1
|
Saffo S, Nagar A. Impact of epinephrine volume on further bleeding due to high-risk peptic ulcer disease in the combination therapy era. World J Gastrointest Pharmacol Ther 2022; 13:67-76. [PMID: 36157267 PMCID: PMC9453442 DOI: 10.4292/wjgpt.v13.i5.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/22/2022] [Accepted: 07/31/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND In monotherapy studies for bleeding peptic ulcers, large volumes of epinephrine were associated with a reduction in rebleeding. However, the impact of epinephrine volume in patients treated with combination endoscopic therapy remains unclear.
AIM To assess whether epinephrine volume was associated with bleeding outcomes in individuals who also received endoscopic thermal therapy and/or clipping.
METHODS Data from 132 patients with Forrest class Ia, Ib, and IIa peptic ulcers were reviewed. The primary outcome was further bleeding at 7 d; secondary outcomes included further bleeding at 30 d, need for additional therapeutic interventions, post-endoscopy blood transfusions, and 30-day mortality. Logistic and linear regression and Cox proportional hazards analyses were performed.
RESULTS There was no association between epinephrine volume and all primary and secondary outcomes in multivariable analyses. Increased odds for further bleeding at 7 d occurred in patients with elevated creatinine values (aOR 1.96, 95%CI 1.30-3.20; P < 0.01) or hypotension requiring vasopressors (aOR 6.34, 95%CI 1.87-25.52; P < 0.01). Both factors were also associated with all secondary outcomes.
CONCLUSION Epinephrine maintains an important role in the management of bleeding ulcers, but large volumes up to a range of 10-20 mL are not associated with improved bleeding outcomes among individuals receiving combination endoscopic therapy. Further bleeding is primarily associated with patient factors that likely cannot be overcome by increased volumes of epinephrine. However, in carefully-selected cases where ulcer location or size pose therapeutic challenges or when additional modalities are unavailable, it is conceivable that increased volumes of epinephrine may still be beneficial.
Collapse
Affiliation(s)
- Saad Saffo
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT 06520, United States
| | - Anil Nagar
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT 06520, United States
| |
Collapse
|
2
|
Systematic review and meta-analysis: monopolar hemostatic forceps with soft coagulation in the treatment of peptic ulcer bleeding. Eur J Gastroenterol Hepatol 2020; 32:678-685. [PMID: 32317587 DOI: 10.1097/meg.0000000000001738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Monopolar hemostatic forceps with soft coagulation (MHFSC) have been compared with hemoclips, heater probe, and argon plasma coagulation (APC) for the treatment of peptic ulcer bleeding. In this systematic review and meta-analysis, we compared MHFSC with other modalities in the treatment of peptic ulcer bleeding. We reviewed MEDLINE, Embase, Scopus, Cochrane, Web of Science, and Scopus from inception to 7 January 2019 to identify studies comparing MHFSC with other modalities for peptic ulcer bleeding. The primary outcome of interest was achievement of initial hemostasis. Secondary outcomes were rebleeding, adverse events, procedure time, and length of hospital stay. Data were analyzed using a random effects model and summarized as pooled odds ratio (OR) with 95% confidence interval (CI). Heterogeneity was assessed by I statistic. We included five randomized controlled trials and one observational study comprising 693 patients with endoscopically confirmed actively bleeding ulcers (spurting or oozing) or nonbleeding visible vessel. MHFSC was superior to other modalities in achieving initial hemostasis (OR 0.25; 95% CI 0.08-0.81; I = 67%) and prevention of rebleeding (OR 0.28; 95% CI 0.09-0.86; I = 46%). Rates of adverse events were similar between MHFSC and other modalities. Procedure times were shorter with MHFSC (mean difference -4.15 min; 95% CI -4.83 to -3.47; I= 59%). Length of hospital stay was also shorter with MHFSC. MHFSC appears to be more effective than other modalities for achievement of initial hemostasis and reduction of rebleeding among patients with peptic ulcer bleeding.
Collapse
|
3
|
Lazăr DC, Ursoniu S, Goldiş A. Predictors of rebleeding and in-hospital mortality in patients with nonvariceal upper digestive bleeding. World J Clin Cases 2019; 7:2687-2703. [PMID: 31616685 PMCID: PMC6789381 DOI: 10.12998/wjcc.v7.i18.2687] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/16/2019] [Accepted: 08/26/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Nonvariceal upper digestive bleeding (NVUDB) represents a severe emergency condition and is associated with significant morbidity and mortality. Despite a decrease in the incidence due to the widespread use of potent therapy with proton pump inhibitors as well as the implementation of modern endoscopic techniques, the mortality rate associated with NVUDB is still high.
AIM To identify the clinical, biological, and endoscopic parameters associated with a poor outcome in patients with NVUDB to allow the stratification of risk, which will lead to the implementation of the most accurate management.
METHODS We performed a retrospective study including patients who were admitted to the Gastroenterology Department of Clinical Emergency County Hospital Timisoara, Romania, with a diagnosis of NVUDB between 1 January 2008 and 31 December 2016. All the data were collected from the patient’s records, including demographic data, medication history, hemodynamic status, paraclinical tests, and endoscopic features as well as the methods of hemostasis, rate of rebleeding, need for surgery and death; we also assessed the Rockall score of the patients, length of hospitalization and associated comorbidities. All these parameters were evaluated as potential risk factors associated with rebleeding and death in patients with NVUDB.
RESULTS We included a batch of 1581 patients with NVUDB, including 523 (33%) females and 1058 (67%) males with a median age of 66 years. The main cause of NVUDB was peptic ulcer (73% of patients). More than one-third of the patients needed endoscopic treatment. Rebleeding rate was 7.72%; surgery due to failure of endoscopic hemostasis was needed in 3.22% of cases; the in-hospital mortality rate was 8.09%, and the bleeding-episode-related mortality rate was 2.97%. Although our predictive models for rebleeding and death had a low sensitivity, the specificity was very high, suggesting a better discriminative capacity for identifying patients with better outcomes. Our results showed that the Rockall score was associated with both rebleeding and death; comorbidities such as respiratory conditions, liver cirrhosis and sepsis increased significantly the risk of in-hospital mortality (OR of 3.29, 2.91 and 8.03).
