Factors predicting failure of endoscopic injection therapy in bleeding duodenal ulcer

Preliminary exploration of the application of cyanoacrylate glue in Forrest IIa and IIb peptic ulcer hemorrhage

OBJECTIVE

This study aims to preliminarily investigate the therapeutic effect of cyanoacrylate glue (CG) on Forrest IIa and IIb peptic ulcer hemorrhage (PCH).

METHODS

From January 2020 to May 2024, we retrospectively collected data on patients with Forrest IIa and IIb PCH treated with CG using emergency endoscopic hemostasis at a single center and subsequently evaluated and compared the efficacy of CG with respect to ulcer location, Forrest staging, and ulcer size.

RESULTS

A total of 93 patients were enrolled, achieving 100% technical success without 24-h rebleeding. The rebleeding rate at 72 h was 1.1% (95% confidence interval [CI]: 0.2-5.9%), and the rebleeding rate at 7 days was 2.2% (95% CI: 0.6-7.6%). The median age of the patients was 43.0 years. There were 42 patients (45.2%) with Forrest IIa ulcers and 51 patients (54.8%) with Forrest IIb ulcers. Sixty patients (64.5%) had ulcers ranging in size from 1.0 to 2.0 cm, while 33 patients (35.5%) had ulcers larger than 2.0 cm. The ulcers were located in the antrum (19 cases), angulus (38 cases), gastric body (11 cases), and duodenal bulb (25 cases). Median procedure time was 12.0 min, with duodenal PCH requiring significantly less time than stomach PCH (P < 0.05). CG treatment efficacy was comparable between Forrest IIa/IIb ulcers as well as across ulcer sizes (P > 0.05).

CONCLUSIONS

CG is particularly effective and safe for PCH located in the duodenal bulb, as well as for both Forrest IIa and IIb PCH.

Factors influencing re-bleeding after trans-arterial embolization for endoscopically unmanageable peptic ulcer bleeding

BACKGROUND/AIMS

Acute peptic ulcer bleeding is the most common cause of non-variceal upper gastrointestinal bleeding (NVUGIB). Endoscopic hemostasis is the standard treatment. However, various conditions complicate endoscopic hemostasis. Transarterial visceral embolization (TAE) may be helpful as a rescue therapy. This study aimed to investigate the factors associated with rebleeding after TAE.

METHODS

We retrospectively investigated the records of 156 patients treated with TAE between January 2007 and December 2021. Rebleeding was defined as the presence of melena, hematemesis, or hematochezia, with a fall (>2.0 g/dl) in hemoglobin level or shock after TAE. The primary outcomes were rebleeding rate and 30-day mortality.

RESULTS

Seventy patients with peptic ulcer bleeding were selected, and rebleeding within a month after TAE occurred in 15 patients (21.4%). Among the patients included in rebleeding group, significant increases were observed in the prevalence of thrombocytopenia (73.3% vs. 16.4%, p<.001) and ulcers >1 cm (93.3% vs 54.5%, p = .014). The mean AIMS65 (albumin, international normalized ratio, mental status, systolic blood pressure, age >65 years) score (2.3 vs 1.4, p = .009) was significantly higher in the rebleeding group. Multivariate logistic analysis revealed that thrombocytopenia (odds ratio 31.92, 95% confidence interval 6.24-270.6, p<.001) and larger ulcer size (odds ratio 27.19, 95% confidence interval 3.27-677.7, p=.010) significantly increased the risk of rebleeding after TAE.

CONCLUSION

TAE was effective in the treatment of patients with high-risk peptic ulcer bleeding. AIMS65 score was a significant predictor of rebleeding after TAE, and thrombocytopenia and larger ulcer size increased the risk of rebleeding after TAE.

At admission hemodynamic instability is associated with increased mortality and rebleeding rate in acute gastrointestinal bleeding: a systematic review and meta-analysis

Background

Acute gastrointestinal bleeding (GIB) is a life-threatening event. Around 20-30% of patients with GIB will develop hemodynamic instability (HI).

Objectives

We aimed to quantify HI as a risk factor for the development of relevant end points in acute GIB.

Design

A systematic search was conducted in three medical databases in October 2021.

Data sources and methods

Studies of GIB patients detailing HI as a risk factor for the investigated outcomes were selected. For the overall results, pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated based on a random-effects model. Subgroups were formed based on the source of bleeding. The Quality of Prognostic Studies tool was used to assess the risk of bias.

Results

A total of 62 studies were eligible, and 39 were included in the quantitative synthesis. HI was found to be a risk factor for both in-hospital (OR: 5.48; CI: 3.99-7.52) and 30-day mortality (OR: 3.99; CI: 3.08-5.17) in upper GIB (UGIB). HI was also associated with higher in-hospital (OR: 3.68; CI: 2.24-6.05) and 30-day rebleeding rates (OR: 4.12; 1.83-9.31) among patients with UGIB. The need for surgery was also more frequent in hemodynamically compromised UGIB patients (OR: 3.65; CI: 2.84-4.68). In the case of in-hospital mortality, the risk of bias was high for 1 (4%), medium for 13 (48%), and low for 13 (48%) of the 27 included studies.

Conclusion

Hemodynamically compromised patients have increased odds of all relevant untoward end points in GIB. Therefore, to improve the outcomes, adequate emergency care is crucial in HI.

Registration

PROSPERO registration number: CRD42021285727.

Peripheral Microneedle Patch for First-Aid Hemostasis

Despite the minimized puncture sizes and high efficiency, microneedle (MN) patches have not been used to inject hemostatic drugs into bleeding wounds because they easily destroy capillaries when a tissue is pierced. In this study, a shelf-stable dissolving MN patch is developed to prevent rebleeding during an emergency treatment. A minimally and site-selectively invasive hemostatic drug delivery system is established by using a peripheral MN (p-MN) patch that does not directly intrude the wound site but enables topical drug absorption in the damaged capillaries. The invasiveness of MNs is histologically examined by using a bleeding liver of a Sprague-Dawley (SD) rat as an extreme wound model in vivo. The skin penetration force is quantified to demonstrate that the administration of the p-MN patch is milder than that of the conventional MN patch. Hemostatic performance is systematically studied by analyzing bleeding weight and time and comparing them with that of conventional hemostasis methods. The superior performance of a p-MN for the heparin-pretreated SD rat model is demonstrated by intravenous injection in vivo.

Independent risk factors of 30-day outcomes in 1264 patients with peptic ulcer bleeding in the USA: large ulcers do worse

BACKGROUND

Predictors of worse outcomes (rebleeding, surgery and death) of peptic ulcer bleeds (PUBs) are essential indicators because of significant morbidity and mortality rates of PUBs. However those have been infrequently reported since changes in medical therapy (PPI, proton pump inhibitors) and application of newer endoscopic haemostatic technique.

AIMS

To determine: (i) independent risk factors for 30-day rebleeding, surgery, and death and (ii) whether ulcer size is an independent predictor of major outcomes in patients with severe PUB after successful endoscopic haemostasis and treatment with optimal medical (high dose IV PPI) vs. prior treatment (high dose IV histamine 2 antagonists - H2RAs).

METHODS

A large prospectively followed population of patients hospitalised with severe PUBs between 1993 and 2011 at two US tertiary care academic medical centres, stratified by stigmata of recent haemorrhage (SRH) was studied. Using multivariable logistic regression analyses, independent risk factors for each outcome (rebleeding, surgery and death) up to 30 days were analysed. Effects for medical treatment (H2RA patients 1993-2005 vs. PPIs 2006-2011) were also analysed.

