Endotherapy of Peptic Ulcer Bleeding

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.

Comparison and validation of the Japanese score and other scoring systems in patients with peptic ulcer bleeding: A retrospective study

Acute upper gastrointestinal bleeding (UGIB) is one of the most urgent medical conditions, with peptic ulcer bleeding (PUB) accounting for most gastrointestinal bleeding cases. The Japanese scoring system was developed to predict the probability of intervention in patients with UGIB, and it is more effective than other scoring systems, according to several studies. This study aimed to verify whether the Japanese scoring system is better than other scoring systems in predicting the probability of intervention when limited to PUB in patients with UGIB. We enrolled patients who presented with symptoms of UGIB and were diagnosed with peptic ulcers using endoscopy. The performances of the scoring systems in predicting patient outcomes were validated and compared using the receiver-operating characteristic curve analysis. Additionally, we used the chi-square test, Fisher exact test, and the t test to analyze the association between the patients characteristics and clinical outcomes. Of the 1228 patients diagnosed with peptic ulcers, 90.6% underwent endoscopy. rebleeding occurred in 12.5% of the patients, and 2.5% of the patients died within 30 days. The Japanese score was the most effective in predicting the need for endoscopic intervention for PUB. Sex, systolic blood pressure, hematemesis, syncope, blood urea nitrogen level, and the American Society of Anesthesiologists score were predictive factors for the probability of endoscopic intervention in patients with PUB. The Japanese score is an effective predictor of the probability of endoscopic intervention in patients with PUB.

A Magnetic Bio-Inspired Soft Carrier as a Temperature-Controlled Gastrointestinal Drug Delivery System

Currently, gastrointestinal bleeding in the colon wall and the small bowel is diagnosed and treated with endoscopes. However, the locations of this condition are often problematic to treat using traditional flexible and tethered tools. New studies commonly consider untethered devices for solving this problem. However, there still exists a gap in the extant literature, and more research is needed to diagnose and deliver drugs in the lower gastrointestinal tract using soft robotic carriers. This paper discusses the development of an untethered, magnetically-responsive bio-inspired soft carrier. A molding process is utilized to produce prototypes from Diisopropylidene-1,6-diphenyl-1,6-hexanediol-based Polymer with Ethylene Glycol Dimethacrylate (DiAPLEX) MP-3510 - a shape memory polymer with a low transition temperature to enable the fabrication of these carriers. The soft carrier design is validated through simulation results of deformation caused by magnetic elements embedded in the carrier in response to an external field. The thermal responsiveness of the fabricated prototype carriers is assessed ex vivo and in a phantom. The results indicate a feasible design capable of administering drugs to a target inside a phantom of a large intestine. The soft carrier introduces a method for the controlled release of drugs by utilizing the rubbery modulus of the polymer and increasing the recovery force through magnetic actuation.

High Rate of Gastrointestinal Bleeding in Patients with Secondary Sclerosing Cholangitis in Critically Ill Patients (SC-CIP)

Secondary sclerosing cholangitis in critically ill patients (SC-CIP) is a rare cholestatic liver disease triggered by long-term intensive care treatment. The aim of this study was to evaluate the frequency and characteristics of gastrointestinal bleeding in SC-CIP. Patients with diagnosed SC-CIP were retrospectively identified and compared to a control group of patients with cardiac surgery and intensive care treatment but without the development of SC-CIP. Fifty-three patients with SC-CIP and 19 controls were included in the study. The frequency of gastrointestinal bleeding was 30% in SC-CIP (16 patients) and 5% in the control group (1 patient) (p = 0.03). Bleeding occured in the mean 13 months after admission to an intensive care unit in SC-CIP, three patients (19%) suffered bleeding during intensive care treatment. Three SC-CIP patients (19%) had cirrhosis at the time of bleeding, five (31%) had splenomegaly, and four (25%) received oral anticoagulation. In SC-CIP, 13 bleedings were identified in the upper gastrointestinal tract, two in the lower, and one remained unknown. The most common reasons for bleeding were gastroduodenal ulcers. In total, 80% of patients needed blood units, and one death due to bleeding occurred in SC-CIP. In conclusion, gastrointestinal bleeding is a frequent complication in patients with SC-CIP. Whether the liver disease itself or cofactors cause the susceptibility for bleeding remains unclear.

Medical care setting is associated with survival in acute upper gastro-intestinal bleeding: A cohort study

BACKGROUND

There are limited data on the effect of the medical care setting on survival in patients admitted with acute upper gastrointestinal bleeding.

