Epinephrine or epinephrine plus alcohol for injection of bleeding ulcers: a prospective randomized trial

Hepatic arterial haemorrhage caused by duodenal ulcer

A man in his late 60s with prior Hartman's procedure underwent colostomy takedown and complex ventral hernia repair. He subsequently developed gastrointestinal (GI) bleeding from a duodenal bulb ulcer. Despite five endoscopic procedures aimed at achieving haemostasis, including placement of an over-the-scope clip, and four endovascular embolisations (inferior and superior pancreaticoduodenal, right gastroepiploic and gastroduodenal arteries), the patient continued to experience episodic, haemodynamically significant bleeding. He eventually required emergency exploratory laparotomy, where the proper hepatic artery was identified as the source (a previously unreported phenomenon). He underwent antrectomy and proper hepatic artery ligation. This case highlights the need to interrogate all portions of the hepatic vasculature in the treatment of refractory GI bleeding.

An insight into gastrointestinal macromolecule delivery using physical oral devices

Oral delivery is preferred over other routes of drug administration by both patients and physicians. The bioavailability of some therapeutics that are delivered via the oral route is restricted due to the protease- and bacteria-rich environment in the gastrointestinal tract, and by the pH variability along the delivery route. Given these harsh environments, the oral delivery of therapeutic macromolecules is complicated and remains challenging. Various formulation approaches, including the use of permeation enhancers and nanosized carriers, as well as chemical alteration of the drug structure, have been studied as ways to improve the oral absorption of macromolecular drugs. Nevertheless, the bioavailability of marketed oral peptide medicines is often relatively poor. This review highlights the most recent and promising physical methods for improving the oral bioavailability of macromolecules such as peptides. These methods include microneedle injections, high-speed stream injectors, magnetic drug targeting, expandable hydrogels, and iontophoresis. We highlight the potential and challenges of these new technologies, which may impact the future approaches used by pharmaceutical companies to create more efficient and safer orally administered macromolecules. Teaser: Despite substantial effort, the oral delivery of macromolecules remains challenging due to their low bioavailability. This review discusses the potential, challenges, and safety concerns associated with new technologies and devices for oral macromolecule delivery.

Devices for drug delivery in the gastrointestinal tract: A review of systems physically interacting with the mucosa for enhanced delivery

The delivery of macromolecules via the gastrointestinal (GI) tract remains a significant challenge. A variety of technologies using physical modes of drug delivery have been developed and investigated to overcome the epithelial cell layer of the GI tract for local and systemic delivery. These technologies include direct injection, jetting, ultrasound, and iontophoresis, which have been largely adapted from transdermal drug delivery. Direct injection of agents using needles through endoscopy has been used clinically for over a century. Jetting, a needle-less method of drug delivery where a high-speed stream of fluid medication penetrates tissue, has been evaluated pre-clinically for delivery of agents into the buccal mucosa. Ultrasound has been shown to be beneficial in enhancing delivery of macromolecules, including nucleic acids, in pre-clinical animal models. The application of an electric field gradient to drive drugs into tissues through the technique of iontophoresis has been shown to deliver highly toxic chemotherapies into GI tissues. Here in, we provide an in-depth overview of these physical modes of drug delivery in the GI tract and their clinical and preclinical uses.

Systematic review with network meta-analysis: dual therapy for high-risk bleeding peptic ulcers

BACKGROUND

Adding a second endoscopic therapy to epinephrine injection might improve hemostatic efficacy in patients with high-risk bleeding ulcers but the optimum modality remains unknown. We aimed to estimate the comparative efficacy of different dual endoscopic therapies for the management of bleeding peptic ulcers through random-effects Bayesian network meta-analysis.

METHODS

Different databases were searched for controlled trials comparing dual therapy versus epinephrine monotherapy or epinephrine combined with another second modality until September, 30 2016. We estimated the ORs for rebleeding, surgery and mortality among different treatments. Adverse events were also evaluated.

RESULTS

Seventeen eligible articles were included in the network meta-analysis. The addition of mechanical therapy (OR 0.19, 95% CrI 0.07-0.52 and OR 0.10, 95% CrI 0.01-0.50, respectively) after epinephrine injection significantly reduced the probability of rebleeding and surgery. Similarly, patients who received epinephrine plus thermal therapy showed a significantly decreased rebleeding rate (OR 0.30, 95% CrI 0.10-0.91), as well as a non-significant reduction in surgery (OR 0.47, 95% CrI 0.16-1.20). Although differing, epinephrine plus mechanical therapy did not provide a significant reduction in rebleeding (OR 0.62, 95% CrI 0.19-2.22) and surgery (OR 0.21, 95% CrI 0.03-1.73) compared to epinephrine plus thermal therapy. Sclerosant failed to confer further benefits and was ranked highest among the 5 treatments in relation to adverse events.

CONCLUSIONS

Mechanical therapy was the most appropriate modality to add to epinephrine injection. Epinephrine plus thermal coagulation was effective for controlling high risk bleeding ulcers. There was no further benefit with sclerosants with regard to rebleeding or surgery, and sclerosants were also associated with more adverse events than any other modality.

Delayed Bleeding Rate According to the Forrest Classification in Second-Look Endoscopy After Endoscopic Submucosal Dissection

BACKGROUND AND AIM

Forrest classification is a valid tool to predict rebleeding rate in peptic ulcer, not in post-endoscopic resection ulcer. We evaluated the delayed bleeding rate in Forrest classification II and III lesions when they were not treated in second-look endoscopy.

METHODS

Between July 2011 and February 2012, 706 lesions in 656 consecutive patients who underwent second-look endoscopy performed on the second day after endoscopic submucosal dissection (ESD) were prospectively investigated. Endoscopic findings were described according to Forrest classification, and late delayed bleeding was defined as bleeding from second-look endoscopy to 1 month. We evaluated the rate of late delayed bleeding in untreated Forrest classification II and III lesions during second-look endoscopy.

