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Hameed H, Hussain J, Cláudia Paiva-Santos A, Zaman M, Hamza A, Sajjad I, Asad F. Comprehensive insights on treatment modalities with conventional and herbal drugs for the treatment of duodenal ulcers. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024:10.1007/s00210-024-03178-5. [PMID: 38837070 DOI: 10.1007/s00210-024-03178-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 05/21/2024] [Indexed: 06/06/2024]
Abstract
Areas of the body accessible to gastric secretions, such as the stomach and duodenum, are most commonly damaged by circumscribed lesions of the upper gastrointestinal tract mucosa. Peptic ulcer disease is the term for this illness (PUD). About 80% of peptic ulcers are duodenal ulcers, with stomach ulcers accounting for the remaining 20%. Duodenal ulcers are linked to the two primary results about Helicobacter pylori infection and COX inhibitor users. Additional causes might include drinking, smoking, stress, and coffee consumption. The indications and symptoms of a duodenal ulcer depend on the patient's age and the lesion's location. For duodenal ulcers, proton pump inhibitors (PPIs) are the usual course of treatment. This comprehensive study included an in-depth literature search in the literature and methods section using electronic databases such as PubMed, ScienceDirect, and Google Scholar. The search method included publications published from the inception of the relevant database to the present. Inclusion criteria included studies investigating different treatment options for duodenal ulcer disease, including traditional pharmacotherapy and naturopathic treatments. Data mining includes information on treatment techniques, treatment outcomes, and possible synergies between conventional and herbal treatments. In addition, this review critically examines the available information on the effectiveness, safety, and possible side effects of different treatments. The inclusion of conventional and herbal treatments is intended to provide a comprehensive overview of the many treatment options available for duodenal ulcer disease. A more comprehensive and personalized treatment plan can be achieved by incorporating dietary changes, lifestyle modifications, and, if necessary, herbal therapies to complement other treatments normally.
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Affiliation(s)
- Huma Hameed
- Faculty of Pharmaceutical Sciences, University of Central Punjab, Lahore, 54000, Pakistan.
| | - Jahangir Hussain
- Faculty of Pharmaceutical Sciences, University of Central Punjab, Lahore, 54000, Pakistan
| | - Ana Cláudia Paiva-Santos
- Department of Pharmaceutical Technology, Faculty of Pharmacy of the University of Coimbra, University of Coimbra, Coimbra, 3000-548, Portugal
- REQUIMTE/LAQV, Group of Pharmaceutical Technology, Faculty of Pharmacy of the University of Coimbra, University of Coimbra, Coimbra, 3000-548, Portugal
| | - Muhammad Zaman
- Faculty of Pharmaceutical Sciences, University of Central Punjab, Lahore, 54000, Pakistan
| | - Ali Hamza
- Faculty of Pharmaceutical Sciences, University of Central Punjab, Lahore, 54000, Pakistan
| | - Irsa Sajjad
- Faculty of Pharmaceutical Sciences, University of Central Punjab, Lahore, 54000, Pakistan
| | - Faria Asad
- Faculty of Pharmaceutical Sciences, University of Central Punjab, Lahore, 54000, Pakistan
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Kamal S, Varshney K, Lo SW, Ramachandran V, Lewis D. Endoscopic Visualization of the Embolization Coil With Subsequent Endoscopic Therapy: A Case Report. Cureus 2024; 16:e58769. [PMID: 38779257 PMCID: PMC11110468 DOI: 10.7759/cureus.58769] [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] [Accepted: 04/20/2024] [Indexed: 05/25/2024] Open
Abstract
Severe gastrointestinal bleeding is a common presentation to the emergency department. In such settings, trans-arterial embolization (TAE) may be conducted to address the bleeding. However, in some circumstances, this treatment may fail. Over-the-scope clips (OTSCs) have also shown efficacy when the first-line treatment is unsuccessful, and in this case report, we describe what we believe is the first reported application of OTSCs after TAE with partial coil migration. The patient had initially arrived at the emergency department with severe gastrointestinal bleeding, and despite the usage of inotropes and TAE, the patient had developed severe rebleeding. She ultimately recovered well after the utilization of OTSCs. This case report highlights that this form of management may be a valuable endoscopic therapy in preventing further coil migration for patients with emergency gastrointestinal bleeding.
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Affiliation(s)
- Shahed Kamal
- Department of Internal Medicine, Northern Hospital Epping, Melbourne, AUS
| | - Karan Varshney
- Department of Public Health, School of Medicine, Deakin University, Waurn Ponds, AUS
| | - Sheng-Weng Lo
- Department of Gastroenterology, Northern Health, Melbourne, AUS
| | | | - Diana Lewis
- Department of Gastroenterology, Northern Health, Melbourne, AUS
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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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Shishido Y, Mitsuoka E, Tanigawa Y, Ooki H, Shio S, Monzawa S, Ishii M, Fujimoto K. Duodenal ulcer bleeding from a branch of the middle colic artery: A case report. Medicine (Baltimore) 2023; 102:e35955. [PMID: 37933022 PMCID: PMC10627650 DOI: 10.1097/md.0000000000035955] [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: 06/19/2023] [Accepted: 10/13/2023] [Indexed: 11/08/2023] Open
Abstract
RATIONALE Duodenal ulcer bleeding is a potentially life-threatening condition commonly caused by the erosion of the duodenal arteries. PATIENT CONCERNS A 55-year-old male was referred to our hospital with abdominal pain for the past 3 days. Contrast-enhanced computed tomography of the abdomen revealed wall thickening in the descending part of the duodenum and a cystic lesion (27 × 19 mm) contiguous with the duodenum, with an accumulation of fluid. An esophagogastroduodenoscopy showed the significantly stenotic duodenum, which prevented passage of the endoscope and evaluation of the main lesion. Based on these findings, duodenal ulcer perforation and concomitant abscess formation were suspected. Two days after admission, he had massive hematochezia with bloody drainage from the nasogastric tube. DIAGNOSES Emergency angiography revealed duodenal ulcer bleeding from the gastroduodenal artery and the branch artery of the inferior pancreaticoduodenal artery and middle colic artery (MCA). INTERVENTIONS The patient was treated with transcatheter arterial embolization (TAE) of the gastroduodenal artery, the branch vessel of the inferior pancreaticoduodenal artery, and the main trunk of the MCA. OUTCOMES Hemostasis was achieved with TAE. The patient recovered uneventfully and undergone a gastro-jejunal bypass surgery for the duodenal stenosis 2 weeks after TAE. He was discharged without any abnormal complaints on postoperative day 12. LESSONS We have experienced a rare case of duodenal ulcer bleeding from a branch of the MCA. In patients with refractory upper gastrointestinal bleeding, careful evaluation of bleeding sites is recommended considering unexpected culprit vessels.
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Affiliation(s)
- Yutaka Shishido
- Department of Gastrointestinal Surgery, Shinko Hospital, Kobe, Hyogo, Japan
| | - Eisei Mitsuoka
- Department of Gastrointestinal Surgery, Shinko Hospital, Kobe, Hyogo, Japan
| | - Yuma Tanigawa
- Department of Gastrointestinal Surgery, Shinko Hospital, Kobe, Hyogo, Japan
| | - Hodaka Ooki
- Department of Diagnostic Radiology, Shinko Hospital, Kobe, Hyogo, Japan
| | - Seiji Shio
- Department of Gastroenterology, Shinko Hospital, Kobe, Hyogo, Japan
| | - Shuichi Monzawa
- Department of Diagnostic Radiology, Shinko Hospital, Kobe, Hyogo, Japan
| | - Masayuki Ishii
- Department of Gastrointestinal Surgery, Shinko Hospital, Kobe, Hyogo, Japan
| | - Koji Fujimoto
- Department of Gastrointestinal Surgery, Shinko Hospital, Kobe, Hyogo, Japan
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Ahmad H, Khan U, Jannat H, Ahmad N. Recurrent Gastrointestinal Bleeding in an Elderly Patient With Peptic Ulcer Disease: Successful Management Through Multidisciplinary Intervention and Close Monitoring. Cureus 2023; 15:e41468. [PMID: 37546113 PMCID: PMC10404137 DOI: 10.7759/cureus.41468] [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] [Accepted: 07/06/2023] [Indexed: 08/08/2023] Open
Abstract
Upper gastrointestinal bleeding (UGIB) is a medical emergency with substantial morbidity and mortality worldwide. It is defined as bleeding originating in the gastrointestinal (GI) tract proximal to the ligament of Treitz and can be caused by various conditions, including peptic ulcers, gastritis, esophageal varices, Mallory-Weiss tears, and malignancies. Common complications include anemia, hemodynamic instability, perforation, and rebleeding. It is associated with high mortality and a poor prognosis, especially in high-risk populations. Management includes medical treatment, endoscopic intervention, endovascular arterial embolization, and surgery. We present an interesting case of an 87-year-old male with a history of duodenal ulcers who presented with a bleeding duodenal ulcer complicated by recurrent bleeding despite multiple hemostatic endoscopic interventions and arterial embolization. This case highlights the complexities involved in managing recurrent upper GI bleeding and emphasizes the significance of multidisciplinary approaches, timely interventions, and close monitoring.
