Endoscopic injection for the arrest of peptic ulcer hemorrhage: final results of a prospective, randomized comparative trial

Endoscopic treatment for high-risk bleeding peptic ulcers: A randomized, controlled trial of epinephrine alone with epinephrine plus fresh frozen plasma

BACKGROUND

Acute upper gastrointestinal bleeding is a common and potentially life-threatening emergency with substantial mortality. Fresh frozen plasma (FFP), a good source of coagulation factors, might be an ideal injection agent based on its physiologic properties. Therefore, we evaluated the role of FFP as a hemostatic agent in patients with high-risk bleeding peptic ulcers.

MATERIALS AND METHODS

From August 2015 to April 2016, 108 consecutive patients with high-risk bleeding ulcers were admitted to our university hospital. They were randomly assigned to undergo injection of epinephrine alone (A) or epinephrine plus FFP (B). The primary outcomes assessed were the initial hemostasis, recurrent bleeding, hospital stay, blood transfusion, surgery rate, and 14-day mortality.

RESULTS

Initial hemostasis was achieved in 47 of 50 patients (94%) in the Group A and 49 of 50 patients (98%) in the Group B (P = 0.61). There were no significant differences in the rate of recurrent bleeding between Group A (14%) and Group B (8%) (P = 0.52). We found no significant differences between Group A and Group B with respect to the surgery rate, bleeding death, procedure-related death, and duration of hospitalization (P > 0.05).

CONCLUSION

It is concluded the injection of epinephrine alone was equally effective as injection of epinephrine plus FFP to endoscopic hemostasis. Epinephrine alone and epinephrine plus FFP were not different in recurrent bleeding, rate of surgery, blood transfusion, or mortality.

Injection and Cautery Methods for Nonvariceal Bleeding Control

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.

Endoscopic Therapy of Bleeding from Radiation Enteritis with Hypertonic Glucose Spray

Non-variceal and non-ulcerative bleeding in the gastrointestinal (GI) tract, such as radiation enteritis with active and extensive oozing, is common, and management of these conditions can be challenging. We describe the first case in the literature to use hypertonic glucose spray in radiation enteritis-associated diffuse mucosal bleeding.

Current endoscopic and pharmacological therapy of peptic ulcer bleeding

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.

Therapeutic endoscopy for nonvariceal gastrointestinal bleeding

The evaluation and management of acute gastrointestinal bleeding in infants, children, and adolescents is a reason for emergency consultation frequently cited by pediatric gastroenterologists. After stabilization of the patient's condition, endoscopic evaluation remains the most rapid and accurate method to identify the origin of acute bleeding in the majority of lesions in the pediatric age group. Several endoscopic techniques may be applied to bleeding lesions to achieve hemostasis. Familiarity with the various techniques and with the specifics of their use is essential for the pediatric endoscopist. This review focuses on the endoscopic management of acute nonvariceal bleeding in infants and children.

Large-volume endoscopic injection of epinephrine plus normal saline for peptic ulcer bleeding

BACKGROUND AND AIM

Large-volume endoscopic injection of epinephrine has been proven to significantly reduce rates of recurrent peptic ulcer bleeding. Injection of normal saline may be equally effective for the similar hemostatic effect of local tamponade. The aim of our study was to compare the therapeutic effects of large-volume (40 mL) endoscopic injections of epinephrine, normal saline and a combination of the two in patients with active bleeding ulcers.

METHOD

A total of 216 patients with actively bleeding ulcers (spurting or oozing) were randomly assigned to three groups (1:10,000 epinephrine, normal saline or diluted epinephrine plus normal saline). The hemostatic effects and clinical outcomes were compared between the three groups.

RESULTS

The initial hemostatic rate was significantly lower in the normal saline group (P < 0.05). The volume of injected solution required for the arrest of bleeding was significantly larger in the normal saline group (P < 0.01). Mean duration for arrest of bleeding was significantly longer in the normal saline group (P < 0.01). There were no significant differences between the three groups with respect to the rates of recurrent bleeding, surgical intervention, 30-day mortality, amount of transfusion and duration of hospitalization. Significant elevation of systolic blood pressure (P < 0.05) and persistent high pulse rate after endoscopic injection were observed in the epinephrine group.

