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Seong G, Cha B, Shin J, Kong SM, Hong JT, Kwon KS. UI-EWD hemostatic powder in the management of refractory lower gastrointestinal bleeding: a multicenter study. Scand J Gastroenterol 2024; 59:1172-1177. [PMID: 39264069 DOI: 10.1080/00365521.2024.2403120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 09/01/2024] [Accepted: 09/05/2024] [Indexed: 09/13/2024]
Abstract
INTRODUCTION Lower gastrointestinal bleeding (LGIB) is a common cause of emergency hospitalization and may require readmission for re-bleeding. A novel adhesive endoscopic hemostatic powder (UI-EWD/NexpowderTM, Nextbiomedical, Incheon, South Korea) has been developed and recently utilized for LGIB hemostasis. The aim of the current study was to assess the efficacy and safety of UI-EWD as a rescue therapy for the treatment of refractory LGIB. METHODS In this study, a total of 59 consecutive patients with LGIB who experienced initial hemostasis failure with conventional endoscopic therapy were enrolled into this multicenter single-arm study. These patients subsequently underwent UI-EWD application for the refractory LGIB hemostasis. We evaluated the success rate of hemostasis, re-bleeding rate within 30 d, and adverse events related to UI-EWD. RESULTS UI-EWD was successfully administered to the bleeding sites in all enrolled refractory bleeding patients. Hemostasis was achieved in the entirety of the 59 patients (100%). The cumulative re-bleeding rate within 30 d was 8.5% (5/59). There were no UI-EWD-related adverse events, such as perforation nor embolism. CONCLUSION Based on our results, the utilization of UI-EWD demonstrated a remarkable success rate in achieving hemostasis for refractory LGIB, while also exhibiting promising outcomes in reducing the re-bleeding rate within a 30-day period. Particularly, UI-EWD exhibits a favorable safety profile across all segments of the colon in cases of refractory LGIB.
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Affiliation(s)
- Gyeol Seong
- Digestive Disease Center, Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, South Korea
| | - Boram Cha
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, South Korea
| | - Jongbeom Shin
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, South Korea
| | - Sung Min Kong
- Division of Gastroenterology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine
| | - Ji Taek Hong
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, South Korea
| | - Kye Sook Kwon
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, South Korea
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Lu MH, Chiang HC. Turn over the new leaf of the treatment in peptic ulcer bleeding: a review of the literature. Therap Adv Gastroenterol 2024; 17:17562848241275318. [PMID: 39253108 PMCID: PMC11382247 DOI: 10.1177/17562848241275318] [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: 05/12/2024] [Accepted: 07/26/2024] [Indexed: 09/11/2024] Open
Abstract
Peptic ulcer bleeding is the most common cause of upper gastrointestinal bleeding, which has a high mortality risk. The standard therapy for acute peptic ulcer bleeding combines medication administration and endoscopic therapies. Both pharmacologic and endoscopic therapies have developed continuously in the past few decades. Proton pump inhibitors (PPIs) already reached a high efficacy in ulcer healing and have been widely used in the past few decades. Endoscopic hemostasis, which includes local epinephrine injection, heater probe coagulation, use of hemostatic clips, and/or band ligation, is highly effective with an overall hemostatic success rate of 85%-90%. However, 10%-20% of patients could not be cured by the current standard combination treatment. Recurrent ulcer bleeding, despite an initial successful hemostasis, is also a big problem for longer hospitalization stays, higher mortality, and higher complication rates, especially for malignant ulcer bleeding. How to manage all types of peptic ulcer bleeding and how to prevent early recurrent peptic ulcer bleeding remain unresolved clinical problems. Recently, several novel medications and endoscopic methods have been developed. Potassium competitive acid blockers have shown a stronger and longer acid suppression than PPI. Hemostatic powder spray and hemostatic gel emulsion are novel hemostatic weapons with emerging evidence, which are potential missing pieces of the puzzle. This literature review will go through the development of endoscopic hemostasis to the prospects of novel endoscopic treatments.
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Affiliation(s)
- Meng-Hsuan Lu
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsueh-Chien Chiang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, Tainan 70428, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Deopujari CE, Ambekar S, Yetukuri BR, Diyora B, Ghosh A, Krishnan P, Panigrahi M, Ranjan R, Raman C, Tyagi S, Vaishya S, Venkataramana N, Sinha VD, Paniker D, Das S. Expert panel recommendations for topical hemostatic agent use in varied bleeding sites and situations during neuro-spine surgeries. J Clin Neurosci 2024; 120:30-35. [PMID: 38176112 DOI: 10.1016/j.jocn.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/22/2023] [Accepted: 12/11/2023] [Indexed: 01/06/2024]
Abstract
Intraoperative bleeding poses a substantial challenge, particularly in neuro-spine surgeries leading to complications such as hematomas, infections, and hemodynamic instability. Despite their proven efficacy, use of topical hemostatic agents (THAs) lacks comprehensive published literature and guidelines particularly in the Indian setting. The present study provides the first-ever Indian expert panel recommendations for effective adjunct THA use in different intraoperative bleeding sites and situations in neuro-spine surgeries. A comprehensive approach, encompassing a literature review, followed by experience sharing in a meeting using a survey helped integrate expert opinions in the form of practical algorithms to guide THA selection. Our survey results revealed a strong inclination towards specific THAs, flowable gelatin + thrombin being choice of THA for difficult to access and problematic bleeding situations during tumor removal/resection, transsphenoidal hypophysectomy and skull-based procedures. Both oxidized regenerated cellulose (ORC)/Fibrillar and flowable gelatin + thrombin were recommended for continuous oozing. ORC/Fibrillar was preferred for arteriovenous and cavernous malformations. This expert-panel guidance on THA use aims to optimize hemostat use practices and improve surgical outcomes in neuro-spine surgery.