CONCLUSION Our study revealed that the Rockall score, need for endoscopic therapy, necessity of transfusion and sepsis were risk factors for rebleeding. Moreover, an increased Rockall score and the presence of comorbidities were predictive factors for in-hospital mortality.
Collapse
Affiliation(s)
- Daniela Cornelia Lazăr
- Department of Internal Medicine I, University Medical Clinic, University of Medicine and Pharmacy “Victor Babeş”, Timişoara 300041, Timiş County, Romania
| | - Sorin Ursoniu
- Department of Public Health and Health Management, University of Medicine and Pharmacy “Victor Babeş”, Timişoara 300041, Timiş County, Romania
| | - Adrian Goldiş
- Department of Gastroenterology and Hepatology, University of Medicine and Pharmacy “Victor Babeş”, Timişoara 300041, Timiş County, Romania
| |
Collapse
|
4
|
Parsi MA, Schulman AR, Aslanian HR, Bhutani MS, Krishnan K, Lichtenstein DR, Melson J, Navaneethan U, Pannala R, Sethi A, Trikudanathan G, Trindade AJ, Watson RR, Maple JT. Devices for endoscopic hemostasis of nonvariceal GI bleeding (with videos). VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2019; 4:285-299. [PMID: 31334417 PMCID: PMC6616320 DOI: 10.1016/j.vgie.2019.02.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Endoscopic intervention is often the first line of therapy for GI nonvariceal bleeding. Although some of the devices and techniques used for this purpose have been well studied, others are relatively new, with few available outcomes data. METHODS In this document, we review devices and techniques for endoscopic treatment of nonvariceal GI bleeding, the evidence regarding their efficacy and safety, and financial considerations for their use. RESULTS Devices used for endoscopic hemostasis in the GI tract can be classified into injection devices (needles), thermal devices (multipolar/bipolar probes, hemostatic forceps, heater probe, argon plasma coagulation, radiofrequency ablation, and cryotherapy), mechanical devices (clips, suturing devices, banding devices, stents), and topical devices (hemostatic sprays). CONCLUSIONS Endoscopic evaluation and treatment remains a cornerstone in the management of nonvariceal upper- and lower-GI bleeding. A variety of devices is available for hemostasis of bleeding lesions in the GI tract. Other than injection therapy, which should not be used as monotherapy, there are few compelling data that strongly favor any one device over another. For endoscopists, the choice of a hemostatic device should depend on the type and location of the bleeding lesion, the availability of equipment and expertise, and the cost of the device.
Collapse
Key Words
- ABS, Ankaferd blood stopper
- APC, argon plasma coagulation
- ASGE, American Society for Gastrointestinal Endoscopy
- CPT, Current Procedural Terminology
- CSEMS, covered self-expandable metallic stent
- EBL, endoscopic band ligation
- EDP, endoscopic Doppler probe
- GAVE, gastric antral vascular ectasia
- HP, heater probe
- LGIB, lower GI bleeding
- MPEC, multipolar electrocoagulation
- OTSC, over-the-scope clip
- PTFE, polytetrafluoroethylene
- RCT, randomized controlled trial
- TTS, through-the-scope
- U.S. FDA, United States Food and Drug Administration
- UGIB, upper GI bleeding
Collapse
Affiliation(s)
| | - Mansour A. Parsi
- Section for Gastroenterology & Hepatology, Tulane University Health Sciences Center, New Orleans, LA
| | - Allison R. Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Harry R. Aslanian
- Section of Digestive Diseases, Department of Internal Medicine, Yale University, New Haven, CT
| | - Manoop S. Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Kuman Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - David R. Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, IL
| | | | - Rahul Pannala
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, New York-Presbyterian/Columbia University Medical Center, New York, NY
| | | | - Arvind J. Trindade
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, NY
| | - Rabindra R. Watson
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, CA
| | - John T. Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | | |
Collapse
|
5
|
Cipolletta L, Cipolletta F, Granata A, Ligresti D, Barresi L, Tarantino I, Traina M. What Is the Best Endoscopic Strategy in Acute Non-variceal Gastrointestinal Bleeding? ACTA ACUST UNITED AC 2018; 16:363-375. [PMID: 30229463 DOI: 10.1007/s11938-018-0192-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OPINION STATEMENT PURPOSE OF REVIEW: Upper non-variceal gastrointestinal bleeding (UNVGIB) remains an important clinical challenge for endoscopists, requiring skill and expertise for correct management. In this paper, we suggest the best strategy for an effective treatment of this complex category of patients. RECENT FINDINGS Early endoscopic examination, the increasingly widespread use of endoscopic hemostasis methods, and the most powerful antisecretory agents that induce clot stabilization have radically modified the clinical scenario for treating this pathology. While hospitalization for digestive hemorrhage is decreasing, the incidence of bleeding seems to be increasing, especially in the elderly for whom a greater use of gastrolesive drugs and the presence of comorbidities are more common. A multidisciplinary approach for initial patient evaluation and hemodynamic resuscitation prior to endoscopic treatment is crucial for correct management, prevention of rebleeding, and reduction of morbidity and mortality rates and hospital stays. Appropriate operator technical expertise, together with the availability of a wide range of endoscopes and devices, is mandatory. Newer endoscopic techniques may improve patient outcomes for difficult-to-treat lesions. Today, endoscopic hemostasis can be achieved in over 95% of patients.