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Affiliation(s)
- Hamad Ahmad
- Internal Medicine, Westchester Medical Center, Valhalla, USA
| | - Urooj Khan
- Internal Medicine, Khyber Medical University, Peshawar, PAK
| | - Hoore Jannat
- Internal Medicine, Khyber Medical College, Peshawar, PAK
| | - Noaman Ahmad
- Internal Medicine, Huntsville Hospital, Huntsville, USA
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Kuellmer A, Mangold T, Bettinger D, Schiemer M, Mueller J, Wannhoff A, Caca K, Wedi E, Kleemann T, Thimme R, Schmidt A. Reduced mortality for over-the-scope clips (OTSC) versus surgery for refractory peptic ulcer bleeding: a retrospective study. Surg Endosc 2023; 37:1854-1862. [PMID: 36253626 PMCID: PMC10017662 DOI: 10.1007/s00464-022-09679-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/25/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Surgery or transcatheter arterial embolization or are both considered as standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over-The-Scope clips (OTSC) have shown superiority to standard endoscopic treatment but a comparison with surgery has not been performed, yet. PATIENTS AND METHODS In this retrospective, multicenter study, 103 patients treated with OTSC (n = 66) or surgery (n = 37) for refractory PUB in four tertiary care centers between 2009 and 2019 were analyzed. Primary endpoint was clinical success (successful hemostasis and no rebleeding within seven days). Secondary endpoints were adverse events, length of ICU-stay and in-hospital mortality. Univariable and multivariable regression models were performed to define predictive factors for allocation to surgical therapy and for mortality. RESULTS Age, comorbidities, anticoagulation therapy, number of pretreatments, ulcer location, and Rockall-Score were similar in both groups. In the surgical group, there were significantly more patients in shock at rebleeding (78.1% vs. 43.9%; p = 0.002), larger ulcers (18.6 ± 7.4 mm vs. 23.0 ± 9.4 mm; p = 0.017) and more FIa bleedings (64.9% vs. 19.7%; p < 0.001) were detected. Clinical success was comparable (74.2% vs. 83.8%; p = 0.329). In the surgical group, length of ICU-stay (16.2 ± 18.0 days vs. 4.7 ± 6.6 days; p < 0.001), severe adverse events (70.3% vs. 4.5%; p < 0.001) and in-hospital mortality (35.1% vs. 9.1%; p = 0.003) were significantly higher. Multivariable analysis defined shock at rebleeding as the main predictor for allocation to surgical therapy (OR 4.063, 95%CI {1.496-11.033}, p = 0.006). Postsurgical adverse events were the main reason for the in-hospital mortality (OR 5.167, 95% CI {1.311-20.363}, p = 0.019). CONCLUSION In this retrospective study, OTSC compared to surgical treatment showed comparable clinical success but was associated with shorter ICU-stay, less severe adverse events and lower in-hospital mortality.
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Affiliation(s)
- Armin Kuellmer
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Tobias Mangold
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Moritz Schiemer
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Julius Mueller
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Andreas Wannhoff
- Department of Internal Medicine and Gastroenterology, Hospital Ludwigsburg, Ludwigsburg, Germany
| | - Karel Caca
- Department of Internal Medicine and Gastroenterology, Hospital Ludwigsburg, Ludwigsburg, Germany
| | - Edris Wedi
- Medizinische Klinik II / IV, Sana Klinikum Offenbach, Offenbach, Germany
| | - Tobias Kleemann
- Medinische Klinik IV, Carl-Thiem-Klinikum Cottbus, Cottbus, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.
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Caragher S, Wang D, Moonsamy P, Fagenholz P. Hepatic arterial haemorrhage caused by duodenal ulcer. BMJ Case Rep 2022; 15:e249523. [PMID: 36316056 PMCID: PMC9628537 DOI: 10.1136/bcr-2022-249523] [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: 11/06/2022] Open
Abstract
A man in his late 60s with prior Hartman's procedure underwent colostomy takedown and complex ventral hernia repair. He subsequently developed gastrointestinal (GI) bleeding from a duodenal bulb ulcer. Despite five endoscopic procedures aimed at achieving haemostasis, including placement of an over-the-scope clip, and four endovascular embolisations (inferior and superior pancreaticoduodenal, right gastroepiploic and gastroduodenal arteries), the patient continued to experience episodic, haemodynamically significant bleeding. He eventually required emergency exploratory laparotomy, where the proper hepatic artery was identified as the source (a previously unreported phenomenon). He underwent antrectomy and proper hepatic artery ligation. This case highlights the need to interrogate all portions of the hepatic vasculature in the treatment of refractory GI bleeding.
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Affiliation(s)
| | - Danny Wang
- General Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Philicia Moonsamy
- General Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter Fagenholz
- Trauma, Emergency Surgery & Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
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8
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Ishak C, Ghazanfar H, Kandhi S, Alemam A, Abbas H, Patel H, Chilimuri S. Role of Transcatheter Arterial Embolization in Acute Refractory Non-variceal Upper Gastrointestinal Bleeding Not Controlled by Endoscopy: A Single-Center Experience and a Literature Review. Cureus 2022; 14:e29962. [DOI: 10.7759/cureus.29962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 11/07/2022] Open
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9
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Orpen-Palmer J, Stanley AJ. Update on the management of upper gastrointestinal bleeding. BMJ MEDICINE 2022; 1:e000202. [PMID: 36936565 PMCID: PMC9951461 DOI: 10.1136/bmjmed-2022-000202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/15/2022] [Indexed: 11/04/2022]
Abstract
Upper gastrointestinal bleeding is a common emergency presentation requiring prompt resuscitation and management. Peptic ulcers are the most common cause of the condition. Thorough initial management with a structured approach is vital with appropriate intravenous fluid resuscitation and use of a restrictive transfusion threshold of 7-8 g/dL. Pre-endoscopic scoring tools enable identification of patients at high risk and at very low risk who might benefit from specific management. Endoscopy should be carried out within 24 h of presentation for patients admitted to hospital, although optimal timing for patients at a higher risk within this period is less clear. Endoscopic treatment of high risk lesions and use of subsequent high dose proton pump inhibitors is a cornerstone of non-variceal bleeding management. Variceal haemorrhage results in higher mortality than non-variceal haemorrhage and, if suspected, antibiotics and vasopressors should be administered urgently, before endoscopy. Oesophageal variceal bleeding requires endoscopic band ligation, whereas bleeding from gastric varices requires thrombin or tissue glue injection. Recurrent bleeding is managed by repeat endoscopic treatment. If uncontrolled bleeding occurs, interventional radiological embolisation or surgery is required for non-variceal bleeding or transjugular intrahepatic portosystemic shunt placement for variceal bleeding.
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Kubota Y, Yamauchi H, Nakatani K, Iwai T, Ishido K, Masuda T, Maruhashi T, Tanabe S. Factors for unsuccessful endoscopic hemostasis in patients with severe peptic ulcer bleeding. Scand J Gastroenterol 2021; 56:1396-1405. [PMID: 34455892 DOI: 10.1080/00365521.2021.1969593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Although the first approach for peptic ulcer bleeding is endoscopic hemostasis, quick determination of a hemostatic strategy is important in patients with vitals indicating shock. However, the unsuccessful factors for endoscopic treatment have yet to be sufficiently examined. We aimed to investigate the factors for unsuccessful endoscopic hemostasis in severe peptic ulcer bleeding. MATERIALS AND METHODS Unsuccessful factors were retrospectively investigated in 150 eligible patients who underwent endoscopic hemostasis for shock-presenting peptic ulcer bleeding at our critical care center between April 2007 and March 2021. RESULTS There were 123 and 27 cases of successful and unsuccessful endoscopic hemostasis, respectively. Causative diseases included gastric ulcer bleeding in 124 patients (82.7%) and duodenal ulcer bleeding in 26 patients (17.3%). Shock index (SI) (1.46 vs. 1.60) (p = .013), exposed blood vessel diameter (1.4 mm vs. 3.1 mm) (p < .001) identified on contrast-enhanced computed tomography (CE-CT), duodenal ulcer bleeding (p = .012), and Forrest classification Ia (p = .004) were extracted as independent factors for unsuccessful endoscopic hemostasis. In receiving operating curve analysis, when the cut-off value for the SI was set at 1.53, the sensitivity and specificity were 70.4% and 63.4%, respectively. When the cut-off value for the exposed blood vessel diameter was set at 1.9 mm, these were 88.9% and 83.7%, respectively. CONCLUSIONS When these factors (SI ≥ 1.53, exposed blood vessel diameter ≥1.9 mm identified on CE-CT, duodenal ulcer bleeding, and Forrest Ia) are present in patients with severe peptic ulcer bleeding, non-endoscopic hemostasis, such as interventional radiology (IVR) and surgery, should be considered.
