Nonvariceal upper gastrointestinal bleeding

Severe upper gastrointestinal bleeding is halted by endoscopically delivered self-propelling thrombin powder: A porcine pilot study

Background and study aims  Hemostatic powders have emerged recently to treat upper gastrointestinal bleeding (UGIB). Previously, we developed a novel self-propelling thrombin powder (SPTP) that effectively manages external pulsatile arterial bleed without compression, by effervescing and carrying thrombin into the wound. Here, we tested if SPTP, sprayed endoscopically, can manage severe UGIB in a live porcine model. Materials and methods  Anesthetized pigs underwent laparotomy to insert the gastroepiploic vascular bundles into the stomach lumen via a gastrotomy. Bleeding was initiated endoscopically in the stomach by needle knife. SPTP was delivered to the site of bleeding from a CO ₂ -powered spray device using a 7 FR catheter. Successful primary hemostasis, time to hemostasis, and the mass of SPTP delivered were measured. Results  Hemostasis was achieved at all bleeding sites using SPTP. Mean time to hemostasis was 4.2 ± 0.9 minutes (mean ± standard error of the mean, n = 12). The average mass of SPTP delivered was 2.4 ± 0.6 g. Conclusions  In this pilot study, SPTP successfully stopped 12 cases of severe UGIB, demonstrating early promise asa novel hemostatic powder.

Efficacy and toxicity of Samen-ista emulsion on treatment of cutaneous and mucosal bleeding

Despite new treatment methods, upper gastrointestinal bleeding remains challenging. Samen-ista emulsion is a new agent based on traditional medicine with coagulant properties. The efficacy and safety of Samen-ista were assessed in cutaneous and mucosal bleeding animal models. Coagulant properties of Samen-ista were evaluated using mice tail bleeding assay, marginal ear vein and upper gastrointestinal mucosal bleeding times in rabbits. After 7 days, clinical signs, mortality and end-organ (kidney, liver, lung, brain and gastric mucosa) histopathological changes were also examined. Samen-ista dose-dependently decreased mean cutaneous tail (128 vs. 14 s) and marginal ear vein (396 vs. 84 s) bleeding times. Rabbit's upper gastrointestinal bleeding time was also significantly decreased (214 vs. 15.8 s) upon Samen-ista local endoscopic application. Treatment with Samen-ista for 7 days did not cause any mortality, abnormal signs of bleeding, changes in appetite or significant histopathologicl changes. Samen-ista emulsion is well tolerated and highly effective in achieving hemostasis in cutaneous and mucosal bleeding animal models.

Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy

Acute upper gastrointestinal bleeding is a relatively common,potentially life-threatening condition that causes more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper gastrointestinal bleeding lesions. Endoscopic therapy is indicated for lesions with high risk stigmata of recent hemorrhage, including active bleeding, oozing, a visible vessel, and possibly an adherent clot. Endoscopic therapies include injection therapy, such as epinephrine or sclerosant injection; ablative therapy, such as heater probe or argon plasma coagulation; and mechanical therapy, such as endoclips or endoscopic banding. Endoscopic therapy reduces the risk of rebleeding,the need for blood transfusions, the requirement for surgery, and patient morbidity.

Superselective coil embolization of arterial esophageal hemorrhage

The authors report a case of arterial esophageal bleeding resistant to endoscopic hemostasis in a patient in critical condition after complicated gastrointestinal and pulmonary surgery. Unfit for surgery, the patient's massive hemorrhage was successfully treated with superselective coil embolization of the afferent esophageal branch of the thoracic aorta. In patients with severe arterial bleeding of the esophagus, percutaneous superselective arterial coil embolization may be feasible for control of hemorrhage.

Risk stratification in upper gastrointestinal bleeding

Acute upper gastrointestinal (UGI) bleeding is a common clinical problem that accounts for a large number of hospitalizations and results in substantial health care expenditures. Risk stratification after UGI hemorrhage involves the use of clinical and endoscopic parameters to predict the likelihood of rebleeding and death. This information can guide management decisions, such as the necessity of hospital admission, the application of endoscopic hemostatic therapy, and the length of inpatient stay. This concise review examines the current literature on risk stratification in UGI hemorrhage and attempts to integrate evidence-based data into the clinical decision-making process.

Management of bleeding in patients with advanced cancer

Bleeding occurs in up to 10% of patients with advanced cancer. It can present in many different ways. This article provides a qualitative review of treatment options available to manage visible bleeding. Local modalities, such as hemostatic agents and dressings, radiotherapy, endoscopic ligation and coagulation, and transcutaneous arterial embolization, are reviewed in the context of advanced cancer, as are systemic treatments such as vitamin K, vasopressin/desmopressin, octreotide/somatostatin, antifibrinolytic agents (tranexamic acid and aminocaproic acid), and blood products. Considerations at the end of life are described.

Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial

BACKGROUND

Many patients with upper gastrointestinal (GI) bleeding have a benign outcome and could receive less intensive and costly care if accurately identified. We sought to determine whether early endoscopy performed shortly after admission in the emergency department could significantly reduce the health care use and costs of caring for patients with nonvariceal upper GI bleeding without adversely affecting the clinical outcome.

METHODS

All eligible patients with upper GI bleeding and stable vital signs were randomized after admission to undergo endoscopy in 1 to 2 days (control) or early endoscopy in the emergency department. Patients with low-risk findings on early endoscopy were discharged directly from the emergency department. Clinical outcomes and costs were prospectively assessed for 30 days.

