg/hour infusion for 48-72 hours. Then, all patients received omeprazole 20 mg orally for 30 days. On the day of discharge Helicobacter pylori infected patients received standard regimens.

RESULTS

Figure 1 showed the primary and secondary end points.

DISCUSSION

Intravenous administration of PPIs has limitations. They are expensive, require a dedicated intravenous line, need nursing supervision and hospital admission. So, it would be reasonable to prescribe oral PPIs to patients with high risk bleeding ulcers provided that it is as effective as its intravenous counterpart. Oral PPIs have a high bioavailability. Its effect initiates one hour after ingestion and the maximal plasma concentration is achieved after 2-3 hours. However, there are few studies comparing oral and intravenous PPI in decreasing risk of rebleeding in peptic ulcer patients. More high quality randomized controlled trials are still necessary.

REGISTRATION NUMBER

researchregistry 6588.

Cost-Effectiveness Analysis of Transcatheter Arterial Embolization Techniques for the Treatment of Gastrointestinal Bleeding in the United States

OBJECTIVES

Gastrointestinal (GI) bleeding is a common medical emergency associated with significant mortality. Transcatheter arterial embolization first was introduced by Rosch et al as an alternative to surgery for upper GI bleeding. The clinical success in patients with GI bleeding treated with transcatheter arterial embolization previously has been reported. However, there are no cost-effectiveness analyses reported to date. Here we report cost-effectiveness analysis of N-butyl 2-cyanoacrylate glue (NBCA) and ethylene-vinyl alcohol copolymer (Onyx) versus coil (gold standard) for treatment of GI bleeding from a healthcare payer perspective.

METHODS

Fixed-effects modeling with a generalized linear mixed method was used in NBCA and coil intervention arms to determine the pooled probabilities of clinical success and mortality with complications with their confidence intervals, while the Clopper-Pearson model was used for Onyx to determine the same parameters. Models were provided by the "Meta-Analysis with R" software package. A decision tree was built for cost-effectiveness analysis, and Microsoft Excel was used for probabilistic sensitivity analysis. The cost-effective option was determined based on the incremental cost-effectiveness ratio and scatter plots of incremental cost versus incremental quality-adjusted life-years.

RESULTS

Comparing scatter plots and incremental cost-effectiveness ratio results, -$1024 and -$1349 per quality-adjusted life-year for Onyx and N-butyl 2-cyanoacrylate glue, respectively, Onyx was the least expensive and most effective intervention.

CONCLUSION

Onyx was the dominant strategy regardless of threshold values. Our analyses provide a framework for researchers to predict the target clinical effectiveness for early-stage TAE interventions and guide resource allocation decisions.

Prophylactic transcatheter angiographic embolization reduces Forrest IIa ulcer rebleeding: A retrospective study

The application of transcatheter angiographic embolization (TAE) is controversial in the treatment of ulcer bleeding. This study aims to determine rebleeding risk factors and evaluate the efficacy of prophylactic TAE (p-TAE) following endoscopic hemostasis in rebleeding prevention of Forrest lla ulcers.The medical records of Forrest lla ulcer patients who underwent endoscopic hemostasis (E group) and endoscopic hemostasis plus p-TAE (E + p-TAE group) in West China Hospital from May 2009 to May 2018 were retrospectively reviewed. Baseline characteristics, clinical efficacy, and rebleeding risk factors were analyzed.As a result, a total of 102 patients were included, with 75 and 27 patients in E and E + p-TAE group, respectively. Most of the baseline data in E and E + p-TAE group were similar except for the proportion of protruded non-bleeding visible vessel (NBVV) (E group vs E + p-TAE group, 50.7% vs 74.1%, P = .035). The rebleeding rate of E + p-TAE group (3.7%) was significantly lower than E group (24.0%) (P = .02). The protruded NBVV (OR: 6.896, 95% confidence interval [CI]: 1.532-30.642, P = .01) and employment of p-TAE (OR: 0.038, 95% CI: 0.003-0.448, P = .009) were identified as independent risk factors for Forrest IIa ulcer rebleeding. Additionally, log-rank test indicated the rebleeding occurrence was greatly reduced by p-TAE in patients with protruded NBVVs (P = .006).In conclusion, the protruded NBVV and employment of p-TAE were the independent risk factors tightly associated with rebleeding of Forrest IIa ulcer. P-TAE following endoscopic hemostasis could effectively prevent Forrest IIa ulcer from rebleeding.

Selected nasogastric lavage in patients with nonvariceal upper gastrointestinal bleeding

BACKGROUND

Risk stratification before endoscopy is crucial for proper management of patients suspected as having upper gastrointestinal bleeding (UGIB). There is no consensus regarding the role of nasogastric lavage for risk stratification. In this study, we investigated the usefulness of nasogastric lavage to identify patients with UGIB requiring endoscopic examination.

METHODS

From January 2017 to December 2018, patients who visited the emergency department with a clinical suspicion of UGIB and who underwent nasogastric lavage before endoscopy were eligible. Patients with esophagogastric variceal bleeding were excluded. The added predictive ability of nasogastric lavage to the Glasgow-Blatchford score (GBS) was estimated using category-free net reclassification improvement and integrated discrimination improvement.

RESULTS

Data for 487 patients with nonvariceal UGIB were analyzed. The nasogastric aspirate was bloody in 67 patients (13.8 %), coffee-ground in 227 patients (46.6 %), and clear in 193 patients (39.6 %). The gross appearance of the nasogastric aspirate was associated with the presence of UGIB. Model comparisons showed that addition of nasogastric lavage findings to the GBS improved the performance of the model to predict the presence of UGIB. Subgroup analysis showed that nasogastric lavage improved the performance of the prediction model in patients with the GBS ≤ 11, whereas no additive value was found when the GBS was greater than 11.

CONCLUSIONS

Nasogastric lavage is useful for predicting the presence of UGIB in a subgroup of patients, while its clinical utility is limited in high-risk patients with a GBS of 12 or more.

Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021

1: ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3-5 days.Strong recommendation, moderate quality evidence. 3: ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4: ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5: ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6: ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 : ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8: ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9: ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (A): PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (B): High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10: ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.

Treatment of upper gastrointestinal bleeding in 2020: New techniques and outcomes

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.