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Affiliation(s)
- Yo Kubota
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hiroshi Yamauchi
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan.,Department of Emergency and Disaster medical center, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kento Nakatani
- Department of Emergency and Disaster medical center, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tomohisa Iwai
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kenji Ishido
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tomonari Masuda
- Department of Emergency and Disaster medical center, Kitasato University School of Medicine, Sagamihara, Japan
| | - Takaaki Maruhashi
- Department of Emergency and Disaster medical center, Kitasato University School of Medicine, Sagamihara, Japan
| | - Satoshi Tanabe
- Department of Research and Development Center for New Frontiers, Kitasato University School of Medicine, Sagamihara, Japan
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Kuellmer A, Mangold T, Bettinger D, Maruschke L, Wannhoff A, Caca K, Wedi E, Hosseini ASA, Kleemann T, Schulz T, Jung C, Thimme R, Schmidt A. Over-the-scope clip versus transcatheter arterial embolization for refractory peptic ulcer bleeding-A propensity score matched analysis. United European Gastroenterol J 2021; 9:1048-1056. [PMID: 34432392 PMCID: PMC8598957 DOI: 10.1002/ueg2.12135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/02/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Transcatheter arterial embolization (TAE) or surgery are standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over-the-scope clips (OTSC) have shown superiority to standard endoscopic treatment. OBJECTIVE To compare OTSC treatment to TAE in refractory peptic ulcer bleeding. PATIENTS AND METHODS In this retrospective, multicenter study, 128 patients treated with OTSC (n = 66) or TAE (n = 62) for refractory PUB between 2009 and 2019 in four academic centers were analyzed. Primary endpoint was clinical success (hemostasis + no rebleeding within 7 days). Secondary endpoints were adverse events, length of ICU stay, and mortality. Propensity score matching was performed to adjust for differences in baseline characteristics. RESULTS Patients characteristics were similar in both groups but ulcers in the TAE group were larger, more often located in the duodenal bulb (85.5% vs. 65.2%; p = 0.014), and that the proportion of Forrest Ia bleedings was higher (38.7% vs. 19.7%; p = 0.018). Clinical success was comparable in both groups (74.2% vs. 59.7%; p = 0.092). Stay on the intensive care unit (ICU) was significantly longer in the TAE group (mean 8.0 vs. 4.7 days; p = 0.002). Serious adverse events after re-therapy (12.9% vs. 1.5%; p = 0.042) and in-hospital mortality were significantly higher in the TAE group (9.1 vs. 22.6%, OR 2.92 [95% CI 1.04-8.16]; p = 0.05). After propensity score matching, the differences found regarding ICU stay (4.9± 5.9 and 9.2 ± 11.2; p = 0.009) and in-hospital mortality (5% vs. 22.5%; OR 5.52 [95% CI: 1.11-27.43]; p = 0.048) stayed significant. CONCLUSIONS OTSC treatment for refractory PUB was superior to TAE in terms of ICU stay and in-hospital mortality.
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Affiliation(s)
- Armin Kuellmer
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Tobias Mangold
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Dominik Bettinger
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
- Berta‐Ottenstein‐ProgrammeUniversity of FreiburgFreiburgGermany
| | - Lars Maruschke
- Department of RadiologySt.‐Josef HospitalRkK‐KlinikumFreiburgGermany
| | - Andreas Wannhoff
- Department of Internal Medicine and GastroenterologyHospital LudwigsburgLudwigsburgGermany
| | - Karel Caca
- Department of Internal Medicine and GastroenterologyHospital LudwigsburgLudwigsburgGermany
| | - Edris Wedi
- Medizinische Klinik II / IVSana Klinikum OffenbachOffenbachGermany
| | - Ali Seif Amir Hosseini
- Department of Diagnostic and Interventional RadiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Tobias Kleemann
- Medinische Klinik IVCarl‐Thiem‐Klinikum CottbusCottbusGermany
| | - Thomas Schulz
- Institut für RadiologieCarl‐Thiem‐Klinikum CottbusCottbusGermany
| | - Carlo Jung
- Gastroenterology and Digestive Endoscopy UnitForlì‐Cesena HospitalsAUSL RomagnaForlì‐CesenaItaly
| | - Robert Thimme
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Arthur Schmidt
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
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Li JL, Cheng P, Sheng WY, Zhang JX. Progress in new hemostasis techniques for acute upper gastrointestinal bleeding. Shijie Huaren Xiaohua Zazhi 2021; 29:1035-1042. [DOI: 10.11569/wcjd.v29.i18.1035] [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] [Indexed: 02/06/2023] Open
Abstract
Acute upper gastrointestinal bleeding (AUGIB) is one of the most common acute and critical illnesses in the emergency department. It mainly refers to gastrointestinal bleeding above the Treitz ligament, and the mortality rate is about 2%-10%. The main clinical manifestations are hematemesis and/or hematochezia. The diagnosis is mainly based on clinical manifestations combined with laboratory and imaging findings. Due to the rapid onset and severe nature of the condition, there are various treatment methods according to different causes. This article reviews the diagnosis and treatment of acute upper gastrointestinal bleeding.
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Affiliation(s)
- Jing-Lei Li
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Ping Cheng
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Wei-Yong Sheng
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Jin-Xiang Zhang
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
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Birda CL, Kumar A, Samanta J. Endotherapy for Nonvariceal Upper Gastrointestinal Hemorrhage. JOURNAL OF DIGESTIVE ENDOSCOPY 2021. [DOI: 10.1055/s-0041-1731962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AbstractNonvariceal upper gastrointestinal hemorrhage (NVUGIH) is a common GI emergency with significant morbidity and mortality. Triaging cases on the basis of patient-related factors, restrictive blood transfusion strategy, and hemodynamic stabilization are key initial steps for the management of patients with NVUGIH. Endoscopy remains a vital step for both diagnosis and definitive management. Multiple studies and guidelines have now defined the optimum timing for performing the endoscopy after hospitalization, to better the outcome. Conventional methods for achieving endoscopic hemostasis, such as injection therapy, contact, and noncontact thermal therapy, and mechanical therapy, such as through-the-scope clips, have reported to have 76 to 90% efficacy for primary hemostasis. Newer modalities to enhance hemostasis rates have come in vogue. Many of these modalities, such as cap-mounted clips, coagulation forceps, and hemostatic powders have proved to be efficacious in multiple studies. Thus, the newer modalities are recommended not only for management of persistent bleed and recurrent bleed after failed initial hemostasis, using conventional modalities but also now being advocated for primary hemostasis. Failure of endotherapy would warrant radiological or surgical intervention. Some newer tools to optimize endotherapy, such as endoscopic Doppler probes, for determining flow in visible or underlying vessels in ulcer bleed are now being evaluated. This review is focused on the technical aspects and efficacy of various endoscopic modalities, both conventional and new. A synopsis of the various studies describing and comparing the modalities have been outlined. Postendoscopic management including Helicobacter pylori therapy and starting of anticoagulants and antiplatelets have also been outlined.
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Affiliation(s)
- Chhagan L. Birda
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Antriksh Kumar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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14
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Kamada T, Satoh K, Itoh T, Ito M, Iwamoto J, Okimoto T, Kanno T, Sugimoto M, Chiba T, Nomura S, Mieda M, Hiraishi H, Yoshino J, Takagi A, Watanabe S, Koike K. Evidence-based clinical practice guidelines for peptic ulcer disease 2020. J Gastroenterol 2021; 56:303-322. [PMID: 33620586 PMCID: PMC8005399 DOI: 10.1007/s00535-021-01769-0] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/03/2021] [Indexed: 02/05/2023]
Abstract
The Japanese Society of Gastroenterology (JSGE) revised the third edition of evidence-based clinical practice guidelines for peptic ulcer disease in 2020 and created an English version. The revised guidelines consist of nine items: epidemiology, hemorrhagic gastric and duodenal ulcers, Helicobacter pylori (H. pylori) eradication therapy, non-eradication therapy, drug-induced ulcers, non-H. pylori, and nonsteroidal anti-inflammatory drug (NSAID) ulcers, remnant gastric ulcers, surgical treatment, and conservative therapy for perforation and stenosis. Therapeutic algorithms for the treatment of peptic ulcers differ based on ulcer complications. In patients with NSAID-induced ulcers, NSAIDs are discontinued and anti-ulcer therapy is administered. If NSAIDs cannot be discontinued, the ulcer is treated with proton pump inhibitors (PPIs). Vonoprazan (VPZ) with antibiotics is recommended as the first-line treatment for H. pylori eradication, and PPIs or VPZ with antibiotics is recommended as a second-line therapy. Patients who do not use NSAIDs and are H. pylori negative are considered to have idiopathic peptic ulcers. Algorithms for the prevention of NSAID- and low-dose aspirin (LDA)-related ulcers are presented in this guideline. These algorithms differ based on the concomitant use of LDA or NSAIDs and ulcer history or hemorrhagic ulcer history. In patients with a history of ulcers receiving NSAID therapy, PPIs with or without celecoxib are recommended and the administration of VPZ is suggested for the prevention of ulcer recurrence. In patients with a history of ulcers receiving LDA therapy, PPIs or VPZ are recommended and the administration of a histamine 2-receptor antagonist is suggested for the prevention of ulcer recurrence.
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Affiliation(s)
- Tomoari Kamada
- Department of Health Care Medicine, Kawasaki Medical School General Medical Center, 2-6-1, Nakasange, Kita-ku, Okayama, 700-8505, Japan.
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan.
| | - Kiichi Satoh
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshiyuki Itoh
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Masanori Ito
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Junichi Iwamoto
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Tadayoshi Okimoto
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Takeshi Kanno
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Mitsushige Sugimoto
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshimi Chiba
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Sachiyo Nomura
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Mitsuyo Mieda
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Hideyuki Hiraishi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Junji Yoshino
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Atsushi Takagi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Sumio Watanabe
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kazuhiko Koike
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
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Method of diagnosis and treatment of profusional bleeding from stenosing postbulbar ulcers of the duodenum. EUREKA: HEALTH SCIENCES 2021. [DOI: 10.21303/2504-5679.2021.001730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The aim. To evaluate the effectiveness of X-ray interventions in arosive bleeding in patients with complicated duodenal ulcer.
Materials and methods. X-ray endovascular interventions were used in 8 patients who developed arosive bleeding as a complication of duodenal ulcer. All patients with signs of gastrointestinal bleeding were examined according to clinical protocols. Hemodynamically stable patients underwent X-ray endovascular interventions.
Results and discussion. In the near future, bleeding stopped in all 8 (100 %, OR–0.04 [0.005–0.29], p=0.03) patients. On day 2, two patients who underwent embolization of their own hepatic artery had a recurrence of bleeding (0.56 [0.065–4.76], p=0.29). Repeated angiography and embolization attempts were ineffective, and both patients died. In patients who underwent gastroduodenal and pancreatouodenal artery embolization, bleeding did not resume. Thus, we obtained good results as 6 out of 8 patients recovered (75 %), despite the severity of their condition and a disappointing prognosis (OR–9.0 [1.0–46.7], p <0.05).
