The visible vessel on the bleeding gastric ulcer: an endoscopic-pathological study

The Importance of Arterial Blood Flow Detection for Risk Stratification and Eradication to Achieve Definitive Hemostasis of Severe Non-Variceal UGI Hemorrhage

BACKGROUND

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common medical problem worldwide. Independent endoscopic risk factors for rebleeding and mortality of NVUGIB that are treatable are stigmata of recent hemorrhage (SRH) and arterial blood flow underneath SRH. The specific aims of this paper are to describe the importance of arterial blood flow detection for risk stratification and as a guide to definitive hemostasis of severe NVUGIB.

METHODS

This is a review of randomized controlled trials and prospective cohort study methodologies and results which utilized a Doppler endoscopic probe (DEP) for the detection of arterial blood underneath SRH, for risk stratification, and as a guide to definitive hemostasis. The results are compared to visually guided hemostasis based upon SRH.

RESULTS

Although SRH have been utilized to guide endoscopic hemostasis of NVUGIB for 50 years, when most visually guided treatments are applied to lesions with major SRH, arterial blood flow underneath SRH is not obliterated in 25-30% of patients and results in rebleeding. Definitive hemostasis, significantly lower rebleeding rates, and improvements in other clinical outcomes resulted when DEP was used for risk stratification and as a guide to obliteration of arterial blood flow underneath SRH.

CONCLUSIONS

DEP-guided endoscopic hemostasis is a very effective and safe new method to improve patient outcomes for NVUGIB.

Use of Doppler Probe in Nonvariceal Upper-Gastrointestinal Bleeding Is Less Costly and More Effective Than Standard of Care

BACKGROUND & AIMS

Upper gastrointestinal bleeding is a common emergency and rebleeding is associated with an increased risk of death. Proper assessment of high-risk lesions and appropriate endoscopic hemostasis are required for the best outcomes. The endoscopic Doppler probe examination (DPE) allows for a more complete assessment of the stigmata of hemorrhage, providing better evaluation of the need for endoscopic hemostasis and determination of its completeness. We aimed to evaluate whether use of the DPE provides an additional advantage in cost and effectiveness compared with traditional endoscopic visual assessment (TEA) of high-risk stigmata in patients with nonvariceal upper gastrointestinal bleeding.

METHODS

We drew a decision tree representing the choice between DPE and TEA approaches for patients undergoing an index endoscopy for active nonvariceal upper gastrointestinal bleeding. Clinical probabilities were retrieved from randomized controlled trial data. Costs were expressed in 2017 US dollars. A third-party payer perspective was adopted. We performed deterministic and probabilistic sensitivity analyses. The adopted time horizon was 30 days after the index endoscopy.

RESULTS

We found that DPE is a dominant strategy over the TEA, in that DPE is more efficacious (92.6% of patients avoiding rebleeding vs 78.6% for TEA) and less expensive ($8502 vs $9104 for TEA). The economic dominance of DPE over TEA was robust to sensitivity analyses across all assumptions of the model when varied among ranges spanning 30% of their respective baseline values.

CONCLUSIONS

In a cost-effectiveness analysis, we found DPE to be an economically dominant strategy to TEA (the traditional approach) in the management of high-risk lesions in patients with nonvariceal upper gastrointestinal bleeding. DPE was less costly and more effective.

Doppler endoscopic probe as a guide to risk stratification and definitive hemostasis of peptic ulcer bleeding

BACKGROUND AND AIMS

For more than 4 decades endoscopists have relied on ulcer stigmata for risk stratification and as a guide to hemostasis. None used arterial blood flow underneath stigmata to predict outcomes. For patients with severe peptic ulcer bleeding (PUB), we used a Doppler endoscopic probe (DEP) for (1) detection of blood flow underlying stigmata of recent hemorrhage (SRH), (2) quantitating rates of residual arterial blood flow under SRH after visually directed standard endoscopic treatment, and (3) comparing risks of rebleeding and actual 30-day rebleed rates for spurting arterial bleeding (Forrest [F] IA) and oozing bleeding (F IB).