CONCLUSIONS

For patients with active bleeding ulcers (spurting or oozing), we recommend a large-volume (40 mL) combination injection using diluted epinephrine to cease bleeding, followed by injection of normal saline to achieve sustained hemostasis.

Optimal injection volume of epinephrine for endoscopic treatment of peptic ulcer bleeding

AIM: To define the optimal injection volume of epinephrine with high efficacy for hemostasis and low complication rate in patients with actively bleeding ulcers.

METHODS: This prospective, randomized, comparative trial was conducted in a medical center. A total of 228 patients with actively bleeding ulcers (spurting or oozing) were randomly assigned to three groups with 20, 30 and 40 mL endoscopic injections of an 1:10 000 solution of epinephrine. The hemostatic effects and clinical outcomes were compared between the three groups.

RESULTS: There were no significant differences in all background variables between the three groups. Initial hemostasis was achieved in 97.4%, 98.7% and 100% of patients respectively in the 20, 30 and 40 mL epinephrine groups. There were no significant differences in the rate of initial hemostasis between the three groups. The rate of peptic ulcer perforation was significantly higher in the 40 mL epinephrine group than in the 20 and 30 mL epinephrine groups (P < 0.05). The rate of recurrent bleeding was significantly higher in the 20 mL epinephrine group (20.3%) than in the 30 (5.3%) and 40 mL (2.8 %) epinephrine groups (P < 0.01). There were no significant differences in the rates of surgical intervention, the amount of transfusion requirements, the days of hospitalization, the deaths from bleeding and 30 d mortality between the three groups. The number of patients who developed epigastric pain due to endoscopic injection, was significantly higher in the 40 mL epinephrine group (51/76) than in the 20 (2/76) and 30 mL (5/76) epinephrine groups (P < 0.001). Significant elevation of systolic blood pressure after endoscopic injection was observed in the 40 mL epinephrine group (P < 0.01). Significant decreasing and normalization of pulse rates after endoscopic injections were observed in the 20 mL and 30 mL epinephrine groups (P < 0.01).

CONCLUSION: Injection of 30 mL diluted epinephrine (1:10 000) can effectively prevent recurrent bleeding with a low rate of complications. The optimal injection volume of epinephrine for endoscopic treatment of an actively bleeding ulcer (spurting or oozing) is 30 mL.

Endoscopic Treatment of Upper Gastrointestinal Bleeding

Endoscopic therapy for nonvariceal bleeding should only be used if major stigmata of hemorrhage such as active bleeding and nonbleeding visible vessel are present. Treatment of peptic ulcers with adherent clots is currently controversial. Combination of epinephrine injection and coaptive coagulation is most effective in achieving endoscopic hemostasis. Hemoclips may be preferable for very deep ulcers and large visible blood vessels if coaptive coagulation is anticipated to have a high risk of perforation or bleeding. Adrenaline injection or hemoclip application should be used in bleeding Mallory-Weiss tears, as the safety of thermal methods is not well established. Argon plasma coagulation is the mainstay of endoscopic treatment for superficial lesions such as angiodysplasia and gastric antral vascular ectasia. Both sclerotherapy and band ligation are effective in acute hemostasis of bleeding esophageal varices. Variceal band ligation is preferred due to its superior safety profile and shorter procedure time. Due to the early recurrence of varices after banding ligation, there may be a role for metachronous combination therapy of ligation followed by sclerotherapy. Histoacryl glue is the preferred method of endoscopic hemostasis in gastric varices.

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.

A randomized trial comparing heater probe plus thrombin with heater probe plus placebo for bleeding peptic ulcer

BACKGROUND & AIMS

This multicenter, double-blind, controlled trial compared the efficacy of combined endoscopic hemostatic treatment using the heater probe plus thrombin injection with that of the heater probe plus placebo injection as treatment for peptic ulcers with active bleeding or nonbleeding visible vessels. Efficacy was defined in terms of primary hemostasis, prevention of rebleeding, and need for urgent surgery.