RESULTS

Among the 706 gastric tumors analyzed, late delayed bleeding after ESD occurred in 29 lesions (4.1%). At second-look endoscopy, Forrest I lesions (immediately treated by endoscopic hemostasis) were found in 63 cases [Ia, 8 lesions (1.1%); Ib, 55 lesions (7.8%)]; there was no further bleeding after discharge. Forrest II and III lesions (not treated in second-look endoscopy) were found in 643 cases [IIa, 62 lesions (8.8%); IIb, 119 lesions (16.9%); IIc, 460 lesions (65.2 %); III, 2 lesions (0.3%)]; and there was no significant difference in the late delayed bleeding rate between these groups [IIa, 2/62 (3.2%); IIb, 5/119 (4.2%); IIc and III, 22/462 (4.8%); P = 1.000].

CONCLUSIONS

The rate of late delayed bleeding of post-ESD ulcers with non-bleeding visible vessels was not significantly different from that of ulcers with non-visible vessels ( http://cris.nih.go.kr , identifier KCT0000268).

Do We Perform a Perfect Endoscopic Hemostasis Prophylactically with Argon Plasma Coagulation in Colonic Endoscopic Mucosal Resection?

BACKGROUND

Submucosal injection for endoscopic mucosal resection (EMR) may effect performing the prophylactic argon plasma coagulation (APC) of non-bleeding visible vessels on ulcer crater.

AIMS

The purpose of this study was to evaluate the clinical features of visible vessels in iatrogenic ulcers over time after prophylactic APC in colonic EMR.

PATIENTS AND METHODS

This study was designed as a prospective study. Between August and November 2013, a total of 40 patients who were admitted underwent prophylactic APC for non-bleeding visible vessels after colonic EMR. After confirming whether visible vessels were completely coagulated or not, the number of visible vessels in ulcers was counted over a specific time period, e.g. 1, 3, 5, or 7 min.

RESULTS

The mean number of visible vessels was significantly higher at 5 min (0.85 ± 1.14) after EMR with prophylactic APC compared to 1 and 3 min (1 min: 0.28 ± 0.60, P < 0.001; 3 min: 0.65 ± 0.87, P = 0.02) and there was no significant difference between 5 and 7 min (P = 0.31). Multivariate analysis showed that the size of the iatrogenic ulcer after EMR was associated with the occurrence of visible vessels (ulcer size >1 vs. ≤0.5 cm: OR 27.32, 95% CI 2.86-infinity).

CONCLUSIONS

A 5-min observation of the ulcer may be advantageous for the assessment of visible vessels after performing colonic EMR with prophylactic APC, and large (>1 cm) iatrogenic ulcers were associated with the occurrence of visible vessels after colonic EMR.

Hemostatic powder spray: a new method for managing gastrointestinal bleeding

Gastrointestinal bleeding is a leading cause of morbidity and mortality in the United States. The management of gastrointestinal bleeding is often challenging, depending on its location and severity. To date, widely accepted hemostatic treatment options include injection of epinephrine and tissue adhesives such as cyanoacrylate, ablative therapy with contact modalities such as thermal coagulation with heater probe and bipolar hemostatic forceps, noncontact modalities such as photodynamic therapy and argon plasma coagulation, and mechanical hemostasis with band ligation, endoscopic hemoclips, and over-the-scope clips. These approaches, albeit effective in achieving hemostasis, are associated with a 5-10% rebleeding risk. New simple, effective, universal, and safe methods are needed to address some of the challenges posed by the current endoscopic hemostatic techniques. The use of a novel hemostatic powder spray appears to be effective and safe in controlling upper and lower gastrointestinal bleeding. Although initial reports of hemostatic powder spray as an innovative approach to manage gastrointestinal bleeding are promising, further studies are needed to support and confirm its efficacy and safety. The aim of this study was to evaluate the technical feasibility, clinical efficacy, and safety of hemostatic powder spray (Hemospray, Cook Medical, Winston-Salem, North Carolina, USA) as a new method for managing gastrointestinal bleeding. In this review article, we performed an extensive literature search summarizing case reports and case series of Hemospray for the management of gastrointestinal bleeding. Indications, features, technique, deployment, success rate, complications, and limitations are discussed. The combined technical and clinical success rate of Hemospray was 88.5% (207/234) among the human subjects and 81.8% (9/11) among the porcine models studied. Rebleeding occurred within 72 hours post-treatment in 38 patients (38/234; 16.2%) and in three porcine models (3/11; 27.3%). No procedure-related adverse events were associated with the use of Hemospray. Hemospray appears to be a safe and effective approach in the management of gastrointestinal bleeding.

Hemostatic powder spray: a new method for managing gastrointestinal bleeding

Gastrointestinal bleeding is a leading cause of morbidity and mortality in the United States. The management of gastrointestinal bleeding is often challenging, depending on its location and severity. To date, widely accepted hemostatic treatment options include injection of epinephrine and tissue adhesives such as cyanoacrylate, ablative therapy with contact modalities such as thermal coagulation with heater probe and bipolar hemostatic forceps, noncontact modalities such as photodynamic therapy and argon plasma coagulation, and mechanical hemostasis with band ligation, endoscopic hemoclips, and over-the-scope clips. These approaches, albeit effective in achieving hemostasis, are associated with a 5-10% rebleeding risk. New simple, effective, universal, and safe methods are needed to address some of the challenges posed by the current endoscopic hemostatic techniques. The use of a novel hemostatic powder spray appears to be effective and safe in controlling upper and lower gastrointestinal bleeding. Although initial reports of hemostatic powder spray as an innovative approach to manage gastrointestinal bleeding are promising, further studies are needed to support and confirm its efficacy and safety. The aim of this study was to evaluate the technical feasibility, clinical efficacy, and safety of hemostatic powder spray (Hemospray, Cook Medical, Winston-Salem, North Carolina, USA) as a new method for managing gastrointestinal bleeding. In this review article, we performed an extensive literature search summarizing case reports and case series of Hemospray for the management of gastrointestinal bleeding. Indications, features, technique, deployment, success rate, complications, and limitations are discussed. The combined technical and clinical success rate of Hemospray was 88.5% (207/234) among the human subjects and 81.8% (9/11) among the porcine models studied. Rebleeding occurred within 72 hours post-treatment in 38 patients (38/234; 16.2%) and in three porcine models (3/11; 27.3%). No procedure-related adverse events were associated with the use of Hemospray. Hemospray appears to be a safe and effective approach in the management of gastrointestinal bleeding.