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Affiliation(s)
- C E Deopujari
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - S Ambekar
- Department of Neurosurgery, Jaslok Hospital, Mumbai, India
| | - B R Yetukuri
- Department of Neurosurgery and Spine Surgery, Yashoda Hospitals, Hyderabad, India
| | - B Diyora
- Department of Neurosurgery, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Mumbai, India
| | - A Ghosh
- Department of Neurosurgery, Institute of Neurosciences Kolkata, Kolkata, India
| | - P Krishnan
- Department of Neurosurgery, National Neurosciences Centre Calcutta, Kolkata, India
| | - M Panigrahi
- Department of Neurosurgery, Krishna Institute of Medical Sciences, Hyderabad, India
| | - R Ranjan
- Department of Neurosurgery, Aditya Birla Memorial Hospital, Pune, India
| | - C Raman
- Department of Neurosurgery, Nobel Hospital, Pune, India
| | - S Tyagi
- Department of Neurosurgery, Indraprastha Apollo Hospital, New Delhi, India
| | - S Vaishya
- Department of Neurosurgery, Fortis Memorial Research Institute, Gurugram, India
| | - N Venkataramana
- Department of Neurosurgery, Brains Hospital, Bengaluru, India
| | - V D Sinha
- Department of Neurosurgery, Santokba Durlabhji Memorial Hospital, Jaipur, India
| | - D Paniker
- Department of Neurosurgery, Aster Medcity, Kochi, India
| | - S Das
- Johnson and Johnson Private Limited, Mumbai, India.
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Kozarek RA. DDS Perspective: If Gastroenterology Were a Dog, Would Endoscopy Be Its Tail? Has Therapeutic GI Endoscopy Learned to Wag the Dog? Dig Dis Sci 2023; 68:4297-4300. [PMID: 37798571 DOI: 10.1007/s10620-023-08115-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 09/14/2023] [Indexed: 10/07/2023]
Affiliation(s)
- Richard A Kozarek
- Emeritus Executive Director, Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98101, USA.
- Clinical Investigator, Center for Interventional Immunology, Benaroya Research Institute, 1201 Ninth Ave, Seattle, WA, 98101, USA.
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Yang Z, Chen L, Liu J, Zhuang H, Lin W, Li C, Zhao X. Short Peptide Nanofiber Biomaterials Ameliorate Local Hemostatic Capacity of Surgical Materials and Intraoperative Hemostatic Applications in Clinics. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2023; 35:e2301849. [PMID: 36942893 DOI: 10.1002/adma.202301849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/12/2023] [Indexed: 06/18/2023]
Abstract
Short designer self-assembling peptide (dSAP) biomaterials are a new addition to the hemostat group. It may provide a diverse and robust toolbox for surgeons to integrate wound microenvironment with much safer and stronger hemostatic capacity than conventional materials and hemostatic agents. Especially in noncompressible torso hemorrhage (NCTH), diffuse mucosal surface bleeding, and internal medical bleeding (IMB), with respect to the optimal hemostatic formulation, dSAP biomaterials are the ingenious nanofiber alternatives to make bioactive neural scaffold, nasal packing, large mucosal surface coverage in gastrointestinal surgery (esophagus, gastric lesion, duodenum, and lower digestive tract), epicardiac cell-delivery carrier, transparent matrix barrier, and so on. Herein, in multiple surgical specialties, dSAP-biomaterial-based nano-hemostats achieve safe, effective, and immediate hemostasis, facile wound healing, and potentially reduce the risks in delayed bleeding, rebleeding, post-operative bleeding, or related complications. The biosafety in vivo, bleeding indications, tissue-sealing quality, surgical feasibility, and local usability are addressed comprehensively and sequentially and pursued to develop useful surgical techniques with better hemostatic performance. Here, the state of the art and all-round advancements of nano-hemostatic approaches in surgery are provided. Relevant critical insights will inspire exciting investigations on peptide nanotechnology, next-generation biomaterials, and better promising prospects in clinics.
