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Ayoub M, Faris C, Tomanguillo J, Anwar N, Chela H, Daglilar E. The Use of Pre-Endoscopic Metoclopramide Does Not Prevent the Need for Repeat Endoscopy: A U.S. Based Retrospective Cohort Study. Life (Basel) 2024; 14:526. [PMID: 38672796 PMCID: PMC11051147 DOI: 10.3390/life14040526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/14/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Peptic ulcer disease (PUD) can cause upper gastrointestinal bleeding (UGIB), often needing esophagogastroduodenoscopy (EGD). Second-look endoscopies verify resolution, but cost concerns prompt research on metoclopramide's efficacy compared to erythromycin. METHODS We analyzed the Diamond Network of TriNetX Research database, dividing UGIB patients with PUD undergoing EGD into three groups: metoclopramide, erythromycin, and no medication. Using 1:1 propensity score matching, we compared repeat EGD, post-EGD transfusion, and mortality within one month in two study arms. RESULTS Out of 97,040 patients, 11.5% received metoclopramide, 3.9% received erythromycin, and 84.6% received no medication. Comparing metoclopramide to no medication showed no significant difference in repeat EGD (10.1% vs. 9.7%, p = 0.34), transfusion (0.78% vs. 0.86%, p = 0.5), or mortality (1.08% vs. 1.08%, p = 0.95). However, metoclopramide had a higher repeat EGD rate compared to erythromycin (9.4% vs. 7.5%, p = 0.003), with no significant difference in transfusion or mortality. CONCLUSIONS The need to repeat EGD was not decreased with pre-EGD use of metoclopramide. If a prokinetic agent is to be used prior to EGD, erythromycin shows superior reduction in the need of repeat EGD as compared to metoclopramide.
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Affiliation(s)
- Mark Ayoub
- Department of Internal Medicine, Charleston Area Medical Center, West Virginia University, Charleston, WV 25304, USA
| | - Carol Faris
- Department of General Surgery, Marshall University, Huntington, WV 25755, USA;
| | - Julton Tomanguillo
- Department of Internal Medicine, Charleston Area Medical Center, West Virginia University, Charleston, WV 25304, USA
| | - Nadeem Anwar
- Division of Gastroenterology and Hepatology, Charleston Area Medical Center, West Virginia University, Charleston, WV 25304, USA
| | - Harleen Chela
- Division of Gastroenterology and Hepatology, Charleston Area Medical Center, West Virginia University, Charleston, WV 25304, USA
| | - Ebubekir Daglilar
- Division of Gastroenterology and Hepatology, Charleston Area Medical Center, West Virginia University, Charleston, WV 25304, USA
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Manupeeraphant P, Wanichagool D, Songlin T, Thanathanee P, Chalermsuksant N, Techathuvanan K, Sethasine S. Intravenous metoclopramide for increasing endoscopic mucosal visualization in patients with acute upper gastrointestinal bleeding: a multicenter, randomized, double-blind, controlled trial. Sci Rep 2024; 14:7598. [PMID: 38556533 PMCID: PMC10982284 DOI: 10.1038/s41598-024-57913-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/22/2024] [Indexed: 04/02/2024] Open
Abstract
Acute upper gastrointestinal hemorrhage (UGIH) is the most common emergency condition that requires rapid endoscopic treatment. This study aimed to evaluate the effects of pre-endoscopic intravenous metoclopramide on endoscopic mucosal visualization (EMV) in patients with acute UGIH. This was a multicenter, randomized, double-blind controlled trial of participants diagnosed with acute UGIH. All participants underwent esophagogastroduodenoscopy within 24 h. Participants were assigned to either the metoclopramide or placebo group. Modified Avgerinos scores were evaluated during endoscopy. In total, 284 out of 300 patients completed the per-protocol procedure. The mean age was 62.8 ± 14.3 years, and 67.6% were men. Metoclopramide group achieved a higher total EMV and gastric body EMV score than the other group (7.34 ± 1.1 vs 6.94 ± 1.6; P = 0.017 and 1.80 ± 0.4 vs 1.64 ± 0.6; P = 0.006, respectively). Success in identifying lesions was not different between the groups (96.5% in metoclopramide and 93.6% in placebo group; P = 0.26). In the metoclopramide group, those with active variceal bleeding compared with the control group demonstrated substantial improvements in gastric EMV (1.83 ± 0.4 vs 1.28 ± 0.8, P = 0.004), antral EMV (1.96 ± 0.2 vs 1.56 ± 0.6, P = 0.003), and total EMV score (7.48 ± 1.1 vs 6.2 ± 2.3, P = 0.02). Pre-endoscopic intravenous metoclopramide improved the quality of EMV in variceal etiologies of UGIH, which was especially prominent in those who had signs of active bleeding based on nasogastric tube assessment.Trial Registration: Trial was registered in Clinical Trials: TCTR 20210708004 (08/07/2021).
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Affiliation(s)
- Paveeyada Manupeeraphant
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, 681 Samsen Road, Dusit District, Bangkok, 10300, Thailand
| | - Dhanusorn Wanichagool
- Division of Gastroenterology, Phra Nakhon Si Ayutthaya Hospital, Ayutthaya, Thailand
| | - Thaphat Songlin
- Division of Gastroenterology, Panyananthaphikkhu Chonprathan Medical Center, Nonthaburi, Thailand
| | - Piyarat Thanathanee
- Division of Gastroenterology, Banphaeo General Hospital, Samut Sakhon, Thailand
| | - Nalerdon Chalermsuksant
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, 681 Samsen Road, Dusit District, Bangkok, 10300, Thailand
| | - Karjpong Techathuvanan
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, 681 Samsen Road, Dusit District, Bangkok, 10300, Thailand
| | - Supatsri Sethasine
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, 681 Samsen Road, Dusit District, Bangkok, 10300, Thailand.