Upper gastrointestinal active bleeding ulcers: review of literature on the results of endoscopic techniques and our experience with Hemospray

INTRODUCTION AND OBJECTIVES

Acute gastrointestinal (GI) bleeding can lead from mild to immediately life-threatening clinical conditions. Upper GI bleeding (UGIB) is associated with a mortality of 6-10%. Spurting and oozing bleeding are associated with major risk of failure. Hemospray™ (TC-325), a new hemostatic powder, may be useful in these cases. Aim of this study is to review the efficacy of traditional endoscopic treatment in Forrest 1a-1b ulcers and to investigate the usefulness of Hemospray in these patients.

PATIENTS AND METHODS

A MEDLINE search was performed and articles that evaluated hemostatic efficacy and rebleeding rate with traditional endoscopic techniques related to Forrest classification were reviewed. Patients with Forrest 1a-1b ulcers were treated with Hemospray, either as monotherapy or in association with other endoscopic techniques. Primary outcome was immediate hemostasis, secondary outcomes were recurrent bleeding and adverse events related to Hemospray use.

RESULTS

Analysis of literature showed that mean initial hemostasis success rate in Forrest 1a-1b ulcers was of 92.8%, and mean rebleeding rate was of 13.3%. We enrolled 13 patients treated with Hemospray. Initial hemostasis was achieved in 100% and we reported three cases of rebleeding. No adverse events occurred.

CONCLUSION

Forrest 1a-1b bleeding ulcer is very difficult to treat. Hemospray appears to be an effective hemostatic therapy for these ulcers. However, additional prospective studies are needed to validate these findings.

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.

Management of upper gastrointestinal bleeding emergencies: evidence-based medicine and practical considerations

Acute upper gastrointestinal (GI) bleeding remains one of the most common encounters in emergency medicine. The increased use of non-steroid anti-inflammatory drugs by the general population and the increased prescription of anti-platelet agents and anti-coagulants after cardiovascular interventions and for prevention of cerebral vascular accidents may have aggravated the situation. Significant progress has been made in the past decade or so in the non-surgical management of acute upper GI bleeding emergencies. This article will review the current standard treatment of the most common upper GI bleeding emergencies in adults as supported by evidence-based medicine with practical considerations from the authors' own practice experience.

Update on the endoscopic management of peptic ulcer bleeding

Upper gastrointestinal bleeding is the most common gastrointestinal emergency, with peptic ulcer as the most common cause. Appropriate resuscitation followed by early endoscopy for diagnosis and treatment are of major importance in these patients. Endoscopy is recommended within 24 h of presentation. Endoscopic therapy is indicated for patients with high-risk stigmata, in particular those with active bleeding and visible vessels. The role of endoscopic therapy for ulcers with adherent clots remains to be elucidated. Ablative or mechanical therapies are superior to epinephrine injection alone in terms of prevention of rebleeding. The application of an ulcer-covering hemospray is a new promising tool. High dose proton pump inhibitors should be administered intravenously for 72 h after endoscopy in high-risk patients. Helicobacter pylori should be tested for in all patients with peptic ulcer bleeding and eradicated if positive. These recommendations have been captured in a recent international guideline.

Current status of endoscopic management for nonvariceal upper gastrointestinal bleeding

Endoscopic hemostasis is widely performed for nonvariceal upper gastrointestinal (UGI) bleeding. As the aged Japanese population rapidly increases, the number of patients experiencing complications increases. The aim of this study was to evaluate the recent results of endoscopic hemostasis for nonvariceal UGI bleeding. A retrospective analysis of patients who underwent endoscopic procedures for nonvariceal UGI bleeding was performed. We performed 223 endoscopic procedures on 217 patients between January 1995 and July 2000, and 238 endoscopic procedures on 236 patients between January 2006 and September 2009 at the Kyoto Second Red Cross Hospital. We divided the patients into the 1995-2000 group and the 2006-2009 group. Patient characteristics, hemostasis methods chosen, rates of temporary hemostasis and rebleeding, and mortality were analyzed. There were many serious and actively bleeding cases in the 2006-2009 group (P < 0.001). The endoclip method and intravenous proton pump inhibitor were mainly used in the 2006-2009 group compared with the drug-injection method and intravenous H2 receptor antagonist in the 1995-2000 group (P < 0.001). Through these treatments, the two groups were able to obtain similar treatment outcomes. Through the progress of endoscopic management we obtained similar satisfactory results in the 2006-2009 group, which had multiple complicated cases, compared to the 1995-2000 group.

Evaluation of hemostasis with soft coagulation using endoscopic hemostatic forceps in comparison with metallic hemoclips for bleeding gastric ulcers: a prospective, randomized trial

BACKGROUND

Endoscopic high-frequency soft coagulation, recently developed in Japan, is available for the management of gastric bleeding in cases of bleeding gastric ulcers and bleeding during endoscopic submucosal dissection. The aim of this study was to evaluate the efficacy of hemostasis with soft coagulation for bleeding gastric ulcers by comparing it with hemoclips in a prospective, randomized trial.