Conclusions. Adherence to the tactics mentioned above in the treatment of bleeding in duodenal ulcer was highly effective, especially in superselective embolization with the detection of bleeding gel. If the presence of arosive bleeding is confirmed, emergency surgical treatment with suturing of the damaged vessel is shown in hemodynamically unstable patients, and endovascular intervention is possible in hemodynamically stable patients. Further studies are needed to determine the criteria for a high risk of arosive bleeding developing in patients with complicated duodenal ulcer as well as to prevent its occurrence through the use of X-ray endovascular interventions.
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Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, Laursen SB, Radaelli F, Papanikolaou IS, Cúrdia Gonçalves T, Dinis-Ribeiro M, Awadie H, Braun G, de Groot N, Udd M, Sanchez-Yague A, Neeman Z, van Hooft JE. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021; 53:300-332. [PMID: 33567467 DOI: 10.1055/a-1369-5274] [Citation(s) in RCA: 175] [Impact Index Per Article: 58.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
1: ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3-5 days.Strong recommendation, moderate quality evidence. 3: ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4: ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5: ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6: ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 : ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8: ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9: ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (A): PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (B): High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10: ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.
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Affiliation(s)
- Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - A John Morris
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Marine Camus
- Sorbonne University, Endoscopic Unit, Saint Antoine Hospital Assistance Publique Hopitaux de Paris, Paris, France
| | - James Lau
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Angel Lanas
- Digestive Disease Services, University Clinic Hospital, University of Zaragoza, IIS Aragón (CIBERehd), Spain
| | - Stig B Laursen
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Franco Radaelli
- Department of Gastroenterology, Valduce Hospital, Como, Italy
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Tiago Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- School of Medicine, University of Minho, Braga/Guimarães, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Mario Dinis-Ribeiro
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Portugal
| | - Halim Awadie
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Georg Braun
- Medizinische Klinik 3, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Marianne Udd
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Andres Sanchez-Yague
- Gastroenterology Unit, Hospital Costa del Sol, Marbella, Spain
- Gastroenterology Department, Vithas Xanit International Hospital, Benalmadena, Spain
| | - Ziv Neeman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Diagnostic Imaging and Nuclear Medicine Institute, Emek Medical Center, Afula, Israel
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Mille M, Engelhardt T, Stier A. Bleeding Duodenal Ulcer: Strategies in High-Risk Ulcers. Visc Med 2020; 37:52-62. [PMID: 33718484 DOI: 10.1159/000513689] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/09/2020] [Indexed: 12/26/2022] Open
Abstract
Background Acute peptic ulcer bleeding is still a major reason for hospital admission. Especially the management of bleeding duodenal ulcers needs a structured therapeutic approach due to the higher morbidity and mortality compared to gastric ulcers. Patient with these bleeding ulcers are often in a high-risk situation, which requires multidisciplinary treatment. Summary This review provides a structured approach to modern management of bleeding duodenal ulcers and elucidates therapeutic practice in high-risk situations. Initial management including pharmacologic therapy, risk stratification, endoscopy, surgery, and transcatheter arterial embolization are reviewed and their role in the management of bleeding duodenal ulcers is critically discussed. Additionally, a future perspective regarding prophylactic therapeutic approaches is outlined. Key Messages Beside pharmacotherapeutic and endoscopic advances, bleeding management of high-risk duodenal ulcers is still a challenge. When bleeding persists or rebleeding occurs and the gold standard endoscopy fails, surgical and radiological procedures are indicated to manage ulcer bleeding. Surgical procedures are performed to control hemorrhage, but they are still associated with a higher morbidity and a longer hospital stay. In the meantime, transcatheter arterial embolization is recommended as an alternative to surgery and more often replaces surgery in the management of failed endoscopic hemostasis. Future studies are needed to improve risk stratification and therefore enable a better selection of high-risk ulcers and optimal treatment. Additionally, the promising approach of prophylactic embolization in high-risk duodenal ulcers has to be further investigated to reduce rebleeding and improve outcomes in these patients.
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Affiliation(s)
- Markus Mille
- Department of General and Visceral Surgery, HELIOS Hospital Erfurt, Erfurt, Germany
| | - Thomas Engelhardt
- Department of General and Visceral Surgery, HELIOS Hospital Erfurt, Erfurt, Germany
| | - Albrecht Stier
- Department of General and Visceral Surgery, HELIOS Hospital Erfurt, Erfurt, Germany
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18
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Loffroy R, Desmyttere AS, Mouillot T, Pellegrinelli J, Facy O, Drouilllard A, Falvo N, Charles PE, Bardou M, Midulla M, Aho-Gléglé S, Chevallier O. Ten-year experience with arterial embolization for peptic ulcer bleeding: N-butyl cyanoacrylate glue versus other embolic agents. Eur Radiol 2020; 31:3015-3026. [PMID: 33128601 DOI: 10.1007/s00330-020-07427-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 09/01/2020] [Accepted: 10/14/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To compare our experience with N-butyl cyanoacrylate glue as the primary embolic agent versus other embolic agents for transcatheter arterial embolization (TAE) in refractory peptic ulcer bleeding and to identify factors associated with early rebleeding and 30-day mortality. METHODS Retrospective study of 148 consecutive patients comparing the clinical success rate in 78 patients managed with Glubran®2 N-butyl cyanoacrylate metacryloxysulfolane (NBCA-MS) alone or with other agents and 70 with other embolic agents only (coils, microspheres, ethylene-vinyl alcohol copolymer, or gelatin sponge) at a university center in 2008-2019. Univariate and multivariate logistic regression analyses were done to identify prognostic factors. RESULTS The technical success rate was 95.3% and the primary clinical success was 64.5%. The early rebleeding and day-30 mortality rates were 35.4% and 21.3%, respectively. Rebleeding was significantly less common with than without Glubran®2 (OR, 0.47; 95% CI, 0.22-0.99; p = .047) and significantly more common with coils used alone (OR, 20.4; 95% CI, 10.13-50.14; p = .024). The only other factor independently associated with early rebleeding was having two or more comorbidities (OR, 20.14; 95% CI, 10.01-40.52; p = .047). Day-30 mortality was similar in the two treatment groups. A lower initial hemoglobin level was significantly associated with higher day-30 mortality (OR, 10.38; 95% CI, 10.10-10.74; p = .006). Fluoroscopy time was significantly shorter with Glubran®2 (20.8 ± 11.5 min vs. 35.5 ± 23.4 min, p = .002). Both groups (Glubran®2 vs. other agents) had similar rates of overall complications (10.7% vs. 9.1%, respectively, p = .786). CONCLUSIONS Glubran®2 NBCA-MS as the primary agent allowed for faster and better clinical success compared to other embolic agents when used for TAE to safely stop refractory peptic ulcer bleeding. KEY POINTS • Choice of embolic agent for arterial embolization of refractory peptic ulcer bleeding is still debated. We compared our experience with N-butyl cyanoacrylate (NBCA) glue vs. other embolic agents. • The use of Glubran®2 NBCA glue in the endovascular management of refractory peptic ulcer bleeding was significantly faster and more effective, and at least as safe compared to other embolic agents. • NBCA glue offers several advantages compared to other embolic agents and provides rapid hemostasis when used for arterial embolization to treat refractory peptic ulcer bleeding. It should be the first-line therapy.
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Affiliation(s)
- Romaric Loffroy
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, Dijon, France. .,Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079, Dijon Cedex, France.
| | - Anne-Solène Desmyttere
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, Dijon, France
| | - Thomas Mouillot
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, Dijon, France
| | - Julie Pellegrinelli
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, Dijon, France
| | - Olivier Facy
- Department of Digestive and Visceral Surgery, François-Mitterrand University Hospital, Dijon, France
| | - Antoine Drouilllard
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, Dijon, France
| | - Nicolas Falvo
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, Dijon, France
| | - Pierre-Emmanuel Charles
- Department of Anesthesia and Intensive Care, François-Mitterrand University Hospital, Dijon, France
| | - Marc Bardou
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, Dijon, France
| | - Marco Midulla
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, Dijon, France
| | - Serge Aho-Gléglé
- Department of Epidemiology and Biostatistics, François-Mitterrand University Hospital, Dijon, France
| | - Olivier Chevallier
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, Dijon, France
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Żyluk A, Zeair S, Kordowski J, Gabrysz-Trybek E. Persisting bleeding from the duodenal ulcer in patients with occlusion of the celiac trunk: a case report. POLISH JOURNAL OF SURGERY 2020; 93:1-5. [PMID: 34057429 DOI: 10.5604/01.3001.0014.8072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
INTRODUCTION Endoscopic measures have continued to be the primary procedures in the management of ulcer bleeding. Nevertheless, in cases of failed endoscopic hemostasis and re-bleedings, endovascular techniques have gradually gained increased acceptance as an alternative to surgery, allowing to avoid surgical intervention in some cases. <br/> Case report: A case of a 42-year-old patient presenting to the authors' institution with massive bleeding from the duodenal ulcer, sprang from a pathologically enlarged gastroduodenal artery is reported. This vascular anomaly was a consequence of occlusion of the coeliac trunk (Dunbar syndrome), which was shown on an angio-CT scan. In spite of several endoscopic and endovascular measures, as well as three operations, the bleeding persistently recurred (a total of 6 episodes) and the patient eventually died. The article presents details of operative and endovascular treatments. Contemporary trends in management in cases of failed endoscopic interventions and re-bleedings form peptic ulcers are shown in the discussion.
