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Liu R, Yuan X, Liu J, Liu S, Xie J, Hu B. A novel endoscopic electrocoagulation hemostasis technique for uncontrolled intraprocedural bleeding: series connection of foreign body forceps and hemostatic forceps. Endoscopy 2024; 56:E338-E340. [PMID: 38594009 PMCID: PMC11003816 DOI: 10.1055/a-2291-9766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Affiliation(s)
- Ruide Liu
- Department of Gastroenterology and Hepatology & Digestive Endoscopy Medical Engineering Research Laboratory West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xianglei Yuan
- Department of Gastroenterology and Hepatology & Digestive Endoscopy Medical Engineering Research Laboratory West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jia Liu
- Department of Gastroenterology and Hepatology & Digestive Endoscopy Medical Engineering Research Laboratory West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Shuang Liu
- Department of Gastroenterology and Hepatology & Digestive Endoscopy Medical Engineering Research Laboratory West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jia Xie
- Department of Gastroenterology and Hepatology & Digestive Endoscopy Medical Engineering Research Laboratory West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bing Hu
- Department of Gastroenterology and Hepatology & Digestive Endoscopy Medical Engineering Research Laboratory West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Maity R, Dhali A, Biswas J. Importance of risk assessment, endoscopic hemostasis, and recent advancements in the management of acute non-variceal upper gastrointestinal bleeding. World J Clin Cases 2024; 12:5462-5467. [DOI: 10.12998/wjcc.v12.i24.5462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 04/20/2024] [Accepted: 05/17/2024] [Indexed: 07/11/2024] Open
Abstract
Acute non-variceal upper gastrointestinal bleeding (ANVUGIB) is a common medical emergency in clinical practice. While the incidence has significantly reduced, the mortality rates have not undergone a similar reduction in the last few decades, thus presenting a significant challenge. This editorial outlines the key causes and risk factors of ANVUGIB and explores the current standards and recent updates in risk assessment scoring systems for predicting mortality and endoscopic treatments for achieving hemostasis. Since ANUVGIB predominantly affects the elderly population, the impact of comorbidities may be responsible for the poor outcomes. A thorough drug history is important due to the increasing use of antiplatelet agents and anticoagulants in the elderly. Early risk stratification plays a crucial role in deciding the line of management and predicting mortality. Emerging scoring systems such as the ABC (age, blood tests, co-morbidities) score show promise in predicting mortality and guiding clinical decisions. While conventional endoscopic therapies remain cornerstone approaches, novel techniques like hemostatic powders and over-the-scope clips offer promising alternatives, particularly in cases refractory to traditional modalities. By integrating validated scoring systems and leveraging novel therapeutic modalities, clinicians can enhance patient care and mitigate the substantial morbidity and mortality associated with ANVUGIB.
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Affiliation(s)
- Rick Maity
- General Medicine, Institute of Post Graduate Medical Education and Research, Kolkata 700020, India
| | - Arkadeep Dhali
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield S5 7AU, United Kingdom
- School of Medicine and Population Health, University of Sheffield, Sheffield S102HQ, United Kingdom
| | - Jyotirmoy Biswas
- General Medicine, College of Medicine and Sagore Dutta Hospital, Kolkata 700058, India
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Lai Y, Jiang M, Zhang X, Zhang L, Chen Z, Du Y, Wang S, Zhao J, Li Z. Novel endoscopic tattooing dye based on polyvinylpyrrolidone-modified polydopamine nanoparticles for labeling gastrointestinal lesions. J Mater Chem B 2024. [PMID: 39171740 DOI: 10.1039/d4tb01298d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
Endoscopic tattooing is a localization technique that is particularly important for identifying gastrointestinal lesions for follow-up and subsequent treatment. However, the dyes currently used for endoscopic tattooing have a short tattooing time, high cost, and many side effects. Herein, we designed and prepared polydopamine (PDA) nanoparticles modified with polyvinylpyrrolidone (PVP) for endoscopic tattooing using a physical encapsulation method. PDA has good stability and high adhesion properties, and its stability was further enhanced after PVP modification. In vitro and in vivo tests demonstrated that PDA/PVP has good biosafety. Endoscopic tattooing with PDA/PVP in a porcine model showed that the dye could be stabilized in the digestive tract for at least 60 days. Furthermore, our research results demonstrated that PDA/PVP has excellent reactive oxygen species (ROS) and reactive nitrogen species (RNS) scavenging ability and can promote wound healing. Overall, the strategy proposed herein will lead to the use of an innovative dye for endoscopic tattooing of gastrointestinal lesions.
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Affiliation(s)
- Yongkang Lai
- Department of Gastroenterology, Shanghai Changhai Hospital, Naval Medical University, Shanghai 200433, China.
- Department of Gastroenterology, Ganzhou People's Hospital, Jiangxi Medical College, Nanchang University, Ganzhou 341000, China
| | - Mengni Jiang
- Department of Gastroenterology, Shanghai Changhai Hospital, Naval Medical University, Shanghai 200433, China.
| | - Xinyuan Zhang
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China
- School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai 200093, China.
| | - Liang Zhang
- Department of Gastroenterology, Shanghai Changhai Hospital, Naval Medical University, Shanghai 200433, China.
| | - Zheng Chen
- School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai 200093, China.
| | - Yiqi Du
- Department of Gastroenterology, Shanghai Institute of Pancreatic Diseases, Changhai Hospital; National Key Laboratory of Immunity and Inflammation, Naval Medical University, Shanghai, China.
| | - Shige Wang
- School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai 200093, China.
| | - Jiulong Zhao
- Department of Gastroenterology, Shanghai Changhai Hospital, Naval Medical University, Shanghai 200433, China.
| | - Zhaoshen Li
- Department of Gastroenterology, Shanghai Changhai Hospital, Naval Medical University, Shanghai 200433, China.
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Jiang Y, Li Y, Xiong Z, Morelli JN, Shen Y, Hu X, Hu D, Li Z. Localization and etiological stratification of non-neoplastic small bowel bleeding via CT imaging: a 10-year study. Insights Imaging 2024; 15:189. [PMID: 39090483 PMCID: PMC11294299 DOI: 10.1186/s13244-024-01778-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 07/10/2024] [Indexed: 08/04/2024] Open
Abstract
OBJECTIVES The purpose of this study is to assess the diagnostic efficacy of contrast-enhanced CT scans for small bowel bleeding. METHODS This retrospective study evaluated patients diagnosed with non-neoplastic small intestinal bleeding (including duodenum) who underwent abdominal CT at our institution from December 2013 to March 2023. Patients were categorized into diverticulum and non-diverticulum groups based on the cause of bleeding. Active bleeding was defined on the CT images as extravasation of contrast material in the intestinal lumen during the arterial phase and/or progressive accumulation of contrast material during the venous phase. We have documented the original report (extracted from the medical record system and additional consultation opinions from senior radiologists), including the presence of active bleeding and its potential bleeding location. Furthermore, two radiologists reassessed the CT images, seeking consensus on the diagnosis between them. RESULTS The study included 165 patients, predominantly male, with a median age of 30 years. Active bleeding was identified in 48.3% of patients. Notably, all identified bleeding diverticula in the diverticulum group exhibited cul-de-sac termination. Among the identified causes of bleeding, Crohn's disease was most prevalent (46.7%, N of causes = 64). Significant differences were observed in the diagnostic methods between the diverticulum and non-diverticulum groups, with surgery predominantly applied in the diverticulum group, and endoscopy in the non-diverticulum group (n = 49 vs n = 15, p = 0.001). Contrast agent extravasation was significantly higher in the diverticulum group (n = 54 vs n = 16, p = 0.001), and Meckel's diverticulum cases appearing tubular were significantly higher than in other diverticulum cases (n = 25 vs n = 3, p < 0.001). CONCLUSION CT allows for a higher detection rate of diverticular bleeding, even if asymptomatic, guiding classification into multiple potentially clinically relevant categories. CRITICAL RELEVANCE STATEMENT Contrast-enhanced CT imaging is effective in determining the location and cause of non-neoplastic small bowel bleeding, especially diverticular bleeding. Therefore, the use of enhanced CT should be prioritized in the diagnosis and management of small bowel bleeding. KEY POINTS CT has potential value in the diagnosis of small bowel bleeding. CT imaging suggests possible surgical intervention for active bleeding detection. CT diagnoses and localizes small bowel bleeding, aiding in treatment and prioritizing in guidelines.
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Affiliation(s)
- Yuchen Jiang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuanqiu Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ziman Xiong
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - John N Morelli
- Department of Radiology, St. John's Medical Center, Tulsa, OK, USA
| | - Yaqi Shen
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Xuemei Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Daoyu Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhen Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Karna R, Hans B, Nasereddin T, Chaudhary D, Dhawan M. Comparison of mechanical and thermal therapy in upper gastrointestinal bleeding: an analysis of efficacy outcomes. Proc AMIA Symp 2024; 37:734-741. [PMID: 39165805 PMCID: PMC11332638 DOI: 10.1080/08998280.2024.2381180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 07/04/2024] [Accepted: 07/07/2024] [Indexed: 08/22/2024] Open
Abstract
Background Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a complication of dual antiplatelet therapy (DAPT) and direct oral anticoagulant therapy (DOAC). There is a lack of data comparing mechanical therapy (clips) with thermal therapy in this population. Methods We conducted a retrospective chart review of patients undergoing urgent/emergent endoscopy for NVUGIB while being on DAPT or DOAC. Patients who had DAPT/DOAC held as per American Society of Gastrointestinal Endoscopy guidelines were excluded from the study. Results A total of 122 patients were included in the study. There was no difference in primary hemostasis, rebleeding rate, rescue hemostatic procedure, and 30-day mortality between the mechanical and thermal therapy groups. The mechanical therapy group had a significantly higher rate of prolonged length of stay (61.2% vs 38.9%, P = 0.02), serious clinical outcomes (56% vs 37.5%, P = 0.04), and intensive care unit admissions (50% vs 20.8%, P = 0.001) than the thermal therapy group. Conclusion Patients on DAPT/DOAC presenting with NVUGIB can undergo mechanical or thermal endoscopic intervention without a significant difference in achieving primary hemostasis, rebleeding, requiring a secondary procedure, or mortality outcomes.
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Affiliation(s)
- Rahul Karna
- Division of Gastroenterology and Hepatology, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Bandhul Hans
- Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Thayer Nasereddin
- Indianapolis Gastroenterology and Hepatology, Indianapolis, Indiana, USA
| | - Dhruv Chaudhary
- Division of Gastroenterology and Hepatology, Columbus, Georgia, USA
| | - Manish Dhawan
- Division of Gastroenterology and Hepatology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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Li XJ, Fung BM. Advancements in endoscopic hemostasis for non-variceal upper gastrointestinal bleeding. World J Gastrointest Endosc 2024; 16:376-384. [PMID: 39072248 PMCID: PMC11271718 DOI: 10.4253/wjge.v16.i7.376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/06/2024] [Accepted: 06/26/2024] [Indexed: 07/08/2024] Open
Abstract
Non-variceal upper gastrointestinal (GI) bleeding is a significant cause of morbidity and mortality. Traditionally, through-the-scope (TTS) clips, thermal therapy, and injection therapies are used to treat GI bleeding. In this review, we provide an overview of novel endoscopic treatments that can be used to achieve hemostasis. Specifically, we discuss the efficacy and applicability of over-the-scope clips, hemostatic agents, TTS doppler ultrasound, and endoscopic ultrasound, each of which offer an effective method of reducing rates of GI rebleeding.
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Affiliation(s)
- Xue Jing Li
- Department of Gastroenterology and Hepatology, Banner-University Medical Center Phoenix, Phoenix, AZ 85006, United States
| | - Brian M Fung
- Department of Gastroenterology, Arizona Digestive Health, Mesa, AZ 85210, United States
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Luo Q, Luo J, Luan Z, Xu K, Tian L, Zhang K, Peng X, Yuan M, Zheng C, Shu Z, Zhang Y, Tan S, Dan R, Mequanint K, Fan C, Xing M, Yang S. Blue Laser Triggered Hemostatic Peptide Hydrogel for Gastrointestinal Bleeding Treatment. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024:e2405290. [PMID: 39011814 DOI: 10.1002/adma.202405290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 06/16/2024] [Indexed: 07/17/2024]
Abstract
In an emergency, nonvariceal upper gastrointestinal bleeding (NVUGIB), endoscopic hemostasis is considered the gold standard intervention. However, current endoscopic hemostasis is very challenging to manage bleeding in large-diameter or deep lesions highly prone to rebleeding risk. Herein, a novel hemostatic peptide hydrogel (HPH) is reported, consisting of a self-assembly peptide sequence CFLIVIGSIIVPGDGVPGDG (PFV) and gelatin methacryloyl (GelMA), which can be triggered by blue laser endoscopy (BLE) for nonvariceal upper gastrointestinal bleeding treatment without recurring bleeding concerns. Upon contact with GelMA solution, PFV immediately fibrillates into β-sheet nanofiber and solvent-induced self-assembly to form HPH gel. HPH nanofiber networks induced ultrafast coagulation by enveloping blood cells and activating platelets and coagulation factors even to the blood with coagulopathy. Besides its remarkable hemostatic performance in artery and liver injury models, HPH achieves instant bleeding management in porcine NVUGIB models within 60 s by preventing the rebleeding risk. This work demonstrates an extraordinary hemostatic agent for NVUGIB intervention by BLE for the first time, broadening potential application scenarios, including patients with coagulopathy and promising clinical prospects.