METHODS

Two hundred forty-seven patients presenting with major peptic ulcer bleeding were randomized to heater probe plus thrombin or to heater probe plus placebo. The groups were well matched for all risk categories including age, endoscopic stigmata, shock, and severity of comorbid diseases. Endoscopic therapy was applied using the heater probe followed by injection of thrombin or placebo.

RESULTS

Successful primary hemostasis was achieved in 97% of patients. Rebleeding developed in 19 (15%) of thrombin plus heater probe patients and 17 (15%) of placebo plus heater probe patients. Emergency surgery was necessary in 16 and 13 patients, respectively. Eight patients in the thrombin group had adverse events compared with 4 in the placebo group. Eight (6%) of thrombin plus heater probe patients and 14 (12%) of placebo plus heater probe patients died (P = 0.21).

CONCLUSIONS

The combination of thrombin and the heater probe does not confer an additional benefit over heater probe and placebo as endoscopic treatment for bleeding peptic ulcer. Our trial does not support the use of this combination of hemostatic therapy.

N/A

N/A

A prospective, randomized trial of endoscopic hemoclip placement and distilled water injection for treatment of high-risk bleeding ulcers

BACKGROUND

Although endoscopic hemoclip therapy is widely used in the treatment of GI bleeding, there are few prospective trials that assess its efficacy. This study evaluated the efficacy and safety of hemoclip placement and distilled water injection for the treatment of high-risk bleeding ulcers.

METHODS

Seventy-nine patients with major stigmata of ulcer hemorrhage were randomly assigned to either endoscopic hemoclip placement (n = 39) or injection with distilled water (n = 40).

RESULTS

Initial hemostasis was achieved in all patients treated with hemoclips and 39 treated by distilled water injection (respectively, 100.0% vs. 97.5%; p = 1.00). Bleeding recurred in 4 and 11 of patients, respectively, in the hemoclip and water injection groups. It occurred significantly more frequently in the injection group (hemoclip, 10.3%; injection, 28.2%; p = 0.04). No major procedure-related complication occurred in either group. Emergency operations were performed in 5.1% of patients treated with hemoclips versus 12.5% of those in the water injection group (p = 0.43). Hospital days and mortality rate were similar in both groups.

CONCLUSION

Endoscopic hemoclip placement is a safe and effective hemostatic method that is superior to distilled water injection for treatment of bleeding peptic ulcer.

Minimizing recurrent peptic ulcer hemorrhage after endoscopic hemostasis: the cost-effectiveness of competing strategies

OBJECTIVES

Controversy exists regarding the optimal strategy to minimize recurrent ulcer hemorrhage after successful endoscopic hemostasis. Our objective was to evaluate the cost-effectiveness of competing strategies for the posthemostasis management of patients with high risk ulcer stigmata.

METHODS

Through decision analysis, we calculated the cost-effectiveness of four strategies: 1) follow patients clinically after hemostasis and repeat endoscopy only in patients with evidence of rebleeding (usual care); 2) administer intravenous proton pump inhibitors (i.v. PPIs) after hemostasis and repeat endoscopy only in patients with clinical signs of rebleeding; 3) perform second look endoscopy at 24 h in all patients with successful endoscopic hemostasis; and 4) perform selective second look endoscopy at 24 h only in patients at high risk for rebleeding as identified by the prospectively validated Baylor Bleeding Score. Probability estimates were derived from a systematic review of the medical literature. Cost estimates were based on Medicare reimbursement. Effectiveness was defined as the proportion of patients with rebleeding, surgery, or death prevented.

RESULTS

The selective second look endoscopy strategy was the most effective and least expensive of the four competing strategies, and therefore dominated the analysis. The i.v. PPI strategy required 50% fewer endoscopies than the competing strategies, and became the dominant strategy when the rebleed rate with i.v. PPIs fell below 9% and when the cost of i.v. PPIs fell below 10 dollars/day.