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Affiliation(s)
- Andrzej Żyluk
- Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, Poland
| | - Samir Zeair
- Department of General, Vascular and Transplant Surgery, Independent Provincial Complex Hospital Maria Curie-Skłodowska in Szczecin, Poland
| | - Janusz Kordowski
- Department of Imaging Diagnostics and Interventional Radiology, Pomeranian Medical University in Szczecin, Poland
| | - Ewa Gabrysz-Trybek
- Department of Imaging Diagnostics and Interventional Radiology, Pomeranian Medical University in Szczecin, Poland
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20
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Mohan SC, Srinivasan S, Paul SPL, Chung R, Natarajan SK. Hemosuccus pancreatitis due to a ruptured splenic artery pseudoaneurysm - diagnosis and endovascular management. J Radiol Case Rep 2020; 14:7-15. [PMID: 33082922 DOI: 10.3941/jrcr.v14i5.3938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Hemosuccus pancreatitis is a rare and potentially fatal cause of upper gastrointestinal bleeding characterized by hemorrhage from the ampulla of Vater via the pancreatic duct. In this case, a patient with chronic pancreatitis on a background of chronic alcoholism is found to have a splenic artery pseudoaneurysm that was bleeding into the pancreatic duct. This was identified on contrast-enhanced computed tomography imaging and successfully managed via microcoil embolization.
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Affiliation(s)
| | | | - See Poh Lye Paul
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Raymond Chung
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore, Singapore
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Darmon I, Rebibo L, Diouf M, Chivot C, Riault C, Yzet T, Le Mouel JP, Regimbeau JM. Management of bleeding peptic duodenal ulcer refractory to endoscopic treatment: surgery or transcatheter arterial embolization as first-line therapy? A retrospective single-center study and systematic review. Eur J Trauma Emerg Surg 2020; 46:1025-1035. [PMID: 32246169 DOI: 10.1007/s00068-020-01356-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 03/25/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND The objective of this study was to compare the results of transcatheter arterial embolization (TAE) with surgery in terms of efficacy in the context of bleeding duodenal ulcer (BDU) refractory to endoscopic treatment. MATERIALS AND METHODS From January 2006 to December 2016, all patients treated for a BDU refractory to endoscopic treatment were included in this observational, comparative, retrospective, single-center study. Primary endpoint was the overall success of treatment of BDU requiring surgical and/or TAE. The secondary endpoints were pre-interventional data, recurrence rates, feasibility of secondary treatment, morbidity and mortality of surgical and radiological treatment, intensive care unit and length of stay. A systematic review of the literature was performed to compare results of surgery and TAE. RESULTS 59 out of 396 patients (14.9%) treated for BDU required embolization and/or surgery: 15 patients underwent surgery (group S) including 7 patients after embolization failure and 44 patients underwent TAE (group TAE). The overall treatment success in intention to treat (85.7% vs 67.3%), per protocol (80% vs 79.5%) and bleeding recurrence rates (20% vs 15.9%) were also identical. Mortality (14.2% vs 15.3%) was similar between the two groups. Our study data were pooled with data from eight published studies and suggest that surgery have significant increased overall success (68.3% vs. 55.4%, p < 0.005). CONCLUSION The overall success rate was in favour of surgery according our meta-analysis. Our single-center study highlights the fact that predictive factors for recurrent bleeding after TAE must be identified to select good candidates for TAE and/or surgery.
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Affiliation(s)
- Ilan Darmon
- Department of Digestive Surgery, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Lionel Rebibo
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, 75018, Paris, France
- Université de Paris, Inserm UMR 1149, 75018, Paris, France
| | - Momar Diouf
- Biostatistics Unit, Clinical Research and Innovation Department, Amiens-Picardie University Hospital, 80054, Amiens, France
| | - Cyril Chivot
- Department of Radiology, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Clémentine Riault
- Department of Gastroenterology, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Thierry Yzet
- Department of Radiology, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Jean Philippe Le Mouel
- Department of Gastroenterology, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, Amiens University Medical Center, Avenue René Laennec, 80054, Amiens cedex 01, France.
- SSPC (Simplification of Surgical Patients Care), Clinical Research Unit, University of Picardie Jules Verne, 80054, Amiens Cedex 01, France.
- Service de Chirurgie Digestive, CHU Amiens-Picardie, Site Sud, 1 Rond-Point du Professeur Christian Cabrol, 80054, Amiens Cedex 1, France.
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22
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Lai HY, Wu KT, Liu Y, Zeng ZF, Zhang B. Angiography and transcatheter arterial embolization for non-variceal gastrointestinal bleeding. Scand J Gastroenterol 2020; 55:931-940. [PMID: 32650690 DOI: 10.1080/00365521.2020.1790650] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND GOALS Acute non-variceal gastrointestinal bleeding (NVGIB) is one of the most common medical emergencies, leading to significant morbidity and mortality without proper management. This study was to analyze the causes of NVGIB and to evaluate the safety, efficacy, and feasibility of transcatheter arterial embolization (TAE) for the treatment of NVGIB. STUDY From November 2012 to October 2018, 158 patients with NVGIB underwent digital subtraction angiography, and TAE was performed for confirmed gastrointestinal bleeding. Patient characteristics, cause of bleeding, angiographic findings, technical and clinical success rates, complication rates, and outcomes were retrospectively analyzed. RESULTS Bleeding was confirmed in 71.5% (113/158) of performed angiographies, and 68 patients had visible contrast extravasation on angiography, with the other 45 patients having indirect signs of bleeding. Among the 113 patients with confirmed gastrointestinal bleeding, TAE was technically successful in 111 patients (98.2%). The mean procedure time required for TAE was 116 ± 44 min (ranging from 50 to 225 min). The primary total clinical success rate of TAE was 84.7% (94/111). The primary clinical success rates of TAE for vascular abnormality, neoplastic disease, and iatrogenic condition were 84.5% (49/58), 84.1% (37/44), and 88.9% (8/9), respectively. Intestinal necrosis and perforation were found in two patients after TAE. CONCLUSIONS The causes of NVGIB are complex and the onset, location, risk, and clinical presentations are variable. NVGIB can be generally divided into three types: vascular abnormality, neoplastic disease, and iatrogenic condition. TAE is a safe, effective, and fast procedure in the management of gastrointestinal bleeding.
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Affiliation(s)
- Hai-Yang Lai
- Department of Radiology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ke-Tong Wu
- Department of Radiology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yang Liu
- Department of Radiology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhao-Fei Zeng
- Department of Radiology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bo Zhang
- Department of Radiology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Tarasconi A, Coccolini F, Biffl WL, Tomasoni M, Ansaloni L, Picetti E, Molfino S, Shelat V, Cimbanassi S, Weber DG, Abu-Zidan FM, Campanile FC, Di Saverio S, Baiocchi GL, Casella C, Kelly MD, Kirkpatrick AW, Leppaniemi A, Moore EE, Peitzman A, Fraga GP, Ceresoli M, Maier RV, Wani I, Pattonieri V, Perrone G, Velmahos G, Sugrue M, Sartelli M, Kluger Y, Catena F. Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg Surg 2020; 15:3. [PMID: 31921329 PMCID: PMC6947898 DOI: 10.1186/s13017-019-0283-9] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 12/18/2019] [Indexed: 02/08/2023] Open
Abstract
Background Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment. Methods The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached. Conclusions The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
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Affiliation(s)
- Antonio Tarasconi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | | | - Matteo Tomasoni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Sarah Molfino
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Dieter G. Weber
- Royal Perth Hospital, Perth, Australia & The University of Western Australia, Crawley, Australia
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Fabio C. Campanile
- Division of Surgery, ASL VT - Ospedale “Andosilla”, Civita Castellana, Italy
| | - Salomone Di Saverio
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Claudio Casella
- Department of Molecular and Translational Medicine, Surgical Clinic, University of Brescia, Brescia, Italy
| | - Michael D. Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Andrew W. Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta Canada
| | | | - Ernest E. Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO USA
| | - Andrew Peitzman
- University of Pittsburgh, School of Medicine, UPMC – Presbyterian, Pittsburgh, PA USA
| | - Gustavo Pereira Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | - Marco Ceresoli
- Department of General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Ronald V. Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Imtaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | | | - Gennaro Perrone
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - George Velmahos
- Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, USA
| | - Michael Sugrue
- Letterkenny University Hospital, Donegal Clinical Research Academy Centre for Personalized Medicine, Donegal, Ireland
| | | | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fausto Catena
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
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24
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[Treatment of nonvariceal upper gastrointestinal bleeding: endoluminal-endovascular-surgical]. Chirurg 2019; 90:607-613. [PMID: 31392464 DOI: 10.1007/s00104-019-0948-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Nonvariceal upper gastrointestinal bleeding (UGIB) has a high mortality. Hematemesis sometimes with melena are the leading clinical symptoms. Peptic ulcers and (erosive) inflammation are common, whereas Mallory-Weiss syndrome, neoplasms, angiodysplasia and diffuse UGIB are less common. PROBLEM A risk stratification is based on the medical history, clinical presentation and laboratory tests, which are considered in the Glasgow-Blatchford score; however, which treatment approach is optimal? RESULTS After stabilisation under restricted transfusion indications, temporary stoppage of anticoagulants and optimized coagulation is beneficial and proton pump inhibitors (PPI) should be started. Prokinetics improve the endoscopic conditions in UGIB. The use of an endoscopic Doppler probe optimizes localization of the bleeding site. The use of the Forrest classification and Helicobacter pylori diagnostics are recommended. Mechanical (clips, injection), thermal (argon plasma coagulation, APC) and topical (hemostatic powder) endoscopic treatment procedures are available. Endoluminal hemostasis is very effective. Only clip application is suitable as monotherapy whereas all other endoscopic options should be combined. Angiography followed by transarterial embolization (TAE) can be used for therapy. Despite the high primary success rate, the risk of rebleeding is high. Surgery as the primary treatment is rarely necessary, although effective. Compared to TAE complications are higher, but there is no difference regarding mortality. CONCLUSION Endoscopy remains the gold standard for the initial diagnostics and treatment of UGIB. In cases of rebleeding repeated endoscopy is recommended. With persistent UGIB an endovascular procedure should be evaluated. Surgery remains an important salvage option.