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Affiliation(s)
- Qiang Luo
- Department of Gastroenterology, Xinqiao Hospital, No. 183, Xinqiao Street, Chongqing, 400037, China
| | - Jie Luo
- Department of Gastroenterology, Xinqiao Hospital, No. 183, Xinqiao Street, Chongqing, 400037, China
| | - Zhaohui Luan
- Department of Gastroenterology, Xinqiao Hospital, No. 183, Xinqiao Street, Chongqing, 400037, China
| | - Kaige Xu
- Department of Mechanical Engineering, University of Manitoba, Winnipeg, R3T 2N2, Manitoba, Canada
| | - Lixing Tian
- Department of Gastroenterology, Xinqiao Hospital, No. 183, Xinqiao Street, Chongqing, 400037, China
| | - Kebin Zhang
- Clinical Medical Research Center, Xinqiao Hospital, No.183, Xinqiao Street, Chongqing, 400037, China
| | - Xue Peng
- Department of Gastroenterology, Xinqiao Hospital, No. 183, Xinqiao Street, Chongqing, 400037, China
| | - Mengxue Yuan
- Department of Gastroenterology, Xinqiao Hospital, No. 183, Xinqiao Street, Chongqing, 400037, China
| | - Chuanhao Zheng
- Department of Gastroenterology, Xinqiao Hospital, No. 183, Xinqiao Street, Chongqing, 400037, China
| | - Zhenzhen Shu
- Department of Gastroenterology, Xinqiao Hospital, No. 183, Xinqiao Street, Chongqing, 400037, China
| | - Yuchen Zhang
- Department of Gastroenterology, Xinqiao Hospital, No. 183, Xinqiao Street, Chongqing, 400037, China
| | - Shali Tan
- Department of Gastroenterology, Xinqiao Hospital, No. 183, Xinqiao Street, Chongqing, 400037, China
| | - Ruijue Dan
- Department of Gastroenterology, Xinqiao Hospital, No. 183, Xinqiao Street, Chongqing, 400037, China
| | - Kibret Mequanint
- Department of Chemical and Biochemical Engineering, The University of Western Ontario, London, N6A 5B9, Canada
| | - Chaoqiang Fan
- Department of Gastroenterology, Xinqiao Hospital, No. 183, Xinqiao Street, Chongqing, 400037, China
| | - Malcolm Xing
- Department of Mechanical Engineering, University of Manitoba, Winnipeg, R3T 2N2, Manitoba, Canada
| | - Shiming Yang
- Department of Gastroenterology, Xinqiao Hospital, No. 183, Xinqiao Street, Chongqing, 400037, China
- Chongqing Municipality Clinical Research Center for Gastroenterology, Chongqing, 400037, China
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Cui H, Gao Q, Zhao Z, Ma X. Upper gastrointestinal bleeding as a warning sign of gastrointestinal cancer. Prev Med Rep 2024; 43:102773. [PMID: 38883926 PMCID: PMC11176783 DOI: 10.1016/j.pmedr.2024.102773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/18/2024] Open
Abstract
Background Upper gastrointestinal bleeding (UGIB) is a prevalent etiology for hospital admissions on a global scale. However, the significance of UGIB as a warning sign of gastrointestinal (GI) cancer is frequently disregarded due to its uncommon and atypical symptoms. Methods In the Kailuan study, participants diagnosed with UGIB were assigned as the case group and were randomly matched in a 1:4 ratio with a control group of comparable age and sex from 2006 to 2018 in Tangshan. The statistical analysis included a total of 1250 UGIB patients and 5000 individuals without UGIB. The impact of UGIB on cancer incidence was evaluated using a Cox proportional hazards model, enabling the investigation of both site-specific and time-dependent effects of UGIB on cancer incidence. Results The mean age of the patients was 60.91 ± 13.08 years. Over an average follow-up period of 8.92 years, there were 102 cases of cancer in the UGIB group and 210 cases in the non-UGIB group. The results of the Cox model analysis indicated that the strength of association between UGIB and cancer depends on specific cancer site. Excluding patients with follow-up periods of less than 1, 3, and 5 years weakened the associations between UGIB and GI cancer in sensitivity analysis. Conclusion UGIB may serve as a sign of occult cancer, necessitating thorough evaluation of middle-aged and elderly patients presenting with this warning symptom to detect the possibility of missing a cancer diagnosis.
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Affiliation(s)
- Haozhe Cui
- School of Medicine, Nankai University, Tianjin, China
- Department of Hepatobiliary Surgery, Kailuan General Hospital, Tangshan, China
| | - Qinglun Gao
- Department of Hepatobiliary Surgery, Shandong Provincial Third Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zhiming Zhao
- The Faculty of Hepatopancreatobiliary Surgery, The First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Xiangming Ma
- Department of Hepatobiliary Surgery, Kailuan General Hospital, Tangshan, China
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Saha B, Danielson AP, Mundell WC. 49-Year-Old Man With Melena and Abdominal Pain. Mayo Clin Proc 2024; 99:992-996. [PMID: 38520448 DOI: 10.1016/j.mayocp.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 03/25/2024]
Affiliation(s)
- Bibek Saha
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Alex P Danielson
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - William C Mundell
- Advisor to residents and Consultant in Hospital Internal Medicine, Mayo Clinic, Rochester, MN.
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Acehan F, Karsavuranoğlu B, Aslan M, Kalkan C, Sahiner ES, Inan O, Comoglu M, Yilmaz Y, Ates I. Improved outcomes in patients with non-variceal upper gastrointestinal bleeding while undergoing antithrombotic therapy: A propensity score matching analysis. Dig Liver Dis 2024:S1590-8658(24)00741-2. [PMID: 38755023 DOI: 10.1016/j.dld.2024.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/22/2024] [Accepted: 04/30/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND This study sought to examine the effect of antithrombotic use on clinical outcomes in non-variceal upper gastrointestinal bleeding (UGIB). METHODS Patients consecutively diagnosed with non-variceal UGIB between February 2019 and September 2020 were divided into two groups based on their antithrombotic use: users and non-users. Using propensity score matching (PSM) and multivariable regression analyses, the impact of antithrombotic use prior to UGIB presentation on clinical outcomes was examined. RESULTS In the entire cohort, there were 210 and 260 patients in the antithrombotic user and non-user groups, respectively. Using PSM analysis with seven covariates, two matched groups of 157 patients were created at a 1:1 ratio. In the matched cohort, despite their longer hospital stays and a higher rate of intensive care unit admissions, the patients in the user group had lower 30- and 90-day mortality rates (4.5% vs. 14.0 %; p = 0.003 and 8.9% vs. 18.5 %; p = 0.014, respectively). In the entire cohort, multivariable analyses adjusted for confounding factors revealed that antithrombotic use was associated with lower risks of in-hospital (adjusted OR: 0.437; 95 % CI: 0.191-0.999), 30-day (adjusted OR: 0.261; 95 % CI: 0.099-0.689), and 90-day (adjusted OR: 0.386; 95 % CI: 0.182-0.821) mortality. CONCLUSION Antithrombotic use prior to UGIB presentation was found to be an independent protective factor for all-cause mortality.
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Affiliation(s)
- Fatih Acehan
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey.
| | | | - Meryem Aslan
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | - Cagdas Kalkan
- Department of Gastroenterology, Ankara City Hospital, Ankara, 06800, Turkey
| | - Enes Seyda Sahiner
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | - Osman Inan
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | - Mustafa Comoglu
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | - Yusufcan Yilmaz
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | - Ihsan Ates
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
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Vimonsuntirungsri T, Thungsuk R, Nopjaroonsri P, Faknak N, Pittayanon R. The Efficacy of Metoclopramide for Gastric Visualization by Endoscopy in Patients With Active Upper Gastrointestinal Bleeding: Double-Blind Randomized Controlled Trial. Am J Gastroenterol 2024; 119:846-855. [PMID: 38059896 DOI: 10.14309/ajg.0000000000002620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 11/30/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION The 2021 American College of Gastroenterology Guidelines suggested using of intravenous erythromycin before endoscopy in patients with upper gastrointestinal bleeding (UGIB) to enhance endoscopic view and reduce the need for repeat endoscopy. Evidence on intravenous metoclopramide, which is more accessible, is scant, especially in patients with active UGIB. This study aimed to evaluate the efficacy of metoclopramide for gastric visualization in patients with active UGIB. METHODS Between April 10, 2021, and October 8, 2022, this double-blind, double-center randomized controlled trial enrolled patients with active UGIB (hematemesis or presence of fresh blood in the nasogastric tube). The eligible patients were randomly assigned in a concealed 1:1 allocation to metoclopramide or placebo. The primary outcome was adequate visualization by objective endoscopic visualized gastroduodenal scores (EVS). Secondary outcomes included mean difference in EVS, duration of esophagogastroduodenoscopy (EGD), immediate hemostasis, need for a second look EGD, units of blood transfusion, length of hospital stay, and 30-day rebleeding rate. RESULTS Of the 68 eligible patients, 3 of each group were excluded by protocol violation. Finally, 62 patients (31 metoclopramide and 31 placebo) were analyzed. The percentage of patients with adequate visualization in metoclopramide and placebo group was 77.4% and 61.6% (odds ratio [OR] 2.16 [0.71-6.58], P = 0.16). The need for a second look EGD in the 72 hours was lower in the metoclopramide group (3.2% vs 22.6%, OR 0.11 [0.01-0.99], P = 0.02), whereas the other secondary outcomes were not different. However, in gastric lesions subgroup analysis, metoclopramide improved the adequate visualization rate (92.9% vs 50%, OR 13 [1.32-128.10], P = 0.03) and mean EVS at fundus (1.79 ± 0.42 vs 1.29 ± 0.72; P = 0.03). DISCUSSION Metoclopramide did not improve endoscopic visualization but decreased the need for second look EGD in patients with overall active UGIB. It improved gastric visualization in those with UGIB due to gastric lesions, primarily by improving visualization in the fundus ( ClinicalTrials.gov number NCT04771481).
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Affiliation(s)
- Thanrada Vimonsuntirungsri
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | | | - Natee Faknak
- Department of Medicine, Sawanpracharak Hospital, Nakhon Sawan, Thailand
| | - Rapat Pittayanon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Kukeev I, Quint E, Sebbag G, Dukhno O. Left gastric artery embolization for recurrent massive intraluminal postoperative bleeding after revisional laparoscopic one anastomosis gastric bypass surgery. J Surg Case Rep 2024; 2024:rjae070. [PMID: 38706484 PMCID: PMC11068415 DOI: 10.1093/jscr/rjae070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/15/2024] [Indexed: 05/07/2024] Open
Abstract
Laparoscopic one-anastomosis gastric bypass (LOAGB) has gained popularity as safe weight-reduction procedure. Bleeding is the common postoperative complication. We present a successful treatment of recurrent bleeding after LOAGB by embolization of the left gastric artery (LGA) and later development of necrotizing pancreatitis. A 41-year-old patient with previous bariatric surgeries undergone LOAGB surgery with development of massive intraluminal bleeding in the postoperative period. Attempts of unsuccessful endoscopic treatment were done and the bleeding was stopped by LGA embolization. In the post-embolization period, the patients developed necrotizing pancreatitis. Postoperative bleeding is the serious complications of the bariatric LOAGB procedure. Transcatheter Arterial Embolization (TAE) is the possible treatments after unsuccessful endoscopic attempts to stop the bleeding. The technical and clinical success rates of TAE in post-gastrectomy bleeding are 100 and 79%, respectively. TAE can be successfully used to stop obstinate recurrent postoperative bleeding after a LOAGB procedure.