RESULTS

A total of 1264 patients were included. For ulcers ≥10 mm, the odds of 30-day rebleeding increased 6% per each 10% increase in ulcer size (OR 1.06, 95% CI 1.02-1.10, P = 0.0053). Other risk factors for 30-day rebleeding were major SRH, in-patient start of bleeding, and prior GI bleeding. Major SRH and ulcer size≥10 mm were predictors of 30-day surgery. Risk factors for 30-day death were major SRH, in-patient bleeding, and any initial platelet transfusion or fresh frozen plasma transfusion ≥2 units. Among patients with major SRH and out-patient start of bleeding, larger ulcer size was also a risk factor for death (OR 1.08 per 10% increase in ulcer size, 95% CI 1.02-1.14, P = 0.0095). Ulcer size was a significant independent variable for both time periods.

CONCLUSIONS

Ulcer size is a risk factor for worse outcomes after PUB and should be carefully recorded at initial endoscopy to improve patient triage and management.

Clinical outcome of acute nonvariceal upper gastrointestinal bleeding after hours: the role of urgent endoscopy

BACKGROUND/AIMS

This study was performed to investigate the clinical role of urgent esophagogastroduodenoscopy (EGD) for acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) performed by experienced endoscopists after hours.

METHODS

A retrospective analysis was performed for consecutively collected data of patients with ANVUGIB between January 2009 and December 2010.

RESULTS

A total of 158 patients visited the emergency unit for ANVUGIB after hours. Among them, 60 underwent urgent EGD (within 8 hours) and 98 underwent early EGD (8 to 24 hours) by experienced endoscopists. The frequencies of hemodynamic instability, fresh blood aspirate on the nasogastric tube, and high-risk endoscopic findings were significantly higher in the urgent EGD group. Primary hemostasis was achieved in all except two patients. There were nine cases of recurrent bleeding, and 30-day mortality occurred in three patients. There were no significant differences between the two groups in primary hemostasis, recurrent bleeding, and 30-day mortality. In a multiple linear regression analysis, urgent EGD significantly reduced the hospital stay compared with early EGD. In patients with a high clinical Rockall score (more than 3), urgent EGD tended to decrease the hospital stay, although this was not statistically significant (7.7 days vs. 12.0 days, p > 0.05).

CONCLUSIONS

Urgent EGD after hours by experienced endoscopists had an excellent endoscopic success rate. However, clinical outcomes were not significantly different between the urgent and early EGD groups.

Predictive Factors for Endoscopic Visibility and Strategies for Pre-endoscopic Prokinetics Use in Patients with Upper Gastrointestinal Bleeding

BACKGROUND

Although current guideline recommends selective use of pre-endoscopic prokinetics to increase diagnostic yield in upper gastrointestinal bleeding (UGIB) patients, no data to guide the use of these drugs are available.

AIMS

We aimed to investigate predictive factors for endoscopic visibility and develop simple and useful strategies for pre-endoscopic prokinetics use in UGIB patients.

METHODS

A total of 220 consecutive patients who underwent upper endoscopy for suspicious UGIB were enrolled. Patients were randomly allocated to either a training or a validation set at a 2:1 ratio. Significant parameters on univariate analysis were subsequently tested by a classification and regression tree (CART) analysis.

RESULTS

Time to endoscopy and nasogastric aspirate findings were independently related to endoscopic visibility. The CART analysis generated algorithms proposed sequential use of time to endoscopy (≤5.2 vs. >5.2 h) and nasogastric aspirate findings (red blood or coffee rounds vs. clear aspirate) for predicting endoscopic visibility. Prediction of unacceptable visibility in the validation set produced sensitivity, specificity, positive predictive value, and negative predictive value of 75.8, 67.5, 65.8, and 77.1 %, respectively. Accurate prediction for visibility was identified in 52 of 73 patients (71.2 %).

CONCLUSIONS

Time to endoscopy and nasogastric aspirate findings were independently related to endoscopic visibility in patients with UGIB. A decision-tree model incorporating these two variables may be useful for selecting UGIB patients who benefit from pre-endoscopic prokinetics use.

What if endoscopic hemostasis fails?: Alternative treatment strategies: surgery

Management of bleeding peptic ulcers is increasingly challenging in an aging population. Endoscopic therapy reduces the need for emergency surgery in bleeding peptic ulcers. Initial endoscopic control offers an opportunity for selecting high-risk ulcers for potential early preemptive surgery. However, such an approach has not been supported by evidence in the literature. Endoscopic retreatment can be an option to control ulcer rebleeding and reduce complications. The success of endoscopic retreatment largely depends on the severity of rebleeding and ulcer characteristics. Large chronic ulcers with urgent bleeding are less likely to respond to endoscopic retreatment. Expeditious surgery is advised.

Initial assessment and management of patients with nonvariceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is a substantial clinical and economic burden, with an estimated mortality rate between 3% and 15%. The initial management starts with hemodynamic assessment and resuscitation. Blood transfusions may be needed in patients with low hemoglobin levels or massive bleeding, and patients who are anticoagulated may require administration of fresh frozen plasma. Patients with significant bleeding should be started on a proton-pump inhibitor infusion, and if there is concern for variceal bleeding, an octreotide infusion. Patients with UGIB should be stratified into low-risk and high-risk categories using validated risk scores. The use of these risk scores can aid in separating low-risk patients who are suitable for outpatient management or early discharge following endoscopy from patients who are at increased risk for needing endoscopic intervention, rebleeding, and death. Upper endoscopy after adequate resuscitation is required for most patients and should be performed within 24 hours of presentation. Key to improving outcomes is appropriate initial management of patients presenting with UGIB.

Epinephrine injection versus epinephrine injection and a second endoscopic method in high-risk bleeding ulcers

BACKGROUND

Endoscopic therapy reduces the rebleeding rate and the need for surgery in patients with bleeding peptic ulcers.

OBJECTIVES

To determine whether a second procedure improves haemostatic efficacy or patient outcomes or both after epinephrine injection in adults with high-risk bleeding ulcers.

SEARCH METHODS

For our update in 2014, we searched the following versions of these databases, limited from June 2009 to May 2014: Ovid MEDLINE(R) 1946 to May Week 2 2014; Ovid MEDLINE(R) Daily Update May 22, 2014; Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations May 22, 2014 (Appendix 1); Evidence-Based Medicine (EBM) Reviews-the Cochrane Central Register of Controlled Trials (CENTRAL) April 2014 (Appendix 2); and EMBASE 1980 to Week 20 2014 (Appendix 3).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing epinephrine alone versus epinephrine plus a second method. Populations consisted of patients with high-risk bleeding peptic ulcers, that is, patients with haemorrhage from peptic ulcer disease (gastric or duodenal) with major stigmata of bleeding as defined by Forrest classification Ia (spurting haemorrhage), Ib (oozing haemorrhage), IIa (non-bleeding visible vessel) and IIb (adherent clot) (Forrest Ia-Ib-IIa-IIb).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by The Cochrane Collaboration. Meta-analysis was undertaken using a random-effects model; risk ratios (RRs) with 95% confidence intervals (CIs) are presented for dichotomous data.