METHODS

Prospective cohort study of 163 consecutive patients with severe PUB and different SRH.

RESULTS

All blood flow detected by the DEP was arterial. Detection rates were 87.4% in major SRH-spurting arterial bleeding (F IA), non-bleeding visible vessel (F IIA), clot (F IIB)-and were significantly lower at 42.3% (P < .0001) for an intermediate group of oozing bleeding (F IB) or flat spot (F IIC). For spurting bleeding (F IA) versus oozing (F IB), baseline DEP arterial flow was 100% versus 46.7%, residual blood flow detected after endoscopic hemostasis was 35.7% versus 0%, and 30-day rebleed rates were 28.6% versus 0% (all P < .05).

CONCLUSIONS

(1) For major SRH versus oozing or spot, the arterial blood flow detection rate by the DEP was significantly higher, indicating a higher rebleed risk. (2) Before and after endoscopic treatment, spurting (F IA) PUB had significantly higher rates of blood flow detection than oozing (F IB) PUB and a significantly higher 30-day rebleed rate. (3) The DEP is recommended as a new endoscopic guide with SRH to improve risk stratification and potentially definitive hemostasis for PUB.

New diagnostic imaging technologies in nonvariceal upper gastrointestinal bleeding

This article covers new endoscopic imaging modalities in nonvariceal upper gastrointestinal bleeding, such as Doppler ultrasound probe technology, endoscopic ultrasonography, color Doppler optical coherence tomography, and magnification endoscopy. A more in-depth discussion of these modalities and the published evidence supporting their use are included. Furthermore, the shift in focus from identification of conventional visual surface stigmata of recent hemorrhage to an assessment and understanding of subsurface blood flow as it relates to the bleeding lesion is discussed.

Therapeutic endoscopy for acute upper gastrointestinal bleeding

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

Endoscopic Doppler ultrasound versus endoscopic stigmata-directed management of acute peptic ulcer hemorrhage: a multimodel cost analysis

Recurrent bleeding from acute peptic ulcer hemorrhage is problematic. Studies have shown that Doppler ultrasound (DOP-US) is useful in decreasing rebleeding. We analyzed associated costs and outcomes to better define the role of DOP-US versus Conventional (Forrest classification endoscopic stigmata) in the management of acute peptic ulcer bleeding. Two separate decision analyses were constructed. Recurrent bleeding, failed esophagogastroduodenoscopy (EGD) hemostasis, complications, and surgery rates were derived from medical literature. Costs were based on Medicare data. DOP-US is preferred over Conventional in acute peptic ulcer bleeding with average cost savings per patient ranging from 853 dollars (decision-tree modeling) to 1,160 dollars (Monte Carlo simulation). High-dose intravenous proton-pump inhibitors lowered rates of recurrent bleeding for both Conventional and DOP-US, resulting in a lower but still persistent average cost savings per patient for DOP-US (decision-tree modeling = 328 dollars, Monte Carlo simulation = 560 dollars). This decision analyses identified DOP-US as the preferred cost-minimizing strategy in acute peptic ulcer hemorrhage. Results of cost analyses were most dependent on hospitalization costs and recurrent bleeding rates.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

The role of endoscopic Doppler US in patients with peptic ulcer bleeding

BACKGROUND

Stigmata of recent hemorrhage are important prognostic signs for patients with ulcer bleeding, but these are subjective findings. This study evaluated the additional diagnostic value of Doppler US assessment in patients with a bleeding peptic ulcer.

METHODS

A prospective, multicenter study was performed of patients with ulcer bleeding. Stigmata of recent hemorrhage were classified according to the Forrest classification, after which the ulcer was assessed by using an endoscopic Doppler US system. Patients with a Forrest Ib-IIb ulcer with a positive Doppler signal received endoscopic therapy. Patients with a Forrest IIc-III ulcer with a positive Doppler signal were allocated randomly to endoscopic therapy or no therapy. No ulcer without a Doppler signal was treated.