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Adão D, Gois AF, Pacheco RL, Pimentel CF, Riera R. Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage. Cochrane Database Syst Rev 2023; 2:CD013176. [PMID: 36723439 PMCID: PMC9891197 DOI: 10.1002/14651858.cd013176.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Upper endoscopy is the definitive treatment for upper gastrointestinal haemorrhage (UGIH). However, up to 13% of people who undergo upper endoscopy will have incomplete visualisation of the gastric mucosa at presentation. Erythromycin acts as a motilin receptor agonist in the upper gastrointestinal (GI) tract and increases gastric emptying, which may lead to better quality of visualisation and improved treatment effectiveness. However, there is uncertainty about the benefits and harms of erythromycin in UGIH. OBJECTIVES To evaluate the benefits and harms of erythromycin before endoscopy in adults with acute upper gastrointestinal haemorrhage, compared with any other treatment or no treatment/placebo. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 15 October 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) that investigated erythromycin before endoscopy compared to any other treatment or no treatment/placebo before endoscopy in adults with acute UGIH. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. UGIH-related mortality and 2. serious adverse events. Our secondary outcomes were 1. all-cause mortality, 2. visualisation of gastric mucosa, 3. non-serious adverse events, 4. rebleeding, 5. blood transfusion, and 5. rescue invasive intervention. We used GRADE criteria to assess the certainty of the evidence for each outcome. MAIN RESULTS: We included 11 RCTs with 878 participants. The mean age ranged from 53.13 years to 64.5 years, and most participants were men (72.3%). One RCT included only non-variceal haemorrhage, one included only variceal haemorrhage, and eight included both aetiologies. We defined short-term outcomes as those occurring within one week of initial endoscopy. Erythromycin versus placebo Three RCTs (255 participants) compared erythromycin with placebo. There were no UGIH-related deaths. The evidence is very uncertain about the short-term effects of erythromycin compared with placebo on serious adverse events (risk difference (RD) -0.01, 95% confidence interval (CI) -0.04 to 0.02; 3 studies, 255 participants; very low certainty), all-cause mortality (RD 0.00, 95% CI -0.03 to 0.03; 3 studies, 255 participants; very low certainty), non-serious adverse events (RD 0.01, 95% CI -0.03 to 0.05; 3 studies, 255 participants; very low certainty), and rebleeding (risk ratio (RR) 0.63, 95% CI 0.13 to 2.90; 2 studies, 195 participants; very low certainty). Erythromycin may improve gastric mucosa visualisation (mean difference (MD) 3.63 points on 16-point ordinal scale, 95% CI 2.20 to 5.05; higher MD means better visualisation; 2 studies, 195 participants; low certainty). Erythromycin may also result in a slight reduction in blood transfusion (MD -0.44 standard units of blood, 95% CI -0.86 to -0.01; 3 studies, 255 participants; low certainty). Erythromycin plus nasogastric tube lavage versus no intervention/placebo plus nasogastric tube lavage Six RCTs (408 participants) compared erythromycin plus nasogastric tube lavage with no intervention/placebo plus nasogastric tube lavage. There were no UGIH-related deaths and no serious adverse events. The evidence is very uncertain about the short-term effects of erythromycin plus nasogastric tube lavage compared with no intervention/placebo plus nasogastric tube lavage on all-cause mortality (RD -0.02, 95% CI -0.08 to 0.03; 3 studies, 238 participants; very low certainty), visualisation of the gastric mucosa (standardised mean difference (SMD) 0.48 points on 10-point ordinal scale, 95% CI 0.10 to 0.85; higher SMD means better visualisation; 3 studies, 170 participants; very low certainty), non-serious adverse events (RD 0.00, 95% CI -0.05 to 0.05; 6 studies, 408 participants; very low certainty), rebleeding (RR 1.13, 95% CI 0.63 to 2.02; 1 study, 169 participants; very low certainty), and blood transfusion (MD -1.85 standard units of blood, 95% CI -4.34 to 0.64; 3 studies, 180 participants; very low certainty). Erythromycin versus nasogastric tube lavage Four RCTs (287 participants) compared erythromycin with nasogastric tube lavage. There were no UGIH-related deaths and no serious adverse events. The evidence is very uncertain about the short-term effects of erythromycin compared with nasogastric tube lavage on all-cause mortality (RD 0.02, 95% CI -0.05 to 0.08; 3 studies, 213 participants; very low certainty), visualisation of the gastric mucosa (RR 1.19, 95% CI 0.79 to 1.79; 2 studies, 198 participants; very low certainty), non-serious adverse events (RD -0.10, 95% CI -0.34 to 0.13; 3 studies, 213 participants; very low certainty), rebleeding (RR 0.77, 95% CI 0.40 to 1.49; 1 study, 169 participants; very low certainty), and blood transfusion (median 2 standard units of blood, interquartile range 0 to 4 in both groups; 1 study, 169 participants; very low certainty). Erythromycin plus nasogastric tube lavage versus metoclopramide plus nasogastric tube lavage One RCT (30 participants) compared erythromycin plus nasogastric tube lavage with metoclopramide plus nasogastric tube lavage. The evidence is very uncertain about the effects of erythromycin plus nasogastric tube lavage on all the reported outcomes (serious adverse events, visualisation of gastric mucosa, non-serious adverse events, and blood transfusion). AUTHORS' CONCLUSIONS We are unsure if erythromycin before endoscopy in people with UGIH has any clinical benefits or harms. However, erythromycin compared with placebo may improve gastric mucosa visualisation and result in a slight reduction in blood transfusion.
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Affiliation(s)
- Diego Adão
- Department of Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Aecio Ft Gois
- Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
| | - Rafael L Pacheco
- Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
| | | | - Rachel Riera
- Cochrane Brazil Rio de Janeiro, Cochrane Brazil, Petrópolis, Brazil
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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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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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6
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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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Rai M, Cooper M, Shulman S, Kottachchi D, Nelles S, Macmillan M, Heitman S, Barkun A, Tse F, Hookey L. Canadian Association of Gastroenterology Communique: After-Hours Endoscopy Cart. J Can Assoc Gastroenterol 2020; 3:222-227. [PMID: 32905048 PMCID: PMC7465551 DOI: 10.1093/jcag/gwz032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 10/09/2019] [Indexed: 11/19/2022] Open
Abstract
Background Endoscopic procedures performed after-hours often require therapeutic interventions that are technically demanding for the endoscopist. The aim of this position paper is to provide guidance on the minimum standard of equipment that should be available on a mobile endoscopy cart for provision of a safe and effective after-hours emergency endoscopy service. The guidance is based on consensus among academic and community gastroenterologists in Canada. Methods A modified Delphi process was used to establish consensus among 9 participants. A list of statements was prepared by an expert panel of endoscopists. The statements were divided into three broad sections for what should be on an after-hours endoscopy cart including medications, nonendoscopic tools and therapeutic/diagnostic equipment. Consensus for being on the endoscopy cart was achieved when 75% or more of voting members indicated ‘agree’. Results For nonendoscopic tools, there was agreement for having sterile saline, sterile water, endoscope lubricant, various syringes, bite blocks (paediatric and adult size), a water pump with foot peddle, formalin jars for biopsy specimens, digital photo and printing capability and an overtube. For medications, there was agreement for having hyoscine butylbromide and epinephrine on the cart. For therapeutic/diagnostic tools, there was agreement for having biopsy forceps (standard and jumbo), polypectomy snares, sclerotherapy needles and agent (for a variceal bleed), band ligation kit, multipolar electrocautery probes, heater probe catheter, endoscopic clips, hemostatic powder and retrieval devices. Interpretation This position paper provides guidance on the minimum standard of items that should be on an after-hours endoscopy cart. Standardization of equipment may help improve safety and quality of after-hours endoscopic procedures.