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Kantowski M, Schoepfer AM, Settmacher U, Stallmach A, Schmidt C. Assessment of endoscopic Doppler to guide hemostasis in high risk peptic ulcer bleeding. Scand J Gastroenterol 2019; 53:1311-1318. [PMID: 30394134 DOI: 10.1080/00365521.2018.1509121] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Rebleeding or emergency surgery in failed endoscopic therapy of peptic ulcer bleeding are associated with high rates of morbidity and mortality. The clinical benefit of an endoscopic Doppler (ED) examination prior to endoscopic injection therapy was evaluated in high risk ulcer patients for rebleeding episode. Standard injection therapy (non-Doppler (ND)) was compared with targeted injection therapy after examination of the supplying vessel in the ulcer base by the ED. MATERIALS AND METHODS Sixty patients with peptic ulcer bleeding (Forrest Ia-IIa; Rockall score of 5 or higher) were included in the study. Patients were assigned to ED or ND group with conventional therapy by chance. In the ND group injection was directed by the visual aspect of the ulcer, whereas in ED therapy was directed by ED. RESULTS Thirty-five patients were allocated to the ED group, and 25 to the ND group, respectively. No significant differences in patient or ulcer characteristics were observed regarding ulcer size, localization, Forrest classification or endoscopic treatment. Recurrent bleeding was observed in 7/35 (20%) in the ED group and in 13/25 (52%) of patients in the ND group (p = .013). Fewer ED patients needed surgery for rebleeding (1/35 vs. 6/25; p = .017). Bleeding related, but not all-cause mortality was significantly lower in the ED group (1/35 vs. 6/25, p = .017). DISCUSSION In this comparative analysis, use of ED to guide hemostatic therapy was associated with a significant reduction in recurrence of bleeding, surgical intervention and bleeding associated mortality.
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Affiliation(s)
- Marcus Kantowski
- a Clinic for Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases) , Jena University Hospital , Jena , Germany.,b Department of Interdisciplinary Endoscopy , University Hospital Hamburg-Eppendorf , Hamburg , Germany
| | - Alain M Schoepfer
- c Division of Gastroenterology and Hepatology , Centre Hospitalier Universitaire Vaudois/CHUV , Lausanne , Switzerland
| | - Utz Settmacher
- d Clinic for General, Visceral und Vascular Surgery , Jena University Hospital , Jena , Germany
| | - Andreas Stallmach
- a Clinic for Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases) , Jena University Hospital , Jena , Germany
| | - Carsten Schmidt
- a Clinic for Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases) , Jena University Hospital , Jena , Germany.,e Department of Gastoenterology, Hepatology, Endocrinology, Diabetology and Infectiology , Clinic Fulda , Fulda , Germany
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26
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Abstract
Upper gastrointestinal bleeding (UGIB) is a common medical emergency, with a reported mortality of 2-10%. Patients identified as being at very low risk of either needing an intervention or death can be managed as outpatients. For all other patients, intravenous fluids as needed for resuscitation and red cell transfusion at a hemoglobin threshold of 70-80 g/L are recommended. After resuscitation is initiated, proton pump inhibitors (PPIs) and the prokinetic agent erythromycin may be administered, with antibiotics and vasoactive drugs recommended in patients who have cirrhosis. Endoscopy should be undertaken within 24 hours, with earlier endoscopy considered after resuscitation in patients at high risk, such as those with hemodynamic instability. Endoscopic treatment is used for variceal bleeding (for example, ligation for esophageal varices and tissue glue for gastric varices) and for high risk non-variceal bleeding (for example, injection, thermal probes, or clips for lesions with active bleeding or non-bleeding visible vessel). Patients who require endoscopic therapy for ulcer bleeding should receive high dose proton pump inhibitors after endoscopy, whereas those who have variceal bleeding should continue taking antibiotics and vasoactive drugs. Recurrent ulcer bleeding is treated with repeat endoscopic therapy, with subsequent bleeding managed by interventional radiology or surgery. Recurrent variceal bleeding is generally treated with transjugular intrahepatic portosystemic shunt. In patients who require antithrombotic agents, outcomes appear to be better when these drugs are reintroduced early.
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Affiliation(s)
- Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow G4 OSF, UK
| | - Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Connecticut, CT 06520, USA
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27
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Loffroy R, Comby PO, Falvo N, Pescatori L, Nakaï M, Midulla M, Chevallier O. Transcatheter arterial embolization versus surgery for uncontrolled peptic ulcer bleeding: game is over. Quant Imaging Med Surg 2019; 9:144-145. [PMID: 30976537 DOI: 10.21037/qims.2019.02.01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Romaric Loffroy
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon Cedex, France
| | - Pierre-Olivier Comby
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon Cedex, France
| | - Nicolas Falvo
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon Cedex, France
| | - Lorenzo Pescatori
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon Cedex, France
| | - Motoki Nakaï
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon Cedex, France
| | - Marco Midulla
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon Cedex, France
| | - Olivier Chevallier
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon Cedex, France
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28
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Transcatheter Arterial Embolization Compared With Surgery for Uncontrolled Peptic Ulcer Bleeding. Ann Surg 2019; 269:304-309. [DOI: 10.1097/sla.0000000000002565] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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29
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Anami S, Minamiguchi H, Shibata N, Koyama T, Sato H, Ikoma A, Nakai M, Yamagami T, Sonomura T. Successful endovascular treatment of endoscopically unmanageable hemorrhage from a duodenal ulcer fed by a renal artery: A case report. World J Clin Cases 2018; 6:1012-1017. [PMID: 30568956 PMCID: PMC6288507 DOI: 10.12998/wjcc.v6.i15.1012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/13/2018] [Accepted: 11/15/2018] [Indexed: 02/05/2023] Open
Abstract
A 52-year-old woman was admitted with hypovolemic shock. Emergency endoscopy revealed three hemorrhagic duodenal ulcers (all stage A1) with exposed vessels. Two ulcers were successfully treated by endoscopic clipping; however, the remaining ulcer on the posterior wall of the horizontal portion of the duodenum could not be clipped. Because her vital signs were rapidly worsening, we performed transcatheter arterial embolization (TAE) as it is less invasive than surgery. Computed tomography aortography showed that the duodenal hemorrhage was sourced from the lower branch of the right renal artery. In general, the duodenum is fed by branches from the gastroduodenal artery or superior mesenteric artery. However, this patient had three right renal arteries. The lower branch of the right renal artery at the L3 vertebral level was at the same level as the horizontal portion of the duodenum. Complete hemostasis was achieved by TAE using metallic coils and n-butyl-2-cyanoacrylate. After TAE, she recovered from the hypovolemic shock and was discharged from hospital. She has had no recurrence of the hemorrhagic duodenal ulcer for over 1 yr, and follow-up endoscopy showed no necrosis or stricture of the duodenum. Although she developed a small infarct of her right kidney, her renal function was satisfactory. In summary, the present case is the first reported case of hemorrhagic duodenal ulcer in which the culprit vessel was a renal artery that was successfully treated by TAE. Computed tomography aortography before TAE provides valuable information regarding the source of a duodenal hemorrhage.
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Affiliation(s)
- Shimpei Anami
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
| | - Hiroki Minamiguchi
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
- Department of Radiology, Kochi Medical School Kochi University, Nankokushi, Kochi 783-8505, Japan
| | - Naoaki Shibata
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
| | - Takao Koyama
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
| | - Hirotatsu Sato
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
| | - Akira Ikoma
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
| | - Motoki Nakai
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
| | - Takuji Yamagami
- Department of Radiology, Kochi Medical School Kochi University, Nankokushi, Kochi 783-8505, Japan
| | - Tetsuo Sonomura
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama 641-8510, Japan
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30
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Spiliopoulos S, Inchingolo R, Lucatelli P, Iezzi R, Diamantopoulos A, Posa A, Barry B, Ricci C, Cini M, Konstantos C, Palialexis K, Reppas L, Trikola A, Nardella M, Adam A, Brountzos E. Transcatheter Arterial Embolization for Bleeding Peptic Ulcers: A Multicenter Study. Cardiovasc Intervent Radiol 2018; 41:1333-1339. [PMID: 29671058 DOI: 10.1007/s00270-018-1966-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 04/12/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE To investigate the outcomes of transcatheter arterial embolization (TAE) for the treatment of peptic ulcer bleeding (PUB). MATERIALS AND METHODS This is a retrospective, multicenter study, which investigated all patients who underwent TAE for the treatment of severe upper gastrointestinal hemorrhage from peptic ulcers in five European centers, between January 1, 2012 and May 1, 2017. All patients had undergone failed endoscopic hemostasis. Forty-four patients (male; mean age 74.0 ± 11.1 years, range 49-94), with bleeding from duodenum (36/44; 81.8%) or gastric ulcer (8/44; 18.2%) were followed up to 3.5 years (range 2-1354 days). In 42/44 cases, bleeding was confirmed by pre-procedural CT angiography. In 50% of the cases, coils were deployed, while in the remaining glue, microparticles, gel foam and combinations of the above were used. The study's outcome measures were 30-day survival technical success (occlusion of feeding vessel and/or no extravasation at completion DSA), overall survival, bleeding relapse and complication rates. RESULTS The technical success was 100%. The 30-day survival rate was 79.5% (35/44 cases). No patients died due to ongoing or recurrent hemorrhage. Re-bleeding occurred in 2/44 cases (4.5%) and was successfully managed with repeat TAE (one) or surgery (one). The rate of major complications was 4.5% (2/44; one acute pancreatitis and one partial pancreatic ischemia), successfully managed conservatively. According to Kaplan-Meier analysis survival was 71.9% at 3.5 years. CONCLUSIONS TAE for the treatment of PUB was technically successful in all cases and resulted in high clinical success rate. Minimal re-bleeding rates further highlight the utility of TAE as the second line treatment of choice, after failed endoscopy.