Collapse
Affiliation(s)
- Livio Cipolletta
- Endoscopy Unit, Ruesch Clinic, Via San Domenico, 24, 80127, Naples, Italy.
| | - Fabio Cipolletta
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Antonino Granata
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| |
Collapse
|
6
|
Baracat F, Moura E, Bernardo W, Pu LZ, Mendonça E, Moura D, Baracat R, Ide E. Endoscopic hemostasis for peptic ulcer bleeding: systematic review and meta-analyses of randomized controlled trials. Surg Endosc 2015; 30:2155-68. [PMID: 26487199 DOI: 10.1007/s00464-015-4542-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 09/01/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Peptic ulcer represents the most common cause of upper gastrointestinal bleeding. Endoscopic therapy can reduce the risks of rebleeding, continued bleeding, need for surgery, and mortality. The objective of this review is to compare the different modalities of endoscopic therapy. METHODS Studies were identified by searching electronic databases MEDLINE, Embase, Cochrane, LILACS, DARE, and CINAHL. We selected randomized clinical trials that assessed contemporary endoscopic hemostatic techniques. The outcomes evaluated were: initial hemostasis, rebleeding rate, need for surgery, and mortality. The possibility of publication bias was evaluated by funnel plots. An additional analysis was made, including only the higher-quality trials. RESULTS Twenty-eight trials involving 2988 patients were evaluated. Injection therapy alone was inferior to injection therapy with hemoclip and with thermal coagulation when evaluating rebleeding and the need for emergency surgery. Hemoclip was superior to injection therapy in terms of rebleeding; there were no statistically significant differences between hemoclip alone and hemoclip with injection therapy. There was considerable heterogeneity in the comparisons between hemoclip and thermal coagulation. There were no statistically significant differences between thermal coagulation and injection therapy, though their combination was superior, in terms of rebleeding, to thermal coagulation alone. CONCLUSIONS Injection therapy should not be used alone. Hemoclip is superior to injection therapy, and combining hemoclip with an injectate does not improve hemostatic efficacy above hemoclip alone. Thermal coagulation has similar efficacy as injection therapy; combining these appears to be superior to thermal coagulation alone. Therefore, we recommend the application of hemoclips or the combined use of injection therapy with thermal coagulation for the treatment of peptic ulcer bleeding.
Collapse
Affiliation(s)
- Felipe Baracat
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6° andar, São Paulo, SP, CEP 05403-900, Brazil. .,, Rua Martinico Prado, 241, apt 94, CEP 01224-010, São Paulo, SP, Brazil.
| | - Eduardo Moura
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6° andar, São Paulo, SP, CEP 05403-900, Brazil
| | - Wanderley Bernardo
- Thoracic Surgery Department, Instituto do Coraçao (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | - Leonardo Zorron Pu
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6° andar, São Paulo, SP, CEP 05403-900, Brazil
| | - Ernesto Mendonça
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6° andar, São Paulo, SP, CEP 05403-900, Brazil
| | - Diogo Moura
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6° andar, São Paulo, SP, CEP 05403-900, Brazil
| | - Renato Baracat
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6° andar, São Paulo, SP, CEP 05403-900, Brazil
| | - Edson Ide
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo Medical School, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6° andar, São Paulo, SP, CEP 05403-900, Brazil
| |
Collapse
|
7
|
Abstract
Upper gastrointestinal bleeding remains one of the most common challenges faced by gastroenterologists and endoscopists in daily clinical practice. Endoscopic management of nonvariceal bleeding has been shown to improve clinical outcomes, with significant reduction of recurrent bleeding, need for surgery, and mortality. Early upper gastrointestinal endoscopy is recommended in all patients presenting with upper gastrointestinal bleeding within 24 hours of presentation, although appropriate resuscitation, stabilization of hemodynamic parameters, and optimization of comorbidity before endoscopy are essential.
Collapse
|
8
|
Kim JS, Park SM, Kim BW. Endoscopic management of peptic ulcer bleeding. Clin Endosc 2015; 48:106-11. [PMID: 25844337 PMCID: PMC4381136 DOI: 10.5946/ce.2015.48.2.106] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/06/2015] [Accepted: 03/11/2015] [Indexed: 01/14/2023] Open
Abstract
Acute upper gastrointestinal bleeding is a common medical emergency around the world and the major cause is peptic ulcer bleeding. Endoscopic treatment is fundamental for the management of peptic ulcer bleeding. Despite recent advances in endoscopic treatment, mortality from peptic ulcer bleeding has still remained high. This is because the disease often occurs in elderly patients with frequent comorbidities and are taking ulcerogenic medications. Therefore, the management of peptic ulcer bleeding is still a challenge for clinicians. This article reviews the various endoscopic methods available for management of peptic ulcer bleeding and the techniques in using these methods.
Collapse
Affiliation(s)
- Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Sung Min Park
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Byung-Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| |
Collapse
|
9
|
Comparison of the efficacy of two combined therapies for peptic ulcer bleeding: adrenaline injection plus haemoclipping versus adrenaline injection followed by bipolar electrocoagulation. GASTROENTEROLOGY REVIEW 2015; 9:354-60. [PMID: 25653731 PMCID: PMC4300351 DOI: 10.5114/pg.2014.47898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 10/21/2014] [Accepted: 10/23/2014] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Peptic ulcer remains the most frequent cause of upper gastrointestinal bleeding. Treatment of bleeding with simultaneous combination of two endoscopic techniques has proved to be more efficient than monotherapy. None of the published comparative studies of various contact coagulation modalities have confirmed the superiority of one of these techniques over the others. AIM To compare the therapeutic outcomes of the use of a device enabling both injection of adrenaline solution and bipolar electrocoagulation (A + BE) to those of combined adrenaline injection with mechanical therapy (haemostatic clips) (A + HC) in the treatment of peptic ulcer bleeding. MATERIAL AND METHODS Fifty-two subjects with bleeding ulcers were assigned to the A + BE group, and 55 patients were treated with A + HC. RESULTS Overall, treatment failed in 20 patients (20/107, 18.7%): in 10 individuals from the A + BE group (10/52; 18.2%) and in 10 individuals from the A + HC group (10/55; 19.2%) (p > 0.05). Primary haemostasis was not obtained in 7 patients (6.5%): in 4 patients in the A + BE group and in 3 patients in the A + HC group (p > 0.05). Ten individuals (9.3%) experienced recurrent bleeding during hospitalisation: 4 patients from the A + BE group and 6 patients from the A + HC group (p > 0.05). Finally, in 96.3% of the patients (n = 103) the endoscopic treatment proved efficient with regards to obtaining haemostasis during hospitalisation. Surgical intervention was required in 4 individuals (3.7%): 2 patients in the A + BE group and 2 patients treated with A + HC (p > 0.05). Three patients (2.8%) - all from the A + HC group - died during hospitalisation. No significant intergroup differences were documented with regards to the mean number of transfused blood units and the mean length of hospital stay. CONCLUSIONS The efficacy of combined endoscopic treatment of ulcer bleeding with a probe enabling simultaneous bipolar electrocoagulation and adrenaline injection seems comparable to the widely used dual technique of adrenaline injection and haemostatic clipping.