RESULTS

A total of 80 patients were enrolled. Of the Forrest Ib-IIb ulcers, 82% had a positive Doppler signal. Of the Forrest IIc-III ulcers, 53% had a positive Doppler signal. There was no difference in the rates of recurrent bleeding, surgery, or mortality between the group with Forrest Ib-IIb ulcers and between the Forrest IIc-III group with and without Doppler signal, but there was little power in the sample size to detect differences. Bleeding recurred in 3 patients without a Doppler signal. Recurrent bleeding was more frequent in the group in which a Doppler signal was still present immediately after endoscopic therapy (3/11 vs. 1/27; p=0.06).

CONCLUSIONS

This study did not substantiate a role for endoscopic Doppler US when this was added to the Forrest classification for making clinical decisions in patients with ulcer bleeding.

Review article: Helicobacter pylori infection in peptic ulcer haemorrhage

In this overview, medical advice for routine clinical practice regarding peptic ulcer haemorrhage (PUH) is given, based on the extensive literature about Helicobacter pylori and the controversial results about the interaction of H. pylori infection and nonsteriodal anti-inflammatory drug (NSAID) use. PUH remains an important emergency situation with an incidence between 32 and 51/100 000 persons per year. There is a high association between H. pylori infection and peptic ulcer disease. The association between H. pylori infection and PUH is less clear, but a strong argument for the aetiological role is the fact that eradication of H. pylori decreases recurrence of bleeding. NSAID use is another important risk factor for PUH. H. pylori infection and NSAID use seem to act independently, although some studies show a synergistic interaction while other studies report that H. pylori is protective against the development of PUH in NSAID users. All patients with PUH should be tested for H. pylori infection, regardless of the use of NSAIDs. Because invasive tests are less sensitive in PUH patients, negative tests in patients with no other risk factors should be confirmed by serology or urea breath test (UBT). Eradication therapy with a proton pump inhibitor or ranitidine bismuth citrate-based triple therapy should be given to all H. pylori-positive patients. Only for nonaspirin-NSAID users does the effect of eradication therapy on the healing of gastric ulcers remain controversial, but currently we also advise eradication of H. pylori in this subgroup. After eradication therapy, acid-suppressant therapy is advised to heal the ulcer. The success of eradication should always be confirmed because of the risk of recurrence of peptic ulcer disease and bleeding in H. pylori-infected patients.

Value of stigmata in decision-making in gastrointestinal haemorrhage

The stigmata of recent haemorrhage are endoscopically identified features that have a predictive value for the risk of further bleeding and thus help to determine which patients should receive endoscopic therapy. In conjunction with endoscopic features, clinical features related to the magnitude of bleeding and to patient co-morbidity have important independent effects on the risk of further haemorrhage. Stigmata have been best studied in the context of bleeding ulcers, the most common cause of upper gastrointestinal bleeding. Stigmata in ulcers are usually classified as active bleeding (spurting or oozing), a non-bleeding visible vessel, an adherent clot, a flat pigmented spot, or a clean base, in order of decreasing risk of further haemorrhage. Ulcer size and location may also affect the re-bleeding potential. Recent data suggest that both non-pigmented visible vessels and adherent clots have a higher risk of re-bleeding than was previously thought. The wide variation in prevalence and re-bleeding rates reported for various stigmata in the literature probably reflects variations in the definitions of stigmata and of re-bleeding, the vigour with which the ulcer bases are washed, the co-morbidity and ages of the patients, and the severity of bleeding encountered. Inter-observer agreement in the classification of stigmata is relatively poor and limits the utility of endoscopic features alone in making decisions regarding the management of patients with bleeding peptic ulcers. Imaging devices such as Doppler probes are being evaluated to refine the identification of underlying vessels and their re-bleeding potential, but the utility of these is currently uncertain. The findings of low-risk endoscopic stigmata in a haemodynamically and otherwise stable patient can in many cases allow out-patient management.