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Affiliation(s)
- Ivan Kukeev
- Department of General Surgery B, Soroka University Medical Center, Ben-Gurion University of the Negev, Yitzhack I. Rager Blvd 151, PO Box 151, Beer Sheva 84101, Israel
| | - Elchanan Quint
- Department of General Surgery B, Soroka University Medical Center, Ben-Gurion University of the Negev, Yitzhack I. Rager Blvd 151, PO Box 151, Beer Sheva 84101, Israel
| | - Gilbert Sebbag
- Department of General Surgery B, Soroka University Medical Center, Ben-Gurion University of the Negev, Yitzhack I. Rager Blvd 151, PO Box 151, Beer Sheva 84101, Israel
| | - Oleg Dukhno
- Bariatric Surgery Unit, Department of General Surgery B, Soroka University Medical Center, Ben-Gurion University of the Negev, Yitzhack I. Rager Blvd 151, PO Box 151, Beer Sheva 84101, Israel
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13
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Abe H, Tarasawa K, Hatta W, Koike T, Sato I, Ono Y, Ogata Y, Saito M, Jin X, Kanno T, Uno K, Asano N, Imatani A, Fujimori K, Fushimi K, Masamune A. Similar Effect of Vonoprazan and Oral Proton Pump Inhibitors for Preventing Rebleeding in Cases of Upper Gastrointestinal Bleeding. Intern Med 2024; 63:911-918. [PMID: 37558479 PMCID: PMC11045377 DOI: 10.2169/internalmedicine.2211-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/03/2023] [Indexed: 08/11/2023] Open
Abstract
Objective The use of a proton pump inhibitor (PPI) reduces rebleeding and mortality in patients with upper gastrointestinal bleeding (UGIB). Vonoprazan is a novel oral agent with strong and sustained acid-inhibitory activity. We clarified the effect of vonoprazan compared with oral PPIs in such patients. Methods We analyzed the Diagnosis Procedure Combination database. The primary outcome was rebleeding, and secondary outcomes were in-hospital mortality and in-hospital mortality after rebleeding. Propensity score matching was performed to balance the comparison groups, and logistic regression analyses were used to compare the outcomes between vonoprazan and oral PPIs. Patients Patients on vonoprazan or oral PPIs who underwent endoscopic hemostasis for UGIB between 2014 and 2019 were included. Results We enrolled 78,964 patients, of whom 27,101 and 51,863 were prescribed vonoprazan and a PPI, respectively. After propensity score matching, the rebleeding rate of vonoprazan did not significantly differ from that of oral PPIs [6.4% vs. 6.1%; odds ratio (OR), 1.05; 95% confidence interval (CI), 0.98-1.13]; similarly, the in-hospital mortality rate (1.4% vs. 1.5%; OR, 0.91; 95% CI, 0.79-1.05) and in-hospital mortality after rebleeding (0.3% vs. 0.2%; OR, 1.09; 95% CI, 0.78-1.54) also did not significantly differ between the groups. The acquired findings were robust across dose-restricted analyses and several sensitivity analyses. Conclusion Rebleeding and in-hospital mortality risks in patients on vonoprazan were similar to those in patients on oral PPIs. Considering the higher cost of vonoprazan, oral PPIs might be an optimal oral agent as an acid-suppressive therapy in such patients.
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Affiliation(s)
- Hiroko Abe
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Kunio Tarasawa
- Department of Health Administration and Policy, Tohoku University Graduate School of Medicine, Japan
| | - Waku Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Isao Sato
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Yoshitaka Ono
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Yohei Ogata
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Masahiro Saito
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Xiaoyi Jin
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Takeshi Kanno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Kaname Uno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Naoki Asano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Akira Imatani
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Kenji Fujimori
- Department of Health Administration and Policy, Tohoku University Graduate School of Medicine, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
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Wang J, Peng X, Ye Z, He S, Liu L, Luo Y, Lv N, Shu X, Zhu Z. Medical therapy has similar hemostatic efficacy with endoscopic treatment for PUB patients with adherent clot (FIIb ulcers). Surg Endosc 2024; 38:1791-1806. [PMID: 38291159 DOI: 10.1007/s00464-024-10679-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 12/30/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Currently, there is no clear consensus on whether medical treatment or endoscopic treatment should be used for peptic ulcer bleeding patients with adherent clot. The aim of this study is to investigate the hemostatic effects of medical treatment, single endoscopic treatment, and combination endoscopic treatment for peptic ulcer bleeding (PUB) patients with adherent clot. METHODS We retrospectively analyzed PUB patients with adherent clot who underwent endoscopic examination or treatment in our center from March 2014 to January 2023 and received intravenous administration of proton pump inhibitors. Patients were divided into medical treatment (MT) group, single endoscopic treatment (ST) group, and combined endoscopic treatment (CT) group. Subsequently, inverse probability of treatment weighting (IPTW) was performed to calculate the rebleeding rate. RESULTS A total of 605 eligible patients were included in this study. After IPTW, the rebleeding rate in the MT group on days 3, 7, 14, and 30 were 13.3 (7.3), 14.2 (7.8), 14.5 (7.9), and 14.5 (7.9), respectively; the rebleeding rates in the ST group were 17.4 (5.1), 20.8 (6.1), 20.8 (6.1), and 20.8 (6.1), respectively; the rebleeding rates in the CT group were 0.4 (0.9), 1.7 (3.3), 2.3 (4.5), and 2.3 (4.5), respectively. Although the rebleeding rate in the medical treatment group was higher, there was no significant difference among the three groups on days 3, 7, 14, and 30 (P = 0.132, 0.442, 0.552, and 0.552). CONCLUSIONS Medical therapy has similar hemostatic efficacy with endoscopic treatment for PUB patients with adherent clot (FIIb ulcers). However, for patients with more risk factors and access to well-equipped endoscopy centers, endoscopic treatment may be considered. The choice of treatment approach should be based on the individual conditions of the patient, as well as other factors such as medical resources available.
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Affiliation(s)
- Jingsong Wang
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Xiang Peng
- Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhen Ye
- Department of Postgraduate, Jiangxi University of Traditional Chinese Medicine, Nanchang, 330004, Jiangxi, China
| | - Shan He
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Linlin Liu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Yixing Luo
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Nonghua Lv
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Xu Shu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Zhenhua Zhu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China.
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Gaoxin Branch, Nanchang, 330096, Jiangxi, China.
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Vakil N. Endoscopic Diagnosis, Grading, and Treatment of Bleeding Peptic Ulcer Disease. Gastrointest Endosc Clin N Am 2024; 34:217-229. [PMID: 38395480 DOI: 10.1016/j.giec.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Peptic ulcer bleeding is a major cause for hospital admissions and has a significant mortality. Endoscopic interventions reduce the risk of rebleeding in high-risk patients and several options are available including injection therapies, thermal therapies, mechanical clips, hemostatic sprays, and endoscopic suturing. Proton-pump inhibitors and Helicobacter pylori treatment are important adjuncts to endoscopic therapy. Endoscopic therapy is indicated in Forrest 1a, 1b, and 2a lesions. Patients with Forrest 2b lesions may do well with proton-pump inhibitor therapy alone but can also be managed by removal of the clot and targeting endoscopic therapy to the underlying lesion.
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Affiliation(s)
- Nimish Vakil
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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16
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Manupeeraphant P, Wanichagool D, Songlin T, Thanathanee P, Chalermsuksant N, Techathuvanan K, Sethasine S. Intravenous metoclopramide for increasing endoscopic mucosal visualization in patients with acute upper gastrointestinal bleeding: a multicenter, randomized, double-blind, controlled trial. Sci Rep 2024; 14:7598. [PMID: 38556533 PMCID: PMC10982284 DOI: 10.1038/s41598-024-57913-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/22/2024] [Indexed: 04/02/2024] Open
Abstract
Acute upper gastrointestinal hemorrhage (UGIH) is the most common emergency condition that requires rapid endoscopic treatment. This study aimed to evaluate the effects of pre-endoscopic intravenous metoclopramide on endoscopic mucosal visualization (EMV) in patients with acute UGIH. This was a multicenter, randomized, double-blind controlled trial of participants diagnosed with acute UGIH. All participants underwent esophagogastroduodenoscopy within 24 h. Participants were assigned to either the metoclopramide or placebo group. Modified Avgerinos scores were evaluated during endoscopy. In total, 284 out of 300 patients completed the per-protocol procedure. The mean age was 62.8 ± 14.3 years, and 67.6% were men. Metoclopramide group achieved a higher total EMV and gastric body EMV score than the other group (7.34 ± 1.1 vs 6.94 ± 1.6; P = 0.017 and 1.80 ± 0.4 vs 1.64 ± 0.6; P = 0.006, respectively). Success in identifying lesions was not different between the groups (96.5% in metoclopramide and 93.6% in placebo group; P = 0.26). In the metoclopramide group, those with active variceal bleeding compared with the control group demonstrated substantial improvements in gastric EMV (1.83 ± 0.4 vs 1.28 ± 0.8, P = 0.004), antral EMV (1.96 ± 0.2 vs 1.56 ± 0.6, P = 0.003), and total EMV score (7.48 ± 1.1 vs 6.2 ± 2.3, P = 0.02). Pre-endoscopic intravenous metoclopramide improved the quality of EMV in variceal etiologies of UGIH, which was especially prominent in those who had signs of active bleeding based on nasogastric tube assessment.Trial Registration: Trial was registered in Clinical Trials: TCTR 20210708004 (08/07/2021).
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Affiliation(s)
- Paveeyada Manupeeraphant
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, 681 Samsen Road, Dusit District, Bangkok, 10300, Thailand
| | - Dhanusorn Wanichagool
- Division of Gastroenterology, Phra Nakhon Si Ayutthaya Hospital, Ayutthaya, Thailand
| | - Thaphat Songlin
- Division of Gastroenterology, Panyananthaphikkhu Chonprathan Medical Center, Nonthaburi, Thailand
| | - Piyarat Thanathanee
- Division of Gastroenterology, Banphaeo General Hospital, Samut Sakhon, Thailand
| | - Nalerdon Chalermsuksant
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, 681 Samsen Road, Dusit District, Bangkok, 10300, Thailand
| | - Karjpong Techathuvanan
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, 681 Samsen Road, Dusit District, Bangkok, 10300, Thailand
| | - Supatsri Sethasine
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, 681 Samsen Road, Dusit District, Bangkok, 10300, Thailand.
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17
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Toro Tole D, Maurel A, Hedger J, Kwan S, Weber D. A systematic review of failed endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding. J Gastrointest Surg 2024; 28:309-315. [PMID: 38446116 DOI: 10.1016/j.gassur.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/13/2023] [Accepted: 12/16/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a surgical emergency, usually managed via endoscopy. Approximately 2% of patients will have another significant bleed after therapeutic endoscopy and may require either transarterial embolization (TAE) or surgery. In 2011, the National Institute for Health and Care Excellence guidelines recommended that TAE should be the preferred option offered in this setting. METHODS This study aimed to conduct an appraisal of guidelines on NVUGIB using the Appraisal of Guidelines for Research and Evaluation II tool. A specific review of their recommendations on the management of adult patients with failed endoscopic hemostasis that required TAE or surgery was conducted. RESULTS The quality of the guidelines was moderate; most could be recommended with changes. However, their recommendations regarding TAE vs surgery were widely heterogeneous. A closer review of the underpinning evidence showed that most studies were retrospective, with a small sample size and missing data. CONCLUSION Because of the heterogeneity in evidence, the decision regarding TAE vs surgery requires further research. Deciding between these modalities is primarily based on TAE availability and patient comorbidities. However, surgery should not be dismissed as a key option after failed endoscopic hemostasis.
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Affiliation(s)
- David Toro Tole
- Department of Surgery, Royal Darwin Hospital, Darwin, Australia.
| | - Amelie Maurel
- Department of Surgery, Royal Darwin Hospital, Darwin, Australia
| | - Joe Hedger
- School of Medicine, Flinders University, Darwin, Australia.
| | - Sherman Kwan
- Department of Surgery, Royal Perth Hospital, Perth, Australia
| | - Dieter Weber
- Department of Surgery, Royal Perth Hospital, Perth, Australia
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18
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Ito N, Funasaka K, Fujiyoshi T, Nishida K, Satta Y, Furukawa K, Kakushima N, Furune S, Ishikawa E, Mizutani Y, Sawada T, Maeda K, Ishikawa T, Yamamura T, Ohno E, Nakamura M, Miyahara R, Sasaki Y, Haruta JI, Fujishiro M, Kawashima H. Risk factors for rebleeding in gastroduodenal ulcers. Ir J Med Sci 2024; 193:173-179. [PMID: 37432526 DOI: 10.1007/s11845-023-03450-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/02/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Rebleeding after hemostasis of the gastroduodenal ulcer (GDU) is one of the indicators associated with death among GDU patients. However, there are few studies on risk score that contribute to rebleeding after endoscopic hemostasis of bleeding peptic ulcers. AIMS The aim of this study was to identify factors associated with rebleeding, including patient factors, after endoscopic hemostasis of bleeding gastroduodenal ulcers and to stratify the risk of rebleeding. METHODS We retrospectively enrolled 587 consecutive patients who were treated for Forrest Ia to IIa bleeding gastroduodenal ulcers with endoscopic hemostasis at three institutions. Risk factors associated with rebleeding were assessed using univariate and multivariate logistic regression analyses. The Rebleeding Nagoya University (Rebleeding-N) scoring system was developed based on the extracted factors. The Rebleeding-N score was internally validated using bootstrap resampling methods. RESULTS Sixty-four patients (11%) had rebleeding after hemostasis of gastroduodenal ulcers. Multivariate logistic regression analysis revealed four independent rebleeding risk factors: blood transfusion, albumin <2.5, duodenal ulcer, and diameter of the exposed vessel ≧2 mm. Patients with 4 risk factors in the Rebleeding-N score had a 54% rebleeding rate, and patients with 3 risk factors had 44% and 25% rebleeding rates. In the internal validation, the mean area under the curve of the Rebleeding-N score was 0.830 (95% CI = 0.786-0.870). CONCLUSIONS Rebleeding after clip hemostasis of bleeding gastroduodenal ulcers was associated with blood transfusion, albumin <2.5, diameter of the exposed vessel ≧2 mm, and duodenal ulcer. The Rebleeding-N score was able to stratify the risk of rebleeding.