Collapse
|
10
|
Masci E, Arena M, Morandi E, Viaggi P, Mangiavillano B. Upper gastrointestinal active bleeding ulcers: review of literature on the results of endoscopic techniques and our experience with Hemospray. Scand J Gastroenterol 2014; 49:1290-5. [PMID: 25180549 DOI: 10.3109/00365521.2014.946080] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Acute gastrointestinal (GI) bleeding can lead from mild to immediately life-threatening clinical conditions. Upper GI bleeding (UGIB) is associated with a mortality of 6-10%. Spurting and oozing bleeding are associated with major risk of failure. Hemospray™ (TC-325), a new hemostatic powder, may be useful in these cases. Aim of this study is to review the efficacy of traditional endoscopic treatment in Forrest 1a-1b ulcers and to investigate the usefulness of Hemospray in these patients. PATIENTS AND METHODS A MEDLINE search was performed and articles that evaluated hemostatic efficacy and rebleeding rate with traditional endoscopic techniques related to Forrest classification were reviewed. Patients with Forrest 1a-1b ulcers were treated with Hemospray, either as monotherapy or in association with other endoscopic techniques. Primary outcome was immediate hemostasis, secondary outcomes were recurrent bleeding and adverse events related to Hemospray use. RESULTS Analysis of literature showed that mean initial hemostasis success rate in Forrest 1a-1b ulcers was of 92.8%, and mean rebleeding rate was of 13.3%. We enrolled 13 patients treated with Hemospray. Initial hemostasis was achieved in 100% and we reported three cases of rebleeding. No adverse events occurred. CONCLUSION Forrest 1a-1b bleeding ulcer is very difficult to treat. Hemospray appears to be an effective hemostatic therapy for these ulcers. However, additional prospective studies are needed to validate these findings.
Collapse
Affiliation(s)
- Enzo Masci
- Department of Gastrointestinal Endoscopy, University San Paolo Hospital , Milano , Italy
| | | | | | | | | |
Collapse
|
11
|
Abstract
This guideline presents recommendations for the step-wise management of patients with overt upper gastrointestinal bleeding. Hemodynamic status is first assessed, and resuscitation initiated as needed. Patients are risk-stratified based on features such as hemodynamic status, comorbidities, age, and laboratory tests. Pre-endoscopic erythromycin is considered to increase diagnostic yield at first endoscopy. Pre-endoscopic proton pump inhibitor (PPI) may be considered to decrease the need for endoscopic therapy but does not improve clinical outcomes. Upper endoscopy is generally performed within 24h. The endoscopic features of ulcers direct further management. Patients with active bleeding or non-bleeding visible vessels receive endoscopic therapy (e.g., bipolar electrocoagulation, heater probe, sclerosant, clips) and those with an adherent clot may receive endoscopic therapy; these patients then receive intravenous PPI with a bolus followed by continuous infusion. Patients with flat spots or clean-based ulcers do not require endoscopic therapy or intensive PPI therapy. Recurrent bleeding after endoscopic therapy is treated with a second endoscopic treatment; if bleeding persists or recurs, treatment with surgery or interventional radiology is undertaken. Prevention of recurrent bleeding is based on the etiology of the bleeding ulcer. H. pylori is eradicated and after cure is documented anti-ulcer therapy is generally not given. Nonsteroidal anti-inflammatory drugs (NSAIDs) are stopped; if they must be resumed low-dose COX-2-selective NSAID plus PPI is used. Patients with established cardiovascular disease who require aspirin should start PPI and generally re-institute aspirin soon after bleeding ceases (within 7 days and ideally 1-3 days). Patients with idiopathic ulcers receive long-term anti-ulcer therapy.
Collapse
Affiliation(s)
- Loren Laine
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut 06520-8019, USA.
| | | |
Collapse
|
12
|
Nonvariceal upper gastrointestinal bleeding in patients with liver cirrhosis. Clinical features, outcomes and predictors of in-hospital mortality. A prospective study. Ann Hepatol 2011. [PMID: 21677330 DOI: 10.1016/s1665-2681(19)31540-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
|
13
|
Enestvedt BK, Gralnek IM, Mattek N, Lieberman DA, Eisen GM. Endoscopic therapy for peptic ulcer hemorrhage: practice variations in a multi-center U.S. consortium. Dig Dis Sci 2010; 55:2568-76. [PMID: 20585979 PMCID: PMC3922223 DOI: 10.1007/s10620-010-1311-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 06/14/2010] [Indexed: 12/19/2022]
Abstract
BACKGROUND Peptic ulcer disease is a common cause of acute upper gastrointestinal hemorrhage. The aim of this study was to describe the endoscopic management of bleeding peptic ulcers in a large, U.S. multi-center endoscopic consortium with diverse practice settings. METHODS Adult patients who underwent upper endoscopy (EGD) for hematemesis, melena or "suspected upper GI bleed" between January 2000 and December 2004 in the Clinical Outcomes Research Initiative (CORI) endoscopic database were screened for the finding of peptic ulcer. The ulcer stigmata, endoscopic therapy and the need for repeat EGD were compared across practice sites. RESULTS Of 12,392 patients who underwent EGD for an upper gastrointestinal bleeding indication, 3,692 (30%) had at least one peptic ulcer (clean base 59.9%; flat pigmented spot 13.4%; active bleeding 10.7%; clot 7.2%; non-bleeding visible vessel (NBVV) 6.3%). Endoscopic therapy was applied to 93% of actively bleeding ulcers and 95% of NBVV. Repeat endoscopy was required in 7.3% of patients. Ulcers treated with injection monotherapy had the highest repeat EGD rates (12.2%) compared with contact thermal monotherapy (6.1%) and combination thermal/injection therapy (7.1%) (P=0.02). Immediate hemostasis rates were 88-97% across all therapeutic modalities. There was no statistical difference in hemostasis rates across therapy nor practice types. CONCLUSION In this multi-center consortium, initial hemostasis rates were high across therapy types and sites studied. Injection monotherapy was associated with the highest rates of repeat EGD, supporting guidelines that advise against its use in bleeding peptic ulcers.