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Affiliation(s)
- Stavros Spiliopoulos
- 2nd Department of Radiology, Interventional Radiology Unit, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece.
| | - Riccardo Inchingolo
- Department of Radiological Sciences, Institute of Radiology, Università Cattolica del Sacro Cuore, Rome, Italy
- Institute of Radiology, Madonna delle Grazie Hospital, Matera, Italy
| | - Pierleone Lucatelli
- Vascular Interventional Radiology Unit, University of Siena, Viale Mario Bracci 53, 53100, Siena, Italy
| | - Roberto Iezzi
- Department of Radiological Sciences, Institute of Radiology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Athanasios Diamantopoulos
- Department of Interventional Radiology, Guy's and St Thomas' Hospitals, NHS Foundation Trust, London, UK
| | - Alessandro Posa
- Department of Radiological Sciences, Institute of Radiology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bryan Barry
- Department of Interventional Radiology, Guy's and St Thomas' Hospitals, NHS Foundation Trust, London, UK
| | - Carmelo Ricci
- Vascular Interventional Radiology Unit, University of Siena, Viale Mario Bracci 53, 53100, Siena, Italy
| | - Marco Cini
- Vascular Interventional Radiology Unit, University of Siena, Viale Mario Bracci 53, 53100, Siena, Italy
| | - Chrysostomos Konstantos
- 2nd Department of Radiology, Interventional Radiology Unit, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Konstantinos Palialexis
- 2nd Department of Radiology, Interventional Radiology Unit, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Lazaros Reppas
- 2nd Department of Radiology, Interventional Radiology Unit, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Artemis Trikola
- 2nd Department of Radiology, Interventional Radiology Unit, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Michele Nardella
- Institute of Radiology, Madonna delle Grazie Hospital, Matera, Italy
| | - Andreas Adam
- Department of Interventional Radiology, Guy's and St Thomas' Hospitals, NHS Foundation Trust, London, UK
| | - Elias Brountzos
- 2nd Department of Radiology, Interventional Radiology Unit, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
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31
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Byrne BE, Bassett M, Rogers CA, Anderson ID, Beckingham I, Blazeby JM. Short-term outcomes after emergency surgery for complicated peptic ulcer disease from the UK National Emergency Laparotomy Audit: a cohort study. BMJ Open 2018; 8:e023721. [PMID: 30127054 PMCID: PMC6104767 DOI: 10.1136/bmjopen-2018-023721] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES This study used national audit data to describe current management and outcomes of patients undergoing surgery for complications of peptic ulcer disease (PUD), including perforation and bleeding. It was also planned to explore factors associated with fatal outcome after surgery for perforated ulcers. These analyses were designed to provide a thorough understanding of current practice and identify potentially modifiable factors associated with outcome as targets for future quality improvement. DESIGN National cohort study using National Emergency Laparotomy Audit (NELA) data. SETTING English and Welsh hospitals within the National Health Service. PARTICIPANTS Adult patients admitted as an emergency with perforated or bleeding PUD between December 2013 and November 2015. INTERVENTIONS Laparotomy for bleeding or perforated peptic ulcer. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was 60-day in-hospital mortality. Secondary outcomes included length of postoperative stay, readmission and reoperation rate. RESULTS 2444 and 382 procedures were performed for perforated and bleeding ulcers, respectively. In-hospital 60-day mortality rates were 287/2444 (11.7%, 95% CI 10.5% to 13.1%) for perforations, and 68/382 (17.8%, 95% CI 14.1% to 22.0%) for bleeding. Median (IQR) 2-year institutional volume was 12 (7-17) and 2 (1-3) for perforation and bleeding, respectively. In the exploratory analysis, age, American Society of Anesthesiology score and preoperative systolic blood pressure were associated with mortality, with no association with time from admission to operation, surgeon grade or operative approach. CONCLUSIONS Patients undergoing surgery for complicated PUD face a high 60-day mortality risk. Exploratory analyses suggested fatal outcome was primarily associated with patient rather than provider care factors. Therefore, it may be challenging to reduce mortality rates further. NELA data provide important benchmarking for patient consent and has highlighted low institutional volume and high mortality rates after surgery for bleeding peptic ulcers as a target for future research and improvement.
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Affiliation(s)
- Benjamin E Byrne
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Bassett
- National Emergency Laparotomy Audit, The Royal College of Anaesthetists, London, UK
- Department of Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Iain D Anderson
- National Emergency Laparotomy Audit, The Royal College of Anaesthetists, London, UK
- Department of Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Ian Beckingham
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Association of Upper Gastrointestinal Surgeons, Royal College of Surgeons of England, London, UK
| | - Jane M Blazeby
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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The role of interventional radiology in the management of hemodynamically compromised patients. Intensive Care Med 2018; 44:1334-1338. [DOI: 10.1007/s00134-018-5236-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 05/18/2018] [Indexed: 11/25/2022]
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Abstract
Peptic ulcer bleeding remains an important medical emergency. Important recent advances are reviewed. These include further support for a more restrictive transfusion strategy aiming for a target haemoglobin of 70-90 g/L. The Glasgow-Blatchford score remains the most useful assessment score for identifying the lowest risk patients suitable for outpatient management and predicting the need for intervention. Newer scores such as the AIMS65 and Progetto Nazionale Emorragia Digestive score (PNED) may be more accurate in predicting mortality. Pre-endoscopy erythromycin improves outcomes and is underused. A new disposable Doppler probe appears to provide more accurate determination of both rebleeding risk and the success of endoscopic therapy than purely visual guidance. Over-the-scope clips and haemostatic powders appear to have some role as endoscopic salvage therapies. Non- H. pylori, non-aspirin/non-steroidal anti-inflammatory drug (NSAID) ulcers contribute to an increasing percentage of bleeding peptic ulcers and are associated with a high rebleeding rate. The optimal management of these ulcers remains to be determined.
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Affiliation(s)
- Ian LP Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
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Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is bleeding that develops in the oesophagus, stomach or proximal duodenum. Peptic ulcers, caused by Helicobacter pylori infection or use of NSAIDs and low-dose aspirin (LDA), are the most common cause. Although the incidence and mortality associated with NVUGIB have been decreasing owing to considerable advances in the prevention and management of NVUGIB over the past 20 years, it remains a common clinical problem with an annual incidence of ∼67 per 100,000 individuals in the United States in 2012. NVUGIB is a medical emergency, and mortality is in the range ∼1-5%. After resuscitation and initial assessment, early (within 24 hours) diagnostic and therapeutic endoscopy together with intragastric pH control with proton pump inhibitors (PPIs) form the basis of treatment. With a growing ageing population treated with antiplatelet and/or anticoagulant medications, the clinical management of NVUGIB is complex as the risk between gastrointestinal bleeding events and adverse cardiovascular events needs to be balanced. The best clinical approach includes identification of risk factors and prevention of bleeding; available strategies include continuous treatment with PPIs or H. pylori eradication in those at increased risk of developing NVUGIB. Treatment with PPIs and/or use of cyclooxygenase-2-selective NSAIDs should be implemented in those patients at risk of NVUGIB who need NSAIDs and/or LDA.
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Kaminskis A, Ivanova P, Ponomarjova S, Mukans M, Boka V, Pupelis G. Rockall Score Larger Than 7 as a Reliable Criterion for the Selection of Indications for Preventive Transarterial Embolization in a Subgroup of High-Risk Elderly Patients After Primary Endoscopic Hemostasis for Non-Variceal Upper Gastrointestinal Bleeding. Gastroenterology Res 2018; 10:339-346. [PMID: 29317941 PMCID: PMC5755635 DOI: 10.14740/gr909w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 10/19/2017] [Indexed: 12/11/2022] Open
Abstract
Background Transarterial embolization (TAE) is an alternative procedure to repeat endoscopy or surgical intervention in the case of re-bleeding after primary endoscopic treatment. The aim of the study was to assess the Rockall score as a criterion for TAE in the case of re-bleeding after endoscopic treatment of non-variceal upper gastrointestinal bleeding (NVUGIB). Methods Out of the 673 patients who underwent emergent endoscopic hemostasis due to NVUGIB, 111 had a high risk of re-bleeding having a Forrest I-IIb ulcer and the Rockall score ≥ 5. From 111 patients, 37 accepted preventive TAE (PE+ group). The control group consisted of 74 patients who underwent standard treatment (PE- group). Results There were no differences in the demographic status between both groups, nor in the main clinical data on admission. The performance of TAE resulted in a significantly lower re-bleeding rate (1 (4.8%) vs. 11 (33%), P = 0.018). No patient who underwent TAE with the Rockall score ≥ 7 required surgery, resulting in only one re-bleeding episode (P = 0.004). Mortality reached 5% and 11% in the PE+ and PE- groups accordingly. Conclusion The Rockall score ≥ 7 could be a reliable predictor of re-bleeding after primary endoscopic hemostasis as one criterion for the selection of indications for preventive TAE.