CONCLUSIONS

Compared with the usual practice of "watchful waiting," performing selective second look endoscopy in high risk patients may prevent more cases of rebleeding, surgery, or death at a lower overall cost. However, i.v. PPIs are likely to reduce the need for second look endoscopy and may be preferred overall if the rebleed rate and cost of i.v. PPIs remains low.

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 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.

Randomized trial of normal saline solution injection versus bipolar electrocoagulation for treatment of patients with high-risk bleeding ulcers: is local tamponade enough?

BACKGROUND

Endoscopic injection of normal saline solution is reportedly an effective treatment for bleeding ulcers. If it is as effective as standard therapy, low cost, wide availability, and lack of injury would make saline solution injection an attractive option.

METHODS

Patients with clinical evidence of major bleeding from an ulcer with active bleeding or a nonbleeding visible vessel were randomly assigned to injection with normal saline solution (1-2 mL boluses; mean volume 30 mL) or bipolar electrocoagulation (20 W, 10-sec applications; mean time 100 sec). Patients, those caring for patients, and those collecting data were blinded to therapy.

RESULTS

Further bleeding occurred in 14 (29%) of 48 patients in the saline solution group versus 6 (12%) of 52 patients in the bipolar group (95% CI [2%, 33%]; p = 0.04). Significantly more units of blood were transfused in the saline solution group (median 2 units vs. 0 units; p = 0.01). Hospital days (median 4 vs. 3) and mortality (6% vs. 2%) were not significantly different in the 2 groups. Independent risk factors for further bleeding were saline solution injection (p = 0.02), units transfused before therapy (p = 0.02), and ulcer size (p = 0.03).

CONCLUSION

Local tamponade with saline solution injection is less effective than bipolar electrocoagulation for the treatment of bleeding ulcers.

Upper Gastrointestinal Bleeding of Nonvariceal Origin in the ICU Setting

Upper gastrointestinal bleeding (UGI) is a common medical emergency in the intensive care unit (ICU). Although it can be caused by a number of gastrointestinal disorders, its management usually follows a few simple management rules. Prior to endoscopy, the key to management is to resuscitate the patient, to determine the need for airway protection, and to assess the need for transfusions according to the American Society of Gastrointestinal Endoscopy guidelines. During endoscopy, the key to management is to recognize the cause of the bleeding and to achieve hemostasis. Following endoscopy, the key to management is to determine the need for medical therapy and to determine a proper disposition for the patient given his potential risk for rebleeding. Stress-related erosions syndrome (SRES) is a disease that usually develops in the ICU setting and is known to be associated with a high degree of morbidity and mortality. Although it is approached in the same fashion as other causes of UGI bleeding, patients tend to do better if they are recognized early and treated prophylactically. Criteria for proper patient selection and the recommended prophylactic therapy are reviewed.

Acute gastrointestinal bleeding

Acute gastrointestinal bleeding is a significant worldwide medical problem. Despite modern measures for diagnosis and treatment, morbidity and mortality rates associated with gastrointestinal bleeding remain largely unchanged. Aggressive medical resuscitation while initiating an evaluation to localize the site of blood loss remains the key to successful management of acute gastrointestinal bleeding. A multidisciplinary approach with early involvement of a gastroenterologist, surgeon, and radiologist can be extremely helpful in the management of these patients. With the logical and direct approach to the evaluation of patients with gastrointestinal bleeding described in this article, most episodes can be managed successfully.