Collapse
Affiliation(s)
- Brintha K. Enestvedt
- The Division of Gastroenterology, Oregon Health and Sciences University, Portland, Oregon
| | - Ian M. Gralnek
- The Rappaport Faculty of Medicine, Technion Israel Institute of Technology, GI Outcomes Unit and Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Nora Mattek
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Sciences University, Portland, Oregon
| | - David A. Lieberman
- The Division of Gastroenterology, Oregon Health and Sciences University, Portland, Oregon
| | - Glenn M. Eisen
- The Division of Gastroenterology, Oregon Health and Sciences University, Portland, Oregon
| |
Collapse
|
14
|
Herrlinger K. [Classification and management of upper gastrointestinal bleeding]. Internist (Berl) 2010; 51:1145-56; quiz 1157. [PMID: 20680239 DOI: 10.1007/s00108-010-2590-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The upper gastrointestinal bleeding remains the most frequent emergency in gastroenterology. Due to the different therapeutic approach a distinction between the variceal and the non-variceal bleeding has been established. A risk assessment for the individual patient is crucial for timing of the endoscopic procedure as well as for the estimation of prognosis. This review gives an overview on modern therapeutic techniques for both, variceal and non-variceal bleeding highlighting on success rates but also on potential complications of the different therapeutic interventions.
Collapse
Affiliation(s)
- K Herrlinger
- Abteilung für Gastroenterologie, Hepatologie und Endokrinologie, Robert-Bosch-Krankenhaus, Auerbachstraße 110, 70376 Stuttgart, Deutschland.
| |
Collapse
|
15
|
Cipolletta L, Bianco MA, Salerno R, Prisco A, Marmo R, Cipolletta F, Piscopo R, Sansone S, Rotondano G. Improved characterization of visible vessels in bleeding ulcers by using magnification endoscopy: results of a pilot study. Gastrointest Endosc 2010; 72:413-8. [PMID: 20430383 DOI: 10.1016/j.gie.2010.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2009] [Accepted: 02/01/2010] [Indexed: 12/10/2022]
Abstract
BACKGROUND Not all exposed vessels carry the same risk of recurrent bleeding, and sometimes endoscopic therapy may not be warranted in the setting of profound acid inhibition therapy. OBJECTIVE To investigate the role of magnification endoscopy (ME) in improving the characterization of exposed vessels in ulcer hemorrhage. DESIGN Prospective study. SETTING Single-center teaching hospital. MAIN OUTCOME MEASUREMENTS Diagnostic accuracy and safety of ME in patients with bleeding peptic ulcers. RESULTS A total of 43 patients were studied. Exposed vessels were initially categorized as high risk (protuberant, translucent, or pale) in 25 and low risk (nonprotruding through the ulcer floor, pigmented, or dark red) in 18 cases. ME was subsequently performed, and the operator was asked to reclassify the vessel into 1 of these 2 categories. A magnified view provided a clear image of the vessel and allowed visualization of the artery, the site of rupture, and the presence of a clot plugging the hole. In 6 cases previously categorized as low risk, ME clearly showed the 2 ends of the vessel, the longitudinal tear in the vessel wall, and a protuberant aspect that was not seen with standard view. The lesion was then reclassified as high risk (diagnostic gain 33%). The mean procedure time for ME inspection was 7 +/- 4 minutes. No complications occurred. LIMITATIONS Absence of controls. CONCLUSIONS In patients with peptic ulcer bleeding and exposed vessels, ME allows clear visualization of the vessel wall and provides detailed clues to further characterize the lesion.
Collapse
Affiliation(s)
- Livio Cipolletta
- Division of Gastroenterology, Hospital A. Maresca, Torre del Greco, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Anjiki H, Kamisawa T, Sanaka M, Ishii T, Kuyama Y. Endoscopic hemostasis techniques for upper gastrointestinal hemorrhage: A review. World J Gastrointest Endosc 2010; 2:54-60. [PMID: 21160691 PMCID: PMC2998874 DOI: 10.4253/wjge.v2.i2.54] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 09/12/2009] [Accepted: 09/19/2009] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal hemorrhage (UGIH) is an urgent disease that is often encountered in daily medical practice. Endoscopic hemostasis is currently indispensable for the treatment of UGIH. Initially, when UGIH is suspected, a cause of UGIH is presumed from the medical interview and physical findings. After ample primary treatment, urgent endoscopy is performed. Many methods of endoscopic hemostasis are in wide use, including hemoclip, injection and thermo-coagulation methods. Although UGIH develops from a wide variety of diseases, such as esophageal varices and gastric and duodenal ulcer, hemostasis is almost always possible. Identification of the causative diseases, primary treatment and characteristic features of endoscopic hemostasis are needed to allow appropriate treatment.