AIMS

To identify the organisational and care setting which provides the optimal survival in patients with acute upper gastrointestinal bleeding.

METHODS

A retrospective observational study of administrative data from a cohort of patients admitted to a Regional or Local hospital, and cared for in a gastroenterology or general ward.

PRIMARY OUTCOME

30 day survival for non-variceal bleeding and 42 day survival for variceal bleeding.

RESULTS

Out of 3368 patients, the source of bleeding was non-variceal in 2980 (88.5%). Survival, adjusted for clinical and organisational factors, was higher in patients admitted to a gastroenterology ward vs other wards (OR = 2.02 p < 0.0006). Management in a gastroenterology ward in a Regional hospital provided a higher survival rate (95.6% ± 0.08) vs a non-gastroenterology ward in a Local hospital (92.9% ± 0.05 p < 0.01) or a non-gastroenterology ward in a Regional hospital (89.5% ± 0.01 p < 0.0001). Survival (94.0% ± 1.6) in a Local hospital with a gastroenterology ward was significantly higher than in a Regional hospital without (89.5% ± 1.1) p < 0.01.

CONCLUSION

Survival was optimal for patients treated in a gastroenterology ward independently of Regional or Local hospital setting.

Diagnostic Utility of Ultrasonography for Duodenal Ulcers in Pediatric Cases in Japan

Objective: To evaluate the diagnostic utility of wall hypertrophy of the duodenal bulb with a hyperechoic lumen, designated as the "HH sign," using ultrasound sonography (US) in pediatric duodenal ulcer (DU) patients. Study design: We performed a US for five pediatric subjects diagnosed with DU by upper gastroscopy to determine the presence of the potentially diagnostic HH sign. The sonographic images were analyzed before and after DU treatment. Computed tomography was performed in three cases and fecal occult blood test (FOBT) in all five cases. Results: Upper gastroscopy confirmed DU in all patients. While the HH sign was observed using US in four cases, with the DU located in the anterior bulb, the FOBT was positive in only one case. In these four cases, the HH sign diminished in response to treatment, as visualized by US. This was observed for both the initial as well as recurrent episodes. A mass-like region was observed in only one case, with the ulcer located in the proximity of the inferior duodenal wall. Conclusion: The HH sign is useful for the follow-up of DU, and US may be a suitable modality for the follow-up. We believe that this diagnostic marker can aid in following up a greater number of DU cases.

Endoscopic advances in the management of non-variceal upper gastrointestinal bleeding: A review

Upper gastrointestinal bleeding is defined as the bleeding originating from the esophagus to the ligament of Treitz and further classified into variceal and non-variceal gastrointestinal bleeding. Non-variceal upper gastrointestinal bleeding remains a common clinical problem globally. It is associated with high mortality, morbidity, and cost of the health care system. Despite the continuous improvement of therapeutic endoscopy, the 30-d readmission rate secondary to rebleeding and associated mortality is an ongoing issue. Available Food and Drug Administration approved traditional or conventional therapeutic endoscopic modalities includes epinephrine injection, argon plasma coagulation, heater probe, and placement of through the scope clip, which can be used alone or in combination to decrease the risk of rebleeding. Recently, more attention has been paid to the novel advanced endoscopic devices for primary treatment of the bleeding lesion and as a secondary measure when conventional therapies fail to achieve hemostasis. This review highlights emerging endoscopic modalities used in the management of non-variceal upper gastrointestinal related bleeding such as over-the-scope clip, Coagrasper, hemostatic sprays, radiofrequency ablation, cryotherapy, endoscopic suturing devices, and endoscopic ultrasound-guided angiotherapy. In this review article, we will also discuss the technical aspects of the common procedures, outcomes in terms of safety and efficacy, and their advantages and limitations in the setting of non-variceal upper gastrointestinal bleeding.