Mechanical endoscopic methods of haemostasis for bleeding peptic ulcers: a review

Re-bleeding following endoscopic therapy for gastrointestinal bleeding remains common probably because injection and thermal methods for treating bleeding are of limited efficacy, especially in the presence of a large bleeding artery. This chapter reviews mechanical methods of endoscopic haemostasis. The design of clips, which can be delivered through flexible endoscopes, is reviewed with experimental and clinical data of their efficacy. The need for improvements in clip design is stressed. Experimental studies and preliminary clinical data where available on a variety of other mechanical methods of haemostasis are presented, including band ligation, endoloops, sewing machines, stapling machines, ulcer clamps, corkscrews, balloon tamponade and ferromagnetic tamponade. New, less invasive, surgical methods which might have a place in ulcer haemostasis, including transgastric endoluminal surgery and flexible endoscopic ulcer excision with wound closure, are discussed. Mechanical methods offer the best prospect for improvements in security of endoscopic haemostasis for bleeding peptic ulcer. More development is required if the results are to improve.

Therapeutic endoscopy for nonvariceal gastrointestinal bleeding

This article reviews the role of therapeutic endoscopy in the diagnosis and treatment of nonvariceal upper and lower gastrointestinal (GI) hemorrhage. The initial approach to patients with GI bleeding is reviewed. Endoscopic treatment of various stigmata of recent peptic ulcer hemorrhage is discussed in detail. Management of less common causes of nonvariceal bleeding, such as Dieulafoy's lesions, Mallory-Weiss tears, angiomas, and bleeding colonic diverticula is described. Recommendations for endoscopic techniques are based on the results of UCLA-CURE hemostasis studies.

Injection therapy for endoscopic haemostasis

Endoscopic injection is widely used for the arrest of active ulcer bleeding and for prevention of re-bleeding from ulcers with visible vessels. Although of proven value in clinical trials, mechanisms of action are unclear; tamponade, vasoconstriction, endarteritis and a direct effect upon the clotting process at the site of the arterial defect have been proposed. Clinical trials show that dilute adrenaline is an effective agent and that the addition of sclerosants or alcohol confirms no extra benefit, yet risks serious side-effects. The best results are associated with injection of fibrin glue or thrombin which stimulate formation of a stable blood clot. The efficacy of injection, thermal modalities such as the heater probe and electrocoagulation using BICAP are comparable. In general, there is an advantage in combining injection with a thermal modality, although this may have merit in patients with severe, active ulcer bleeding. Patients who re-bleed following successful primary haemostatic injection treatment can be considered for further endoscopic intervention, but the decision to undertake a surgical operation or repeat endoscopic therapy is a matter of clinical judgement.

Comparison of the hemostatic efficacy of the endoscopic hemoclip method with hypertonic saline-epinephrine injection and a combination of the two for the management of bleeding peptic ulcers

BACKGROUND

The endoscopic hemoclip method is a safe and effective hemostatic method for managing bleeding peptic ulcers. We compared the hemostatic efficacy of the endoscopic hemoclip method with that of hypertonic saline-epinephrine (HSE) injection and a combined method in the management of bleeding peptic ulcers.

METHODS

From July 1994 to July 1997, we conducted a randomized clinical trial of endoscopic hemostasis involving 124 patients with actively bleeding or visible vessels at endoscopic inspection.

RESULTS

Patients were randomly assigned to hemoclip (41 patients), HSE (41 patients), and combined treatment groups (42 patients). Initial hemostasis was achieved in 97.6%, 95.1%, and 97.6% of cases, respectively. Recurrent bleeding developed in 2.4%, 14.6%, and 9.5% of cases. Emergency operations were performed in 4.9%, 14.6%, and 2.3% of cases. The hemostasis rate was 71.4%, 50%, and 66.7% for spurting hemorrhage in each group. Permanent hemostasis was achieved in 95.1%, 85.4%, and 95.2% of cases. Three patients had complications, all in the HSE group.

CONCLUSIONS

The hemoclip method is an effective hemostatic procedure and is safer than HSE injection. The combined method does not provide substantial advantage over use of the hemoclip method alone in the hemostatic management of bleeding peptic ulcers.

The effect of endoscopic injection therapy on the clinical outcome of patients with benign peptic ulcer bleeding

BACKGROUND

Our aim was to investigate the effect of endoscopic injection therapy on the clinical outcome of patients with benign peptic ulcer bleeding.