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Affiliation(s)
- Aleksejs Kaminskis
- Department of General and Emergency Surgery, Riga East University Hospital, Riga, Latvia
| | - Patricija Ivanova
- Department of Interventional Radiology, Riga East University Hospital, Riga, Latvia
| | - Sanita Ponomarjova
- Department of Interventional Radiology, Riga East University Hospital, Riga, Latvia
| | - Maksims Mukans
- Statistical Unit, Riga Stradins University, Riga, Latvia
| | | | - Guntars Pupelis
- Surgical Department, Riga East University Hospital, Riga, Latvia
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36
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Abstract
Acute upper gastrointestinal haemorrhage due to peptic ulcer bleeding remains an important cause of emergency presentation and hospital admission. Despite advances in many aspects of management, peptic ulcer bleeding is still associated with significant morbidity, mortality, and healthcare costs. Comprehensive international guidelines have been published, but advances as well as controversies continue to evolve. Important recent advances include the evidence supporting a more restrictive transfusion strategy aiming for a target haemoglobin of 70–90 g/l. Comparative studies have confirmed that the Glasgow–Blatchford score remains the most useful score for predicting the need for intervention as well as for identifying the lowest-risk patients suitable for outpatient management. New scores, including the AIMS65 and Progetto Nazionale Emorragia Digestiva score, may be more accurate in predicting mortality. Pre-endoscopy erythromycin appears to improve outcomes and is probably underused. High-dose oral proton pump inhibition (PPI) for 11 days after PPI infusion is advantageous in those with a Rockall score of 6 or more. Oral is as effective as parenteral iron at restoring haemoglobin levels after a peptic ulcer bleed and both are superior to placebo in this respect. Within endoscopic techniques, haemostatic powders and over-the-scope clips can be used when other methods have failed. A disposable Doppler probe appears to provide more accurate determination of both rebleeding risk and the success of endoscopic therapy than purely visual guidance. Non-
Helicobacter pylori, non-aspirin/non-steroidal anti-inflammatory drug ulcers contribute an increasing percentage of bleeding peptic ulcers and are associated with a poor prognosis and high rebleeding rate. The optimal management of these ulcers remains to be determined.
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Affiliation(s)
- Ian Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
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Wedi E, von Renteln D, Gonzalez S, Tkachenko O, Jung C, Orkut S, Roth V, Tumay S, Hochberger J. Use of the over-the-scope-clip (OTSC) in non-variceal upper gastrointestinal bleeding in patients with severe cardiovascular comorbidities: a retrospective study. Endosc Int Open 2017; 5:E875-E882. [PMID: 28924593 PMCID: PMC5595576 DOI: 10.1055/s-0043-105496] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 02/13/2017] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The over-the-scope-clip (OTSC) can potentially overcome limitations of standard clips and achieve more efficient and reliable hemostasis. Data on OTSC use for non-variceal upper gastrointestinal bleeding (NVUGIB) in patients with cardiovascular comorbidities are currently limited. PATIENTS AND METHODS We prospectively collected and retrospectively analyzed our database from February 2009 to September 2015 from all patients who underwent emergency endoscopy for high-risk NVUGIB in 2 academic centers and were treated with OTSC as first-line (n = 81) or second-line therapy (n = 19). RESULTS One hundred patients mean age 72 (range 27 - 97 years) were included in this study. Fifty-one percent (n = 51) had severe cardiovascular co-morbidity (ischemic heart disease, congestive heart failure, hypertension, valvular heart disease, peripheral arterial occlusive disease and atrial fibrillation) and 73 % (n = 73) were on antiplatelet or/and anticoagulation therapy. The median size of the treated ulcers was 3 cm (range 1 - 5 cm). In 94 % (n = 94) primary hemostasis with OTSC was achieved. Clinical long-term success during a mean 6-month follow-up without rebleeding was 86 % (n = 86). CONCLUSIONS In this cohort OTSC was demonstrated to be a safe and effective first- or second-line treatment for NVUGIB in high-risk patients with cardiovascular disease and complex, large ulcers.
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Affiliation(s)
- Edris Wedi
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany,Department of Gastroenterology, Nouvel
Hôpital Civil, University Hospitals, Strasbourg, France,Corresponding author Edris Wedi,
MD Department of Gastroenterology and GI
OncologyUniversity Medical Centre
GoettingenCenter of Interdisciplinary
EndoscopyGeorg-August-UniversityEndoscopyD-37075
GoettingenGermany+495121901241
| | - Daniel von Renteln
- Division of Gastroenterology, Centre
Hospitalier de l’Université de Montréal (CHUM), Research Centre CHUM (CRCHUM)
Montreal, Quebec, Canada
| | - Susana Gonzalez
- Division of Gastroenterology, NYU Langone
Medical Center, New York, New York, United States
| | - Olena Tkachenko
- Division of Reproductive and Developmental
Sciences, Oregon National Primate Research Center, Oregon Health & Science
University, Beaverton, Oregon, United States
| | - Carlo Jung
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany,Department of Gastroenterology, Nouvel
Hôpital Civil, University Hospitals, Strasbourg, France
| | - Sinan Orkut
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany
| | - Victor Roth
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany
| | - Selin Tumay
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany
| | - Juergen Hochberger
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany,Division of Gastroenterology, Vivantes
Klinikum in Friedrichshain, Teaching Hospital of Charité Humboldt University,
Berlin, Germany
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Availability of on-site acute vascular interventional radiology techniques performed by trained acute care specialists: A single-emergency center experience. J Trauma Acute Care Surg 2017; 82:126-132. [PMID: 27280941 PMCID: PMC5213014 DOI: 10.1097/ta.0000000000001154] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Comprehensive treatment of a patient in acute medicine and surgery requires the use of both surgical techniques and other treatment methods. Recently, acute vascular interventional radiology techniques (AVIRTs) have become increasingly popular, enabling adequately trained in-house experts to improve the quality of on-site care. METHODS After obtaining approval from our institutional ethics committee, we conducted a retrospective study of AVIRT procedures performed by acute care specialists trained in acute medicine and surgery over a 1-year period, including those conducted out of hours. Trained acute care specialists were required to be certified by the Japanese Association of Acute Medicine and to have completed at least 1 year of training as a member of the endovascular team in the radiology department of another university hospital. The study was designed to ensure that at least one of the physicians was available to perform AVIRT within 1 h of a request at any time. Femoral sheath insertion was usually performed by the resident physicians under the guidance of trained acute care specialists. RESULTS The study sample comprised 77 endovascular procedures for therapeutic AVIRT (trauma, n = 29, and nontrauma, n = 48) among 62 patients (mean age, 64 years; range, 9–88 years), of which 55% were male. Of the procedures, 47% were performed out of hours (trauma, 52%; and nontrauma, 44%). Three patients underwent resuscitative endovascular balloon occlusion of the aorta in the emergency room. No major device-related complications were encountered, and the overall mortality rate within 60 days was 8%. The recorded causes of death included exsanguination (n = 2), pneumonia (n = 2), sepsis (n = 1), and brain death (n = 1). CONCLUSION When performed by trained acute care specialists, AVIRT seems to be advantageous for acute on-site care and provides good technical success. Therefore, a standard training program should be established for acute care specialists or trauma surgeons to make these techniques a part of the standard regimen. LEVEL OF EVIDENCE Therapy/care management study, level V.
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Nykänen T, Peltola E, Kylänpää L, Udd M. Bleeding gastric and duodenal ulcers: case-control study comparing angioembolization and surgery. Scand J Gastroenterol 2017; 52:523-530. [PMID: 28270041 DOI: 10.1080/00365521.2017.1288756] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To compare the safety, efficacy and feasibility of transcatheter arterial embolization (TAE) and surgery in the treatment of bleeding gastric and duodenal ulcers (BGDUs). MATERIALS AND METHODS The study group comprised patients receiving TAE or surgery for BGDUs after failed endoscopic hemostasis in Helsinki University Hospital (HUH) during 2000-2015. Hospital medical records provided study data. 30-d mortality and rebleeding rates were the primary outcomes. Postoperative complications, blood transfusion rate, and the durations of intensive care and hospital admissions were the secondary outcomes. RESULTS During the study period, BGDUs lead to 1583 hospital admissions. TAE or surgery was necessary on 85 (5.4%) patients, 43 receiving surgery and 42 TAE. Out of 42, 16 received prophylactic TAE. Two underwent angiography and TAE to localize the bleeding. The remaining 24 received TAE for active or recurrent bleeding after endoscopy. The comparison of TAE (n = 24) and surgery (n = 43) included only patients with active or recurrent bleeding. Mortality rate was 12.5% after TAE and 25.6% after surgery (p = 0.347). Rebleeding rate was 25% after TAE and 16.3% after surgery (p = 0.641). Postprocedural complications were less frequent after TAE than surgery (37.5 vs. 67.4%, p = 0.018). Other secondary outcomes did not differ. Out of 85 procedures, 14 (16.5%) took place between midnight and 8 a.m., all nighttime interventions being surgeries. CONCLUSIONS Mortality and rebleeding rates did not differ between TAE and surgery. With less postoperative complications, TAE should be the preferred hemostatic method when endoscopy fails.
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Affiliation(s)
- Taina Nykänen
- a Gastrointestinal surgery, Abdominal Center , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Erno Peltola
- b Department of Radiology, Helsinki Medical Imaging Center , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Leena Kylänpää
- c Gastrointestinal surgery, Abdominal Center , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Marianne Udd
- d Gastrointestinal surgery, Abdominal Center , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
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