RESULTS

We randomized 110 consecutive stable patients with nonvariceal upper GI bleeding during the 12-month study period. The baseline demographic features, endoscopic findings, and the clinical outcomes were no different between the two groups. However the findings of the early endoscopy allowed us to immediately discharge 26 of 56 (46%) patients randomized to that group. No patient discharged from the emergency department suffered an adverse outcome. The hospital stay (median of 1 day [interquartile range of 0 to 3 days] vs. 2 days [interquartile range of 2 to 3 days], p = 0.0001) and the cost of care ($2068 [interquartile range of $928 to $3960] versus $3662 [interquartile range of $2473 to $7280], p = 0.00006) were significantly less for the early endoscopy group.

CONCLUSIONS

Early endoscopy performed shortly after admission in the emergency department safely triaged 46% of patients with nonvariceal upper GI bleeding to outpatient care, which significantly reduced hospital stay and costs.

Successful outpatient management of acute upper gastrointestinal hemorrhage: use of practice guidelines in a large patient series

BACKGROUND

Acute upper gastrointestinal hemorrhage is a common reason for hospitalization. Clinical and endoscopic characteristics predict outcome. The aim of this study was to determine the characteristics and outcome of patients with acute upper gastrointestinal hemorrhage cared for without hospitalization.

METHODS

One hundred seventy-six consecutive patients in a staff-model health maintenance organization were selected for outpatient care based on absolute endoscopic and non-absolute clinical criteria. Clinical and endoscopic characteristics, British national audit "risk scores," and rates of recurrent bleeding, hospitalization, and mortality were determined.

RESULTS

Mean patient age (+/- SD) was 56.4 +/- 16.0 years, and 106 patients (60%) were men. One hundred one (57%) had endoscopy within 2 days of the onset of hemorrhage. The mean initial hemoglobin concentration was 11.7 +/- 2.3 mg/dL. Ninety-seven patients (55%) had a peptic ulcer, and 57 (32%) had a British risk score greater than 2. Hospitalization, recurrent bleeding, and mortality occurred in two (1%), one (1%), and zero (0%) patients, respectively, during 16.0 +/- 10.8 months of follow-up.

CONCLUSIONS

Many patients with acute upper gastrointestinal hemorrhage can be safely treated as outpatients using endoscopic and clinical guidelines.

Management of haematemesis and melaena

Upper gastrointestinal bleeding remains a common medical emergency with high morbidity and mortality. High risk patients are best managed in specialised units. Endoscopy is the procedure of choice for diagnosis and haemostatic therapy of peptic ulcers, reducing deaths and the probability of rebleeding, as well as the need for surgery; for acute variceal bleeding, pharmacotherapy followed by endoscopic ligation is recommended.

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.

Gastrointestinal bleeding

A systemic approach must be taken with both upper and lower gastrointestinal bleeding. The first priority is stabilization. Once this has been achieved, and in patients who present with stable vital signs, a systematic approach to diagnosis and management must be followed. The urgency with which this is performed will be dictated by such aspects as risk factors and the clinical presentation. Some patients may need immediate diagnostic studies in the emergency department, some in the intensive care unit, some on a regular floor, and others may even be able to receive medical treatment followed by investigation on an outpatient basis.

Radiological intervention in upper and lower gastrointestinal bleeding

The role of angiography in acute upper GI tract bleeding is less a diagnostic than a therapeutic one because it provides a guide to selective embolization of either the left gastric artery, or the gastroduodenal artery and its two principal branches, the pancreaticoduodenal and the right gastroepiploic artery. Angiographic catheter techniques may also provide substantial diagnostic and therapeutic support for the management of acute lower GI bleeding from a variety of bleeding sources. The advantages are minimal invasion and relatively low risk. The intermittent nature of GI bleeding often interferes with the ability of angiography to demonstrate the source of bleeding. However, at times angiographic techniques provide the only reasonable means of localizing and controlling bleeding.

Outpatient care of selected patients with acute non-variceal upper gastrointestinal haemorrhage

Patients with upper gastrointestinal haemorrhage (UGIH) are usually cared for in hospital. To evaluate the efficacy and safety of outpatient care of selected patients with acute non-variceal UGIH who had endoscopy, we retrospectively analysed 4.5 years' experience of patients treated without hospital admission. We developed practice guidelines for outpatient care, and prospectively studied patients treated during the first 6 months of their use. 78 (8.4%) of 933 patients in the retrospective series and 34 (24.1%) of 141 in the prospective series received outpatient care. The guidelines comprised early notification of a gastroenterologist, urgent endoscopy, clinical, laboratory, and endoscopic criteria for outpatient care, and details of care. In the prospective study patients treated as outpatients were younger than those admitted (52.8 [SE 3.6] vs 63.0 [1.5] years) and had a slightly longer time from onset of bleeding to endoscopy (2.4 [0.2] vs 2.1 [0.2] days). Outpatients were less likely to have alcoholism, other major concomitant disease, syncope or presyncope, or supine tachycardia. Outpatients had higher haemoglobin concentrations than inpatients (125 [4] vs 106 [3] g/L). Most patients in both groups had peptic ulcers. There were no complications in the retrospective series; 1 of the 34 prospective outpatients was admitted with rebleeding. All outpatients survived. The estimated hospital cost saved per outpatient was about $990. A substantial proportion of carefully selected patients with acute non-variceal UGIH can be effectively cared for without admission to hospital.