METHODS

In this study 1203 patients admitted with peptic ulcer bleeding over a 5-year period (January 1987 to April 1991) before endoscopic therapy and 1028 patients admitted with peptic ulcer bleeding after introduction of endoscopic therapy (May 1991 to March 1996) were assessed. Endoscopic therapy was performed in all patients with active bleeding or non-bleeding visible vessels during emergency endoscopy with injection of adrenaline, 1:10,000 in 0.9% saline.

RESULTS

The introduction of injection therapy was associated with a reduction in transfusion requirements (from 5.1 +/- 2.6 to 3.4 +/- 1.8 units), hospitalization days (from 10.8 +/- 6.5 to 7.8 +/- 5.1 days), surgical interventions (from 50.6% to 23.6%), and mortality (from 12.9% to 4.6%) in patients with active bleeding or non-bleeding visible vessels (P < 0.05) but remained unchanged in the rest. Patients with gastric ulcer had a more pronounced reduction in emergency surgical haemostasis and mortality than patients with duodenal ulcer. There were no deaths or procedure-related complications.

CONCLUSION

Endoscopic injection therapy with adrenaline/saline is a simple, low-cost, and safe method that improves the clinical outcome and reduces the mortality in patients with peptic ulcer bleeding.

Upper gastrointestinal tract bleeding

Upper GI bleeding is a serious and common emergency. Most upper GI bleeding will stop spontaneously but determining which patients will continue to bleed or rebleed is very difficult in the ED. Resuscitation and stabilization are the primary goals of the emergency physician. Hemorrhage control with pharmacotherapy or balloon tamponade may be necessary until urgent or emergent consultation with a gastroenterologist or surgeon is obtained. Early detection and treatment of H. pylori and the development of safer NSAIDs should alter the future of upper GI bleeding dramatically.

Early or delayed endoscopy for patients with peptic ulcer bleeding. A prospective randomized study

The benefit of early endoscopy in the management of peptic ulcer bleeding remains controversial. In this study we looked at the role of early endoscopy in bleeding peptic ulcer patients with clear, "coffee grounds," or bloody nasogastric aspirate. A consecutive series of 325 patients with peptic ulcer bleeding were included (218 patients with clear aspirate, 77 patients with coffee-grounds aspirate, and 30 patients with bloody aspirate). They were randomized to receive early endoscopy (within 12 h of arrival at the emergency room) or delayed endoscopy (12 h after arrival at the emergency room). Early endoscopy did not benefit patients with clear or coffee-grounds aspirate. However, combined with endoscopic therapy, it did significantly benefit patients with bloody aspirate in reducing the need for blood transfusion (mean, 450 ml vs. 666 ml; p < 0.001) and hospital stay (mean, 4 vs. 14.5 days, p < 0.001). Early endoscopy and endoscopic therapy are not needed in bleeding peptic ulcer patients with clear or coffee-grounds nasogastric aspirate. However, early endoscopy and endoscopic therapy benefit patients with bloody nasogastric aspirate.

Natural history of bleeding peptic ulcers with a tightly adherent blood clot: a prospective observation

BACKGROUND

The natural history of a bleeding peptic ulcer with a tightly adherent blood clot remains uncertain. Controversy exists concerning removal of such blood clots at the bleeding ulcer base. This article presents the natural history of a bleeding peptic ulcer with a tightly adherent clot and defines the characteristics of those requiring aggressive management.

METHODS

Clinical parameters were analyzed to determine the independent predictors of rebleeding in these patients. One hundred one patients with bleeding peptic ulcers and tightly adherent blood clots were enrolled during a period of 12 months.

RESULTS

Twenty-five patients (25%) rebled within 1 month. With a multivariate analysis, we found comorbid illness (odds ratio, 3.41), shock (odds ratio, 3.65), and initial hemoglobin at or below 10 gm/dL (odds ratio, 2.99) to be independent predictors of rebleeding.