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Affiliation(s)
- Mandip Rai
- Division of Gastroenterology, Queen's University, Kingston, Ontario, Canada
| | - Mary Cooper
- Division of Gastroenterology, North Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Scott Shulman
- Division of Gastroenterology, North Bay Regional Health Centre, North Bay, Ontario, Canada
| | - Dan Kottachchi
- Division of Gastroenterology, Guelph General Hospital, Guelph, Ontario, Canada
| | - Sandra Nelles
- Division of Gastroenterology, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Mark Macmillan
- Division of Gastroenterology, Dalhousie University, Memorial University, Fredericton, New Brunswick, Canada
| | - Steven Heitman
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University and the McGill University Health Centre, Montreal, Quebec, Canada
| | - Frances Tse
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Hookey
- Gastrointestinal Diseases Research Unit, Department of Medicine, Queen's University, Kingston, Ontario, Canada
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Abstract
Non-variceal upper gastrointestinal bleeding continues to be an important cause of morbidity and mortality. The most common causes include peptic ulcer disease, Mallory-Weiss syndrome, erosive gastritis, duodenitis, esophagitis, malignancy, angiodysplasias and Dieulafoy's lesion. Initial assessment and early aggressive resuscitation significantly improves outcomes. Upper gastrointestinal endoscopy continues to be the gold standard for diagnosis and treatment. We present a comprehensive review of literature for the evaluation and management of non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Ronald Samuel
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551.
| | - Obada Tayyem
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Praveen Guturu
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551
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9
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Karakonstantis S, Tzagkarakis E, Kalemaki D, Lydakis C, Paspatis G. Nasogastric aspiration/lavage in patients with gastrointestinal bleeding: a review of the evidence. Expert Rev Gastroenterol Hepatol 2018; 12:63-72. [PMID: 29098897 DOI: 10.1080/17474124.2018.1398646] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The usefulness of nasogastric aspiration and nasogastric lavage in patients with gastrointestinal bleeding is controversial, as evidenced by conflicting recommendations, both among and within society guidelines. Areas covered: Considering these controversies, we reviewed the evidence regarding the following questions: 1) Can nasogastric lavage stop or slow down the bleeding and improve subsequent endoscopic visualization? 2) Is nasogastric aspiration helpful for the localization of bleeding? 3) Can nasogastric aspiration identify high risk patients that might benefit from earlier endoscopy? 4) Is there evidence for benefit in terms of outcomes from using nasogastric aspiration? 5) Is nasogastric intubation safe in patients with possible esophageal varices? Our review was conducted according to PRISMA guidelines. Expert commentary: Based on the available literature, nasogastric lavage or aspiration cannot be routinely recommended unless a large properly designed randomized trial (which is currently lacking) proves otherwise. It is a painful and time-consuming procedure with no demonstrated benefit for the patient in terms of outcomes. Other clinical and laboratory parameters, and risk scores, are less invasive and are effective for guiding the stratification and management of patients, while pre-endoscopic erythromycin infusion is a good if not better alternative for improving visualization of the stomach.
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Affiliation(s)
- Stamatis Karakonstantis
- a The Second Department of Internal Medicine , Venizeleio Pananeio General Hospital of Heraklion , Heraklion , Greece
| | - Emmanouil Tzagkarakis
- a The Second Department of Internal Medicine , Venizeleio Pananeio General Hospital of Heraklion , Heraklion , Greece
| | | | - Charalampos Lydakis
- a The Second Department of Internal Medicine , Venizeleio Pananeio General Hospital of Heraklion , Heraklion , Greece
| | - Gregorios Paspatis
- c Department of Gastroenterology , Venizeleio Pananeio General Hospital of Heraklion , Heraklion , Greece
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García-Iglesias P, Botargues JM, Feu Caballé F, Villanueva Sánchez C, Calvet Calvo X, Brullet Benedi E, Cánovas Moreno G, Fort Martorell E, Gallach Montero M, Gené Tous E, Hidalgo Rosas JM, Lago Macía A, Nieto Rodríguez A, Papo Berger M, Planella de Rubinat M, Saló Rich J, Campo Fernández de Los Ríos R. Management of non variceal upper gastrointestinal bleeding: position statement of the Catalan Society of Gastroenterology. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 40:363-374. [PMID: 28109636 DOI: 10.1016/j.gastrohep.2016.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 11/22/2016] [Accepted: 11/25/2016] [Indexed: 12/11/2022]
Abstract
In recent years there have been advances in the management of non-variceal upper gastrointestinal bleeding that have helped reduce rebleeding and mortality. This document positioning of the Catalan Society of Digestologia is an update of evidence-based recommendations on management of gastrointestinal bleeding peptic ulcer.
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Affiliation(s)
- Pilar García-Iglesias
- Servei de Digestiu, Hospital de Sabadell-Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España.
