Injection therapy for endoscopic haemostasis

What Is the Best Endoscopic Strategy in Acute Non-variceal Gastrointestinal Bleeding?

OPINION STATEMENT

PURPOSE OF REVIEW: Upper non-variceal gastrointestinal bleeding (UNVGIB) remains an important clinical challenge for endoscopists, requiring skill and expertise for correct management. In this paper, we suggest the best strategy for an effective treatment of this complex category of patients.

RECENT FINDINGS

Early endoscopic examination, the increasingly widespread use of endoscopic hemostasis methods, and the most powerful antisecretory agents that induce clot stabilization have radically modified the clinical scenario for treating this pathology. While hospitalization for digestive hemorrhage is decreasing, the incidence of bleeding seems to be increasing, especially in the elderly for whom a greater use of gastrolesive drugs and the presence of comorbidities are more common. A multidisciplinary approach for initial patient evaluation and hemodynamic resuscitation prior to endoscopic treatment is crucial for correct management, prevention of rebleeding, and reduction of morbidity and mortality rates and hospital stays. Appropriate operator technical expertise, together with the availability of a wide range of endoscopes and devices, is mandatory. Newer endoscopic techniques may improve patient outcomes for difficult-to-treat lesions. Today, endoscopic hemostasis can be achieved in over 95% of patients.

Complications of therapeutic gastroscopy/colonoscopy other than resection

Gastrointestinal (GI) endoscopy is profoundly utilized for diagnostic and therapeutic purposes. The therapeutic potential of GI endoscopy has amplified many folds with the evolution of novel techniques as well as equipments. However, with the augmentation of therapeutic endoscopy, the extent, likelihood and severity of adverse events have increased as well. The attendant risks and adverse events with therapeutic endoscopy are many folds that of diagnostic endoscopy. Besides endoscopic resection, therapeutic endoscopy is widely utilized for hemostasis in GI bleeds, dilatation of stenosis, enteral stenting, foreign body removal, ablation of Barrett's esophagus etc. Major adverse events associated with interventional endoscopic procedures include bleeding and perforation. Adverse events of endoscopic interventions are diverse and related to the underlying disease, therapeutic modality used and operator's experience. Many of these adverse events can be prevented. Early recognition of an unavoidable adverse event is important to minimize the associated morbidity and 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.

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.

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.

Combined epinephrine and bipolar probe coagulation vs. bipolar probe coagulation alone for bleeding peptic ulcer: a randomized, controlled trial

BACKGROUND

Endoscopic treatment with combined modalities is considered standard of care for patients with high-risk peptic ulcer bleeding. This study compared epinephrine injection plus bipolar probe coagulation with bipolar probe coagulation alone in patients with high-risk peptic ulcer bleeding.

METHODS

Patients with endoscopically confirmed peptic ulcer bleeding (active or visible vessel) seen from January 2000 through December 2002 were prospectively randomized to two groups. The study group (n = 58) had epinephrine injection followed by bipolar coagulation; the control group (n = 56) was treated by bipolar coagulation alone. The primary outcomes assessed were the rate of initial hemostasis and the rate of recurrent bleeding. Secondary outcomes were the following: need for surgical intervention to control bleeding, transfusion requirements, length of hospital stay (in days), and 30-day mortality.

RESULTS

The rate of initial hemostasis was significantly higher in the combination therapy group ( p = 0.02; absolute risk reduction 31.6%: 95% CI [5.4, 57.7]). There was no significant difference between the two treatment groups with respect to all other outcomes measures, except that significantly fewer units of blood were transfused in the combination therapy group ( p = 0.006).

CONCLUSIONS

In patients with active peptic ulcer bleeding, epinephrine injection plus bipolar coagulation achieved significantly higher rate of initial hemostasis. All other outcome measures were similar with either treatment in patients with non-bleeding stigmata.

A new technique for endoscopic mucosal resection with an insulated-tip electrosurgical knife improves the completeness of resection of intramucosal gastric neoplasms

BACKGROUND

En bloc resection is optimal for the cure of gastric neoplasms by endoscopic mucosal resection (EMR). A new technique was developed for EMR by using an insulated-tip electrosurgical knife (IT-EMR). This is a report on the clinical application of IT-EMR.

METHODS

IT-EMR of 123 gastric tumors was performed in 120 patients. The en bloc resection rate, completeness of resection, and associated complications were evaluated. The local recurrence rate was studied for 90 intramucosal lesions followed for more than 6 months without further treatment.

RESULTS

The en bloc resection rate for all lesions was 54% (67/123 lesions). The en bloc resection rates were 82% (27/33) for lesions 10 mm or less in size, 54% (29/54) for those between 11 mm and 20 mm, and 31% (11/36) for those of over 20 mm. Complete resection rates in the cases with en bloc resection were 78% (21/27) for lesions 10 mm or less in size, 76% (22/29) for those between 11 mm and 20 mm, and 73% (8/11) for those over 20 mm. There were no episodes of major bleeding that required blood transfusion or surgical intervention; minor bleeding including oozing occurred in 38% (47/123). Perforation occurred in 1 case (1/123; 0.8%). The local recurrence rate for lesions resected en bloc was significantly lower than that for lesions resected as multiple fragments (respectively, 2/49; 4.1% vs. 7/41; 17%: p = 0.041).

CONCLUSIONS

IT-EMR is feasible in clinical practice and has a high en bloc resection rate. En bloc resection may reduce the rate of local recurrence.

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.