METHODS

During the period of April 2006 to March 2008, 96 patients that had gastric ulcers with bleeding or nonbleeding visible vessels were enrolled in this study. All of the 96 patients were randomly divided into two groups: endoscopic hemostasis with soft coagulation (Group I) or endoscopic hemoclipping (Group II).

RESULTS

A total of 41 (85%) out of 48 patients in Group I and 38 (79%) out of 48 patients in Group II were successfully treated with soft coagulation or clipping alone, respectively. The endoscopic hemostasis rate for the initial modality in combination with another endoscopic procedure performed after the initial method was 98% in both groups. One patient in Group I (2%) and five patients in Group II (10%) experienced recurrent bleeding. The time required to achieve hemostasis was shorter in Group I compared with Group II (9.2 +/- 11.1 vs. 13.6 +/- 9.4 min; P < 0.05).

CONCLUSIONS

This study revealed that soft coagulation is as effective as hemoclipping for treating bleeding gastric ulcers. The time required to achieve hemostasis was shorter with the soft coagulation procedure.

Therapeutic endoscopy for acute upper gastrointestinal bleeding

Endoscopy is the primary diagnostic and therapeutic tool for upper gastrointestinal bleeding (UGIB). The performance of endoscopic therapy depends on findings of stigmata of recent hemorrhage (SRH). For peptic ulcer disease-the most common etiology of UGIB-endoscopic therapy is indicated for findings of major SRH, such as active bleeding, oozing, or the presence of a nonbleeding visible vessel, but not indicated for minor SRH, such as a pigmented flat spot or a simple ulcer with a homogeneous clean base. Endoscopic therapies include injection, ablation, and mechanical therapy. Monotherapy reduces the risk of rebleeding in patients with peptic ulcer disease with major SRH to about 20%. Combination therapy, especially injection followed by either ablation or mechanical therapy, is generally recommended to further reduce the risk of rebleeding to about 10%. Endoscopic dual hemostasis by an experienced endoscopist reduces the risk of rebleeding, the need for surgery, the number of blood transfusions required, and the length of hospital stay. This Review article comprehensively analyzes the principles, indications, instrumentation, techniques, and efficacy of endoscopic hemostasis.

How evidence-based are current guidelines for managing patients with peptic ulcer bleeding?

Current guidelines for managing ulcer bleeding state that patients with major stigmata should be managed by dual endoscopic therapy (injection with epinephrine plus a thermal or mechanical modality) followed by a high dose intravenous infusion of proton pump inhibitors (PPIs). This paper aims to review and critically evaluate evidence supporting the purported superiority of a continuous infusion over less intensive regimens of PPIs administration and the need for adding a second hemostatic endoscopic procedure to epinephrine injection. Systematic searches of PubMed, EMBASE and the Cochrane library were performed. There is strong evidence for an incremental benefit of PPIs over H2-receptor antagonists or placebo for the outcome of patients with peptic ulcer bleeding following endoscopic hemostasis. However, the benefit of PPIs is unrelated to either the dosage (intensive vs standard regimen) or the route of administration (intravenous vs oral). There is significant heterogeneity among the 15 studies that compared epinephrine with epinephrine plus a second modality, which might preclude the validity of reported summary estimates. Studies without second look endoscopy plus re-treatment of re-bleeding lesions showed a significant benefit of adding a second endoscopic modality for hemostasis, while studies with second-look and re-treatment showed equal efficacy between endoscopic mono and dual therapy. Inconclusive experimental evidence supports the current recommendation of the use of dual endoscopic hemostatic means and infusion of high-dose PPIs as standard therapy for patients with bleeding peptic ulcers. Presently, the combination of epinephrine monotherapy with standard doses of PPIs constitutes an appropriate treatment for the majority of patients.

Endoscopic hemostasis in peptic ulcer bleeding for patients with high-risk lesions: a series of meta-analyses

BACKGROUND AND OBJECTIVE

Optimal endoscopic hemostasis remains undetermined. This was a systematic review of contemporary methods of endoscopic hemostasis for patients with bleeding ulcers that exhibited high-risk stigmata.

SETTING

Randomized trials that evaluated injection, thermocoagulation, clips, or combinations of these were evaluated from MEDLINE, EMBASE, and CENTRAL (1990-2006).

PATIENTS

A total of 4261 patients were evaluated.

OUTCOMES

Outcomes were rebleeding (primary), surgery, and mortality (secondary). Summary statistics were determined; publication bias and heterogeneity were sought by using funnel plots or by subgroup analyses and meta-regression.

RESULTS

Forty-one trials assessed 4261 patients. All endoscopic therapies decreased rebleeding versus pharmacotherapy alone, including sole intravenous (IV) proton pump inhibition (PPI) (OR 0.56 [95% CI, 0.34-0.92]); only one trial assessed high-dose IV PPI. Injection alone was inferior compared with other methods, except for thermal hemostasis (OR 1.02 [95% CI, 0.74-1.40]), with a strong trend of increased rebleeding if 1 injectate is used rather than 2 (OR 1.40 [95% CI, 0.95-2.05]). Injection followed by thermal therapy did not decrease rebleeding compared with clips (OR 0.82 [95% CI, 0.28-2.38]) or thermal therapy alone (OR 0.79 [95% CI, 0.24-2.62]). Subgroup analysis, however, suggested that injection followed by thermal therapy was superior to thermal therapy alone. Clips were superior to thermal therapy (OR 0.24 [95% CI, 0.06-0.95]) but, when followed by injection, were not superior to clips alone (OR 1.30 [95% CI, 0.36-4.76]). Surgery or mortality was not altered in most comparisons.

CONCLUSIONS

All endoscopic treatments are superior to pharmacotherapy alone; only 1 study assessed high-dose IV PPI. Optimal endoscopic therapies include thermal therapy or clips, either alone or in combination with other methods. Additional data are needed that compare injection followed by thermal therapy to clips alone or clips combined with another method.