| | - Josep-Maria Botargues
- Servei de Digestiu, Hospital Universitari de Bellvitge, l'Hospitalet, Barcelona, España
| | - Faust Feu Caballé
- Servei de Gastroenterologia, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Barcelona, España
| | | | - Xavier Calvet Calvo
- Servei de Digestiu, Hospital de Sabadell-Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Departament de Medicina, Universitat Autònoma de Barcelona, España
| | - Enric Brullet Benedi
- Servei de Digestiu, Hospital de Sabadell-Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España
| | - Gabriel Cánovas Moreno
- Servei de Cirurgia, Hospital de Sabadell-Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España
| | | | - Marta Gallach Montero
- Servei de Digestiu, Hospital de Sabadell-Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España
| | - Emili Gené Tous
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Departament de Medicina, Universitat Autònoma de Barcelona, España; Servei d'Urgències, Hospital de Sabadell-Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España
| | - José-Manuel Hidalgo Rosas
- Servei de Cirurgia, Hospital de Sabadell-Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España
| | - Amelia Lago Macía
- Servei de Digestiu, Hospital de Tortosa Verge de la Cinta, Tortosa, Tarragona, España
| | | | | | | | - Joan Saló Rich
- Servei de Digestiu, Hospital de Vic, Vic, Barcelona, España
| | - Rafel Campo Fernández de Los Ríos
- Servei de Digestiu, Hospital de Sabadell-Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Departament de Medicina, Universitat Autònoma de Barcelona, España
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Cabrera L, Tandon P, Abraldes JG. An update on the management of acute esophageal variceal bleeding. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 40:34-40. [DOI: 10.1016/j.gastrohep.2015.11.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 11/26/2015] [Accepted: 11/27/2015] [Indexed: 12/14/2022]
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12
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Gené E, Calvet X. ¿Sonda nasogástrica en el paciente con hemorragia digestiva alta? GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 39:497-9. [DOI: 10.1016/j.gastrohep.2015.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 11/30/2015] [Accepted: 12/21/2015] [Indexed: 12/26/2022]
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Franco MC, Nakao FS, Rodrigues R, Maluf-Filho F, Paulo GAD, Libera ED. PROPOSAL OF A CLINICAL CARE PATHWAY FOR THE MANAGEMENT OF ACUTE UPPER GASTROINTESTINAL BLEEDING. ARQUIVOS DE GASTROENTEROLOGIA 2016; 52:283-92. [PMID: 26840469 DOI: 10.1590/s0004-28032015000400007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 08/25/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Upper gastrointestinal bleeding implies significant clinical and economic repercussions. The correct establishment of the latest therapies for the upper gastrointestinal bleeding is associated with reduced in-hospital mortality. The use of clinical pathways for the upper gastrointestinal bleeding is associated with shorter hospital stay and lower hospital costs. OBJECTIVE The primary objective is the development of a clinical care pathway for the management of patients with upper gastrointestinal bleeding, to be used in tertiary hospital. METHODS It was conducted an extensive literature review on the management of upper gastrointestinal bleeding, contained in the primary and secondary information sources. RESULTS The result is a clinical care pathway for the upper gastrointestinal bleeding in patients with evidence of recent bleeding, diagnosed by melena or hematemesis in the last 12 hours, who are admitted in the emergency rooms and intensive care units of tertiary hospitals. In this compact and understandable pathway, it is well demonstrated the management since the admission, with definition of the inclusion and exclusion criteria, passing through the initial clinical treatment, posterior guidance for endoscopic therapy, and referral to rescue therapies in cases of persistent or rebleeding. It was also included the care that must be taken before hospital discharge for all patients who recover from an episode of bleeding. CONCLUSION The introduction of a clinical care pathway for patients with upper gastrointestinal bleeding may contribute to standardization of medical practices, decrease in waiting time for medications and services, length of hospital stay and costs.
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Affiliation(s)
| | - Frank Shigueo Nakao
- Hospital Universitário, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Rodrigo Rodrigues
- Departamento de Endoscopia, Fleury Medicina e Saúde, São Paulo, SP, Brasil
| | - Fauze Maluf-Filho
- Departamento de Endoscopia, Instituto de Câncer de São Paulo, São Paulo, SP, Brasil
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14
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Affiliation(s)
- Loren Laine
- From the Yale School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven - both in Connecticut
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15
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Rahman R, Nguyen DL, Sohail U, Almashhrawi AA, Ashraf I, Puli SR, Bechtold ML. Pre-endoscopic erythromycin administration in upper gastrointestinal bleeding: an updated meta-analysis and systematic review. Ann Gastroenterol 2016; 29:312-7. [PMID: 27366031 PMCID: PMC4923816 DOI: 10.20524/aog.2016.0045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 04/09/2016] [Indexed: 12/13/2022] Open
Abstract
Background In patients suffering from upper gastrointestinal bleeding (UGIB), adequate visualization is essential during endoscopy. Prior to endoscopy, erythromycin administration has been shown to enhance visualization in these patients; however, guidelines have not fully adopted this practice. Thus, we performed a comprehensive, up-to-date meta-analysis on the issue of erythromycin administration in this patient population. Methods After searching multiple databases (November 2015), randomized controlled trials on adult subjects comparing administration of erythromycin before endoscopy in UGIB patients to no erythromycin or placebo were included. Pooled estimates of adequacy of gastric mucosa visualized, need for second endoscopy, duration of procedure, length of hospital stay, units of blood transfused, and need for emergent surgery using odds ratio (OR) or mean difference (MD) were calculated. Heterogeneity and publication bias were assessed. Results Eight studies (n=598) were found to meet the inclusion criteria. Erythromycin administration showed statistically significant improvement in adequate gastric mucosa visualization (OR 4.14; 95% CI: 2.01-8.53, P<0.01) while reduced the need for a second-look endoscopy (OR 0.51; 95% CI: 0.34-0.77, P<0.01) and length of hospital stay (MD -1.75; 95% CI: -2.43 to -1.06, P<0.01). Duration of procedure (P=0.2), units of blood transfused (P=0.08), and need for emergent surgery (P=0.88) showed no significant differences. Conclusion Pre-endoscopic erythromycin administration in UGIB patients significantly improves gastric mucosa visualization while reducing length of hospital stay and the need for second-look endoscopy.
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Affiliation(s)
- Rubayat Rahman
- Division of Gastroenterology and Hepatology, University of Missouri Health Sciences Center (Rubayat Rahman, Umair Sohail, Ashraf A. Almashhrawi, Imran Ashraf, Matthew L. Bechtold), USA
| | - Douglas L Nguyen
- Gastroenterology and Hepatology, University of California-Irvine (Douglas L. Nguyen), USA
| | - Umair Sohail
- Division of Gastroenterology and Hepatology, University of Missouri Health Sciences Center (Rubayat Rahman, Umair Sohail, Ashraf A. Almashhrawi, Imran Ashraf, Matthew L. Bechtold), USA
| | - Ashraf A Almashhrawi
- Division of Gastroenterology and Hepatology, University of Missouri Health Sciences Center (Rubayat Rahman, Umair Sohail, Ashraf A. Almashhrawi, Imran Ashraf, Matthew L. Bechtold), USA
| | - Imran Ashraf
- Division of Gastroenterology and Hepatology, University of Missouri Health Sciences Center (Rubayat Rahman, Umair Sohail, Ashraf A. Almashhrawi, Imran Ashraf, Matthew L. Bechtold), USA
| | - Srinivas R Puli
- Gastroenterology and Hepatology, University of Illinois-Peoria (Srinivas R. Puli), USA
| | - Matthew L Bechtold
- Division of Gastroenterology and Hepatology, University of Missouri Health Sciences Center (Rubayat Rahman, Umair Sohail, Ashraf A. Almashhrawi, Imran Ashraf, Matthew L. Bechtold), USA
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16
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Jung S, Kim EH, Kim HY, Roh YH, Park CH, Park SJ, Chung H, Kim BK, Lee H, Park JJ, Hong SP, Park JY, Shin SK, Lee SK, Lee YC, Park JC. Factors that affect visibility during endoscopic hemostasis for upper GI bleeding: a prospective study. Gastrointest Endosc 2016; 81:1392-400. [PMID: 25771067 DOI: 10.1016/j.gie.2014.12.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 12/01/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Adequate visibility is an important factor for achieving successful endoscopic hemostasis for the treatment of upper GI bleeding (UGIB). The independent factors that affect visibility during endoscopic procedures have yet to be determined. OBJECTIVE To determine the factors that affect endoscopic visibility and to create a model that can predict in which patients unacceptable visibility is suspected before emergent endoscopic procedures for UGIB. DESIGN Prospective, observational study. SETTING University-affiliated tertiary care hospital in South Korea. PATIENTS A total of 121 patients admitted because of UGIB. INTERVENTION Analysis of the visibility score of the emergency endoscopies for UGIB. MAIN OUTCOME MEASUREMENTS Factors affecting the visibility score of endoscopy and a classification and regression tree (CART) model for predicting of visibility. RESULTS The EGD time and the appearance of the nasogastric (NG) tube aspirate were independent factors that were significantly associated with visibility (EGD time, P<.001; red blood appearance in NG tube aspirate, P<.001; coffee grounds appearance of NG tube aspirate, P=.006). Based on these results, a CART model was developed by using 70 patients who had been allocated to the training set. The CART generated algorithms that proposed the use of the appearance of the NG tube aspirate and the EGD time (8.5 hours) to predict visibility. The sensitivity and specificity for predicting poor visibility were 71.4% and 86.4%, respectively. CONCLUSION The use of the CART model enables the prediction of which patients will have poor visibility during emergent endoscopy.