MAIN RESULTS

Nineteen studies of 2033 initially randomly assigned participants were included, of which 11 used a second injected agent, five used a mechanical method (haemoclips) and three employed thermal methods.The risk of further bleeding after initial haemostasis was lower in the combination therapy groups than in the epinephrine alone group, regardless of which second procedure was applied (RR 0.53, 95% CI 0.35 to 0.81). Adding any second procedure significantly reduced the overall bleeding rate (persistent and recurrent bleeding) (RR 0.57, 95% CI 0.43 to 0.76) and the need for emergency surgery (RR 0.68, 95% CI 0.50 to 0.93). Mortality rates were not significantly different when either method was applied.Rebleeding in the 10 studies that scheduled a reendoscopy showed no difference between epinephrine and combined therapy; without second-look endoscopy, a statistically significant difference was observed between epinephrine and epinephrine and any second endoscopic method, with fewer participants rebleeding in the combined therapy group (nine studies) (RR 0.32, 95% CI 0.21 to 0.48).For ulcers of the Forrest Ia or Ib type (oozing or spurting), the addition of a second therapy significantly reduced the rebleeding rate (RR 0.66, 95% CI 0.49 to 0.88); this difference was not seen for type IIa (visible vessel) or type IIb (adherent clot) ulcers. Few procedure-related adverse effects were reported, and this finding was not statistically significantly different between groups. Few adverse events occurred, and no statistically significant difference was noted between groups.The addition of a second injected method reduced recurrent and persistent rebleeding rates and surgery rates in the combination therapy group, but these findings were not statistically significantly different. Significantly fewer participants died in the combined therapy group (RR 0.50, 95% CI 0.25 to 1.00).Epinephrine and a second mechanical method decreased recurrent and persistent bleeding (RR 0.31, 95% CI 0.18 to 0.54) and the need for emergency surgery (RR 0.20, 95% CI 0.06 to 0.62) but did not affect mortality rates.Epinephrine plus thermal methods decreased the rebleeding rate (RR 0.49, 95% CI 0.30 to 0.78) and the surgery rate (RR 0.20, 95% CI 0.06 to 0.62) but did not affect the mortality rate.Our risk of bias estimates show that risk of bias was low, as, although the type of study did not allow a double-blind trial, rebleeding, surgery and mortality were not dependent on subjective observation. Although some studies had limitations in their design or implementation, most were clear about important quality criteria, including randomisation and allocation concealment, sequence generation and blinding.

AUTHORS' CONCLUSIONS

Additional endoscopic treatment after epinephrine injection reduces further bleeding and the need for surgery in patients with high-risk bleeding peptic ulcer. The main adverse events include risk of perforation and gastric wall necrosis, the rates of which were low in our included studies and favoured neither epinephrine therapy nor combination therapy. The main conclusion is that combined therapy seems to work better than epinephrine alone. However, we cannot conclude that a particular form of treatment is equal or superior to another.

Predictive factors for intractability to endoscopic hemostasis in the treatment of bleeding gastroduodenal peptic ulcers in Japanese patients

BACKGROUND/AIMS

Despite improvements in endoscopic hemostasis and pharmacological therapies, upper gastrointestinal (UGI) ulcers repeatedly bleed in 10% to 20% of patients, and those without early endoscopic reintervention or definitive surgery might be at a high risk for mortality. This study aimed to identify the risk factors for intractability to initial endoscopic hemostasis.

METHODS

We analyzed intractability among 428 patients who underwent emergency endoscopy for bleeding UGI ulcers within 24 hours of arrival at the hospital.

RESULTS

Durable hemostasis was achieved in 354 patients by using initial endoscopic procedures. Sixty-nine patients with Forrest types Ia, Ib, IIa, and IIb at the second-look endoscopy were considered intractable to the initial endoscopic hemostasis. Multivariate analysis indicated that age ≥70 years (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.07 to 4.03), shock on admission (OR, 5.26; 95% CI, 2.43 to 11.6), hemoglobin <8.0 mg/dL (OR, 2.80; 95% CI, 1.39 to 5.91), serum albumin <3.3 g/dL (OR, 2.23; 95% CI, 1.07 to 4.89), exposed vessels with a diameter of ≥2 mm on the bottom of ulcers (OR, 4.38; 95% CI, 1.25 to 7.01), and Forrest type Ia and Ib (OR, 2.21; 95% CI, 1.33 to 3.00) predicted intractable endoscopic hemostasis.

CONCLUSIONS

Various factors contribute to intractable endoscopic hemostasis. Careful observation after endoscopic hemostasis is important for patients at a high risk for incomplete hemostasis.

Effect of comorbidity on mortality in patients with peptic ulcer bleeding: systematic review and meta-analysis

OBJECTIVES

By systematic review and meta-analysis, we sought to assess the impact of comorbidity on short-term mortality in patients with peptic ulcer bleeding (PUB).

METHODS

We conducted systematic searches in PubMed and Embase (January 1989-January 2010). Relative risks (RRs) were pooled across selected studies and an analysis of diagnostic test accuracy was performed to validate the results further.

RESULTS

Of 1,572 identified studies, 16 were eligible for inclusion. Only three had a low risk of bias and the overall quality of evidence was low. The risk of death (30-day or in-hospital mortality) was significantly greater in PUB patients with comorbidity than in those without (RR: 4.44; 95% confidence interval (CI): 2.45-8.04). The pooled sensitivity for comorbidity predicting death in patients with PUB was 0.86 (95% CI: 0.66-0.95) and the pooled specificity was 0.53 (95% CI: 0.40-0.65). PUB patients with three or more comorbidities had a greater risk of dying than those with one or two (RR: 3.46; 95% CI: 1.34-8.89). All individual comorbidities that we assessed significantly increased the risk of death associated with PUB. However, RRs were higher for hepatic, renal, and malignant disease (range: 4.04-6.33; no significant heterogeneity) than for cardiovascular and respiratory disease and diabetes (2.39, 2.45, and 1.63, respectively; no significant heterogeneity).

CONCLUSIONS

Underlying comorbidity is consistently associated with increased mortality in patients with PUB. The number and type of comorbidities in patients with PUB should be carefully evaluated and factored into initial management strategies.

Meta-analysis: predictors of rebleeding after endoscopic treatment for bleeding peptic ulcer

BACKGROUND

Determining the risk of rebleeding after endoscopic therapy for peptic ulcer bleeding (PUB) may be useful for establishing additional haemostatic measures in very high-risk patients.

AIM

To identify predictors of rebleeding after endoscopic therapy.

METHODS

Bibliographic database searches were performed to identify studies assessing rebleeding after endoscopic therapy for PUB. All searches and data abstraction were performed in duplicate. A parameter was considered to be an independent predictor of rebleeding when it was detected as prognostic by multivariate analyses in ≥2 studies. Pooled odds ratios (pOR) were calculated for prognostic variables.

RESULTS

Fourteen studies met the prespecified inclusion criteria. Pre-endoscopic predictors of rebleeding were: (i) Haemodynamic instability: significant in 9 of 13 studies evaluating the variable (pOR: 3.30, 95% CI: 2.57-4.24); (ii) Haemoglobin value: significant in 2 of 10 (pOR: 1.73, 95% CI: 1.14-2.62) and (iii) Transfusion: significant in two of six (pOR not calculable). Endoscopic predictors of rebleeding were: (i) Active bleeding: significant in 6 of 12 studies (pOR: 1.70, 95% CI: 1.31-2.22); (ii) Large ulcer size: significant in 8 of 12 studies (pOR: 2.81, 95% CI: 1.98-4.00); (iii) Posterior duodenal ulcer location: significant in four of eight studies (pOR: 3.83, 95% CI: 1.38-10.66) and (iv) High lesser gastric curvature ulcer location: significant in three of eight studies (pOR: 2.86; 95% CI: 1.69-4.86).

CONCLUSIONS

Major predictors for rebleeding in patients receiving endoscopic therapy are haemodynamic instability, active bleeding at endoscopy, large ulcer size, ulcer location, haemoglobin value and the need for transfusion. These risk factors may be useful for guiding clinical management in patients with PUB.

Characteristics and outcomes of acute upper gastrointestinal bleeding after therapeutic endoscopy in the elderly

AIM: To characterize the effects of age on clinical presentations and endoscopic diagnoses and to determine outcomes after endoscopic therapy among patients aged ≥ 65 years admitted for acute upper gastrointestinal bleeding (UGIB) compared with those aged < 65 years.

METHODS: Medical records and an endoscopy data-base of 526 consecutive patients with overt UGIB ad-mitted during 2007-2009 were reviewed. The initial presentations and clinical course within 30 d after endoscopy were obtained.