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

The aim of this study was to determine appropriate endoscopic treatment of patients with bleeding ulcers by synthesizing results of randomized controlled trials. We performed dual independent bibliographic database searches to identify randomized trials of thermal therapy, injection therapy, or clips for bleeding ulcers with active bleeding, visible vessels, or clots, focusing on results from studies without second-look endoscopy and re-treatment. The primary end point was further (persistent plus recurrent) bleeding. Compared with epinephrine, further bleeding was reduced significantly by other monotherapies (relative risk [RR], 0.58 [95% CI, 0.36-0.93]; number-needed-to-treat [NNT], 9 [95% CI, 5-53]), and epinephrine followed by another modality (RR, 0.34 [95% CI, 0.23-0.50]; NNT, 5 [95% CI, 5-7]); epinephrine was not significantly less effective in studies with second-look and re-treatment. Compared with no endoscopic therapy, further bleeding was reduced by thermal contact (heater probe, bipolar electrocoagulation) (RR, 0.44 [95% CI, 0.36-0.54]; NNT, 4 [95% CI, 3-5]) and sclerosant therapy (RR, 0.56 [95% CI, 0.38-0.83]; NNT, 5 [95% CI, 4-13]). Clips were more effective than epinephrine (RR, 0.22 [95% CI, 0.09-0.55]; NNT, 5 [95% CI, 4-9]), but not different than other therapies, although the latter studies were heterogeneous, showing better and worse results for clips. Endoscopic therapy was effective for active bleeding (RR, 0.29 [95% CI, 0.20-0.43]; NNT, 2 [95% CI, 2-2]) and a nonbleeding visible vessel (RR, 0.49; [95% CI, 0.40-0.59]; NNT, 5 [95% CI, 4-6]), but not for a clot. Bolus followed by continuous-infusion proton pump inhibitor after endoscopic therapy significantly improved outcome compared with placebo/no therapy (RR, 0.40 [95% CI, 0.28-0.59]; NNT, 12 [95% CI, 10-18]), but not compared with histamine(2)-receptor antagonists. Thermal devices, sclerosants, clips, and thrombin/fibrin glue appear to be effective endoscopic hemostatic therapies. Epinephrine should not be used alone. Endoscopic therapy should be performed for ulcers with active bleeding and nonbleeding visible vessels, but efficacy is uncertain for clots. Bolus followed by continuous-infusion intravenous proton pump inhibitor should be used after endoscopic therapy.

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.

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.

Dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers: a meta-analysis of controlled trials

BACKGROUND

There is no definite recommendation on the use of dual endoscopic therapy in patients with severe peptic ulcer bleeding. A systematic review and meta-analysis were performed to determine whether the use of two endoscopic hemostatic procedures improved patient outcomes compared with monotherapy.

METHODS

A search for randomized trials comparing dual therapy (i.e., epinephrine injection plus other injection or thermal or mechanical method) versus monotherapy (injection, thermal, or mechanical alone) was performed between 1990 and 2006. Heterogeneity between studies was tested with chi(2) and explained by metaregression analysis.

RESULTS

Twenty studies (2,472 patients) met inclusion criteria. Compared with controls, dual endoscopic therapy reduces the risk of recurrent bleeding (OR [odds ratio] 0.59 [0.44-0.80], P= 0.0001) and the risk of emergency surgery (OR 0.66 [0.49-0.89], P= 0.03) and showed a trend toward a reduction in the risk of death (OR 0.68 [0.46-1.02], P= 0.06). Subcategory analysis showed that dual therapy was significantly superior to injection therapy alone for all the outcomes considered, but failed to demonstrate that any combination of treatments is better than either mechanical therapy alone (OR 1.04 [0.45-2.45] for rebleeding, 0.49 [0.50-4.87] for surgery, and 1.28 [0.34-4.86] for death) or thermal therapy alone (OR 0.67 [0.40-1.20] for rebleeding, 0.89 [0.45-1.76] for surgery, and 0.51 [0.24-1.10] for death).

CONCLUSIONS

Dual endoscopic therapy proved significantly superior to epinephrine injection alone, but had no advantage over thermal or mechanical monotherapy in improving the outcome of patients with high-risk peptic ulcer bleeding.

Non-surgical approach to bleeding gastric ulcer

Bleeding gastric ulcers is a common reason for emergency upper endoscopy in Emergency Center of Clinical Center of Serbia. Randomized controlled trials have shown that endoscopic hemostasis is beneficial for patients with a bleeding peptic ulcer. Aim of this study was to analyze the frequency, etiological factors and localization of bleeding gastric ulcer. At the same time we were evaluated a degree of bleeding activity according to Forrest?s classification and modality of performed endoscopic hemostasis. All patients who underwent upper gastrointestinal (UGI) endoscopy for bleeding gastric ulcer in Emergency Center (January 2001.- December 2005.) were identified from an endoscopy database and the clinical records were reviewed retrospectivel. A total of 3954 patients underwent UGI endoscopy for presumed acute UGI hemorrhage. More than thirty % of them(31,1)- 1230 had an endoscopic diagnosis of bleeding gastric ulcer. We observed 1230 bleeding patients (60 % male and 40 % female) with a mean age of 64,3. The commonest localization of bleeding gastric ulcers was antrum (54 - 15%). Percentage of patients who received non-steroidal anti-inflammatory drugs (NSAIDs) and/or salicilates before bleeding was 54, 6%. The main symptom was melaena, which was observed in 82, 44% of patients with bleeding gastric ulcer. According to Forrest?s classification of bleeding activity, the most of patients had F IB and F III degree (23, 41% and 22, 76%). Injection endoscopic hemostasis was performed in 26,34% patients, which had active bleeding (F IA, F IB) Hemostasis was initially obtained in 96% of bleeding patients. Bleeding gastric ulcer is one of the commonest endoscopic diagnosis in Emergency Center of Clinical Center of Serbia. The most frequent etiology factor was no - steroid antinflamatory drugs and/or salicilates. Injection endoscopic hemostasis is a safe procedure with a low cost, and, if successful, substantially reduces the need for emergency surgery.