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Affiliation(s)
- Sungmo Jung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
| | - Eun Hye Kim
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
| | - Ha Yan Kim
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, South Korea
| | - Yun Ho Roh
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, South Korea
| | - Chan Hyuk Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
| | - Soo Jung Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyunsoo Chung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
| | - Beom Kyung Kim
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyuk Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae Jun Park
- Department of Internal Medicine, Institute of Gastroenterology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung Pil Hong
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Yong Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung Kwan Shin
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong Chan Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Chul Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
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17
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Bai Y, Li ZS. Guidelines for the diagnosis and treatment of acute non-variceal upper gastrointestinal bleeding (2015, Nanchang, China). J Dig Dis 2016; 17:79-87. [PMID: 26853440 DOI: 10.1111/1751-2980.12319] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute non-variceal upper gastrointestinal bleeding (ANVUGIB) is one of the most common medical emergencies in China and worldwide. In 2009, we published the "Guidelines for the diagnosis and treatment of acute non-variceal upper gastrointestinal bleeding" for the patients in China; however, during the past years numerous studies on the diagnosis and treatment of ANVUGIB have been conducted, and the management of ANVUGIB needs to be updated. The guidelines were updated after the databases including PubMed, Embase and CNKI were searched to retrieve the clinical trials on the management of ANVUGIB. The clinical trials were evaluated for high-quality evidence, and the advances in definitions, diagnosis, etiology, severity evaluation, treatment and prognosis of ANVUGIB were carefully reviewed, the recommendations were then proposed. After several rounds of discussions and revisions among the national experts of digestive endoscopy, gastroenterology, radiology and intensive care, the 2015 version of "Guidelines for the diagnosis and treatment of acute non-variceal upper gastrointestinal bleeding" was successfully developed by the Chinese Journal of Internal Medicine, National Medical Journal of China, Chinese Journal of Digestion and Chinese Journal of Digestive Endoscopy. It shall be noted that although much progress has been made, the clinical management of ANVUGIB still needs further improvement and refinement, and high-quality randomized trials are required in the future.
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Affiliation(s)
- Yu Bai
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhao Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
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18
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Jafar W, Jafar AJN, Sharma A. Upper gastrointestinal haemorrhage: an update. Frontline Gastroenterol 2016; 7:32-40. [PMID: 28839832 PMCID: PMC5369541 DOI: 10.1136/flgastro-2014-100492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 09/16/2014] [Accepted: 09/17/2014] [Indexed: 02/04/2023] Open
Abstract
Upper gastrointestinal (GI) haemorrhage is a common cause for admission to hospital and is associated with a mortality of around 10%. Prompt assessment and resuscitation are vital, as are risk stratification of the severity of bleeding, early involvement of the multidisciplinary team and timely access to endoscopy, preferably within 24 h. The majority of bleeds are due to peptic ulcers for which Helicobacter pylori and non-steroidal anti-inflammatory agents are the main risk factors. Although proton pump inhibitors (PPIs) are widely used before endoscopy, this is controversial. Pre-endoscopic risk stratification with the Glasgow Blatchford score is recommended as is the use of the Rockall score postendoscopy. Endoscopic therapy, with at least two haemostatic modalities, remains the mainstay of treating high-risk lesions and reduces rebleeding rates and mortality. High-dose PPI therapy after endoscopic haemostasis also reduces rebleeding rates and mortality. Variceal oesophageal haemorrhage is associated with a higher rebleeding rate and risk of death. Antibiotics and vasopressin analogues are advised in suspected variceal bleeding; however, endoscopic variceal band ligation remains the haemostatic treatment of choice. Balloon tamponade remains useful in the presence of torrential variceal haemorrhage or when endoscopy fails to secure haemostasis, and can be a bridge to further endoscopic attempts or placement of a transjugular intrahepatic portosystemic shunt. This review aims to provide an update on the latest evidence-based recommendations for the management of acute upper GI haemorrhage.
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Affiliation(s)
| | - Anisa Jabeen Nasir Jafar
- Gastroenterology Department, Stockport NHS Foundation Trust, Stockport, UK,Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Abhishek Sharma
- Gastroenterology
Department, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
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19
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Fortinsky KJ, Bardou M, Barkun AN. Role of Medical Therapy for Nonvariceal Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2015; 25:463-78. [PMID: 26142032 DOI: 10.1016/j.giec.2015.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Nonvariceal upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality worldwide. Mortality from UGIB has remained 5-10% over the past decade. This article presents current evidence-based recommendations for the medical management of UGIB. Preendoscopic management includes initial resuscitation, risk stratification, appropriate use of blood products, and consideration of nasogastric tube insertion, erythromycin, and proton pump inhibitor therapy. The use of postendoscopic intravenous proton pump inhibitors is strongly recommended for certain patient populations. Postendoscopic management also includes the diagnosis and treatment of Helicobacter pylori, appropriate use of proton pump inhibitors and iron replacement therapy.