Collapse
Affiliation(s)
- Hajime Anjiki
- Hajime Anjiki, Terumi Kamisawa, Masaki Sanaka, Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo 113-8677, Japan
| | | | | | | | | |
Collapse
|
17
|
Conway JD, Adler DG, Diehl DL, Farraye FA, Kantsevoy SV, Kaul V, Kethu SR, Kwon RS, Mamula P, Rodriguez SA, Tierney WM. Endoscopic hemostatic devices. Gastrointest Endosc 2009; 69:987-96. [PMID: 19410037 DOI: 10.1016/j.gie.2008.12.251] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Accepted: 12/29/2008] [Indexed: 12/15/2022]
|
18
|
Yachimski P, Hur C. Upper endoscopy in patients with acute myocardial infarction and upper gastrointestinal bleeding: results of a decision analysis. Dig Dis Sci 2009; 54:701-11. [PMID: 18661236 PMCID: PMC3108178 DOI: 10.1007/s10620-008-0403-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Accepted: 06/18/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND The management of patients with acute myocardial infarction (AMI) and upper gastrointestinal bleeding (UGIB) can present a challenge. The utility of upper endoscopy (esophagogastroduodenoscopy, EGD) and endoscopic therapy must be weighed against safety considerations. AIM To assess the utility and safety of EGD in patients with UGIB and AMI. METHODS Using decision analysis, patients with UGIB and AMI were assigned to one of two strategies: (1) EGD prior to cardiac catheterization (EGD strategy) and (2) cardiac catheterization without EGD (CATH strategy). RESULTS In patients with overt UGIB, the EGD strategy resulted in 97 deaths per 10,000 patients, compared with 600 deaths in the CATH strategy. The EGD strategy resulted in fewer non-fatal complications (1,271 vs. 6,000 per 10,000 patients). In patients with occult blood loss, the EGD strategy resulted in more deaths (59 vs. 16 per 10,000) and more non-fatal complications (888 vs. 160 per 10,000) than the CATH strategy. CONCLUSIONS Our analysis supports EGD prior to cardiac catheterization in patients with AMI and overt UGIB. This strategy results in fewer deaths and complications compared with a strategy of proceeding directly to catheterization. Our analysis does not support routine EGD prior to cardiac catheterization in patients with fecal occult blood.
Collapse
Affiliation(s)
- Patrick Yachimski
- Blake 4 Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA,Harvard Medical School, Boston, MA, USA
| | - Chin Hur
- Blake 4 Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA,Harvard Medical School, Boston, MA, USA,Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
19
|
Barkun AN, Martel M, Toubouti Y, Rahme E, Bardou M. Endoscopic hemostasis in peptic ulcer bleeding for patients with high-risk lesions: a series of meta-analyses. Gastrointest Endosc 2009; 69:786-99. [PMID: 19152905 DOI: 10.1016/j.gie.2008.05.031] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Accepted: 05/10/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND OBJECTIVE Optimal endoscopic hemostasis remains undetermined. This was a systematic review of contemporary methods of endoscopic hemostasis for patients with bleeding ulcers that exhibited high-risk stigmata. SETTING Randomized trials that evaluated injection, thermocoagulation, clips, or combinations of these were evaluated from MEDLINE, EMBASE, and CENTRAL (1990-2006). PATIENTS A total of 4261 patients were evaluated. OUTCOMES Outcomes were rebleeding (primary), surgery, and mortality (secondary). Summary statistics were determined; publication bias and heterogeneity were sought by using funnel plots or by subgroup analyses and meta-regression. RESULTS Forty-one trials assessed 4261 patients. All endoscopic therapies decreased rebleeding versus pharmacotherapy alone, including sole intravenous (IV) proton pump inhibition (PPI) (OR 0.56 [95% CI, 0.34-0.92]); only one trial assessed high-dose IV PPI. Injection alone was inferior compared with other methods, except for thermal hemostasis (OR 1.02 [95% CI, 0.74-1.40]), with a strong trend of increased rebleeding if 1 injectate is used rather than 2 (OR 1.40 [95% CI, 0.95-2.05]). Injection followed by thermal therapy did not decrease rebleeding compared with clips (OR 0.82 [95% CI, 0.28-2.38]) or thermal therapy alone (OR 0.79 [95% CI, 0.24-2.62]). Subgroup analysis, however, suggested that injection followed by thermal therapy was superior to thermal therapy alone. Clips were superior to thermal therapy (OR 0.24 [95% CI, 0.06-0.95]) but, when followed by injection, were not superior to clips alone (OR 1.30 [95% CI, 0.36-4.76]). Surgery or mortality was not altered in most comparisons. CONCLUSIONS All endoscopic treatments are superior to pharmacotherapy alone; only 1 study assessed high-dose IV PPI. Optimal endoscopic therapies include thermal therapy or clips, either alone or in combination with other methods. Additional data are needed that compare injection followed by thermal therapy to clips alone or clips combined with another method.
Collapse
Affiliation(s)
- Alan N Barkun
- Divisions of Gastroenterology, the McGill University Health Centre, Montreal General Hospital site, Montréal, Québec, Canada.
| | | | | | | | | |
Collapse
|
20
|
Laine L, McQuaid KR. Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials. Clin Gastroenterol Hepatol 2009; 7:33-47; quiz 1-2. [PMID: 18986845 DOI: 10.1016/j.cgh.2008.08.016] [Citation(s) in RCA: 212] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Revised: 08/06/2008] [Accepted: 08/08/2008] [Indexed: 02/07/2023]
Abstract
The aim of this study was to determine appropriate endoscopic treatment of patients with bleeding ulcers by synthesizing results of randomized controlled trials. We performed dual independent bibliographic database searches to identify randomized trials of thermal therapy, injection therapy, or clips for bleeding ulcers with active bleeding, visible vessels, or clots, focusing on results from studies without second-look endoscopy and re-treatment. The primary end point was further (persistent plus recurrent) bleeding. Compared with epinephrine, further bleeding was reduced significantly by other monotherapies (relative risk [RR], 0.58 [95% CI, 0.36-0.93]; number-needed-to-treat [NNT], 9 [95% CI, 5-53]), and epinephrine followed by another modality (RR, 0.34 [95% CI, 0.23-0.50]; NNT, 5 [95% CI, 5-7]); epinephrine was not significantly less effective in studies with second-look and re-treatment. Compared with no endoscopic therapy, further bleeding was reduced by thermal contact (heater probe, bipolar electrocoagulation) (RR, 0.44 [95% CI, 0.36-0.54]; NNT, 4 [95% CI, 3-5]) and sclerosant therapy (RR, 0.56 [95% CI, 0.38-0.83]; NNT, 5 [95% CI, 4-13]). Clips were more effective than epinephrine (RR, 0.22 [95% CI, 0.09-0.55]; NNT, 5 [95% CI, 4-9]), but not different than other therapies, although the latter studies were heterogeneous, showing better and worse results for clips. Endoscopic therapy was effective for active bleeding (RR, 0.29 [95% CI, 0.20-0.43]; NNT, 2 [95% CI, 2-2]) and a nonbleeding visible vessel (RR, 0.49; [95% CI, 0.40-0.59]; NNT, 5 [95% CI, 4-6]), but not for a clot. Bolus followed by continuous-infusion proton pump inhibitor after endoscopic therapy significantly improved outcome compared with placebo/no therapy (RR, 0.40 [95% CI, 0.28-0.59]; NNT, 12 [95% CI, 10-18]), but not compared with histamine(2)-receptor antagonists. Thermal devices, sclerosants, clips, and thrombin/fibrin glue appear to be effective endoscopic hemostatic therapies. Epinephrine should not be used alone. Endoscopic therapy should be performed for ulcers with active bleeding and nonbleeding visible vessels, but efficacy is uncertain for clots. Bolus followed by continuous-infusion intravenous proton pump inhibitor should be used after endoscopic therapy.