Management der Ulkusblutung

Bleeding peptic ulcers are responsible for about half of all upper gastrointestinal hemorrhages, one of the most frequent gastroenterological emergencies. In its pathogenesis, infection with Helicobacter pylori and the use of ulcerogenic drugs play a dominant role. Endoscopy has to be performed urgently when a decline in hemoglobin and/or hemodynamic instability occurs. The indications for local endoscopic therapy depend on the Forrest criteria, which include bleeding and the presence or absence of a blood clot or visible vessel. Local endoscopic therapy comprises injections and mechanical or thermal procedures. The efficacy of these procedures has been demonstrated. Additionally, proton pump inhibitors are administered. The prognosis for bleeding ulcers depends on the endoscopic findings as well as the age and comorbidity of the patients.

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.

Role of intravenous omeprazole in patients with high-risk peptic ulcer bleeding after successful endoscopic epinephrine injection: a prospective randomized comparative trial

BACKGROUND

Epinephrine injection is the most common endoscopic therapy for peptic ulcer bleeding. Controversy exists concerning the optimal dose of proton pump inhibitors (PPI) for patients with bleeding peptic ulcers after successful endoscopic therapy. The objective of this study was to determine the optimal dose of PPI after successful endoscopic epinephrine injection in patients with bleeding peptic ulcers.

METHODS

A total of 200 peptic ulcer patients with active bleeding or nonbleeding visible vessels (NBVV) who had obtained initial hemostasis with endoscopic injection of epinephrine were randomized to receive omeprazole 40 mg infusion every 6 h, omeprazole 40 mg infusion every 12 h or cimetidine (CIM) 400 mg infusion every 12 h. Outcomes were checked at 14 days after enrollment.

RESULTS

Rebleeding episodes were fewer in the group with omeprazole 40 mg infusion every 6 h (6/67, 9%) as compared with that of the CIM infusion group (22/67, 32.8%, p < 0.01). The volume of blood transfusion was less in the group with omeprazole 40 mg every 6 h than in those groups with omepraole 40 mg infusion every 12 h (p= 0.001) and CIM 400 mg infusion every 12 h (p < 0.001). The hospital stay, number of patients requiring urgent operation, and death rate were not statistically different among the three groups.

CONCLUSION

A combination of endoscopic epinephrine injection and a large dose of omeprazole infusion is superior to combined endoscopic epinephrine injection with CIM infusion for preventing recurrent bleeding from peptic ulcers with active bleeding or NBVV.

Nonvariceal upper gastrointestinal bleeding: standard and new treatment

Nonvariceal upper gastrointestinal bleeding remains a challenging problem with a significant morbidity and mortality. In recent years endoscopic techniques have evolved, resulting in improved primary hemostasis and a reduction in the risk of rebleeding. Combination endoscopic therapy followed by high-dose proton pump inhibitor shows improved outcomes. Innovative endoscopic therapies hold promise but are as yet unproved. An aging population with significant medical comorbidities has a major influence on the overall outcome from upper gastrointestinal bleeding.

[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.

Acute endoscopic intervention in non-variceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding is one of the commonest emergencies encountered by general physicians. Once haemodynamic stability has been achieved, therapeutic endoscopy is vital in control and arrest of bleeding. Various methods are available and the evidence is reviewed as to the most optimal approach. Clinical parameters including timing of endoscopy, risk stratification, and predictors of failure will also be discussed together with a summary of recommendations based on current available evidence.

Epinephrine injection therapy versus a combination of epinephrine injection and endoscopic hemoclip in the treatment of bleeding ulcers

AIM: To assess the efficacy of hemoclip application in combination with epinephrine injection in the treatment of bleeding peptic ulcers and to compare the clinical outcomes between patients treated with such a combination therapy and those treated with epinephrine injection alone.

METHODS: A total of 293 patients (211 males, 82 females) underwent endoscopic therapy for bleeding peptic ulcers. Of these, 202 patients (152 males, 50 females) received epinephrine injection therapy while 91 patients (59 males, 32 females) received combination therapy. The choice of endoscopic therapy was made by the endoscopist. Hemostatic rates, rebleeding rates, need for emergency surgery and 30-d mortality were the outcome measures studied.

RESULTS: Patients who received combination therapy were significantly older (mean age 66±16 years, range 24-90 years) and more suffered from chronic renal failure compared to those who received epinephrine injection therapy alone (mean age 61±17 years, range 21-89 years). Failure to achieve permanent hemostasis was 4% in the group who received epinephrine injection alone and 11% in the group who received combination therapy. When the differences in age and renal function between the two treatment groups were taken into account by multivariate analysis, the rates of initial hemostasis, rebleeding rates, need for surgery and 30-d mortality for both treatment options were not significantly different.

CONCLUSION: Combination therapy of epinephrine injection with endoscopic hemoclip application is an effective method of achieving hemostasis in bleeding peptic ulcer diseases. However, superiority of combination therapy over epinephrine injection alone, could not be demonstrated.

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.

Endoscopic therapy for upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is one of the most common medical emergencies and remains a major cause of morbidity and mortality among patients. Although initially employed diagnostically, endoscopy has steadily replaced surgery as a first-line treatment in all but the haemodynamically unstable patient. A vast selection of techniques and devices are now available to the dedicated therapeutic endoscopist, including injection therapy, electrical or thermal coagulation and mechanical banding or clipping. The use of endoscopic ultrasound for targeting treatment is increasing and the development of new technologies, such as capsule endoscopy, is likely to play an important role in future protocols. However, despite numerous randomized controlled trials and meta-analyses comparing the efficacy of different endoscopic interventions, the implementation of obtained results into treatment regimes has so far failed to impact significantly on overall UGIB mortality, which remains stubbornly at 10-14%. Reducing this continues to be one of the main challenges facing the therapeutic endoscopist.