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Affiliation(s)
- Kyle J Fortinsky
- Department of Medicine, Toronto General Hospital, University of Toronto, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Marc Bardou
- Gastroenterology Department & Centre d'Investigations Clinique CIC1432, CHU de Dijon, 14 rue Gaffarel BP77908, Dijon, Cedex 21079, France.
| | - Alan N Barkun
- Gastroenterology Department, McGill University Health Centre, Montreal General Hospital Site, Room D7-346, 1650 Cedar Avenue, Montréal, Québec H3G 1A4, Canada
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20
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Rajala MW, Ginsberg GG. Tips and Tricks on How to Optimally Manage Patients with Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2015; 25:607-17. [PMID: 26142041 DOI: 10.1016/j.giec.2015.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Effective endoscopic therapy for upper gastrointestinal (GI) bleeding has been shown to reduce rebleeding, need for surgery, and mortality. Effective endoscopic management of acute upper GI bleeding can be challenging and worrying. This article provides advice that is complementary to the in-depth reviews that accompany it in this issue. Topics include initial management, resuscitation, when and where to scope, benefits and limitations of devices, device selection based on lesion characteristics, improving visualization to localize the lesion, and tips on how to reduce the endoscopist's trepidation about managing these cases.
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Affiliation(s)
- Michael W Rajala
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA, USA.
| | - Gregory G Ginsberg
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA, USA
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21
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Khamaysi I, Gralnek IM. Nonvariceal Upper Gastrointestinal Bleeding: Timing of Endoscopy and Ways to Improve Endoscopic Visualization. Gastrointest Endosc Clin N Am 2015; 25:443-8. [PMID: 26142030 DOI: 10.1016/j.giec.2015.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Upper gastrointestinal (UGI) endoscopy is the cornerstone of diagnosis and management of patients presenting with acute UGI bleeding. Once hemodynamically resuscitated, early endoscopy (performed within 24 hours of patient presentation) ensures accurate identification of the bleeding source, facilitates risk stratification based on endoscopic stigmata, and allows endotherapy to be delivered where indicated. Moreover, the preendoscopy use of a prokinetic agent (eg, i.v. erythromycin), especially in patients with a suspected high probability of having blood or clots in the stomach before undergoing endoscopy, may result in improved endoscopic visualization, a higher diagnostic yield, and less need for repeat endoscopy.
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Affiliation(s)
- Iyad Khamaysi
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Israel; Interventional Endoscopy Unit, Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Ian M Gralnek
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Israel; The Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, Israel.
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22
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Kapoor A, Dharel N, Sanyal AJ. Endoscopic Diagnosis and Therapy in Gastroesophageal Variceal Bleeding. Gastrointest Endosc Clin N Am 2015; 25:491-507. [PMID: 26142034 PMCID: PMC4862401 DOI: 10.1016/j.giec.2015.03.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Gastroesophageal variceal hemorrhage is a medical emergency with high morbidity and mortality. Endoscopic therapy is the mainstay of management of bleeding varices. It requires attention to technique and the appropriate choice of therapy for a given patient at a given point in time. Subjects must be monitored continuously after initiation of therapy for control of bleeding, and second-line definitive therapies must be introduced quickly if endoscopic and pharmacologic treatment fails.
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23
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Abstract
Overt or occult gastrointestinal bleeding is a frequently observed condition in routine gastroenterological practice. Occult gastrointestinal bleeding is usually a purely incidental finding, based on the discovery of iron deficiency anemia in the laboratory or blood in stool (a positive Hemoccult test). However, overt bleeding accompanied by the clinical features of tarry stool, hematemesis, or hematochezia may be a life-threatening condition, calling for immediate emergency management. In contrast to traumatology, algorithms of emergency and intensive medicine are not sufficiently validated yet for acute life-threatening bleeding. The purpose of this review was to present all established and new endoscopic hemostasis techniques and to evaluate their efficacy, as well as to provide the treating endoscopist with practical advice on how he/she could incorporate these procedures into acute medical management. The recommendations are based on inspection of the study results in the recent published literature, as well as emergency medicine algorithms in traumatology.
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24
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Predictive Factors for Endoscopic Visibility and Strategies for Pre-endoscopic Prokinetics Use in Patients with Upper Gastrointestinal Bleeding. Dig Dis Sci 2015; 60:957-65. [PMID: 25326116 DOI: 10.1007/s10620-014-3393-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 10/08/2014] [Indexed: 12/09/2022]
Abstract
BACKGROUND Although current guideline recommends selective use of pre-endoscopic prokinetics to increase diagnostic yield in upper gastrointestinal bleeding (UGIB) patients, no data to guide the use of these drugs are available. AIMS We aimed to investigate predictive factors for endoscopic visibility and develop simple and useful strategies for pre-endoscopic prokinetics use in UGIB patients. METHODS A total of 220 consecutive patients who underwent upper endoscopy for suspicious UGIB were enrolled. Patients were randomly allocated to either a training or a validation set at a 2:1 ratio. Significant parameters on univariate analysis were subsequently tested by a classification and regression tree (CART) analysis. RESULTS Time to endoscopy and nasogastric aspirate findings were independently related to endoscopic visibility. The CART analysis generated algorithms proposed sequential use of time to endoscopy (≤5.2 vs. >5.2 h) and nasogastric aspirate findings (red blood or coffee rounds vs. clear aspirate) for predicting endoscopic visibility. Prediction of unacceptable visibility in the validation set produced sensitivity, specificity, positive predictive value, and negative predictive value of 75.8, 67.5, 65.8, and 77.1 %, respectively. Accurate prediction for visibility was identified in 52 of 73 patients (71.2 %). CONCLUSIONS Time to endoscopy and nasogastric aspirate findings were independently related to endoscopic visibility in patients with UGIB. A decision-tree model incorporating these two variables may be useful for selecting UGIB patients who benefit from pre-endoscopic prokinetics use.
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Lu Y, Chen YI, Barkun A. Endoscopic management of acute peptic ulcer bleeding. Gastroenterol Clin North Am 2014; 43:677-705. [PMID: 25440919 DOI: 10.1016/j.gtc.2014.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
This review discusses the indications, technical aspects, and comparative effectiveness of the endoscopic treatment of upper gastrointestinal bleeding caused by peptic ulcer. Pre-endoscopic considerations, such as the use of prokinetics and timing of endoscopy, are reviewed. In addition, this article examines aspects of postendoscopic care such as the effectiveness, dosing, and duration of postendoscopic proton-pump inhibitors, Helicobacter pylori testing, and benefits of treatment in terms of preventing rebleeding; and the use of nonsteroidal anti-inflammatory drugs, antiplatelet agents, and oral anticoagulants, including direct thrombin and Xa inhibitors, following acute peptic ulcer bleeding.
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Affiliation(s)
- Yidan Lu
- Division of Gastroenterology, McGill University Health Center, McGill University, 1650 Cedar Avenue, Montréal H3G 1A4, Canada
| | - Yen-I Chen
- Division of Gastroenterology, McGill University Health Center, McGill University, 1650 Cedar Avenue, Montréal H3G 1A4, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, 1650 Cedar Avenue, Montréal H3G 1A4, Canada; Division of Clinical Epidemiology, McGill University Health Center, McGill University, 687 Pine Avenue West, Montréal H3A 1A1, Canada.