RESULTS: A total of 235 patients aged ≥ 65 years constituted the elderly population (mean age of 74.2 ± 6.7 years, 63% male). Compared to young patients, the elderly patients were more likely to present with melena (53% vs 30%, respectively; P < 0.001), have comorbidities (69% vs 54%, respectively; P < 0.001), and receive antiplatelet agents (39% vs 10%, respectively; P < 0.001). Interestingly, hemodynamic instability was observed less in this group (49% vs 68%, respectively; P < 0.001). Peptic ulcer was the leading cause of UGIB in the elderly patients, followed by varices and gastropathy. The elderly and young patients had a similar clinical course with regard to the utilization of endoscopic therapy, requirement for transfusion, duration of hospital stay, need for surgery [relative risk (RR), 0.31; 95% confidence interval (CI), 0.03-2.75; P = 0.26], rebleeding (RR, 1.44; 95% CI, 0.92-2.25; P = 0.11), and mortality (RR, 1.10; 95% CI, 0.57-2.11; P = 0.77). In Cox’s regression analysis, hemodynamic instability at presentation, background of liver cirrhosis or disseminated malignancy, transfusion requirement, and development of rebleeding were significantly associated with 30-d mortality.

CONCLUSION: Despite multiple comorbidities and the concomitant use of antiplatelets in the elderly patients, advanced age does not appear to influence adverse outcomes of acute UGIB after therapeutic endoscopy.

Meta-analysis: erythromycin before endoscopy for acute upper gastrointestinal bleeding

BACKGROUND

Studies evaluating the effect of erythromycin on patients with acute upper gastrointestinal bleeding (UGIB) had been reported, but the results were inconclusive.

AIMS

To compare erythromycin with control in patients with acute UGIB by performing a meta-analysis.

METHODS

Electronic databases including PubMed, EMBASE and the Cochrane Library, Science Citation Index, were searched to find relevant randomised controlled trials (RCTs). Two reviewers independently identified relevant trials evaluating the effect of erythromycin on patients with acute UGIB. Outcome measures were the incidence of empty stomach, need for second endoscopy, blood transfusion, length of hospital stay, endoscopic procedure time and mortality.

RESULTS

Four RCTs including 335 patients were identified. Meta-analysis demonstrated the incidence of empty stomach was significantly increased in patients receiving erythromycin (active group 69%, control group 37%, P<0.00001). The need for second endoscopy, amount of blood transfusion and the length of hospital stay were also significantly reduced (all P<0.05). A trend for shorter endoscopic procedure time and decreased mortality rate was observed.

CONCLUSIONS

Prophylactic erythromycin is useful for patients with upper gastrointestinal bleeding to decrease the amount of blood in the stomach and reduce the need for second endoscopy, amount of blood transfusion. It may shorten the length of hospital stay, but its effects on mortality need further larger trials to be confirmed.

[Classification and management of upper gastrointestinal bleeding]

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.

Predicting poor outcome from acute upper gastrointestinal hemorrhage

In conclusion, numerous prediction models identified pre-endoscopic and endoscopic risk factors for adverse clinical outcomes in patients with acute upper GI hemorrhage. The risk factors for mortality are different from those of rebleeding. Predictors for rebleeding are usually related to the severity of the bleeding and characteristics of the ulcer, whereas advanced age, physical status of the patient, and comorbidities are important predictors for mortality in addition to those for rebleeding. Future studies should focus on validation of these predictors in a prospective cohort and application of these prediction models to guide clinical management in patients with acute upper GI hemorrhage.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

High-risk ED patients with nonvariceal upper gastrointestinal hemorrhage undergoing emergency or urgent endoscopy: a retrospective analysis

OBJECTIVES

The optimal timing of interventional endoscopy within the initial 24 hours remains controversial. We designed a retrospective study to compare the outcomes between emergency endoscopy (EE) and urgent endoscopy (UE) for high-risk patients with nonvariceal upper gastrointestinal hemorrhage presenting to the emergency department (ED).

METHODS

The medical records of 189 patients with nonvariceal upper gastrointestinal hemorrhage who underwent endoscopy within 24 hours of admission to the ED were reviewed. Patients were divided into 2 groups: EE group (<8 hours) or UE group (8-24 hours). We compared the endoscopic findings, hemostatic procedures, rate of hemostasis, rebleeding, need for transfusion, length of hospitalization, and mortality between the 2 groups.

RESULTS

There were 88 patients (47%) in the EE group and 101 patients (53%) in the UE group. Ulcers with active bleeding or exposed vessel were found more frequently in the EE group than in the UE group (19% vs 8%, P = .03; 34% vs 12%, P < .001). Fifty patients had blood retention in the stomach, especially in the EE group (40% vs 15%, P < .001). Forty-four (50%) patients in the EE group and 21 (21%) patients in the UE group received endoscopic interventions. Combination modalities of endoscopic hemostasis were more commonly used in the EE group than in the UE group (40% vs 15%, P < .001). Primary hemostasis was achieved at a rate of 95% in both groups. There was no statistical difference regarding the rate of recurrent bleeding, total amount of transfusion, length of hospital stay, and mortality rate in both groups.

CONCLUSIONS

Although more active lesions were detected and more therapeutic attempts were performed in the EE group, the outcome showed no difference in both groups. Emergency endoscopy performed less than 8 hours after arrival to the ED showed no definite benefit in comparison with UE performed within 8 to 24 hours.

Epinephrine injection versus epinephrine injection and a second endoscopic method in high risk bleeding ulcers

BACKGROUND

Endoscopic therapy reduces rebleeding rate, need for surgery, and mortality in patients with bleeding peptic ulcers. Injection of epinephrine is the most popular therapeutic method. Guidelines disagree on the need for a second haemostatic procedure immediately after epinephrine.

OBJECTIVES

The objective of this review was to determine whether the addition of a second procedure improves efficacy or patient outcomes or both after epinephrine injection in adults with high risk bleeding ulcers.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials - CENTRAL (which includes the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register) (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006) and reference lists of articles. We also contacted experts in the field.

SELECTION CRITERIA

Randomised studies comparing endoscopic treatment: epinephrine alone versus epinephrine associated with a second haemostatic method in adults with haemorrhage from peptic ulcer disease with major stigmata of bleeding as defined by the Forrest classification. Bleeding must have been confirmed by endoscopy.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

Seventeen studies including 1763 people were included. Adding a second procedure reduced further bleeding rate from 18.8% to 10.4%; Peto Odds Ratio 0.51; 95% confidence interval (CI) 0.39 to 0.66, and emergency surgery from 10.8% to 7.1%; OR 0.63; 95% CI 0.45 to 0.89. Mortality fell from 5% to 2.5% OR 0.50; 95% CI 0.30 to 0.82. Subanalysis showed that the risk of further bleeding decreased regardless of which second procedure was applied. In addition, the risk was reduced in all subgroups.

AUTHORS' CONCLUSIONS

Additional endoscopic treatment after epinephrine injection reduces further bleeding, the need for surgery and mortality in patients with bleeding peptic ulcer.

Endoscopic hemoclip versus triclip placement in patients with high-risk peptic ulcer bleeding

BACKGROUND

Hemoclip placement is an effective endoscopic therapy for peptic ulcer bleeding. Triclip is a novel clipping device with three prongs over the distal end. So far, there is no clinical study concerning the hemostatic effect of triclip placement.

AIM

To determine the hemostatic effect of the triclip as compared with that of the hemoclip.

METHODS

A total of 100 peptic ulcer patients with active bleeding or nonbleeding visible vessels received endoscopic therapy with either hemoclip (N = 50) or triclip placement (N = 50). After obtaining initial hemostasis, they received omeprazole 40 mg intravenous infusion every 12 h for 3 days. The main outcome assessment was hemostatic rate and rebleeding rate at 14 days.