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Affiliation(s)
- Nobuhito Ito
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kohei Funasaka
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, 1-98 Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan.
| | - Toshihisa Fujiyoshi
- Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Aichi, Japan
| | - Kazuki Nishida
- Department of Biostatistics Section, Center for Advanced Medicine and Clinical Research, Nagoya University Graduate School of Medicine, Aichi, Japan
| | | | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Naomi Kakushima
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoshi Furune
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Eri Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Tsunaki Sawada
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Keiko Maeda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, 1-98 Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Ryoji Miyahara
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, 1-98 Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | | | - Jun-Ichi Haruta
- Department of Biostatistics Section, Center for Advanced Medicine and Clinical Research, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
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19
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Acehan F, Karsavuranoğlu B, Kalkan C, Aslan M, Altiparmak E, Ates I. Three Simple Parameters on Admission to the Emergency Department are Predictors for Endoscopic Intervention in Patients with Suspected Nonvariceal Upper Gastrointestinal Bleeding. J Emerg Med 2024; 66:64-73. [PMID: 38267298 DOI: 10.1016/j.jemermed.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 07/31/2023] [Accepted: 08/31/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND A considerable number of patients with nonvariceal upper gastrointestinal bleeding (UGIB) need endoscopic intervention. OBJECTIVE The aim of this study was to determine factors that predict the need for endoscopic intervention at the time of admission to the emergency department. METHODS Consecutive patients with International Classification of Diseases, Tenth Revision diagnosis code K92.2 (gastrointestinal hemorrhage) who underwent upper endoscopy between February 2019 and February 2022, including patients diagnosed with nonvariceal UGIB in the emergency department in the study were reviewed retrospectively. The patients were divided into two groups: those treated endoscopically and those not treated endoscopically. These two groups were compared according to clinical and laboratory findings at admission and independent predictors for endoscopic intervention were determined using multivariate regression analysis. RESULTS Although 123 patients (30.3%) were treated endoscopically, endoscopic treatment was not required in 283 (69.7%) patients. Syncope, mean arterial pressure (MAP), and blood urea nitrogen (BUN) at admission were independent predictors for endoscopic intervention in the multivariate analysis, after adjusting for endoscopy time. The area under the curve of the syncope+MAP+BUN combination for endoscopic intervention was 0.648 (95% CI 0.588-0.708). Although the syncope+MAP+BUN combination predicted the need for intervention significantly better than pre-endoscopy Rockall and AIMS65 scores (p = 0.010 and p < 0.001, respectively), there was no significant difference in its comparison with the Glasgow-Blatchford score (p = 0.103). CONCLUSIONS Syncope, MAP, and BUN at admission were independent predictors for endoscopic therapy in patients with nonvariceal UGIB. Rather than using complicated scores, it would be more practical and easier to predict the need for endoscopic intervention with these three simple parameters, which are included in the Glasgow-Blatchford score.
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Affiliation(s)
- Fatih Acehan
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey.
| | | | - Cagdas Kalkan
- Department of Gastroenterology, Ankara City Hospital, Ankara, Turkey
| | - Meryem Aslan
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | - Emin Altiparmak
- Department of Gastroenterology, Ankara City Hospital, Ankara, Turkey
| | - Ihsan Ates
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
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20
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Pittayanon R, Barkun A. Reply. Gastroenterology 2024; 166:226-227. [PMID: 37866764 DOI: 10.1053/j.gastro.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 10/18/2023] [Indexed: 10/24/2023]
Affiliation(s)
- Rapat Pittayanon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross, Bangkok, Thailand
| | - Alan Barkun
- Division of Gastroenterology, McGill University and McGill University Health Center, Montreal, Quebec, Canada
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21
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Gupta S, Anirvan P, Panigrahi MK. Use of Hemospray for Management of Malignant Gastrointestinal Bleeding: Game-Changing Strategy or Just Another Red Herring? Gastroenterology 2024; 166:225-226. [PMID: 37734422 DOI: 10.1053/j.gastro.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Shubham Gupta
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Prajna Anirvan
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Manas Kumar Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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22
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Ramai D, Deliwala SS, Mozell D, Facciorusso A, Chandan S, Persaud A, Singh K, Anderloni A, Barakat MT. Adverse Events of Endoscopic Clip Placement: A MAUDE Database Analysis. J Clin Gastroenterol 2024; 58:76-79. [PMID: 36728443 DOI: 10.1097/mcg.0000000000001822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 11/22/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Clips are endoscopic mechanical devices with tensile and closure strength that can approximate tissue and provide hemostasis through a tamponade effect. Clips are ubiquitously used in endoscopic practice, and numerous studies have validated the clinical efficacy of clips, with recent guidelines recommending them as a first-line intervention for recurrent and persistent nonvariceal gastrointestinal bleeding. However, the safety profile for these devices has yet to be delineated, thus, we aim to investigate this feature by examining the adverse events reported to the Food and Drug Administration. METHODS Postmarketing surveillance data from the Food and Drug Administration Manufacturer And User Facility Device Experience database were analyzed from January 2012 to January 2021. The Manufacturer And User Facility Device Experience database is a reporting software and does not independently verify the details of complications. RESULTS Two thousand five hundred forty reports were issued, of which 287 were patient adverse events and 2766 were device problems. Activation, separation, and positioning issues were most common. No consequences or clinically significant impact on patients were seen in 1968 reports. Foreign bodies were seen in 97 cases, hemorrhage in 57 cases, tissue damage in 42 cases, embedded clips in tissues/plaques in 16 cases, perforation in 15 cases, lacerations in 6 cases, and infection in 3 cases. CONCLUSIONS While the most commonly reported device problems involved activation, separation, and positioning, most patients were clinically unaffected. Moreover, perforation and infection were exceedingly rare, further highlighting the safety profile of endoscopic clips.
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Affiliation(s)
- Daryl Ramai
- Division of Gastroenterology, Hepatology, and Nutrition, University of Utah Health, Salt Lake City, UT
| | - Smit S Deliwala
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, MI
| | - Daniel Mozell
- Department of Internal Medicine, Elmhurst Hospital, Elmhurst
| | - Antonio Facciorusso
- Department of Medical Sciences, Section of Gastroenterology, University of Foggia, Foggia
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology, CHI Health Creighton University Medical Center, Omaha, NE
| | - Alana Persaud
- Division of Gastroenterology and Hepatology, SUNY Downstate, NY
| | - Kelita Singh
- Division of Gastroenterology, Stanford University, CA
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Humanitas Clinical, and Research Center - IRCCS, Milano, Italy
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23
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Huang J, Liao F, Tang J, Shu X. Development of a model for predicting acute cerebral infarction induced by non-variceal upper gastrointestinal bleeding. Clin Neurol Neurosurg 2023; 235:107992. [PMID: 37944305 DOI: 10.1016/j.clineuro.2023.107992] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/04/2023] [Accepted: 09/26/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To evaluate the risk factors for acute cerebral infarction(ACI) in patients with non-variceal upper gastrointestinal bleeding(NVUGIB), and construct a model for predicting ACI in NVUGIB patients. METHODS A model for predicting ACI induced by NVUGIB was established on the basis of a retrospective study that involved 1282 patients who were diagnosed with NVUGIB in the emergency department and Gastroenterology Department of Nanchang University Affiliated Ganzhou Hospital from January 2019 to December 2021. Receiver operating characteristic (ROC) curves were drawn to evaluate the sensitivity and specificity of the model and CHA2DS2-VASc score to predict ACI. Delong's test was used to compare AUCs of the present score and the CHA2DS2-VASc score. RESULTS There were 1282 patients enrolled in the study, including 69 in the ACI group and 1213 in the non-ACI group. Multivariate analysis revealed that hypertension, diabetes, red blood cell (RBC) transfusion, mechanical ventilation, D-dimer, rate pressure product (RPP), somatostatin and mean platelet volume (MPV) were factors associated with ACI induced by NVUGIB. A model based on the eight factors was established, Logit(P)= 0.265 + 1.382 × 1 + 1.120 × 2 + 1.769 × 3 + 0.839 × 4-1.549 × 5-0.361 × 6 + 0.045 × 7 + 1.158 × 8(or 1.069 ×9) (X1, hypertension=1; X2, diabetes=1; X3, RBC transfusion=1; X4, mechanical ventilation=1; X5, somatostatin=1; X6, MPV(fL); X7, D-dimer(ng/l); X8, low RPP= 1; X9, high RPP = 2). The area under ROC curve of the model was 0.873, the sensitivity and specificity were 0.768 and 0.887, respectively. The area under ROC curve of CHA2DS2-VASc score was 0.792, the sensitivity and specificity were 0.728 and 0.716, respectively. Delong's test showed the area under ROC curve of the present study was significantly larger than that of CHA2DS2-VASc score. CONCLUSIONS Hypertension, diabetes, RBC transfusion, mechanical ventilation, D-dimer, RPP, somatostatin and MPV were factors associated with ACI induced by NVUGIB. A model constructed based on these factors showed excellent prediction of ACI, and was superior to CHA2DS2-VASc score. However, this needs to be further validated by multi-center study with a larger sample size.
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Affiliation(s)
- Jiaming Huang
- Department of Gastroenterology, Nanchang University Affiliated Ganzhou Hospital, Ganzhou, Jiangxi 341000, China
| | - Foqiang Liao
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Jianhua Tang
- Department of Gastroenterology, Nanchang University Affiliated Ganzhou Hospital, Ganzhou, Jiangxi 341000, China
| | - Xu Shu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China.
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24
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Kozarek RA. DDS Perspective: If Gastroenterology Were a Dog, Would Endoscopy Be Its Tail? Has Therapeutic GI Endoscopy Learned to Wag the Dog? Dig Dis Sci 2023; 68:4297-4300. [PMID: 37798571 DOI: 10.1007/s10620-023-08115-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 09/14/2023] [Indexed: 10/07/2023]
Affiliation(s)
- Richard A Kozarek
- Emeritus Executive Director, Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98101, USA.
- Clinical Investigator, Center for Interventional Immunology, Benaroya Research Institute, 1201 Ninth Ave, Seattle, WA, 98101, USA.
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25
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Guo H, Stach J, Belletrutti PJ. A Rare Cause of Life-Threatening Upper Gastrointestinal Bleeding. Gastroenterology 2023; 165:1118-1121. [PMID: 37245591 DOI: 10.1053/j.gastro.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/16/2023] [Accepted: 05/20/2023] [Indexed: 05/30/2023]
Affiliation(s)
- Howard Guo
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jesse Stach
- Department of Medicine, Section of Gastroenterology and General Internal Medicine, Medicine Hat Regional Hospital, Medicine Hat, Alberta, Canada
| | - Paul J Belletrutti
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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26
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Dhindsa BS, Tun KM, Scholten KJ, Deliwala S, Naga Y, Dhaliwal A, Ramai D, Saghir SM, Dahiya DS, Chandan S, Singh S, Adler DG. New Alternative? Self-Assembling Peptide in Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. Dig Dis Sci 2023; 68:3694-3701. [PMID: 37402986 DOI: 10.1007/s10620-023-08009-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/15/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is a common and potentially fatal condition with all-cause mortality ranging from 3 to 10%. Endoscopic therapy traditionally involves mechanical, thermal, and injection therapies. Recently, self-assembling peptide (SAP) has become increasingly available in the United States. When applied to an affected area, this gel forms an extracellular matrix-type structure allowing for hemostasis. This is the first systematic review and meta-analysis to assess the safety and efficacy of this modality in GIB. METHODS We performed a comprehensive literature search of major databases from inception to Nov 2022. The primary outcomes assessed were the success of hemostasis, rebleeding rates, and adverse events. The secondary outcomes assessed were successful hemostasis with monotherapy with SAP and combined therapy, which may include mechanical, injection, and thermal therapies. Pooled estimates were calculated using random-effects models with a 95% confidence interval (CI). RESULTS The analysis included 7 studies with 427 patients. 34% of the patients were on anticoagulation or antiplatelet agents. SAP application was technically successful in all patients. The calculated pooled rate of successful hemostasis was 93.1% (95% confidence interval (CI) 84.7-97.0, I2 = 73.6), and rebleeding rates were 8.9% (95% CI 5.3-14.4, I2 = 55.8). The pooled rates of hemostasis with SAP monotherapy and combined therapy were similar. No adverse events were noted related to SAP. CONCLUSION SAP appears to be a safe and effective treatment modality for patients with GIB. This modality provides an added advantage of improved visualization over the novel spray-based modalities. Further, prospective, or randomized controlled trials are needed to validate our findings.