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Kim BSM, Li BT, Engel A, Samra JS, Clarke S, Norton ID, Li AE. Diagnosis of gastrointestinal bleeding: A practical guide for clinicians. World J Gastrointest Pathophysiol 2014; 5:467-478. [PMID: 25400991 PMCID: PMC4231512 DOI: 10.4291/wjgp.v5.i4.467] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 07/15/2014] [Accepted: 08/29/2014] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal bleeding is a common problem encountered in the emergency department and in the primary care setting. Acute or overt gastrointestinal bleeding is visible in the form of hematemesis, melena or hematochezia. Chronic or occult gastrointestinal bleeding is not apparent to the patient and usually presents as positive fecal occult blood or iron deficiency anemia. Obscure gastrointestinal bleeding is recurrent bleeding when the source remains unidentified after upper endoscopy and colonoscopic evaluation and is usually from the small intestine. Accurate clinical diagnosis is crucial and guides definitive investigations and interventions. This review summarizes the overall diagnostic approach to gastrointestinal bleeding and provides a practical guide for clinicians.
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Christian K, Hudson M, Goldberg E. Upper endoscopy in liver disease. Clin Liver Dis (Hoboken) 2014; 4:116-119. [PMID: 30992936 PMCID: PMC6448749 DOI: 10.1002/cld.436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 09/04/2014] [Accepted: 10/05/2014] [Indexed: 02/04/2023] Open
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Jun BY, Choi MG, Lee JY, Baeg MK, Moon SJ, Lim CH, Kim JS, Cho YK, Lee IS, Kim SW, Choi KY. Premedication with erythromycin improves endoscopic visualization of the gastric mucosa in patients with subtotal gastrectomy: a prospective, randomized, controlled trial. Surg Endosc 2014; 28:1641-7. [PMID: 24380989 DOI: 10.1007/s00464-013-3364-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 11/24/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND Food residue in the remnant stomach after subtotal gastrectomy (STG) interferes with endoscopic observation. We investigated whether intravenous erythromycin improves gastric mucosa visualization in patients with STG. METHODS This study was conducted from April 2012 to October 2012 as a double-blinded, placebo-controlled, randomized trial. Patients who received STG with complete resection (stage T1-2N0M0) were included. Exclusion criteria were diabetes mellitus, neurologic disease, myopathy, recent viral enteritis history, concomitant therapy influencing gastrointestinal motility and severe comorbidity. Patients were instructed to consume a soft diet for dinner between 1800 and 2000 h, and endoscopies were performed between 0900 and 1200 h. Patients were assigned randomly to receive either erythromycin (125 mg in normal saline 50 cc) or placebo saline. The endoscopy was performed 15 min after infusion. Grade of residual food was rated as follows: G0, no residual food; G1, a small amount of residual food; G2, a moderate amount of residual food; G3, a moderate amount of residual food that hinders observation of the entire surface, even with body rolling; G4, a great amount of residual food such that endoscopic observation is impossible. RESULTS When good visibility was defined as G0+G1, visibility was significantly better in the erythromycin group (61 + 19 %) than in the placebo group (38 + 12 %, p < 0.001). However, this effect was not seen in patients within 6 months after gastrectomy. The risk factor for food stasis in the placebo group (n = 58) was food stasis at last endoscopy. The only factor predicting erythromycin response in the erythromycin group (n = 56) was elapsed time since surgery. Adverse effects included nausea [11 (19.7 %)] and vomiting [1 (1.8 %)] in the erythromycin group and vomiting [3 (5.2 %)] in the placebo group. However, they were transient and tolerable. CONCLUSIONS Premedication with erythromycin improves mucosal visualization during endoscopy in patients with STG. ( CLINICAL TRIALS REGISTRATION NUMBER NCT01659619).
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Affiliation(s)
- Byoung Yeon Jun
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, 505 Banpo-dong, Seocho-gu, Seoul, 137-701, Republic of Korea,
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Lu Y, Loffroy R, Lau JYW, Barkun A. Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding. Br J Surg 2013; 101:e34-50. [PMID: 24277160 DOI: 10.1002/bjs.9351] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND The modern management of acute non-variceal upper gastrointestinal bleeding is centred on endoscopy, with recourse to interventional radiology and surgery in refractory cases. The appropriate use of intervention to optimize outcomes is reviewed. METHODS A literature search was undertaken of PubMed and the Cochrane Central Register of Controlled Trials between January 1990 and April 2013 using validated search terms (with restrictions) relevant to upper gastrointestinal bleeding. RESULTS Appropriate and adequate resuscitation, and risk stratification using validated scores should be initiated at diagnosis. Coagulopathy should be corrected along with blood transfusions, aiming for an international normalized ratio of less than 2·5 to proceed with possible endoscopic haemostasis and a haemoglobin level of 70 g/l (excluding patients with severe bleeding or ischaemia). Prokinetics and proton pump inhibitors (PPIs) can be administered while awaiting endoscopy, although they do not affect rebleeding, surgery or mortality rates. Endoscopic haemostasis using thermal or mechanical therapies alone or in combination with injection should be used in all patients with high-risk stigmata (Forrest I-IIb) within 24 h of presentation (possibly within 12 h if there is severe bleeding), followed by a 72-h intravenous infusion of PPI that has been shown to decrease further rebleeding, surgery and mortality. A second attempt at endoscopic haemostasis is generally made in patients with rebleeding. Uncontrolled bleeding should be treated with targeted or empirical transcatheter arterial embolization. Surgical intervention is required in the event of failure of endoscopic and radiological measures. Secondary PPI prophylaxis when indicated and Helicobacter pylori eradication are necessary to decrease recurrent bleeding, keeping in mind the increased false-negative testing rates in the setting of acute bleeding. CONCLUSION An evidence-based approach with multidisciplinary collaboration is required to optimize outcomes of patients presenting with acute non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Y Lu
- Division of Gastroenterology and
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Kim S, Muthusamy VR. Prophylactic erythromycin in acute upper gastrointestinal bleeding: moving forward in improving endoscopic efficacy. Saudi J Gastroenterol 2013; 19:193-4. [PMID: 24045591 PMCID: PMC3793469 DOI: 10.4103/1319-3767.118109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Stephen Kim
- Department of Medicine, Division of Digestive Diseases, University of California Los Angeles, Los Angeles, CA, USA E-mail:
| | - V. Raman Muthusamy
- Department of Medicine, Division of Digestive Diseases, University of California Los Angeles, Los Angeles, CA, USA E-mail:
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Theivanayagam S, Lim RG, Cobell WJ, Gowda JT, Matteson ML, Choudhary A, Bechtold ML. Administration of erythromycin before endoscopy in upper gastrointestinal bleeding: a meta-analysis of randomized controlled trials. Saudi J Gastroenterol 2013; 19:205-10. [PMID: 24045593 PMCID: PMC3793471 DOI: 10.4103/1319-3767.118120] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND/AIM Erythromycin infusion before endoscopy in upper gastrointestinal bleeding (UGIB) has been hypothesized to aid in visualization and reduce the need for second-look endoscopy; however, the results have been controversial. To evaluate further, we performed a meta-analysis comparing the efficacy of erythromycin infusion before endoscopy in acute UGIB. METHODS Multiple databases were searched (March 2013). Only randomized controlled trials were included in the analysis. A meta-analysis for the effect of erythromycin or no erythromycin before endoscopy in UGIB were analyzed by calculating pooled estimates of primary (visualization of gastric mucosa and need for second endoscopy) and secondary (units of blood transfused, length of hospital stay, duration of the procedure) outcomes. Statistical analysis was performed using RevMan 5.1 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration). RESULTS Six studies (N = 558) met the inclusion criteria. Erythromycin infusion before endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa [odds ratio (OR) 3.43; 95% confidence interval (CI): 1.81 to 6.50, P < 0.01] compared with no erythromycin. In addition, erythromycin infusion before endoscopy resulted in a statistically significant decrease in the need for a second endoscopy (OR 0.47; 95% CI: 0.26 to 0.83, P = 0.01), units of blood transfused (WMD - 0.41; 95% CI: -0.82 to -0.01, P = 0.04), and the duration of hospital stay (WMD - 1.51; 95% CI: -2.45 to -0.56, P < 0.01). CONCLUSIONS Erythromycin infusion before endoscopy in patients with UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy, units of blood transfused, and duration of hospital stay.