Effectiveness of Opuntia ficus indica L. inermis Seed Oil in the Protection and the Healing of Experimentally Induced Gastric Mucosa Ulcer

Gastric ulcer is a painful lesion of the gastric mucosa which can be disabling, or even more very serious in the case of a perforation of the stomach and internal hemorrhage. Traditional pharmacopeias have shown the efficacy of various plant extracts in the treatment of this pathology. Some extracts from Opuntia ficus indica (OFI) have been proven to have medicinal therapeutic benefits. The aim of this study was to investigate the preventive and curative effects of OFI seed oil extracted by cold pressing on an ethanol-induced gastric ulcer model in rats. Gastroprotective activities of the oil were assessed as pretreatments prior to ethanol gavage of Wistar rats compared to reference drugs. Two oil dose effects were tested. Ulcer and gastric parameters were measured (ulcerated areas (mm²), % of ulcer inhibition, gastric juice volume and pH, and mucus weight). Macroscopical and microscopical assessments of the stomachs as well as gastric biopsy histological studies were carried out. OFI oil exhibited a high efficiency in the protection of the cytoarchitecture and function of the gastric mucosa against the severe damages provoked by ethanol intake. Ulcerated areas were very significantly reduced and the % of ulcer inhibition was the highest under OFI oil pretreatment. Mucus production was stimulated, gastric juice volume was reduced, and its pH was increased. Histopathological examination of H&E-stained biopsies collected from gastric mucosae from the different experimental groups confirmed the gastroprotective efficacy of OFI oil against ethanol-induced symptoms such as inflammation and damages like bleeding, erosions, lesions, necrosis, and ulcers. Furthermore, OFI oil treatment speeded-up the reduction of the surface of ethanol-induced ulcerated areas in a dose-dependent manner, leading to a time gain in the healing process. The healing rate reached 91% on day 2 and 99% on day 3, and a complete heal was attained at the fourth day under OFI oil treatment, while ulcer areas were still partially unhealed in all the other groups. The therapeutic effects of OFI oil against gastric ulcer could be mediated by its varied bioactive compounds that we have demonstrated in the analytical study. They could act synergistically or in a delayed manner to optimize the healing process through protective antioxidant properties, as well as an antagonism against histamine H₂-receptors, a stimulation of the signaling pathways necessary for mucus and bicarbonate production, and reduction of inflammatory processes in the gastric mucosa. Additionally, OFI oil fatty acids (especially unsaturated) and triacylglycerols contribute to the reconstruction and the repair of the cell membrane lipid bilayer during the gastric ulcer healing process.

Management of acute upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is a common medical emergency, with a reported mortality of 2-10%. Patients identified as being at very low risk of either needing an intervention or death can be managed as outpatients. For all other patients, intravenous fluids as needed for resuscitation and red cell transfusion at a hemoglobin threshold of 70-80 g/L are recommended. After resuscitation is initiated, proton pump inhibitors (PPIs) and the prokinetic agent erythromycin may be administered, with antibiotics and vasoactive drugs recommended in patients who have cirrhosis. Endoscopy should be undertaken within 24 hours, with earlier endoscopy considered after resuscitation in patients at high risk, such as those with hemodynamic instability. Endoscopic treatment is used for variceal bleeding (for example, ligation for esophageal varices and tissue glue for gastric varices) and for high risk non-variceal bleeding (for example, injection, thermal probes, or clips for lesions with active bleeding or non-bleeding visible vessel). Patients who require endoscopic therapy for ulcer bleeding should receive high dose proton pump inhibitors after endoscopy, whereas those who have variceal bleeding should continue taking antibiotics and vasoactive drugs. Recurrent ulcer bleeding is treated with repeat endoscopic therapy, with subsequent bleeding managed by interventional radiology or surgery. Recurrent variceal bleeding is generally treated with transjugular intrahepatic portosystemic shunt. In patients who require antithrombotic agents, outcomes appear to be better when these drugs are reintroduced early.

Role of endoscopy in acute gastrointestinal bleeding in real clinical practice: An evidence-based review

Although upper gastrointestinal bleeding is usually segregated from lower gastrointestinal bleeding, and guidelines for gastrointestinal bleeding are divided into two separate sections, they may not be distinguished from each other in clinical practice. Most patients are first observed with signs of bleeding such as hematemesis, melena, and hematochezia. When a patient with these symptoms presents to the emergency room, endoscopic diagnosis and treatment are considered together with appropriate initial resuscitation. Especially, in cases of variceal bleeding, it is important for the prognosis that the endoscopy is performed immediately after the patient stabilizes. In cases of suspected lower gastrointestinal bleeding, full colonoscopy after bowel preparation is effective in distinguishing the cause of the bleeding and treating with hemostasis. The therapeutic aspect of endoscopy, using the mechanical method alone or injection with a certain modality rather than injection alone, can increase the success rate of bleeding control. Therefore, it is important to consider the origin of bleeding and how to approach it. In this article, we aim to review the role of endoscopy in diagnosis, treatment, and prognosis in patients with acute gastrointestinal bleeding in a real clinical setting.