RESULTS

Initial hemostasis was obtained in 47 patients (94%) of the hemoclip group and in 38 patients (76%) of the triclip group (P= 0.011). Rebleeding episodes, volume of blood transfusion, the hospital stay, numbers of patients requiring urgent operation, and mortality were not statistically different between the two groups.

CONCLUSION

Hemoclip is superior to triclip in obtaining primary hemostasis in patients with high-risk peptic ulcer bleeding. In bleeders located over difficult-to-approach sites, hemoclip is more ideal than triclip.

[Gastrointestinal hemorrhage--hemorrhage from the upper digestive system]

Upper gastrointestinal (GI) bleeding represents the commonest emergency managed by gastroenterologists utilizing substantial clinical and economic resources. Manifestations of GI bleeding depend uppon its localization, magnitude and co-morbidity. Although endoscopic haemostasis has significantly improved the outcome of patients with upper GI bleeding, in some cases patients continue to bleed or rebleed after initial control requiaring early elective surgery in order to decrease mortality. Despite recent advances in, both, endoscopic and surgical therapy, mortality rates have remained essentialy unchanged at 6-15%.

A head to head comparison of oral vs intravenous omeprazole for patients with bleeding peptic ulcers with a clean base, flat spots and adherent clots

AIM: To compare the effect of intravenous and oral omeprazole in patients with bleeding peptic ulcers without high-risk stigmata.

METHODS: This randomized study included 211 patients [112 receiving iv omeprazole protocol (Group 1), 99 receiving po omeprazole 40 mg every 12 h (Group 2)] with a mean age of 52.7. In 144 patients the ulcers showed a clean base, and in 46 the ulcers showed flat spots and in 21 old adherent clots. The endpoints were re-bleeding, surgery, hospital stay, blood transfusion and death. After discharge, re-bleeding and death were re-evaluated within 30 d.

RESULTS: The study groups were similar with respect to baseline characteristics. Re-bleeding was recorded in 5 patients of Group 1 and in 4 patients of Group 2 (P = 0.879). Three patients in Group 1 and 2 in Group 2 underwent surgery (P = 0.773). The mean length of hospital stay was 4.6 ± 1.6 d in Group 1 vs 4.5 ± 2.6 d in Group 2 (P = 0.710); the mean amounts of blood transfusion were 1.9 ± 1.1 units in Group 1 vs 2.1 ± 1.7 units in Group 2 (P = 0.350). Four patients, two in each group died (P = 0.981). After discharge, a new bleeding occurred in 2 patients of Group 1 and in 1 patient of Group 2, and one patient from Group 1 died.

CONCLUSION: We demonstrate that the effect of oral omeprazole is as effective as intravenous therapy in terms of re-bleeding, surgery, transfusion requirements, hospitalization and mortality in patients with bleeding ulcers with low risk stigmata. These patients can be treated effectively with oral omeprazole.

Factors associated with failure of initial endoscopic hemoclip hemostasis for upper gastrointestinal bleeding

BACKGROUND

Endoscopic hemoclip is widely used for the management of bleeding peptic ulcers. The major difficulty in clinical application of the hemoclip is deployment to the lesion during initial hemostasis. The aim of this study was to define factors associated with the failure of endoscopic hemoclip for initial hemostasis of upper GI bleeding.

PATIENTS AND METHODS

From January to December 2003, we prospectively studied 77 randomized patients with clinical evidence of upper GI bleeding due to either active bleeding or a visible vessel identified by upper GI endoscopy in our emergency department.

RESULTS

Among the 77 patients, 13 (16.9%) failed treatment (Group 1) and 64 (83.1%) were successfully (Group 2) treated by endoscopic hemoclip for lesions related to upper GI bleeding. There were no differences due to gender, blood pressure, initial heart rate, and hemoglobulin before or after endoscopic treatment, platelet count, serum creatinine, and albumin between groups. The mean age of Group 1 was higher than that of Group 2 (73.31+/-9.38 years vs. 65.41+/-16.45 years, respectively; P=0.083). Most patients who did not achieve initial hemostasis by endoscopic hemoclip had upper GI lesions over the gastric antrum and duodenal bulb. Among the 13 patients who failed to achieve endoscopic hemoclip initial hemostasis, four lesions were located over the posterior wall of the antrum, and four lesions over the lesser curvature side of the duodenal bulb.

CONCLUSION

Endoscopic hemoclip is an effective hemostatic method for upper GI bleeding. Age, gastric antrum, and duodenal bulb lesions may be associated with the failure of initial hemostasis by endoscopic hemoclip.

Outcome of non-variceal acute upper gastrointestinal bleeding in relation to the time of endoscopy and the experience of the endoscopist: a two-year survey

AIM

To prospectively assess the impact of time of endoscopy and endoscopist's experience on the outcome of non-variceal acute upper gastrointestinal (GI) bleeding patients in a large teaching hospital.

METHODS

All patients admitted for non-variceal acute upper GI bleeding for over a 2-year period were potentially eligible for this study. They were managed by a team of seven endoscopists on 24-h call whose experience was categorized into two levels (high and low) according to the number of endoscopic hemostatic procedures undertaken before the study. Endoscopic treatment was standardized according to Forrest classification of lesions as well as the subsequent medical therapy. Time of endoscopy was subdivided into two time periods: routine (8 a.m.-5 p.m.) and on-call (5 p.m.-8 a.m.). For each category of experience and time periods rebleeding rate, transfusion requirement, need for surgery, length of hospital stay and mortality we compared. Multivariate analysis was used to discriminate the impact of different variables on the outcomes that were considered.

RESULTS

Study population consisted of 272 patients (mean age 67.3 years) with endoscopic stigmata of hemorrhage. The patients were equally distributed among the endoscopists, whereas only 19% of procedures were done out of working hours. Rockall score and Forrest classification at admission did not differ between time periods and degree of experience. Univariate analysis showed that higher endoscopist's experience was associated with significant reduction in rebleeding rate (14% vs 37%), transfusion requirements (1.8+/-0.6 vs 3.0+/-1.7 units) as well as surgery (4% vs 10%), but not associated with the length of hospital stay nor mortality. By contrast, outcomes did not significantly differ between the two time periods of endoscopy. On multivariate analysis, endoscopist's experience was independently associated with rebleeding rate and transfusion requirements. Odds ratios for low experienced endoscopist were 4.47 for rebleeding and 6.90 for need of transfusion after the endoscopy.

CONCLUSION

Endoscopist's experience is an important independent prognostic factor for non-variceal acute upper GI bleeding. Urgent endoscopy should be undertaken preferentially by a skilled endoscopist as less expert staff tends to underestimate some risk lesions with a negative influence on hemostasis.

[Endoscopic treatment of bleeding ulcers: has everything been said and done?]

Endoscopic treatment reduces bleeding recurrence, the need for surgery and mortality in patients with bleeding ulcers. However endoscopic treatment fails in 10-15% of patients, leading to high morbidity and mortality. The therapeutic measures with demonstrated effectiveness in reducing the risk of hemorrhagic recurrence and its complications are combined endoscopic treatment (adrenaline plus a second hemostatic intervention) and proton pump inhibitors. Also useful, although there is less evidence, are immediate resuscitation and <<second look>> endoscopy. Some studies suggest that activated recombinant factor VII infusion or supra-selective arterial embolization can be useful in severe hemorrhage. Further studies are required to determine optimal treatment according to the characteristics of each patient.

Comparison of inpatient and outpatient upper gastrointestinal haemorrhage

BACKGROUND AND AIMS

Inpatients developing upper gastrointestinal (GI) haemorrhage are at increased risk of death. This study was performed to elucidate differences in inpatients and outpatients.