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Affiliation(s)
- Banreet Singh Dhindsa
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, 982000 Nebraska Medical Center, Omaha, NE, 68198-2000, USA
| | - Kyaw Min Tun
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, 1701 W Charleston Blvd, Las Vegas, NV, 89102, USA
| | - Kyle J Scholten
- Department of Internal Medicine, University of Nebraska Medical Center, 982000 Nebraska Medical Center, Omaha, NE, 68198-2000, USA
| | - Smit Deliwala
- Division of Gastroenterology and Hepatology, Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA, 30322, USA
| | - Yassin Naga
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Amaninder Dhaliwal
- Division of Gastroenterology and Hepatology, McLeod Regional Medical Center, Florence, SC, 29506, USA
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, 30 N 1900 E, Room 4R118, Salt Lake City, UT, 84132, USA
| | - Syed Mohsin Saghir
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, NE, 68124, USA
| | - Dushyant Singh Dahiya
- Division of Internal Medicine, Central Michigan University, 1015 S Washington Ave, Saginaw, MI, 48603, USA
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, NE, 68124, USA
| | - Shailender Singh
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, 982000 Nebraska Medical Center, Omaha, NE, 68198-2000, USA
| | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy, Professor of Medicine, Centura Health, Denver, CO, USA.
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Yang Z, Chen L, Liu J, Zhuang H, Lin W, Li C, Zhao X. Short Peptide Nanofiber Biomaterials Ameliorate Local Hemostatic Capacity of Surgical Materials and Intraoperative Hemostatic Applications in Clinics. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2023; 35:e2301849. [PMID: 36942893 DOI: 10.1002/adma.202301849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/12/2023] [Indexed: 06/18/2023]
Abstract
Short designer self-assembling peptide (dSAP) biomaterials are a new addition to the hemostat group. It may provide a diverse and robust toolbox for surgeons to integrate wound microenvironment with much safer and stronger hemostatic capacity than conventional materials and hemostatic agents. Especially in noncompressible torso hemorrhage (NCTH), diffuse mucosal surface bleeding, and internal medical bleeding (IMB), with respect to the optimal hemostatic formulation, dSAP biomaterials are the ingenious nanofiber alternatives to make bioactive neural scaffold, nasal packing, large mucosal surface coverage in gastrointestinal surgery (esophagus, gastric lesion, duodenum, and lower digestive tract), epicardiac cell-delivery carrier, transparent matrix barrier, and so on. Herein, in multiple surgical specialties, dSAP-biomaterial-based nano-hemostats achieve safe, effective, and immediate hemostasis, facile wound healing, and potentially reduce the risks in delayed bleeding, rebleeding, post-operative bleeding, or related complications. The biosafety in vivo, bleeding indications, tissue-sealing quality, surgical feasibility, and local usability are addressed comprehensively and sequentially and pursued to develop useful surgical techniques with better hemostatic performance. Here, the state of the art and all-round advancements of nano-hemostatic approaches in surgery are provided. Relevant critical insights will inspire exciting investigations on peptide nanotechnology, next-generation biomaterials, and better promising prospects in clinics.
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Affiliation(s)
- Zehong Yang
- Department of Biochemistry and Molecular Biology, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, China
- Institute for Nanobiomedical Technology and Membrane Biology, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, China
| | - Lihong Chen
- Department of Biochemistry and Molecular Biology, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Ji Liu
- Department of Biochemistry and Molecular Biology, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Hua Zhuang
- Department of Ultrasonography, West China Hospital of Sichuan University, No. 37 Guoxue Road, Wuhou District, Chengdu, Sichuan, 610041, China
| | - Wei Lin
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Women and Children Diseases of the Ministry of Education, Sichuan University, No. 17 People's South Road, Chengdu, Sichuan, 610041, China
| | - Changlong Li
- Department of Biochemistry and Molecular Biology, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Xiaojun Zhao
- Institute for Nanobiomedical Technology and Membrane Biology, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, China
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28
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Pittayanon R, Khongka W, Linlawan S, Thungsuk R, Aumkaew S, Teeratorn N, Maytapa J, Kimtrakool S, Pakvisal P, Kongtub N, Rerknimitr R, Barkun A. Hemostatic Powder vs Standard Endoscopic Treatment for Gastrointestinal Tumor Bleeding: A Multicenter Randomized Trial. Gastroenterology 2023; 165:762-772.e2. [PMID: 37277078 DOI: 10.1053/j.gastro.2023.05.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/14/2023] [Accepted: 05/09/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND & AIMS Current guidelines vary as to their recommendations addressing the role of hemostatic powders when managing patients with malignant gastrointestinal (GI) bleeding because these are based on very-low- to low-quality evidence, in large part due to a paucity of randomized trial data. METHODS This was a patient- and outcome assessor-blinded, multicenter, randomized controlled trial. Patients presenting with active bleeding from an upper or lower GI lesion suspected to be malignant at index endoscopy between June 2019 and January 2022 were randomly allocated to receive either TC-325 alone or standard endoscopic treatment (SET). The primary outcome was 30-day rebleeding, and secondary objectives included immediate hemostasis and other clinically relevant endpoints. RESULTS Overall, 106 patients made up the study population (55 TC-325 and 51 SET, after 1 exclusion in the TC-325 group and 5 in the SET group). Baseline characteristics and endoscopic findings did not differ between the groups. Thirty-day rebleeding was significantly lower in the TC-325 (2.1% TC-325 vs 21.3% SET; odds ratio, 0.09; 95% confidence interval [CI], 0.01-0.80; P = .003). Immediate hemostasis rates were 100% in the TC-325 group vs 68.6% in the SET group (odds ratio, 1.45; 95% CI, 0.93-2.29; P < .001). Other secondary outcomes did not differ between the 2 groups. Independent predictors of 6-month survival included the Charlson comorbidity index (hazard ratio, 1.17; 95% CI, 1.05-1.32; P = .007) and receiving an additional nonendoscopic hemostatic or oncologic treatment during 30 days after the index endoscopy (hazard ratio, 0.16; 95% CI, 0.06-0.43; P < .001) after adjustment for functional status, Glasgow-Blatchford score, and an upper GI source of bleeding. CONCLUSION The TC-325 hemostatic powder results in greater immediate hemostasis rates followed by lower 30-day rebleeding rates when compared to contemporary SET. (ClinicalTrials.gov, Number: NCT03855904).
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Affiliation(s)
- Rapat Pittayanon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand.
| | | | | | | | | | | | | | | | | | - Natanong Kongtub
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Alan Barkun
- Division of Gastroenterology, McGill University, Montreal, Quebec, Canada; McGill University Health Center, Montreal, Quebec, Canada
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29
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Wang J, He S, Shang G, Lv N, Shu X, Zhu Z. Epinephrine injection monotherapy shows similar hemostatic efficacy to epinephrine injection combined therapy in high-risk patients (Forrest Ib) with bleeding ulcers. Surg Endosc 2023; 37:6954-6963. [PMID: 37336844 PMCID: PMC10462566 DOI: 10.1007/s00464-023-10152-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/20/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Whether combination therapy has higher hemostatic efficacy than epinephrine injection monotherapy in different Forrest classifications is not clear. This study aimed to compare hemostatic efficacy between epinephrine injection monotherapy (MT) and combination therapy (CT) based on different Forrest classifications. METHODS We retrospectively analyzed peptic ulcer bleeding (PUB) patients who underwent endoscopic epinephrine injections or epinephrine injections combined with a second therapy between March 2014 and June 2022 in our center, and the patients were divided into MT group or CT group. Subsequently, a propensity score matching analysis (PSM) was performed and rebleeding rates were calculated according to Forrest classifications via a stratified analysis. RESULTS Overall, 605 patients who met the inclusion criteria were included, and after PSM, 173 patients in each of the CT and MT groups were included. For PUB patients with nonbleeding visible vessels (FIIa), the rebleeding rates by Days 3, 7, 14, and 30 after PSM were 8.8%, 17.5%, 19.3%, and 19.3% in the MT group, respectively, and rates were 0%, 4.1%, 5.5%, and 5.5% in the CT group, respectively, with significant differences observed between the two groups by Days 3, 7, 14, and 30 (P = 0.015, P = 0.011, P = 0.014, and P = 0.014, respectively). However, for PUB patients with oozing bleeding (FIb), the rebleeding rates by Days 3, 7, 14, and 30 after PSM were 14.9%, 16.2%, 17.6%, and 17.6% in the MT group, respectively, and rates were 13.2%, 14.7%, 14.7%, and 16.2% in the CT group, respectively, with no significant differences observed between the two groups by Days 3, 7, 14, and 30 (P = 0.78, P = 0.804, P = 0.644 and P = 0.825). CONCLUSION Combined therapy has higher hemostatic efficacy than epinephrine injection monotherapy for PUB patients with visible blood vessel (FIIa) ulcers. However, epinephrine injection monotherapy is equally as effective as combined therapy for PUB patients with oozing blood (FIb) ulcers.
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Affiliation(s)
- Jingsong Wang
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Shan He
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Guanqun Shang
- Queen Mary School, Nanchang University, Nanchang, 330001 Jiangxi China
| | - Nonghua Lv
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Xu Shu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Zhenhua Zhu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
- Department of Gastroenterology, Gaoxin Branch, The First Affiliated Hospital of Nanchang University, Nanchang, 330096 Jiangxi China
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30
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Wang AY. Hemostatic Powder Offers Patients Respite From Malignant Gastrointestinal Bleeding. Gastroenterology 2023; 165:536-537. [PMID: 37393023 DOI: 10.1053/j.gastro.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/24/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
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31
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Martino A, Di Serafino M, Orsini L, Giurazza F, Fiorentino R, Crolla E, Campione S, Molino C, Romano L, Lombardi G. Rare causes of acute non-variceal upper gastrointestinal bleeding: A comprehensive review. World J Gastroenterol 2023; 29:4222-4235. [PMID: 37545636 PMCID: PMC10401659 DOI: 10.3748/wjg.v29.i27.4222] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/11/2023] [Accepted: 05/09/2023] [Indexed: 07/13/2023] Open
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common gastroenterological emergency associated with significant morbidity and mortality. Gastroenterologists and other involved clinicians are generally assisted by international guidelines in its management. However, NVUGIB due to peptic ulcer disease only is mainly addressed by current guidelines, with upper gastrointestinal endoscopy being recommended as the gold standard modality for both diagnosis and treatment. Conversely, the management of rare and extraordinary rare causes of NVUGIB is not covered by current guidelines. Given they are frequently life-threatening conditions, all the involved clinicians, that is emergency physicians, diagnostic and interventional radiologists, surgeons, in addition obviously to gastroenterologists, should be aware of and familiar with their management. Indeed, they typically require a prompt diagnosis and treatment, engaging a dedicated, patient-tailored, multidisciplinary team approach. The aim of our review was to extensively summarize the current evidence with regard to the management of rare and extraordinary rare causes of NVUGIB.