CONCLUSIONS

Most patients with a tightly adherent clot in an ulcer have an uneventful course. However, endoscopic therapy may prove to be beneficial in the subset of patients with independent predictors of rebleeding.

Role of endoscopic injection therapy in the treatment of bleeding peptic ulcer

Of patients with peptic ulceration who are actively bleeding at endoscopy, 80 per cent will continue to bleed or rebleed in hospital; 50 per cent of those who have a non-bleeding visible vessel will also rebleed. Endoscopic injection treatment stops active bleeding and prevents further haemorrhage in most of these patients. The mechanism of action may include tamponade, vasoconstriction, sclerosis, tissue dehydration and thrombogenesis; substances injected include adrenaline, sclerosants, alcohol, thrombin, or a combination of agents. Although trials often define the need for surgery as an injection treatment failure, an alternative view is that endoscopic control may facilitate safe, early, elective surgery. A successful outcome may require a combination of endoscopic and operative approaches.

Therapeutic intervention for nonvariceal gastrointestinal hemorrhage

The choice of therapeutic endoscopic technique depends on the training and equipment available to the endoscopist. If the technique is properly performed, the results are similar using injection, thermal coagulation, or laser therapy. We recommended that pediatric endoscopists concentrate on one thermal and one injection technique, since individual bleeding lesions may be more amenable to one method than another based on their anatomic location or briskness of bleeding.

A cost-effective approach to the patient with peptic ulcer bleeding

The average hospital cost to manage patients hospitalized at Virginia Mason Hospital who bleed from a peptic ulcer is approximately $5000 per patient in our series of 30 patients. Because there are 150,000 admissions per year in the United States for peptic ulcer bleeding, the total hospital cost can be estimated to be $750 million. The actual cost may be higher because our 30 patients had minimal complications and were discharged on average in less than 4 days. The majority of hospital cost is incurred by the intensive care unit or the hospital nursing floor. There is a close to linear relation between the length of stay and the total hospital cost. Upper gastrointestinal endoscopy is a major advance in the treatment of peptic ulcer bleeding. It can provide significant cost savings by identifying some patients with bleeding peptic ulcers who have clean bases on endoscopy who are then eligible for prompt discharge from the hospital. In addition, endoscopic thermal therapy (with multipolar electrocautery or heater probe) and injection therapy cost less than $50 in incremental cost and can reduce further bleeding by 43%, reduce the need for urgent surgery by 63%, and reduce the mortality rate by 60%. Some patients still require urgent surgical intervention, which is substantially more costly than endoscopic hemostasis but is highly effective. Preliminary studies show promise in predicting further bleeding, with clinical scoring systems such as the Baylor Bleeding Score and with the use of Doppler ultrasonography. Better prediction of further bleeding should guide the choice of durable hemostasis early in the hospitalization. Additional studies should clarify the role of NSAID avoidance and H. pylori eradication in the long-term prevention of recurrent peptic ulcer bleeding.

A review on treatment of bleeding peptic ulcer: a collaborative task of gastroenterologist and surgeon

The majority of patients presenting with acute upper gastrointestinal haemorrhage bleed from peptic diseases erosive gastritis and duodenal or gastric ulcers. Early gastroscopy is essential in order to reach a diagnosis, assess the prognosis, and institute appropriate therapy. In a meta-analysis it was shown that H2-antagonists significantly reduced mortality. However, two large, prospective and placebo-controlled studies with famotidine and omeprazole failed to show reduction of rebleeding or death. The value of endoscopic haemostatic therapy in patients with high-risk peptic ulcers (active bleeding and non-bleeding visible vessel) has been firmly established with 75% decrease in rebleeding and operation rate, and a 40% reduction in mortality. Risk factors for an adverse outcome are: elderly patients, concomitant diseases and large ulcers in the posterior duodenal bulb or on the lesser curvature. The mortality for emergency surgery in upper GI bleeding is still 10-50%. The mortality of elective operations is less than 2%. Some studies have reduced mortality by avoiding emergency surgery through early elective surgery in high-risk patients.