PATIENTS/METHODS

Three hundred and sixty-two patients who needed esophagogastroduodenoscopy for upper GI bleeding were identified from endoscopy charts. Patients' characteristics, bleeding parameters, clinical presentation, pre-existing medication, and laboratory data were compared between patients who were admitted because of upper GI bleeding and patients who developed bleeding while in hospital for other reasons.

RESULTS/FINDINGS

Hospital mortality was 39.0% in inpatients vs. 11.1% in outpatients (p<0.01). Death due to bleeding was observed in 9.5% of inpatients vs. 2.5% of outpatients (p<0.01). Whereas peptic ulcer was the most common source of bleeding in both, variceal bleeding was the most common cause of death because of haemorrhage in both. Recurrent bleeding was associated with mortality in outpatients (p<0.001), but not in inpatients (p=0.11). Rates of bleeding recurrence and need for surgery was similar in both groups. Inpatients suffered more often from renal disease, pulmonary disease, diabetes mellitus, coagulopathy, or immunosuppression, and were treated more frequently with acetylsalicylic acid, glucocorticoids and heparin. The frequency of pre-existing disease was higher in inpatients.

INTERPRETATION/CONCLUSION

Higher mortality after GI bleeding in inpatients than in outpatients is due to a generally higher prevalence of co-morbidity rather than a single or a few risk factors.

Optimal injection volume of epinephrine for endoscopic prevention of recurrent peptic ulcer bleeding

BACKGROUND

Although the initial rate of hemostasis achieved by endoscopic epinephrine injection for peptic ulcer bleeding is high, bleeding recurs in 14.6% to 35.5% of patients. The aim of this study was to compare rates of recurrent bleeding after endoscopic injection of two different volumes of epinephrine in patients with peptic ulcer bleeding.

METHODS

A total of 72 patients with peptic ulcer with active bleeding or a non-bleeding visible vessel were randomly assigned to 15 to 25 mL or 35 to 45 mL injections of a 1:10,000 solution of epinephrine.

RESULTS

The two groups were similar with respect to all background variables. The mean volume of epinephrine injected was 19.4 mL: 95% CI [18.7, 20.1] in the 15 to 25 mL group and 41.1 mL: 95% CI [40.0, 42.2] in the 35 to 45 mL group. Initial hemostasis was achieved in 35 of 36 patients (97.2%) in the 15 to 25 mL group and in all 36 patients in the 35 to 45 mL group. The 35 to 45 mL volume was significantly more effective in preventing recurrent bleeding than the 15 to 25 mL volume (0% vs. 17.1%; p < 0.05). For ulcers in the gastric body, the 35 to 45 mL volume was significantly more effective in preventing recurrent bleeding than the 15 to 25 mL volume (0% vs. 31.6%; p = 0.003). For ulcers in other locations, including the gastric antrum and the duodenum, there were no significant differences in the rate of recurrent bleeding between the two groups.

CONCLUSIONS

Injection of 35 to 45 mL of a 1:10,000 solution of epinephrine is more effective than injection of 15 to 25 mL of the same solution for prevention of recurrent bleeding from ulcers in the body of the stomach.

A randomized study of the safety of outpatient care for patients with bleeding peptic ulcer treated by endoscopic injection

BACKGROUND

Outpatient management is safe for patients with non-variceal upper-GI bleeding who are at low risk of recurrent bleeding and death. However, outpatient care cannot be offered to many patients because of the presence of risk factors (severe comorbid disorders, major endoscopic stigmata of bleeding, significant hemorrhage). The present study assessed the safety of outpatient management for selected high-risk patients with bleeding peptic ulcer.

METHODS

Patients hospitalized with upper-GI bleeding because of peptic ulcer with a non-bleeding vessel were eligible for inclusion in the study. Inclusion criteria were the following: ulcer size less than 15 mm, absence of hypovolemia, no associated severe disease, and appropriate family support. After endoscopic therapy (injection of epinephrine and polidocanol), patients were randomized to outpatient or hospital care. Patients remained in the emergency ward for a minimum of 6 hours before discharge, during which time omeprazole was administered intravenously. Outpatients were contacted by telephone daily during the first 3 days; a 24-hour telephone hotline was provided for any queries. For both groups, outpatient visits were scheduled at 7 to 10 and 30 days after discharge.

RESULTS

A total of 82 patients were included: 40 were randomized to outpatient care and 42 to hospital care. Clinical and endoscopic variables were similar in both groups. The rate of recurrent bleeding was similar in both groups (4.8% outpatient, 5% hospital). There was no morbidity or mortality in either group at 30 days. Seven patients (17%) randomized to outpatient care received blood transfusion compared with 14 (38%) in the hospital care group (p=0.06). Mean cost of care per patient was significantly lower for the outpatient vs. the hospital group (970 US dollars vs. 1595 US dollars; p < 0.001).

CONCLUSIONS

Selected patients with bleeding peptic ulcer can be safely managed as outpatients after endoscopic therapy. This policy conserves health care resources without compromising standards of care.

The effect of octreotide as an adjunct treatment in active nonvariceal upper gastrointestinal bleeding

GOALS

The aim of this study was to determine the effect ofoctreotide on active or recent gastrointestinal bleeding from benign peptic ulcers.

STUDY

This is a prospective, randomized study including 110 patients with gastric or duodenal peptic ulcers presenting with active spurting or oozing bleeding or nonbleeding visible vessel. All patients were subjected to endoscopic hemostasis by injection of noradrenaline, and they were then randomized to either receive octreotide (55 patients) or placebo (55 patients). The groups did not differ with respect to age, sex, use of nonsteroidal antiinflammatory drugs, previous history of ulcer or bleeding, Helicobacter pylori infection, site, and severity of bleeding.

RESULTS

The rebleeding rate was 36% in placebo and 32% in octreotide group, which does not present a statistically significant difference. Surgical intervention was required for 18 patients (32.7%) in the placebo group and for 16 patients (29%) in the octreotide group. The mortality rate was 2 patients (3.6%) in the placebo and 4 patients (7.2%) in the octreotide group. All the above presented no statistical difference. In addition, there was no statistically significant difference between the 2 groups with respect to the number of blood units transfused and hospital stay.

CONCLUSIONS

The use of octreotide as an adjunct treatment in patients with acutely bleeding benign peptic ulcer or/and visible vessel did not seem to offer significant benefits regarding their outcome.

Gastrointestinal hemorrhage: is the surgeon obsolete?

The management of GI hemorrhage has undergone tremendous evolution in recent decades. Once commonly managed by surgeons, the almost continuous introduction of new technologies and pharmacotherapies has dramatically improved clinicians' ability to identify and control sources of bleeding without surgery. Although a gastroenterologist can successfully manage most cases of GI hemorrhage endoscopically, surgical consultation remains an important consideration for the emergency physician in selected cases.

Addition of a second endoscopic treatment following epinephrine injection improves outcome in high-risk bleeding ulcers

BACKGROUND & AIMS

Endoscopic therapy reduces the rebleeding rate, the need for surgery, and the mortality in patients with peptic ulcer and active bleeding or visible vessel. Injection of epinephrine is the most popular therapeutic method. Guidelines disagree on the need for a second hemostatic procedure immediately after epinephrine; although it seems to reduce further bleeding, its effects on morbidity, surgery rates, and mortality remain unclear. The aim of this study was to perform a systematic review and meta-analysis to determine whether the addition of a second procedure improves hemostatic efficacy and/or patient outcomes after epinephrine injection.

METHODS

An extensive search for randomized trials comparing epinephrine alone vs. epinephrine plus a second method was performed in MEDLINE and EMBASE and in the abstracts of the AGA Congresses between 1990 and 2002. Selected articles were included in a meta-analysis.