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Affiliation(s)
- Alberto Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Marco Di Serafino
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Luigi Orsini
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Francesco Giurazza
- Department of Interventional Radiology, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | | | - Enrico Crolla
- Department of Oncological Surgery, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Severo Campione
- Department of Pathology, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Carlo Molino
- Department of Oncological Surgery, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Giovanni Lombardi
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Naples 80131, Italy
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Hollenbach M, Decker A, Schmidt A, Möschler O, Jung C, Blasberg T, Seif AAH, Vu Trung K, Hoffmeister A, Hochberger J, Ellenrieder V, Wedi E. Comparison between traumatic and atraumatic over-the-scope clips in patients with duodenal ulcer bleeding: a retrospective analysis with propensity score-based matching. Gastrointest Endosc 2023; 98:51-58.e2. [PMID: 36738794 DOI: 10.1016/j.gie.2023.01.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Over-the-scope clips (OTSCs) substantially improved the endoscopic armamentarium for the treatment of severe GI bleeding and can potentially overcome limitations of standard clips. Data indicate a superiority of OTSCs in hemostasis as first- and second-line therapy. However, the impact of the OTSC designs, in particular the traumatic (-t) or atraumatic (-a) type, in duodenal ulcer bleeding has not been analyzed so far. METHODS This was a retrospective analysis of a prospective collected database from 2009 to 2020 of 6 German endoscopic centers. All patients who underwent emergency endoscopy and were treated using an OTSC for duodenal ulcer bleeding were included. OTSC-t and OTSC-a patients were compared by the Fisher exact test, χ2 test, or Mann-Whitney U test as appropriate. A propensity score-based 1:1 matching was performed to obtain equal distribution of baseline characteristics in both groups. RESULTS The entire cohort comprised 173 patients (93 OTSC-a, 80 OTSC-t). Age, gender, anticoagulant therapy, Rockall score, and treatment regimen had similar distributions in the 2 groups. However, the OTSC-t group showed significantly more active bleeding ulcers (Forrest Ia/b). Matching identified 132 patients (66 in both groups) with comparable baseline characteristics. Initial bleeding hemostasis (OTSC-a, 90.9%; OTSC-t, 87.9%; P = .82) and 72-hour mortality (OTSC-a, 4.5%; OTSC-t, 6.0%; P > .99) were not significantly different, but the OTSC-t group revealed a clearly higher rate of recurrent bleeding (34.9% vs 7.6%, P < .001) and necessity of red blood cell transfusions (5.1 ± 3.4 vs 2.5 ± 2.4 concentrates, P < .001). CONCLUSIONS For OTSC use, the OTSC-a should be the preferred option for duodenal ulcer bleeding.
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Affiliation(s)
- Marcus Hollenbach
- Division of Gastroenterology, Medical Department II, University of Leipzig Medical Center, Leipzig, Germany
| | - Annegrit Decker
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Oliver Möschler
- Department of Internal Medicine and Gastroenterology, Marienhospital Osnabrück, Osnabrück, Germany
| | - Carlo Jung
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Tobias Blasberg
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Offenbach, Germany
| | - Ali Amir Hosseini Seif
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Göttingen, Germany
| | - Kien Vu Trung
- Division of Gastroenterology, Medical Department II, University of Leipzig Medical Center, Leipzig, Germany
| | - Albrecht Hoffmeister
- Division of Gastroenterology, Medical Department II, University of Leipzig Medical Center, Leipzig, Germany
| | - Jürgen Hochberger
- Department of Gastroenterology, Vivantes Hospital Friedrichshain Berlin, Berlin, Germany
| | - Volker Ellenrieder
- Clinic for Gastroenterology, Gastrointestinal Oncology and Endocrinology, University of Göttingen, Göttingen, Germany
| | - Edris Wedi
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Offenbach, Germany; Clinic for Gastroenterology, Gastrointestinal Oncology and Endocrinology, University of Göttingen, Göttingen, Germany
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Kang S, Choi KD, Kim Y, Na HK, Lee JH, Ahn JY, Jung KW, Kim DH, Song HJ, Lee GH, Jung HY. Upper Gastrointestinal Bleeding Due to a Left Gastric Artery Pseudoaneurysm: A Case Series. Dig Dis Sci 2023; 68:1959-1965. [PMID: 36478315 DOI: 10.1007/s10620-022-07776-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 11/14/2022] [Indexed: 04/27/2023]
Abstract
BACKGROUND Left gastric artery (LGA) pseudoaneurysm presenting with upper gastrointestinal (UGI) bleeding is rare but fatal, unless treated. AIMS We aimed to describe the clinical and endoscopic features of patients with UGI bleeding due to LGA pseudoaneurysms. METHODS We performed a computerized search of our hospital's de-identified clinical data warehouse to identify patients with UGI bleeding due to an LGA pseudoaneurysm between 2000 and 2020. Patients' electronic medical records and data on esophagogastroduodenoscopy and digital subtraction angiography were reviewed retrospectively. RESULTS Of 26 patients with an LGA pseudoaneurysm, six patients had UGI bleeding related to an LGA pseudoaneurysm. No patients had previous vascular diseases or pancreatitis. One patient had liver cirrhosis and a history of radiofrequency ablation for hepatocellular carcinoma, one had colon cancer, two had undergone abdominal surgeries, one had received chemoradiotherapy for renal cell carcinoma, and one had no intraabdominal diseases. Symptoms were hematemesis in two, hematochezia in the other two, and melena in the remaining two patients. Esophagogastroduodenoscopy showed a pulsating bulge in the ulcer in two and a large Dieulafoy's lesion-like structure in four patients. All patients achieved hemostasis by angioembolization. CONCLUSION LGA pseudoaneurysm should be suspected in UGI bleeding if a large Dieulafoy's lesion-like structure or a pulsating bulge in the ulcer is found at the lesser curvature of the gastric body on endoscopy and if the patient has any intra-abdominal inflammatory disease.
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Affiliation(s)
- Seokin Kang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, 170, Juhwa-ro, Ilsanseo-gu, Goyang, 10380, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Yuri Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
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Weissman S, Aziz M, Bangolo AI, Ehrlich D, Forlemu A, Willie A, Gangwani MK, Waqar D, Terefe H, Singh A, Gonzalez DMC, Sajja J, Emiroglu FL, Dinko N, Mohamed A, Fallorina MA, Kosoy D, Shenoy A, Nanavati A, Feuerstein JD, Tabibian JH. Relationships of hospitalization outcomes and timing to endoscopy in non-variceal upper gastrointestinal bleeding: A nationwide analysis. World J Gastrointest Endosc 2023; 15:285-296. [PMID: 37138938 PMCID: PMC10150287 DOI: 10.4253/wjge.v15.i4.285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/22/2023] [Accepted: 03/15/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND The optimal timing of esophagogastroduodenoscopy (EGD) and the impact of clinico-demographic factors on hospitalization outcomes in non-variceal upper gastrointestinal bleeding (NVUGIB) remains an area of active research.
AIM To identify independent predictors of outcomes in patients with NVUGIB, with a particular focus on EGD timing, anticoagulation (AC) status, and demographic features.
METHODS A retrospective analysis of adult patients with NVUGIB from 2009 to 2014 was performed using validated ICD-9 codes from the National Inpatient Sample database. Patients were stratified by EGD timing relative to hospital admission (≤ 24 h, 24-48 h, 48-72 h, and > 72 h) and then by AC status (yes/no). The primary outcome was all-cause inpatient mortality. Secondary outcomes included healthcare usage.
RESULTS Of the 1082516 patients admitted for NVUGIB, 553186 (51.1%) underwent EGD. The mean time to EGD was 52.8 h. Early (< 24 h from admission) EGD was associated with significantly decreased mortality, less frequent intensive care unit admission, shorter length of hospital stays, lower hospital costs, and an increased likelihood of discharge to home (all with P < 0.001). AC status was not associated with mortality among patients who underwent early EGD (aOR 0.88, P = 0.193). Male sex (OR 1.30) and Hispanic (OR 1.10) or Asian (aOR 1.38) race were also independent predictors of adverse hospitalization outcomes in NVUGIB.
CONCLUSION Based on this large, nationwide study, early EGD in NVUGIB is associated with lower mortality and decreased healthcare usage, irrespective of AC status. These findings may help guide clinical management and would benefit from prospective validation.
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Affiliation(s)
- Simcha Weissman
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Muhammad Aziz
- Department of Gastroenterology, University of Toledo Medical Center, Toledo, OH 43614, United States
| | - Ayrton I Bangolo
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Dean Ehrlich
- Division of Digestive Diseases, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA 90095, United States
| | - Arnold Forlemu
- Department of Internal Medicine, Creighton University School of Medicine, Phoenix, AZ 85012, United States
| | - Anthony Willie
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Manesh K Gangwani
- Department of Gastroenterology, University of Toledo Medical Center, Toledo, OH 43614, United States
| | - Danish Waqar
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Hannah Terefe
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Amritpal Singh
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Diego MC Gonzalez
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Jayadev Sajja
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Fatma L Emiroglu
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Nicholas Dinko
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Ahmed Mohamed
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Mark A Fallorina
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - David Kosoy
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Ankita Shenoy
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Anvit Nanavati
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View- University of California at Los Angeles Medical Center, Sylmar, CA 91342, United States
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Abe H, Saito M, Uno K, Koike T, Ichikawa S, Saito M, Kanno T, Hatta W, Asano N, Masamune A. A case of refractory bleeding from duodenal angioectasia with acquired hemophilia A. Clin J Gastroenterol 2023; 16:355-360. [PMID: 37022595 DOI: 10.1007/s12328-023-01790-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 03/23/2023] [Indexed: 04/07/2023]
Abstract
Acquired hemophilia A (AHA) is a coagulation disorder related to the factor VIII inhibitors, which might cause intractable bleeding of gastrointestinal tracts. However, its scarcity makes it difficult to recognize AHA as a pitfall of endoscopic hemostasis failure. An 81-year-old female with a history of endoscopic treatment for colon polyps visited a local hospital with chief compliments of bloody stool and severe anemia. During several examinations for the bleeding origin, esophagogastroduodenoscopy depicted a 5 mm-sized hemorrhagic angioectasia of the duodenum, followed by treatment with argon plasma coagulation. However, hemostasis was not achieved by multiple sessions of endoscopic hemostasis and transcatheter arterial embolization, so blood transfusion was repeatedly done and she was transferred to our hospital. Laboratory data showed severe anemia with coagulation disorder. Based on the results of von Willebrand factor activity, factor VIII activity and factor VIII inhibitor, we diagnosed AHA as a comorbidity. Endoscopic hemostasis was confirmed only after improvement of APTT level and negative for the factor VIII inhibitor by hemostatic bypass treatment with recombinant active factor VII and immunosuppressive therapy with prednisolone and cyclophosphamide. In case of refractory bleeding of gastrointestinal tract, we should suspect of a comorbidity of coagulation disorder like AHA.
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Affiliation(s)
- Hiroko Abe
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Masahiro Saito
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Kaname Uno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Satoshi Ichikawa
- Division of Hematology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Masashi Saito
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Takeshi Kanno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Waku Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Naoki Asano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
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Mou H, Zou C, Shi G, Wu S, Xie R, Liu X, Yang J, Tuo B. Endoscopic cyanoacrylate injection therapy for refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy. Scand J Gastroenterol 2023; 58:331-338. [PMID: 36222583 DOI: 10.1080/00365521.2022.2132535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of endoscopic cyanoacrylate injection therapy for refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy. METHODS 154 patients with refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy at the Affiliated Hospital of Zunyi Medical Univesity and the People's Hospital of Liupanshui City from January 2018 to December 2021were enrolled in this study. Endoscopic intracellular cyanoacrylate injection was first carried out. When failure, perintravascullar injection was carried out. The data were retrospectively collected. RESULTS Among the 154 patients, 102 patients (66.23%) obtained successful intravascular injection and perivascular injection was performed in 52 patients (33.77%). Immediate hemostatic rate for active bleeding achieved 93.18%. Overall rebleeding rate within 30 days was 12.99% and successful hemostasis rate achieved 87.01%. Immediate hemostatic rate and successful hemostasis rate in intravascular injection patients were markedly superior over perivascular injection. Rebleeding rate in intravascular injection patients was markedly lower than that in perivascular injection patients. 14 patients complicated abdominal pain and no other complication occurred. CONCLUSION Endoscopic cyanoacrylate injection therapy, especial intravascular injection, was effective and safe, with high successful hemostasis rate for refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy.
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Affiliation(s)
- Haijun Mou
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Cheng Zou
- Department of Gastroenterology, People's Hospital of Liupanshui City, Liupanshui, China
| | - Guoqing Shi
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Sheng Wu
- Department of Gastroenterology, People's Hospital of Liupanshui City, Liupanshui, China
| | - Rui Xie
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Xuemei Liu
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jie Yang
- Department of Gastroenterology, People's Hospital of Liupanshui City, Liupanshui, China
- Department of Gastroenterology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Biguang Tuo
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Choi JH, Cho IR, Lee SH, Kim JS, Park N, Lee MW, Jang DK, Paik WH, Ahn DW, Ryu JK, Kim YT, Kim E, Lee J. Efficacy and safety of novel hemostatic gel in endoscopic sphincterotomy or endoscopic papillectomy: A multicenter, randomized controlled clinical trial. Dig Liver Dis 2023; 55:527-533. [PMID: 36737314 DOI: 10.1016/j.dld.2023.01.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/07/2022] [Accepted: 01/22/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Endoscopists often experience obstacles with traditional hemostasis using the side-viewing duodenoscope for bleeding after endoscopic sphincterotomy (EST) or endoscopic papillectomy (EP). AIMS In this randomized controlled trial, we evaluated the efficacy and safety of a novel hemostatic gel for post-EST or post-EP bleeding. METHODS A randomized trial was conducted from November 2020 to December 2021 at two tertiary centers in South Korea. Patients who experienced bleeding immediately after EST or EP were enrolled in the study, and primary hemostasis was achieved with either the novel hemostatic gel or epinephrine spray. RESULTS A total of 84 patients were enrolled in this study, and 41 patients were finally analyzed in each group. Hemostatic gel was significantly superior to epinephrine spray for successful primary hemostasis (100% vs. 85.4%; P = 0.026). ). In terms of delayed bleeding, no significant difference was observed between the hemostatic gel and epinephrine spray (2.4% vs. 7.3%; P = 0.329). The mean procedural time was significantly higher for the hemostatic gel than epinephrine spray (3.23 ± 1.94 vs. 1.76 ± 0.99 min; P < 0.001), and no differences were observed in the adverse events. CONCLUSIONS The novel hemostatic gel is expected to achieve satisfactory results with easier hemostasis for immediate bleeding after EST or EP. (Registered in Clinical Research Information Service: KCT0005607).
