Upper gastrointestinal bleeding

Use of the over-the-scope-clip (OTSC) in non-variceal upper gastrointestinal bleeding in patients with severe cardiovascular comorbidities: a retrospective study

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.

Platelet aggregation measurement for assessment of hemostasis failure mechanisms in patients with gastroduodenal ulcer bleeding

Background

The purpose of this study was to identify factors associated with the risk of unsustainable hemostasis in patients with gastric and duodenal ulcer bleeding by in vitro assessment of platelet reactivity using artificial neural networks.

Methods

Patients with gastroduodenal ulcers complicated by bleeding were studied. Platelet aggregation was measured using aggregometry with adenosine diphosphate 5 μM, epinephrine 2.5 μM, 5-hydroxytryptophan 10 μM, collagen 1 μM, and thrombin 0.06 NIH Unit/mL as agonists. Multiple logistic regression was used to evaluate the independent relationship between demographic, clinical, endoscopic, and laboratory data and in vitro assessment of platelet reactivity and local parameters of hemostasis in patients with ulcer bleeding.

Results

Analysis of platelet aggregation in patients with gastroduodenal ulcer bleeding allowed the variability of platelet response to different agonists used in effective concentration which induces 50% platelet aggregation (EC₅₀) to be established. The relationship between platelet aggregation and the spatial-temporal characteristics of ulcers complicated by bleeding was demonstrated. Adrenoreactivity of platelets was associated with time elapsed since the start of ulcer bleeding and degree of hemorrhage. The lowest platelet response to collagen and thrombin was detected in patients with active bleeding (P < 0.001) and unsustainable recent bleeding (P < 0.01). Decreased adenosine diphosphate-induced platelet aggregation in patients with ulcer bleeding was correlated with the platelet response to thrombin (r = 0.714, P < 0.001) and collagen (r = 0.584, P < 0.01).

Conclusion

Estimation of platelet reactivity in vitro indicates the key mechanisms of failure of hemostasis in patients with ulcer bleeding. In addition to gender, an important determinant of unsustainable hemostasis was a decreased platelet response to thrombin and adenosine diphosphate.

Double balloon enteroscopy examinations in general anesthesia

AIM

To demonstrate that the double balloon enteroscopy (DBE) can be safely performed in general anesthesia with intubation.

METHODS

We performed a retrospective examination between August 2005 and November 2008 among patients receiving intubation narcosis due to DBE examination. The patients were grouped based on sex, age and physical status. Anesthesia records included duration of anesthesia, quantity of medication used and anesthesia-related complications. We determined the frequency of complications in the different groups and their relation with the quantity of medication used and the duration of anesthesia.

RESULTS

We compiled data for 108 cases of general anesthesia with intubation. We did not observe any permanent anesthesia-related complications; the most frequent side effects of anesthesia were hypotension (30.55%), desaturation (21.29%), and apnea (17.59%). These complications were significantly more frequent among patients with multiple additional diseases [hypotension (23.1% vs 76.9%, P = 0.005), de-saturation (12.3% vs 69.2%, P < 0.001) and apnea (7.7% vs 53.8%, P = 0.001)], however, their incidence was not proportional to the quantity of medication used or the duration of anesthesia.

CONCLUSION

General anesthesia with intubation is definitely a viable option among DBE methods. It is highly recommended in patients with multiple additional diseases.

Application of endoscopic hemoclips for nonvariceal bleeding in the upper gastrointestinal tract

AIM: To investigate acute nonvariceal bleeding in the upper gastrointestinal (GI) tract and evaluate the effects of endoscopic hemoclipping.

METHODS: Sixty-eight cases of acute nonvariceal bleeding in the upper GI tract were given endoscopic treatment with hemoclip application. Clinical data, endoscopic findings, and the effects of the therapy were evaluated.

RESULTS: The 68 cases (male:female = 42:26, age from 9 to 70 years, average 54.4) presented with hematemesis in 26 cases (38.2%), melena in nine cases (13.3%), and both in 33 cases (48.5%). The causes of the bleeding included gastric ulcer (29 cases), duodenal ulcer (11 cases), Dieulafoy’s lesion (11 cases), Mallory-Weiss syndrome (six cases), post-operative (three cases), post-polypectomy bleeding (five cases), and post-sphincterotomy bleeding (three cases); 42 cases had active bleeding. The mean number of hemoclips applied was four. Permanent hemostasis was obtained by hemoclip application in 59 cases; 6 cases required emergent surgery (three cases had peptic ulcers, one had Dieulafoy’s lesion, and two were caused by sphincterotomy); three patients died (two had Dieulafoy’s lesion and one was caused by sphincterotomy); and one had recurrent bleeding with Dieulafoy’s lesion 10 mo later, but in a different location.

CONCLUSION: Endoscopic hemoclip application was an effective and safe method for acute nonvariceal bleeding in the upper GI tract with satisfactory outcomes.

Risk factors for rebleeding after angiographically negative acute gastrointestinal bleeding

AIM: To identify possible predictive factors for rebleeding after angiographically negative findings in patients with acute non-variceal gastrointestinal bleeding.

METHODS: From January 2000 to July 2007, 128 patients with acute non-variceal gastrointestinal bleeding had negative findings after initial angiography. Clinical and laboratory parameters were analyzed retrospectively.

RESULTS: Among 128 patients, 62 had no recurrent gastrointestinal bleeding and 66 had recurrent gastrointestinal bleeding within 30 d. As determined by the use of multivariate analysis, an underlying malignancy, liver cirrhosis and hematemesis were significant factors related to recurrent gastrointestinal bleeding.

CONCLUSION: Clinical factors including underlying malignancy, liver cirrhosis, and hematemesis are important predictors for rebleeding after angiographically negative findings in patients with acute non-variceal gastrointestinal bleeding.

[Less frequent causes of upper gastrointestinal bleeding]

Upper gastrointestinal (GI) bleeding represents emergency which despites modern advances in treatment still carry substantial mortality. Mortality remained relatively constant in the last 50 years at approximately 12%. Peptic ulcers remain the most common cause of upper GI bleeding and account approximately 50% of all cases. Next leading causes are esophageal and gastric varices, and gastroduodenal erosions. Mallory Weiss tears, angiodysplasia and gastric antral vascular ectasia (GAVE)-Watermelon stomach are less frequent but important causes of upper GI bleeding that contribute substantially to the overall morbidity and mortality. Recognition of such lesions is crucial to provide effective hemostasis. In most cases endoscopic therapy is procedure of choice which significantly improved the outcome of patients. In cases where endoscopic hemostasis is not effective, or patients rebleed after initial control surgical therapy may be required. This article will review recent advances in diagnosis and therapy of upper GI bleeding caused by Mallory Weiss tears, angiodysplasia or Watermelon stomach.