RESULTS

Sixteen studies including 1673 patients met inclusion criteria. Adding a second procedure reduced the further bleeding rate from 18.4% to 10.6% (Peto odds ratio 0.53, 95% CI: 0.40-0.69) and emergency surgery from 11.3% to 7.6% (OR: 0.64, 95% CI: 0.46-0.90). Mortality fell from 5.1% to 2.6% (OR: 0.51, 95% CI: 0.31-0.84). Subanalysis showed that the risk of further bleeding decreased regardless of which second procedure was applied. In addition, the risk was reduced in all subgroups, although reduction was more evident in high-risk patients and when no scheduled follow-up endoscopies were performed.

CONCLUSIONS

Additional endoscopic treatment after epinephrine injection reduces further bleeding, need for surgery, and mortality in patients with bleeding peptic ulcer.

Nonvariceal upper gastrointestinal bleeding

Nonvariceal UGI bleeding is one of the most common emergencies that gastroenterologists encounter, and continues to be a significant cause of morbidity and mortality. The keys to management are rapid resuscitation and stabilization; appropriate triage based on pre-endoscopic risk factors; early endoscopy to achieve prompt diagnosis and implement hemostatic therapy to high-risk lesions; and aggressive antisecretory therapy (in the case of peptic ulcer bleeding) to reduce the risk of continued or recurrent bleeding.

Endoscopic haemoclip versus heater probe thermocoagulation plus hypertonic saline-epinephrine injection for peptic ulcer bleeding

BACKGROUND

Treating patients of bleeding peptic ulcers with heater probe thermocoagulation and haemoclip is considered to be safe and very effective. Yet, there is no report comparing the haemostatic effects of endoscopic haemoclip versus heater probe thermocoagulation plus hypertonic saline-epinephrine injection in these patients.

AIM

To compare the clinical outcomes of both therapeutic modalities in patients with peptic ulcer bleeding.

METHODS

A total of 93 patients with active bleeding or non-bleeding visible vessels were randomised to receive either endoscopic haemoclip (n = 46) or heater probe thermocoagulation plus hypertonic saline-epinephrine injection (n = 47). Five patients from the haemoclip group were excluded because of the inability to place the haemoclip.

RESULTS

Initial haemostasis was achieved in 39 patients (95.1%) of the haemoclip group and 47 patients (100%) of the heater probe group (P > 0.1). Rebleeding occurred in four patients (10.3%) of the haemoclip group and three patients (6.4%) of the heater probe group (P > 0.1). The volume of blood transfused after entry into the study, duration of hospital stay, number of patients requiring urgent surgery and the mortality rates were not statistically different between the two groups.

CONCLUSIONS

If the haemoclip can be applied properly, the clinical outcomes of the haemoclip group would be similar to those of the heater probe group in patients with peptic ulcer bleeding. However, if the bleeders are located at the difficult-to-approach sites, heater probe plus hypertonic saline injection is the first choice therapy.

N/A

N/A

Endoscopic injection with fibrin sealant versus epinephrine for arrest of peptic ulcer bleeding: a randomized, comparative trial

BACKGROUND

endoscopic epinephrine and fibrin injection in the treatment of bleeding peptic ulcer are reported to be safe, effective, and easy to use. However, a wide range of rebleeding rates has been reported with epinephrine injection.

GOALS

to compare the hemostatic effects of endoscopic injection with fibrin sealant versus epinephrine.

STUDY

between December 1998 and July 2000, 51 patients with active bleeding or nonbleeding visible vessels entered this trial. The clinical parameters were comparable between both groups. In the epinephrine group, we injected 5 to 10 mL of 1:10,000 epinephrine, surrounding the bleeder. In the fibrin sealant group, we injected fibrin sealant 4 mL, surrounding the bleeder.

RESULTS

initial hemostasis was obtained in all enrolled patients. Rebleeding was more in the epinephrine group than in the fibrin sealant group (4 [15%] of 26 vs. 14 [56%] of 25, = 0.003 on the intention-to-treat basis, and 4 [16.7%] of 24 vs. 14 [58.3%] of 24, = 0.003 on the per protocol basis, respectively). Volume of blood transfusion, number of surgeries, hospital stay, and number of deaths were similar between both groups.

CONCLUSION

fibrin sealant injection is more effective in preventing rebleeding than epinephrine after endoscopic therapy, but this study showed no difference in outcomes with either therapy.

A prospective, randomized trial of endoscopic hemoclip versus heater probe thermocoagulation for peptic ulcer bleeding

OBJECTIVES

Endoscopic heater probe thermocoagulation and hemoclip are considered to be safe and very effective in the treatment of bleeding peptic ulcer. So far, there are only few reports concerning hemostasis with endoscopic hemoclip. The aims of this study were to compare the hemostatic effects of both therapeutic modalities in patients with peptic ulcer bleeding.

METHODS

A total of 80 patients with active bleeding or nonbleeding visible vessels were randomized to receive endoscopic hemoclip (n = 40) or heater probe thermocoagulation (n = 40).

RESULTS

Initial hemostasis was achieved in 34 patients (85%) in the hemoclip group and 40 patients (100%) in the heater probe group (p = 0.01277). Rebleeding occurred in three patients (8.8%) in the hemoclip group and two patients (5%) in the heater probe group (p > 0.1). Among patients with difficult-to-approach bleeding, we obtained a better hemostatic rate in the heater probe group (nine of 11 patients vs three of 10, p = 0.02417). The volume of blood transfused after entry into the study, duration of hospital stay, number of patients requiring urgent surgery, and the mortality rate were not statistically significantly different between the two groups.

CONCLUSIONS

For patients with peptic ulcer bleeding, heater probe thermocoagulation offers an advantage in achieving hemostasis than hemoclip. In difficult-to-approach bleeders, heater probe is a more suitable therapeutic modality.

Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial

BACKGROUND & AIMS

Emergency endoscopy may be difficult in upper gastrointestinal bleeding when blood obscures the visibility. Erythromycin, a motilin agonist, induces gastric emptying. We investigated whether an intravenous bolus infusion of erythromycin would improve the yield of endoscopy in these patients.

METHODS

Patients admitted within 12 hours after hematemesis were randomly assigned to erythromycin (250 mg) or placebo, 20 minutes before endoscopy. The primary end point was endoscopic yield, as assessed by objective and subjective scoring systems and endoscopic duration. Secondary end points were the need for a second look, endoscopy-related complications, blood units transfused, and length of hospital stay.

RESULTS

Fifty-one patients received erythromycin and 54 received placebo. A clear stomach was found more often in the erythromycin group (82% vs. 33%; P < 0.001). This difference remained significant in patients with cirrhosis. Erythromycin shortened the endoscopic duration (13.7 vs. 16.4 minutes in the placebo group; P = 0.036) and reduced the need for second-look endoscopy (6 vs. 17 cases; P = 0.018). Length of hospital stay and blood units transfused did not significantly differ between the 2 groups. No complications were noted.

CONCLUSIONS

Erythromycin infusion before endoscopy in patients with recent hematemesis makes endoscopy shorter and easier, thereby reducing the need for a repeat procedure.

A prospective, randomized trial of large- versus small-volume endoscopic injection of epinephrine for peptic ulcer bleeding

BACKGROUND

Endoscopic injection of epinephrine in the treatment of bleeding peptic ulcer is considered highly effective, safe, inexpensive, and easy to use. However, bleeding recurs in 6% to 36% of patients. The aim of this study was to determine the optimal dose of epinephrine for endoscopic injection in the treatment of patients with bleeding peptic ulcer.

METHODS

One hundred fifty-six patients with active bleeding or nonbleeding visible vessels were randomized to receive small- (5-10 mL) or large-volume (13-20 mL) injections of a 1:10,000 solution of epinephrine.