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Affiliation(s)
- Jin Ho Choi
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - In Rae Cho
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Sang Hyub Lee
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea.
| | - Joo Seong Kim
- Department of Internal Medicine, Dongguk University College of Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Namyoung Park
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Min Woo Lee
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Woo Hyun Paik
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Dong Won Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Ji Kon Ryu
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Yong-Tae Kim
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Eunji Kim
- CG Bio Co., Ltd., Seoul, Republic of Korea
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Pung L, Ronald JS, Befera NT, Cline BC, Martin JG. Utility of CBCT and AVD for intraprocedural diagnosis and treatment of lower GI bleeding. Clin Imaging 2023; 94:103-107. [PMID: 36525881 DOI: 10.1016/j.clinimag.2022.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 11/09/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intraprocedural Cone Beam CT (CBCT) is assessed to examine if use improves diagnosis and embolization rates of acute lower GI bleed (LGIB) and if automatic vessel detection (AVD) software can identify feeding vessels (FV) for embolization. METHODS Patients with inconclusive DSA findings had CBCT and retrospective analysis with AVD software (Innova 3100, GE Company, USA). Technical success was defined as the ability to detect a lower GIB site while clinical success was defined as successful embolization without evidence of rebleeding or death within 30 days. AVD technical success was defined by the ability to identify the FV on both CTA and CBCT upon independent review by 3 blinded IRs, who also assigned a degree of certainty on a 5-point Likert scale. RESULTS 74 patients in total were treated for lower GI bleed of which 34 had indeterminate DSA. Of those, 10 patients received DSA only, of which 1 was super selective. 24 patients with GIB on pre-procedural CTA and inconclusive DSA underwent CBCT. Use of CBCT identified 9 bleeds not seen on DSA and an additional source artery in 1 case representing a 42% change in intraprocedural management as all findings were embolized. When a bleed could not be identified on CBCT, but the FV could be identified on CTA, the same suspected FV could be selected on AVD 62% of the time with an average certainty of 4.0. CONCLUSION CBCT is useful in the intraprocedural detection of GIB when DSA is indeterminate. Furthermore, AVD software can feasibly be utilized to accurately identify FVs for empiric treatment when intraprocedural imaging is inconclusive. LEVEL OF EVIDENCE Level III, therapeutic study.
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AGA Institute Quality Indicator Development and Uses. Clin Gastroenterol Hepatol 2023; 21:1399-1402. [PMID: 36640806 DOI: 10.1016/j.cgh.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Shah A, Kerner V, Stanworth SJ, Agarwal S. Major haemorrhage: past, present and future. Anaesthesia 2023; 78:93-104. [PMID: 36089857 PMCID: PMC10087440 DOI: 10.1111/anae.15866] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 12/15/2022]
Abstract
Major haemorrhage is a leading cause of morbidity and mortality worldwide. Successful treatment requires early recognition, planned responses, readily available resources (such as blood products) and rapid access to surgery or interventional radiology. Major haemorrhage is often accompanied by volume loss, haemodilution, acidaemia, hypothermia and coagulopathy (factor consumption and fibrinolysis). Management of major haemorrhage over the past decade has evolved to now deliver a 'package' of haemostatic resuscitation including: surgical or radiological control of bleeding; regular monitoring of haemostasis; advanced critical care support; and avoidance of the lethal triad of hypothermia, acidaemia and coagulopathy. Recent trial data advocate for a more personalised approach depending on the clinical scenario. Fresh frozen plasma should be given as early as possible in major trauma in a 1:1 ratio with red blood cells until the results of coagulation tests are available. Tranexamic acid is a cheap, life-saving drug and is advocated in major trauma, postpartum haemorrhage and surgery, but not in patients with gastrointestinal bleeding. Fibrinogen levels should be maintained > 2 g.l-1 in postpartum haemorrhage and > 1.5 g.l-1 in other haemorrhage. Improving outcomes after major traumatic haemorrhage is now driving research to include extending blood-product resuscitation into prehospital care.
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Affiliation(s)
- A Shah
- Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - V Kerner
- Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S J Stanworth
- Radcliffe Department of Medicine, University of Oxford, UK
| | - S Agarwal
- Department of Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
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Valladares-Pasquel AG, Lanz-Zubiría L, Hernández Guerrero AI. Modification of the endoscopic hemostatic powder application technique. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2022; 8:47-49. [PMID: 36820253 PMCID: PMC9938313 DOI: 10.1016/j.vgie.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Video 1Modification of the endoscopic hemostatic powder application technique.
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Affiliation(s)
- Alvaro G. Valladares-Pasquel
- Department of Gastrointestinal Endoscopy, Instituto Nacional de Cancerología, Mexico City, Mexico,Gastroenterology Department, Medica Sur, Mexico City, Mexico
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Kawaguchi K, Yoshida A, Yuki T, Shibagaki K, Tanaka H, Fujishiro H, Miyaoka Y, Yanagitani A, Koda M, Ikuta Y, Hamamoto T, Mukoyama T, Sasaki Y, Kushiyama Y, Yuki M, Noguchi N, Miura M, Ikebuchi Y, Yashima K, Kinoshita Y, Ishihara S, Isomoto H. A multicenter prospective study of the treatment and outcome of patients with gastroduodenal peptic ulcer bleeding in Japan. Medicine (Baltimore) 2022; 101:e32281. [PMID: 36626498 PMCID: PMC9750535 DOI: 10.1097/md.0000000000032281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Gastroduodenal peptic ulcers are the main cause of nonvariceal upper gastrointestinal bleeding (UGIB). We believe that recent advances in endoscopic techniques and devices for diagnosing upper gastrointestinal tract tumors have advanced hemostasis for UGIB. However, few prospective multicenter studies have examined how these changes affect the prognosis. This prospective study included 246 patients with gastroduodenal peptic ulcers treated at 14 participating facilities. The primary endpoint was in-hospital mortality within 4 weeks, and the secondary endpoints required intervention and refractory bleeding. Subsequently, risk factors affecting these outcomes were examined using various clinical items. Furthermore, the usefulness of the risk stratification using the Glasgow-Blatchford score, rockall score and AIMS65 based on data from the day of the first urgent endoscopy were examined in 205 cases in which all items were complete there are two periods. Thirteen (5%) patients died within 4 weeks; and only 2 died from bleeding. Significant risk factors for poor outcomes were older age and severe comorbidities. Hemostasis was required in 177 (72%) cases, with 20 cases of refractory bleeding (2 due to unsuccessful endoscopic treatment and 18 due to rebleeding). Soft coagulation was the first choice for endoscopic hemostasis in 57% of the cases and was selected in more than 70% of the cases where combined use was required. Rockall score and AIMS65 predicted mortality equally, and Glasgow-Blatchford score was the most useful in predicting the requirement for intervention. All scores predicted refractory bleeding similarly. Although endoscopic hemostasis for UGIB due to peptic ulcer had a favorable outcome, old age and severe comorbidities were risk factors for poor prognosis. We recommend that patients with UGIB should undergo early risk stratification using a risk scoring system.
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Affiliation(s)
- Koichiro Kawaguchi
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Yonago, Japan
- * Correspondence: Koichiro Kawaguchi, Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago City 683-8504, Japan (e-mail: )
| | - Akira Yoshida
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Takafumi Yuki
- Department of Internal Medicine II, Shimane University Faculty of Medicine, Izumo, Japan
- Division of Gastroenterology, Matsue Red Cross Hospital, Matsue, Japan
| | - Kotaro Shibagaki
- Gastrointestinal Endoscopy, Shimane University Hospital, Izumo, Japan
| | - Hisao Tanaka
- Division of Gastroenterology, Tottori Red Cross Hospital, Tottori, Japan
| | - Hirofumi Fujishiro
- Division of Gastroenterology, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Youichi Miyaoka
- Division of Gastroenterology, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Atsushi Yanagitani
- Division of Gastroenterology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Masaharu Koda
- Division of Gastroenterology, Yonago Medical Center, Yonago, Japan
| | - Yukihiro Ikuta
- Division of Gastroenterology, Hamada Medical Center, Hamada, Japan
| | | | | | - Yuichiro Sasaki
- Division of Gastroenterology, Sakaiminato Saiseikai General Hospital, Sakaiminato, Japan
| | | | - Mika Yuki
- Division of Internal Medicine, Izumo-City General Medical Center, Izumo, Japan
- Endoscopic Center, Izumo Tokushukai Hospital, Izumo, Japan
| | - Naoya Noguchi
- Division of Gastroenterology, Tottori Prefectural Kosei Hospital, Kurayoshi, Japan
| | - Masahiko Miura
- Division of Gastroenterology, Matsue City Hospital, Matsue, Japan
| | - Yuichiro Ikebuchi
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Kazuo Yashima
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yoshikazu Kinoshita
- Department of Internal Medicine II, Shimane University Faculty of Medicine, Izumo, Japan
- Steel Hirohata Memorial Hospital, Himeji, Japan
| | - Shunji Ishihara
- Department of Internal Medicine II, Shimane University Faculty of Medicine, Izumo, Japan
| | - Hajime Isomoto
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Yonago, Japan
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He S, Liu L, Ouyang L, Wang J, Lv N, Chen Y, Shu X, Zhu Z. Nomogram for predicting rebleeding after initial endoscopic epinephrine injection monotherapy hemostasis in patients with peptic ulcer bleeding: a retrospective cohort study. BMC Gastroenterol 2022; 22:368. [PMID: 35909111 PMCID: PMC9341049 DOI: 10.1186/s12876-022-02448-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/22/2022] [Indexed: 11/28/2022] Open
Abstract
Background Although the current guidelines recommend endoscopic combination therapy, endoscopic epinephrine injection (EI) monotherapy is still a simple, common and effective modality for treating peptic ulcer bleeding (PUB). However, the rebleeding risk after EI monotherapy is still high, and identifying rebleeding patients after EI monotherapy is unclear, which is highly important in clinical practice. This study aimed to identify risk factors and constructed a predictive nomogram related to rebleeding after EI monotherapy. Methods We consecutively and retrospectively analyzed 360 PUB patients who underwent EI monotherapy between March 2014 and July 2021 in our center. Then we identified independent risk factors associated with rebleeding after initial endoscopic EI monotherapy by multivariate logistic regression. A predictive nomogram was developed and validated based on the above predictors. Results Among all PUB patients enrolled, 51 (14.2%) had recurrent hemorrhage within 30 days after endoscopic EI monotherapy. After multivariate logistic regression, shock [odds ratio (OR) = 12.691, 95% confidence interval (CI) 5.129–31.399, p < 0.001], Rockall score (OR = 1.877, 95% CI 1.250–2.820, p = 0.002), tachycardia (heart rate > 100 beats/min) (OR = 2.610, 95% CI 1.098–6.203, p = 0.030), prolonged prothrombin time (PT > 13 s) (OR = 2.387, 95% CI 1.019–5.588, p = 0.045) and gastric ulcer (OR = 2.258, 95% CI 1.003–5.084, p = 0.049) were associated with an increased risk of rebleeding after an initial EI monotherapy treatment. A nomogram incorporating these independent high-risk factors showed good discrimination, with an area under the receiver operating characteristic curve (AUROC) of 0.876 (95% CI 0.817–0.934) (p < 0.001). Conclusions We developed a predictive nomogram of rebleeding after EI monotherapy, which had excellent prediction accuracy. This predictive nomogram can be conveniently used to identify low-risk rebleeding patients after EI monotherapy, allowing for decision-making in a clinical setting.