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.

Which types of non-bleeding visible vessels in gastric peptic ulcers should be treated by endoscopic hemostasis?

BACKGROUND AND AIMS

Because non-bleeding visible vessels (NBVV) of gastric peptic ulcers have the potential to re-bleed, endoscopic hemostatic treatment may be necessary during the first emergency endoscopy. However, not all NBVV re-bleed, and endoscopic hemostasis sometimes causes fatal side-effects. Therefore, we have evaluated the risk of re-bleeding from various NBVV in gastric peptic ulcers to determine which types should be treated by endoscopy to prevent re-bleeding.

METHODS

A total of 227 NBVV in 202 patients with gastric peptic ulcers that were endoscopically followed without endoscopic hemostatic procedures were classified by the following factors: vessel color, form, location of the NBVV in the ulcer crater, and location of the ulcer in the stomach. The re-bleeding rate was then analyzed for each type of NBVV.

RESULTS

Significantly high rates of re-bleeding were observed in cases with white, protruded and peripheral NBVV. In particular, white NBVV located in the peripheral zone of the ulcer crater were frequent re-bleeding sources. The location of the ulcer in the stomach was not a statistically significant factor in determining re-bleeding rates.

CONCLUSION

We found that white, protruded and peripherally located NBVV in gastric ulcers have a higher chance of re-bleeding if preventive endoscopic hemostatic procedures are not performed.

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.

Evaluation of endoscopic hemostasis with metallic hemoclips for bleeding gastric ulcer: comparison with endoscopic injection of absolute ethanol in a prospective, randomized study

OBJECTIVE

Although metallic hemoclips have been used for hemostasis of bleeding ulcer, there have been few prospective trials to evaluate their efficacy. In this study, a prospective, randomized trial was performed to evaluate endoscopic hemoclipping for bleeding gastric ulcer in comparison with endoscopic injection of absolute ethanol.

METHODS

During the period 1995-1998, 126 gastric ulcer patients with bleeding or nonbleeding visible vessel were considered for entry. They were randomly assigned to one of three groups: endoscopic hemostasis performed with injection of absolute ethanol (group I, n = 42), hemoclipping (group II, n = 42), and a combination of the two methods (group III, n = 42).

RESULTS

The permanent hemostatic rate was 85.7% in group I, 90.5% in group II, and 92.9% in group III. The mean volume of blood transfusion was 313 +/- 77 ml in group I, 274 +/- 54 ml in group II, and 163 +/- 42 ml in group III, which was significantly less than in groups I or II (p < 0.05). No patients required emergency surgery. Five patients died within a month after initial hemostasis as a result of unrelated conditions.

CONCLUSIONS

Endoscopic hemostasis with hemoclips for bleeding gastric ulcer was as effective and safe as that with injection of absolute ethanol, and a combination of ethanol injection and hemoclips did not result in a great advantage over the two individual procedures.

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.

Prospective evaluation of hemoclip application with injection of epinephrine in hypertonic saline solution for hemostasis in unstable patients with shock caused by upper GI bleeding

BACKGROUND

It is difficult to arrest severe upper GI bleeding with any of the available hemostatic modalities in unstable patients who are in shock, and the rates of persistent bleeding and mortality in this group remain high. This prospective study evaluated hemoclip application alone and in combination with injection of hypertonic saline solution with epinephrine in this subgroup of patients with GI bleeding.

METHODS

Twenty-two patients in shock because of upper GI bleeding were enrolled and divided into 2 groups based on the response of systolic blood pressure to rapid infusion of 1000 mL of lactated Ringer's solution: an unstable shock group, in which systolic blood pressure did not stabilize at greater than 90 mm Hg, and a stable shock group, in which systolic blood pressure stabilized at greater than 90 mm Hg. Emergency endoscopy was performed in both groups; those in the stable group were treated by hemoclip application alone and those in the unstable group were treated by hemoclip application combined with injection of hypertonic saline solution with epinephrine. The following parameters were compared: vital signs on admission and after infusion of lactated Ringer's solution, hemoglobin concentration, endoscopic classification of type and site of bleeding, number of hemoclips required to arrest bleeding, volume of hypertonic saline solution with epinephrine injected, initial hemostatic rate, rate of recurrent bleeding, the need for additional preventive therapy (hemoclip application), and mortality.

RESULTS

The rate of initial hemostasis was 92% in the stable shock group and 100% in the unstable shock group. Bleeding did not recur in either group. The volume of packed red cells transfused and the endotracheal intubation rate were significantly greater in the unstable shock group. Preventive application of hemoclips was performed at endoscopic follow-up 12 times in 10 patients in the stable shock group and 9 times in 7 patients in the unstable shock group. There were no deaths in either group.

CONCLUSION

Endoscopic injection of hypertonic saline solution with epinephrine combined with hemoclip application provides effective hemostasis in unstable patients in shock caused by severe upper GI bleeding. The hemostatic result is comparable with that achieved by hemoclip application alone in patients with bleeding but less severe shock.

Variable use of endoscopic haemostasis in the management of bleeding peptic ulcers

BACKGROUND

Randomised controlled trials (RCTs) have shown that endoscopic haemostasis is beneficial for patients with a bleeding peptic ulcer. The relevance of such data to management outside of RCTs is unclear. Therefore we examined management of patients with a bleeding peptic ulcer in a UK teaching hospital.

METHODS

All patients who underwent upper gastrointestinal (UGI) endoscopy for bleeding peptic ulcer between 1997 and 1999 were identified from an endoscopy database and the clinical records reviewed retrospectively.