Collapse
Affiliation(s)
- Loren Laine
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
| | | |
Collapse
|
21
|
Tajima A, Koizumi K, Suzuki K, Higashi N, Takahashi M, Shimada T, Terano A, Hiraishi H, Kuwayama H. Proton pump inhibitors and recurrent bleeding in peptic ulcer disease. J Gastroenterol Hepatol 2008; 23 Suppl 2:S237-41. [PMID: 19120905 DOI: 10.1111/j.1440-1746.2008.05557.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Peptic ulcer disease (PUD) is one of the main lesions responsible for upper gastrointestinal (GI) bleeding, as well as esophageal varices and Mallory-Weiss tear. Helicobacter pylori and non-steroidal anti-inflammatory drugs (NSAIDs)/aspirin are the major responsible causes. In cases of upper GI bleeding, urgent endoscopy is performed after stabilization of vital signs. There are several modalities for controlling bleeding in PUD, such as ethanol injection or hypertonic saline with epinephrine. Recurrent bleeding occurs in 20% of patients after endoscopic therapy. The combination of endoscopic intervention and a proton pump inhibitor (PPI) is necessary to achieve hemostasis of active bleeding. It has been reported that high-dose omeprazole (80 mg bolus injection, then 8 mg/h continuous infusion for 72 h, then 40 mg/day orally for 1 week) can reduce recurrent bleeding, the need for surgery and mortality from hemorrhagic shock in patients with high-risk peptic ulcer bleeding, as compared with standard-dose omeprazole. The metabolism of PPIs is dependent upon P450 2C19 genotypes and the clinical usefulness of genotypic analysis remains to be determined.
Collapse
Affiliation(s)
- Akihiro Tajima
- Department of Gastroenterology, Dokkyo Medical University, Koshigaya Hospital, Koshigaya, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Abstract
Endoscopic haemostasis should be attempted as the initial approach in most cases of gastrointestinal (GI) bleeding, although cross-disciplinary collaboration is a prerequisite. For variceal bleeding, band ligation is the method of choice in the elective setting, although injection therapy still has a role in acute bleeding. Histoacryl remains preferable for fundic varices in most parts of the world. For peptic ulcer bleeds, injection therapy should be combined with at least one 'mechanical' modality, thermal treatment or clipping. In rebleeding, a single endoscopic retreatment can be attempted, but alternative approaches must be considered. Acute lower GI bleeding is primarily a diagnostic challenge but, if the focus is found, the regular techniques for haemostasis can usually be applied. If small bowel haemorrhage is suspected after upper and lower endoscopy, capsule endoscopy and balloon enteroscopy offer make it possible to address even small bowel foci.
Collapse
|
23
|
Aabakken L. Current endoscopic and pharmacological therapy of peptic ulcer bleeding. Best Pract Res Clin Gastroenterol 2008; 22:243-59. [PMID: 18346682 DOI: 10.1016/j.bpg.2007.10.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Peptic ulcer bleeding is the most significant complication of ulcer disease, remaining the most important reason for upper gastrointestinal bleeding even in the era of Helicobacter eradication. Endoscopic triage and management plays a vital role in the handling of these patients, albeit in close collaboration with radiological and surgical expertise. Injection therapy, preferably with large volume epinephrine remains a core technology. Histoacryl and fibrin glue are more costly and less widely adopted alternatives. Mechanical measures are attractive and clips offer an excellent solution, particularly in soft tissues, and in combination with initial injection. Thermal methods with coagulation and coaptive axial force have similar performance characteristics. Increasingly, the combination of injection therapy with either a mechanical or thermal method appears the best option to achieve permanent haemostasis. PPIs for potent acid inhibition improves the clotting regardless of other treatment modalities. In the setting of rebleeding, patient and ulcer factors determine whether repeat endoscopy should be attempted, but the surgeon should be close at hand in this situation.
Collapse
Affiliation(s)
- Lars Aabakken
- Rikshospitalet University Hospital, N-0027 Oslo, Norway.