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Lee HA, Jung HK, Kim TO, Byeon JR, Jeong ES, Cho HJ, Tae CH, Moon CM, Kim SE, Shim KN, Jung SA. Clinical outcomes of acute upper gastrointestinal bleeding according to the risk indicated by Glasgow-Blatchford risk score-computed tomography score in the emergency room. Korean J Intern Med 2022; 37:1176-1185. [PMID: 36375488 PMCID: PMC9666247 DOI: 10.3904/kjim.2022.099] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/18/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND/AIMS Acute upper gastrointestinal (UGI) bleeding is a significant emergency situation with a mortality rate of 2% to 10%. Therefore, initial risk stratification is important for proper management. We aimed to evaluate the role of contrast-enhanced multidetector computed tomography (MDCT) for risk stratification in patients with acute UGI bleeding in the emergency room (ER). METHODS This retrospective study included patients with UGI bleeding in the ER. Glasgow-Blatchford risk score-computed tomography (GBS-CT) was assessed using a combination of GBS and the MDCT scan scoring system. RESULTS Of the 297 patients with UGI bleeding, 124 (41.8%) underwent abdominal MDCT. Among them, 90.3% were classified as high-risk by GBS, and five patients died (4.0%). Rebleeding occurred in nine patients (7.3%). The high-risk GBS-CT group had significantly higher in-hospital mortality (10.5% in high-risk vs. 1.4% in moderate risk vs. 0% in low-risk, p = 0.049), transfusion amount (p < 0.001), and endoscopic hemostasis (p < 0.001) compared to the moderate- and low-risk groups. CONCLUSION Adding MDCT scans to the existing validated prognosis model when predicting the risk of UGI bleeding in patients in the ER plays a significant role in determining in-hospital mortality, transfusions, and the need for endoscopic hemostasis.
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Affiliation(s)
- Hyun Ae Lee
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Hye-Kyung Jung
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Tae Oh Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Ju-Ran Byeon
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Eui-Sun Jeong
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Hyun-Ji Cho
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Chung Hyun Tae
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Chang Mo Moon
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Seong-Eun Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Ki-Nam Shim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Sung-Ae Jung
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
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Safety and Efficacy of Sedation During Emergency Endoscopy for Upper Gastrointestinal Bleeding: A Propensity Score Matching Analysis. Dig Dis Sci 2022; 68:1426-1434. [PMID: 36272038 PMCID: PMC10102050 DOI: 10.1007/s10620-022-07740-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/13/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM This study aimed to compare patients with and without sedation during emergency endoscopy for upper gastrointestinal bleeding (UGIB) and to clarify the safety and efficacy of sedation in emergency endoscopy. METHODS We retrospectively collected 389 patients who underwent emergency endoscopy for UGIB at Ureshino Medical Center from 2016 to 2021. Patients were divided into two groups: sedation group during emergency endoscopy and nonsedation group. Clinical characteristics, patient status on admission, and UGIB etiology were evaluated. Treatment outcomes and adverse events were evaluated using propensity score matching (PSM), and risk factors for mortality from UGIB were investigated using Cox multivariate analysis. RESULTS The sedation group was significantly younger, composed of a higher proportion of males, and had chronic liver disease. Blood pressure and hemoglobin level on admission were significantly higher in the sedation group. The main cause of bleeding was peptic ulcer, which was significantly higher in the nonsedation group. PSM created 133 matched pairs. The success rate of endoscopic hemostasis was similar in both groups, and procedure time was significantly shorter in the sedation group than in the nonsedation group (17.6 ± 10.0 versus 20.2 ± 10.2 min, P = 0.04). There were no significant differences in adverse events between groups. Cox multivariate analyses revealed that red blood cell transfusion [hazard ratio (HR) 4.45, P < 0.02] and rebleeding (HR 3.30, P = 0.03) were associated with increased risk of 30-day mortality from UGIB. CONCLUSIONS Sedation reduced the procedure time during emergency endoscopy for UGIB. Sedation during emergency endoscopy for UGIB is acceptable for safe endoscopic procedures.
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Saffo S, Nagar A. Impact of epinephrine volume on further bleeding due to high-risk peptic ulcer disease in the combination therapy era. World J Gastrointest Pharmacol Ther 2022; 13:67-76. [PMID: 36157267 PMCID: PMC9453442 DOI: 10.4292/wjgpt.v13.i5.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/22/2022] [Accepted: 07/31/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND In monotherapy studies for bleeding peptic ulcers, large volumes of epinephrine were associated with a reduction in rebleeding. However, the impact of epinephrine volume in patients treated with combination endoscopic therapy remains unclear.
AIM To assess whether epinephrine volume was associated with bleeding outcomes in individuals who also received endoscopic thermal therapy and/or clipping.
METHODS Data from 132 patients with Forrest class Ia, Ib, and IIa peptic ulcers were reviewed. The primary outcome was further bleeding at 7 d; secondary outcomes included further bleeding at 30 d, need for additional therapeutic interventions, post-endoscopy blood transfusions, and 30-day mortality. Logistic and linear regression and Cox proportional hazards analyses were performed.
RESULTS There was no association between epinephrine volume and all primary and secondary outcomes in multivariable analyses. Increased odds for further bleeding at 7 d occurred in patients with elevated creatinine values (aOR 1.96, 95%CI 1.30-3.20; P < 0.01) or hypotension requiring vasopressors (aOR 6.34, 95%CI 1.87-25.52; P < 0.01). Both factors were also associated with all secondary outcomes.
CONCLUSION Epinephrine maintains an important role in the management of bleeding ulcers, but large volumes up to a range of 10-20 mL are not associated with improved bleeding outcomes among individuals receiving combination endoscopic therapy. Further bleeding is primarily associated with patient factors that likely cannot be overcome by increased volumes of epinephrine. However, in carefully-selected cases where ulcer location or size pose therapeutic challenges or when additional modalities are unavailable, it is conceivable that increased volumes of epinephrine may still be beneficial.
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Affiliation(s)
- Saad Saffo
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT 06520, United States
| | - Anil Nagar
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT 06520, United States
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Bai Y, Lei C, Zhang N, Liu Y, Hu Z, Li Y, Qi R. Peri-Ulcerative Mucosal Inflammation Appearance is an Independent Risk Factor for 30-Day Rebleeding in Patients with Gastric Ulcer Bleeding: A Multicenter Retrospective Study. J Inflamm Res 2022; 15:4951-4961. [PMID: 36065317 PMCID: PMC9440673 DOI: 10.2147/jir.s378263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/12/2022] [Indexed: 12/07/2022] Open
Abstract
Aim The aim of this study was to identify clinical endoscopic indicators related to peri-ulcerative mucosal inflammation and to analyze whether the degree of peri-ulcerative mucosal inflammation appearance is an independent risk factor for gastric ulcer rebleeding. Methods We conducted a retrospective study that included patients with gastric ulcer bleeding who were hospitalized at three medical centers in China from January 1, 2016 to December 31, 2019. Ulcer rebleeding that occurred within 30 days of successful initial hemostasis was analyzed to determine whether this event was related to the degree of peri-ulcerative mucosal inflammation appearance or other mucosal inflammation-related factors. Results We enrolled 1111 patients and determined that GBS-Rebleeding-ROC (P<0.001), age (P=0.01), use of NSAIDs (P=0.001), bile reflux (P<0.001), and Helicobacter pylori (P<0.001) are all risk factors for peri-ulcerative mucosal inflammation appearance. Through multivariate analysis, we determined that severe peri-ulcerative mucosal inflammation appearance (P=0.002) was an independent risk factor for ulcer rebleeding within 30 days. Finally, we developed a risk assessment model using factors associated with mucosal inflammation that may be useful for early prediction of rebleeding. Conclusion The risk factors for peri-ulcerative mucosal inflammation appearance were identified. Severe peri-ulcerative mucosal inflammation appearance is an independent risk factor for ulcer rebleeding.
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Affiliation(s)
- Yixuan Bai
- Department of Digestive Internal Medicine, Affiliated Dalian Friendship Hospital of Dalian Medical University, Dalian, People’s Republic of China
| | - Chenggang Lei
- Department of Hepatobiliary Surgery, Qingdao Municipal Hospital, Qingdao, People’s Republic of China
| | - Na Zhang
- Department of Digestive Internal Medicine, Affiliated Dalian Friendship Hospital of Dalian Medical University, Dalian, People’s Republic of China
| | - Yuhui Liu
- Department of Digestive Internal Medicine, Affiliated Dalian Friendship Hospital of Dalian Medical University, Dalian, People’s Republic of China
| | - Zhengyu Hu
- Department of General Surgery, Shanghai Tenth People’s Hospital, Affiliated to Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Yan Li
- Department of Gastroenterology, Shanghai Tenth People’s Hospital, Affiliated to Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Ran Qi
- Department of General Surgery, Tongji Hospital of Tongji University, School of Medicine, Tongji University, Shanghai, People’s Republic of China
- Correspondence: Ran Qi, Department of General Surgery, Tongji Hospital of Tongji University, School of Medicine, Tongji University, 389 Xincun Road, Putuo District, Shanghai, 200092, People’s Republic of China, Email
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Nian B, Wang B, Wang L, Yi L. A Cohort Study to Compare Effects between Ulcer- and Nonulcer-Related Nonvariceal Upper Gastrointestinal Bleeding. Appl Bionics Biomech 2022; 2022:3342919. [PMID: 35721238 PMCID: PMC9205735 DOI: 10.1155/2022/3342919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/09/2022] [Accepted: 05/17/2022] [Indexed: 11/18/2022] Open
Abstract
Objective The aim of this study was to better understand the characteristics and etiology of acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) in recent years in this region and to provide evidence-based medical evidence. Methods 100 patients with acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) who met the clinical diagnostic criteria of ANVUGIB admitted to Suzhou First People's Hospital from January 2017 to December 2021 were analyzed, as well as the age difference and change rule. According to age, 100 patients were divided into young (18-39 years), middle-aged (40-59 years), and elderly (60 years and above), and the differences in the three groups were compared. The etiology was confirmed by endoscopic examination and was recorded one by one in a well-designed ANVUGIB case data registration form. Statistical software SPSS 23.0 was used for analysis. Results Gastric ulcer was the main cause in the elderly group (50.0%), duodenal ulcer was the main cause in the middle and young groups, and gastrointestinal cancer (7.1%) and marginal ulcer (2.3%) in the elderly group were higher than those in the young group. Nonsteroidal anti-inflammatory drugs (52.3%) were the main inducement in the elderly group, which was significantly higher than in the middle-aged group (13.1%) and the young group (5%) (P < 0.01). Drinking, fatigue, and emotional excitement led to a higher proportion in the middle-aged group and the young group, in comparison to the elderly group (P < 0.01). Conclusion Peptic ulcer is the most common cause of acute nonvariceal upper gastrointestinal bleeding, followed by acute gastric mucosal lesions and upper digestive system tumors, compared with nonulcer.
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Affiliation(s)
- Bi Nian
- Department of Gastroenterology, Suzhou First People's Hospital, China
| | - Bangping Wang
- Department of Gastroenterology, Suzhou First People's Hospital, China
| | - Long Wang
- Gastroenterology Department, Suzhou Municipal Hospital, China
| | - Lanjuan Yi
- Department of Gastroenterology, Yantai Mountain Hospital, Yantai, China
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Galloro G, Zullo A, Luglio G, Chini A, Telesca DA, Maione R, Pollastro M, De Palma GD, Manta R. Endoscopic clipping in non-variceal upper gastrointestinal bleeding treatment. Clin Endosc 2022; 55:339-346. [PMID: 35534934 PMCID: PMC9178136 DOI: 10.5946/ce.2021.249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/05/2022] [Indexed: 11/20/2022] Open
Abstract
Since the earliest reports, advanced clipping systems have been developed, and it is possible to choose among many models with different structural and technical features. The main drawback of through-the-scope clips is their small size, which allows the compression of limited amounts of tissue needed for large-size vessel treatment. Therefore, the over-the-scope clip system was realized, allowing a larger and stronger mechanical compression of large tissue areas, with excellent results in achieving a definitive hemostasis in difficult cases. Many studies have analyzed the indications and efficacy of two-pronged endoclips and have shown good results for initial and permanent hemostasis. The aim of this review was to provide updated information on indications, positioning techniques, and results of clip application for endoscopic treatment of upper gastrointestinal non-variceal bleeding lesions.
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Affiliation(s)
- Giuseppe Galloro
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
- Correspondence to: Giuseppe Galloro Department of Clinical Medicine and Surgery, Federico II University of Naples, Via Sergio Pansini, 5, Naples 80131, Italy E-mail:
| | - Angelo Zullo
- Gastroenterology and Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Roma, Italy
| | - Gaetano Luglio
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
| | - Alessia Chini
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
| | | | - Rosa Maione
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
| | - Matteo Pollastro
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
| | - Giovanni Domenico De Palma
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
| | - Raffaele Manta
- Gastroenterology and Digestive Endoscopy Unit, General Hospital, Perugia, Italy
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