RESULTS

The mean volume of epinephrine injected was 16.5 mL (95% CI [15.7, 17.3 mL]) in the large-volume group and 8.0 mL (95% CI [7.5, 8.4 mL]) in the small-volume group. Initial hemostasis was achieved in all patients studied. The number of episodes of recurrent bleeding was smaller in the large-volume group (12/78, 15.4%) compared with the small-volume group (24/78, 30.8%, p = 0.037). The volume of blood transfused after entry into the study, duration of hospital stay, numbers of patients requiring urgent surgery, and mortality rates were not statistically different between the 2 groups.

CONCLUSIONS

Injection of a large volume (>13 mL) of epinephrine can reduce the rate of recurrent bleeding in patients with high-risk peptic ulcer and is superior to injection of lesser volumes of epinephrine when used to achieve sustained hemostasis.

Outpatient management for low-risk nonvariceal upper GI bleeding: a randomized controlled trial

BACKGROUND

Patients with acute nonvariceal upper GI hemorrhage are routinely hospitalized, regardless of clinical status or endoscopic findings. The aim of this study was to compare outcomes for outpatient versus hospital care of patients with nonvariceal upper GI hemorrhage at low risk of recurrent bleeding.

METHODS

Endoscopic and clinical criteria were used to select patients at low risk for recurrent bleeding. Ninety-five consecutive patients were randomized for either early discharge and outpatient care (48) or hospital care (47). Baseline clinical and endoscopic features were comparable. During the first 30 days patients were examined daily by their primary care physician and contacted by a gastroenterologist by telephone to assess clinical status. Rates of recurrent bleeding, hospitalization, surgery, and mortality were determined.

RESULTS

All patients underwent endoscopy within 12 hours of the onset of hemorrhage. No patient underwent surgery or died. Rates of recurrent bleeding were 2.1% in the early discharge group and 2.2% in the hospital-treated group (1 patient in each group). Median costs were $340 for the outpatient group and $3940 for the hospital group (p = 0.001).

CONCLUSIONS

Outpatient care of patients at low risk for recurrent nonvariceal upper GI hemorrhage is safe and can lead to significant savings in hospital costs.

Proton pump inhibitors versus H2-antagonists: a meta-analysis of their efficacy in treating bleeding peptic ulcer

PURPOSE

To evaluate whether proton pump inhibitors are more effective than H2-antagonists (H2-A) for the treatment of bleeding peptic ulcer.

DATA SOURCES

PubMed database until January 2000.

STUDY SELECTION

Comparative randomized trials of proton pump inhibitors (omeprazole, lansoprazole, or pantoprazole) vs. H2-A (cimetidine, ranitidine or famotidine).

DATA EXTRACTION

Meta-analysis combining the odds ratios (OR) of the individual studies in a global OR (Peto method). OUTCOMES EVALUATED: Persistent or recurrent bleeding, need for surgery, or mortality.

DATA SYNTHESIS

Eleven studies fulfilled the inclusion criteria and contained data for at least one of the planned comparisons. Persistent or recurrent bleeding was reported in 6.7% (95% CI: 4.9-8.6%) of the patients treated with proton pump inhibitors, and in 13.4% (95% CI: 10.8-16%) of those treated with H2-A (OR 0.4; 95% CI: 0.27-0.59) (chi2-homogeneity test, 18; P=0.09). Surgery was needed in 5.2% (95% CI: 3.4-6.9%) of the patients treated with proton pump inhibitors, and in 6.9% (95% CI: 4.9-8.9%) of the patients treated with H2-A (OR 0.7; 95% CI: 0.43-1.13). Respective percentages for mortality were 1.6% (95% CI: 0.9-2.9%) and 2.2% (95% CI: 1.3-3.7%) (OR 0.69; 95% CI: 0.31-1.57). SUB-ANALYSIS: Five studies evaluated the effect of both therapies given in bolus injections on persistent or recurrent bleeding rate, which was 6% (95% CI: 3.6-8.3%) and 8.1% (95% CI: 5.3-10.9%), respectively (OR, 0.57; 95% CI: 0.31-1.05). Persistent or recurrent bleeding in high risk patients (Forrest Ia, Ib and IIa) occurred in 13.2% (95% CI: 7.9-8%) of the patients treated with proton pump inhibitors and in 34.5% (27-42%) of those treated with H2-A (OR 0.28; 95% CI: 0.16-0.48). In patients not having endoscopic therapy, persistent or recurrent bleeding was reported, respectively, in 4.3% (95% CI: 2.7-6.7%) and in 12% (95% CI: 8.7-15%) (OR 0.24; 95% CI: 0.13-0.43). Less marked differences were observed in patients having adjunct endoscopic therapy: 10.3% (95% CI: 6.7-13.8%) and 15.2% (11.1-19.3%) (OR 0.59; 95% CI: 0.36-0.97). Moreover, the significance disappeared in this group when a single outlier study was excluded.

CONCLUSIONS

Proton pump inhibitors are more effective than H2-A in preventing persistent or recurrent bleeding from peptic ulcer, although this advantage seems to be more evident in patients not having adjunct sclerosis therapy. This beneficial effect seems to be similar or even more marked in patients with Forrest Ia, Ib or IIa ulcers. However, proton pump inhibitors are not more effective than H2-A for reducing surgery or mortality rates. Nevertheless, the data are too scarce and heterogeneous to draw definitive conclusions, and further comparative trials are clearly warranted.

What is the optimal length of proton pump inhibitor-based triple therapies for H. pylori? A cost-effectiveness analysis

BACKGROUND

Triple therapy with a proton pump inhibitor, clarithromycin and amoxicillin is widely used for H. pylori infection. The appropriate length of treatment remains controversial.

AIM

To determine whether length of treatment has an impact on the cost-effectiveness of triple therapy.

METHODS

The study took the form of a cost-effectiveness analysis spanning 2 years. The perspective was societal and the setting, ambulatory care. Subjects were Helicobacter pylori-positive patients with a duodenal ulcer. The triple therapy trials spanned 7, 10 or 14 days and the main outcome measures were cost per patient and marginal cost for additional cured patient calculated for a low cost-of-care setting (Spain), for a high-cost setting (USA), and for two follow-up strategies: (i) systematic 13C-urea breath test after eradication; (ii) clinical follow-up, breath-test if symptoms recurred.

RESULTS

Base-case analysis showed that for both the 13C-UBT and the clinical follow-up branches, lowest costs were obtained with 7-day schedules both in Spain and the USA. Sensitivity analysis showed that in Spain, 10-day therapies would have to increase 7-day cure rates by 10-12% to become cost-effective. In contrast, in the USA only a 3-5% increase was needed. The corresponding figures for 14-day therapy were 25-35% and 8-11%, respectively.

CONCLUSIONS

Seven-day therapies seem the most cost-effective strategy. However, in high-cost areas the differences were less evident.

Surgery in the acute management of bleeding peptic ulcer

The management of bleeding peptic ulcers is an increasing challenge in an ageing population. Endoscopic therapy reduces the need for emergency surgery in bleeding peptic ulcers, and ulcers that fail endoscopic therapy are often 'difficult' ulcers, highly demanding for most gastric surgeons. Mortality in patients requiring eventual salvage surgery is high. Planned urgent surgery is preferable to emergency surgery in elderly patients. Initial endoscopic control offers an opportunity for selecting high-risk ulcers for early surgery. Such a logical approach has, however, not been supported by evidence in the literature. At surgery, an aggressive approach is recommended. Post-operative bleeding is more common after lesser surgery, and this complication is often fatal. When re-bleeding occurs, a selective approach is suggested as emergency surgery carries with it a substantial mortality. Large chronic ulcers with exigent bleeding are less likely to respond to endoscopic re-treatment. Expedient surgery is advised for these patients.