RESULTS

A total of 872 patients underwent UGI endoscopy for presumed acute UGI haemorrhage; 179 (21%) had an endoscopic diagnosis of bleeding peptic ulcer. Seventy nine patients had a peptic ulcer with stigmata of recent haemorrhage (SRH) but only 61 (77%) of these patients received endoscopic haemostasis (77% adrenaline, 23% combination therapy). Re-bleeding occurred in 24 patients with SRH in whom transfusion requirement was the sole predictor of re-bleeding. The re-bleeding rate among patients who received adrenaline was 25% (n=12), compared with 57% (n=8) in the combination group and 31% (n=4) in those who did not receive endoscopic haemostasis. Patients who received combination endoscopic haemostasis had an increased incidence of active bleeding (p=0.007) and an increased transfusion requirement (p=0.002). Eleven of 20 patients who re-bled had repeat endoscopic haemostasis, with 45% eventually requiring surgery.

CONCLUSIONS

Results of endoscopic management of bleeding peptic ulcers in the unit studied differ markedly from those published by specialised centres. The data reported here suggest that increased standardisation of endoscopic haemostasis is required, especially in units with provision for emergency "out-of-hours" endoscopy, performed by several individuals of different grades.

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.

Adrenaline plus cyanoacrylate injection for treatment of bleeding peptic ulcers after failure of conventional endoscopic haemostasis

BACKGROUND

Endoscopic therapy is a safe and effective method for treating non-variceal upper gastrointestinal bleeding. However failure of therapy, in terms of continuing bleeding or rebleeding, is seen in up to 20%. Cyanoacrylate is a tissue glue used for variceal bleeding that has occasionally been reported as an alternative haemostatic technique in non-variceal haemorrhage.

AIM

To retrospectively describe personal experience using cyanoacrylate injection in the management of bleeding ulcers after failure of first-line endoscopic modalities.

PATIENTS AND METHODS

Between January 1995 and March 1998, 18 [12 M/6 F, mean age 68.1 years) out of 176 patients, referred to our Unit for non-variceal upper gastrointestinal bleeding, were treated with intralesional injection of adrenaline plus undiluted cyanoacrylate. Persistent bleeding after endoscopic haemostasis or early rebleeding were the indications for cyanoacrylate treatment.

RESULTS

Definitive haemostasis was achieved in 17 out of 18 patients treated with cyanoacrylate. One patient needed surgery. No early or late rebleeding occurred during the follow-up. No complications or instrument lesions related to cyanoacrylate were recorded.

CONCLUSIONS

In our retrospective series, cyanoacrylate plus adrenaline injection was found to be a potentially safe and effective alternative to endoscopic haemostasis when conventional treatment modalities fail in controlling bleeding from gastroduodenal ulcers.

Epinephrine versus epinephrine plus fibrin glue injection in peptic ulcer bleeding: a prospective randomized trial

BACKGROUND

Peptic ulcer bleeding remains a disease with considerable morbidity and mortality. Epinephrine is the most widely used endoscopic injection agent, but bleeding recurs in 20% of high-risk cases. Fibrin glue might be an ideal injection agent, based on its physiologic properties, despite its demanding injection technique and high cost. The aim of this study was to determine whether the injection of fibrin glue in combination with epinephrine improves outcome for patients at high risk of recurrent bleeding.

METHODS

Patients were prospectively randomized to injection of epinephrine alone (n = 70) or epinephrine plus fibrin glue (n = 65). Endoscopy was repeated daily until the ulcer base was clean. All patients were treated with high-dose omeprazole.

RESULTS

Initial hemostasis was 100% in both groups. There was no significant overall difference in rates of recurrent bleeding (24.3% and 21.5%, respectively, for epinephrine and epinephrine plus fibrin). When patients were stratified according to Forrest criteria, no significant difference could be found, although there was a trend toward less recurrent bleeding after fibrin injection of actively bleeding ulcers. There was no significant difference in the proportions of patients who required surgery (10% and 6%, respectively, for epinephrine and epinephrine plus fibrin). Mortality was the same (3%) in each group.

CONCLUSIONS

Adding fibrin glue to epinephrine for injection treatment of bleeding peptic ulcers does not improve outcome. Fibrin glue might be of some value in selected cases.

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.

Current status of endoscopic therapy for ulcer bleeding

This article provides an overview of the therapeutic endoscopic modalities available for the treatment of peptic ulcer bleeding. The benefits of endoscopic haemostasis have been fully demonstrated by three meta-analyses, which included most of the controlled trials published until 1992. In this review, an emphasis is placed on randomized, prospective comparative trials published during the past 20 years. Using an evidence-based medicine approach, the results of meta-analyses are translated into efficacy measures known as relative and absolute risk reductions, and number needed to treat. Single-modality treatments with injection agents such as epinephrine, sclerosants and thrombogenic substances, or with thermal therapies, are efficacious and comparable. Combination therapy involving injection and thermal techniques may offer an advantage over single-method therapy. The differences in the results between clinical trials and routine clinical practice, and among the various randomized studies, are probably related to operators' experience and variations in technique rather than to inconsistency of endoscopic haemostasis.

Combination therapies for the endoscopic treatment of gastrointestinal bleeding

This review discusses the background and analysis of data in the literature regarding the effect of a combination of endoscopic therapies on the treatment of bleeding gastroduodenal ulcers. Although these techniques are commonly used, convincing data to support combinations of injection therapies are scarce, and various studies give somewhat conflicting results. In one study, a combination of the injection of adrenaline and a high dose of thrombin was superior to using adrenaline alone. The combination of injection therapy with a thermal method tends to give better results than injection therapy alone in several studies, but the difference is only statistically significant in one study (which uses the gold probe). The data regarding a combination of injection therapy with haemostatic clips are somewhat discordant regarding the effect of the haemoclip itself, but none of the studies found an advantage of combining the two modalities. Some studies suggest that subgroups may exist, such as ulcers with spurting haemorrhage, in which combined treatment might be more useful.

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.