| |
Collapse
|
24
|
Calvet X, Vergara M, Gisbert JP, Brullet E. Dual versus endoscopic monotherapy in bleeding peptic ulcers. Am J Gastroenterol 2007; 102:1826-7; author reply 1827-8. [PMID: 17686075 DOI: 10.1111/j.1572-0241.2007.01266.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
25
|
Park WG, Yeh RW, Triadafilopoulos G. Injection therapies for nonvariceal bleeding disorders of the GI tract. Gastrointest Endosc 2007; 66:343-54. [PMID: 17643711 DOI: 10.1016/j.gie.2006.11.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Accepted: 11/09/2006] [Indexed: 02/08/2023]
Affiliation(s)
- Walter G Park
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California 94305, USA
| | | | | |
Collapse
|
26
|
Iacopini F, Petruzziello L, Marchese M, Larghi A, Spada C, Familiari P, Tringali A, Riccioni ME, Gabbrielli A, Costamagna G. Hemostasis of Dieulafoy's lesions by argon plasma coagulation (with video). Gastrointest Endosc 2007; 66:20-6. [PMID: 17591469 DOI: 10.1016/j.gie.2006.11.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2006] [Accepted: 11/10/2006] [Indexed: 02/06/2023]
Abstract
BACKGROUND A Dieulafoy's lesion is a submucosal artery that may erode the epithelium and lead to severe hemorrhages. The safety and efficacy of argon plasma coagulation (APC) for the hemostasis of these lesions has not been studied. OBJECTIVE To evaluate efficacy of APC alone in the hemostasis of Dieulafoy's lesions. DESIGN A retrospective analysis of hemostasis by chart review, with long-term follow-up by outpatient visit or phone interview. SETTING An academic hospital with 24-hour endoscopic service availability. PATIENTS All patients with acute bleeding from a Dieulafoy's lesion treated with APC. INTERVENTIONS Hemostasis was attempted with 2.3-mm APC probes, with settings varying from 40 W to 60 W, according to lesion location. MAIN OUTCOME MEASUREMENTS Initial hemostasis, recurrent bleeding, and 30-day mortality rates. RESULTS Twenty-three Dieulafoy's lesions were treated with APC, which represented 85% of all such lesions observed. Severe comorbidities and abnormal coagulation were present in 39% and 22%, respectively. Dieulafoy's lesions were located in the upper-GI tract in 20 patients (87%). Active bleeding was found in 20 patients (87%), a nonbleeding visible vessel was found in 2 patients (9%), and a minute mucosal defect below an adherent clot was found in 1 (4%). Initial hemostasis was achieved in all patients, without complications. An injection of an average volume of 3 mL of 1:10,000 epinephrine solution preceded APC in 3 cases for the identification of the bleeding lesion. Recurrent bleeding occurred in a patient after 48 hours; no bleeding-related deaths were observed during a median follow-up of 29 months. LIMITATIONS Retrospective study. CONCLUSIONS Dieulafoy's lesions can be successfully managed by APC alone.
Collapse
Affiliation(s)
- Federico Iacopini
- Digestive Endoscopy Unit, Department of Surgery, Catholic University, Rome, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Marmo R, Rotondano G, Piscopo R, Bianco MA, D'Angella R, Cipolletta L. Dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers: a meta-analysis of controlled trials. Am J Gastroenterol 2007; 102:279-89; quiz 469. [PMID: 17311650 DOI: 10.1111/j.1572-0241.2006.01023.x] [Citation(s) in RCA: 185] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is no definite recommendation on the use of dual endoscopic therapy in patients with severe peptic ulcer bleeding. A systematic review and meta-analysis were performed to determine whether the use of two endoscopic hemostatic procedures improved patient outcomes compared with monotherapy. METHODS A search for randomized trials comparing dual therapy (i.e., epinephrine injection plus other injection or thermal or mechanical method) versus monotherapy (injection, thermal, or mechanical alone) was performed between 1990 and 2006. Heterogeneity between studies was tested with chi(2) and explained by metaregression analysis. RESULTS Twenty studies (2,472 patients) met inclusion criteria. Compared with controls, dual endoscopic therapy reduces the risk of recurrent bleeding (OR [odds ratio] 0.59 [0.44-0.80], P= 0.0001) and the risk of emergency surgery (OR 0.66 [0.49-0.89], P= 0.03) and showed a trend toward a reduction in the risk of death (OR 0.68 [0.46-1.02], P= 0.06). Subcategory analysis showed that dual therapy was significantly superior to injection therapy alone for all the outcomes considered, but failed to demonstrate that any combination of treatments is better than either mechanical therapy alone (OR 1.04 [0.45-2.45] for rebleeding, 0.49 [0.50-4.87] for surgery, and 1.28 [0.34-4.86] for death) or thermal therapy alone (OR 0.67 [0.40-1.20] for rebleeding, 0.89 [0.45-1.76] for surgery, and 0.51 [0.24-1.10] for death). CONCLUSIONS Dual endoscopic therapy proved significantly superior to epinephrine injection alone, but had no advantage over thermal or mechanical monotherapy in improving the outcome of patients with high-risk peptic ulcer bleeding.
Collapse
Affiliation(s)
- Riccardo Marmo
- Department of Medicine, Division of Gastroenterology, Hospital L. Curto, Polla, Italy
| | | | | | | | | | | |
Collapse
|
28
|
Suzuki N, Arebi N, Saunders BP. A novel method of treating colonic angiodysplasia. Gastrointest Endosc 2006; 64:424-7. [PMID: 16923494 DOI: 10.1016/j.gie.2006.04.032] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2005] [Accepted: 04/25/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colonic angiodysplasia is responsible for up to a third of lower-GI bleeding cases. Argon plasma coagulation (APC) is a recognized treatment modality, but active bleeding decreases the ablative efficacy of APC by dissipation of the energy. APC has been associated with colonic perforation. OBJECTIVES We propose a novel and safe method for the treatment of colonic angiodysplasia by a submucosal injection of a saline epinephrine solution followed by the application of APC. PATIENTS Three patients with a total of 10 colonic angiodysplasias were treated with this injection-APC method. INTERVENTIONS Saline adrenaline solution (1:200,000) 2 to 3 mL was injected beneath the angiodysplasia before application of APC. APC 50 W and gas flow 2 L were applied onto the vascular lesion until the sufficient thermal effect was observed. RESULTS There were no procedure-related complications. CONCLUSIONS This new injection-APC method was safe for the treatment of colonic angiodysplasia. This may be useful in treating right-sided colonic lesions where the risks of perforation are greater than for the rest of the colon.
Collapse
Affiliation(s)
- Noriko Suzuki
- Wolfson Unit for Endoscopy, St Mark's Hospital, Harrow, Middlesex, United Kingdom
| | | | | |
Collapse
|