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Affiliation(s)
- Shoba Theivanayagam
- Division of Gastroenterology and Hepatology, CE405, DC 043.00, University of Missouri Health Sciences Center, Five Hospital Drive, Columbia, MO 65212, USA
| | - Roxanne G. Lim
- Division of Gastroenterology and Hepatology, CE405, DC 043.00, University of Missouri Health Sciences Center, Five Hospital Drive, Columbia, MO 65212, USA
| | - William J. Cobell
- Division of Gastroenterology and Hepatology, CE405, DC 043.00, University of Missouri Health Sciences Center, Five Hospital Drive, Columbia, MO 65212, USA
| | - Jayashree T. Gowda
- Division of Gastroenterology and Hepatology, CE405, DC 043.00, University of Missouri Health Sciences Center, Five Hospital Drive, Columbia, MO 65212, USA
| | - Michelle L. Matteson
- Division of Gastroenterology and Hepatology, CE405, DC 043.00, University of Missouri Health Sciences Center, Five Hospital Drive, Columbia, MO 65212, USA
| | - Abhishek Choudhary
- Division of Gastroenterology and Hepatology, CE405, DC 043.00, University of Missouri Health Sciences Center, Five Hospital Drive, Columbia, MO 65212, USA
| | - Matthew L. Bechtold
- Division of Gastroenterology and Hepatology, CE405, DC 043.00, University of Missouri Health Sciences Center, Five Hospital Drive, Columbia, MO 65212, USA,Address for correspondence: Prof. Matthew L. Bechtold, Division of Gastroenterology and Hepatology, CE405, DC 043.00, University of Missouri Health Sciences Center, Five Hospital Drive, Columbia, MO 65212, USA. E-mail:
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Dicu D, Pop F, Ionescu D, Dicu T. Comparison of risk scoring systems in predicting clinical outcome at upper gastrointestinal bleeding patients in an emergency unit. Am J Emerg Med 2012; 31:94-9. [PMID: 23000328 DOI: 10.1016/j.ajem.2012.06.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 06/07/2012] [Accepted: 06/09/2012] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Admission Rockall score (RS), full RS, and Glasgow-Blatchford Bleeding Score (GBS) can all be used to stratify the risk in patients presenting with upper gastrointestinal bleeding (UGIB) in the emergency department (ED). The aim of our study was to compare both admission and full RS and GBS in predicting outcomes at UGIB patients in a Romanian ED. PATIENTS AND METHODS A total of 229 consecutive patients with UGIB were enrolled in the study. Patients were followed up 60 days after admission to ED because of UGIB episode to determine cases of rebleeding or death during this period. By using areas under the curve (AUCs), we compared the 3 scores in terms of identifying the most predictive score of unfavorable outcomes. RESULTS Rebleeding rate was 40.2% (92 patients), and mortality rate was 18.7% (43 patients). For the prediction of mortality, full RS was superior to GBS (AUC, 0.825 vs 0.723; P = .05) and similar to admission RS (AUC, 0.792). Glasgow-Blatchford Bleeding Score had the highest accuracy in detecting patients who needed transfusion (AUC, 0.888) and was superior to both the admission RS and full RS (AUC, 0.693 and 0.750, respectively) (P < .0001). In predicting the need for intervention, the GBS was superior to both the admission RS and full RS (AUC, 0.868, 0.674, and 0.785, respectively) (P < .0001 and P = .04, respectively). CONCLUSIONS The GBS can be used to predict need for intervention and transfusion in patients with UGIB in our ED, whereas full RS can be successfully used to stratify the mortality risk in these patients.
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Affiliation(s)
- Daniela Dicu
- Emergency Department, Regional Institute of Gastroenterology and Hepatology O. Fodor, Cluj-Napoca, Romania
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Abstract
Nonvariceal upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality worldwide. Despite the improvements in the management of this condition in western countries, mortality rates have remained at 5-10% over the past decade. This article presents the main recommendations for the management of UGIB. Pre-endoscopic management (including use of scoring scales, nasogastric tube placement and blood pressure stabilization) is crucial for triage and optimal resuscitation of patients, and should include a multidisciplinary approach at an early stage. Unless the patient has specific comorbidities, transfusion should only be considered if their hemoglobin level is ≤70 g/l. Endoscopic therapy, the cornerstone of therapeutic management of high-risk lesions, should not be delayed for more than 24 h following admission. Several endoscopic techniques, mostly using clips or thermal methods, are available and new approaches are emerging. When endoscopy fails, surgery or arterial embolization should be considered. Although the efficacy of prokinetics and high-dose intravenous PPI prior to endoscopy is controversial, the use of an intravenous PPI following endoscopy is strongly recommended. Antiplatelet therapy should be suspended and resumed in 3-5 days. Finally, all patients should be tested for Helicobacter pylori by serology in the acute setting.
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