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Affiliation(s)
- Zehong Yang
- Department of Biochemistry and Molecular Biology, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, China
- Institute for Nanobiomedical Technology and Membrane Biology, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, China
| | - Lihong Chen
- Department of Biochemistry and Molecular Biology, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Ji Liu
- Department of Biochemistry and Molecular Biology, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Hua Zhuang
- Department of Ultrasonography, West China Hospital of Sichuan University, No. 37 Guoxue Road, Wuhou District, Chengdu, Sichuan, 610041, China
| | - Wei Lin
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Women and Children Diseases of the Ministry of Education, Sichuan University, No. 17 People's South Road, Chengdu, Sichuan, 610041, China
| | - Changlong Li
- Department of Biochemistry and Molecular Biology, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Xiaojun Zhao
- Institute for Nanobiomedical Technology and Membrane Biology, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, China
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Su DS, Li CK, Gao C, Qi XS. Hemostatic powder for acute upper gastrointestinal bleeding: Recent research advances. Shijie Huaren Xiaohua Zazhi 2023; 31:249-255. [DOI: 10.11569/wcjd.v31.i7.249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
Acute upper gastrointestinal bleeding (AUGIB) is a clinically common emergency condition. The common causes of AUGIB are peptic ulcer and esophagogastric variceal bleeding. Despite continuous improvements in endoscopic hemostasis techniques, endoscopic treatment is still unsuccessful in 5%-15% of patients. Hemostatic powder, a new drug for endoscopic hemostasis that is sprayed on the bleeding site with the assistance of an air pump, can absorb water to promote clotting substance aggregation and then adhere over the lesion, forming a mechanical barrier and then achieving hemostasis. It is convenient to spray hemostatic powder under endoscopy, where precise positioning is not warranted. The immediate hemostasis rate of hemostatic powder is often high, and it can be used as a remedy after the failure of conventional hemostasis. However, until now, there have been no recommendations in China regarding the use of hemostatic powder for the treatment of AUGIB. This article summarizes the mechanism, clinical applicability, and side effects of five major types of hemostatic powder by reviewing the existing evidence, with an aim to strengthen endoscopists' understanding of this drug.
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Propensity score matching analysis to evaluate efficacy of polyethylene oxide adhesive on preventing delayed bleeding after gastric endoscopic submucosal dissection. Sci Rep 2022; 12:4538. [PMID: 35297400 PMCID: PMC8927376 DOI: 10.1038/s41598-022-08499-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/07/2022] [Indexed: 02/07/2023] Open
Abstract
Regardless of technical advancements, delayed bleeding is still a common adverse event after gastric endoscopic submucosal dissection (ESD), often occurring in the early postoperative phase. This study aimed to evaluate the efficacy of a newly designed polyethylene oxide (PEO) adhesive for preventing delayed gastric bleeding. Patients who underwent gastric ESD between December 2017 and December 2020 at three Chinese institutions were retrospectively reviewed. Patients receiving PEO application on gastric post-ESD ulcers were included in the PEO group, and patients without this procedure were included in the control group. To minimize potential bias, propensity score matching was performed, and sex, age, lesion size, lesion morphology, ulceration, localization, procedure time, frequency of major intraoperative bleeding, resected specimen size, lesion histopathology, submucosal invasion and the taking of antithrombotic drugs were included as matching factors. The incidence of delayed bleeding and time to bleeding were compared between both groups. After propensity score matching, 270 patients (135 per group) were included in the analysis. The delayed bleeding rate in the PEO group was significantly lower than that in the control group (1.5%, 2/135 vs. 8.9%, 12/135, P = 0.006). The median time (range) to bleeding was 4.5 (4–5) days in the PEO group and 2 (1–15) days in the control group, with no significant difference (P = 0. 198). PEO demonstrated a significant effect in reducing the rate of delayed bleeding. Further study is warranted to confirm the efficacy of PEO for bleeding that occurs in the early phase after gastric ESD.
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Li JL, Cheng P, Sheng WY, Zhang JX. Progress in new hemostasis techniques for acute upper gastrointestinal bleeding. Shijie Huaren Xiaohua Zazhi 2021; 29:1035-1042. [DOI: 10.11569/wcjd.v29.i18.1035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Acute upper gastrointestinal bleeding (AUGIB) is one of the most common acute and critical illnesses in the emergency department. It mainly refers to gastrointestinal bleeding above the Treitz ligament, and the mortality rate is about 2%-10%. The main clinical manifestations are hematemesis and/or hematochezia. The diagnosis is mainly based on clinical manifestations combined with laboratory and imaging findings. Due to the rapid onset and severe nature of the condition, there are various treatment methods according to different causes. This article reviews the diagnosis and treatment of acute upper gastrointestinal bleeding.
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Affiliation(s)
- Jing-Lei Li
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Ping Cheng
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Wei-Yong Sheng
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Jin-Xiang Zhang
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
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Wang JH, Tsai CW, Tsai NY, Chiang CY, Lin RS, Pereira RF, Li YCE. An injectable, dual crosslinkable hybrid pectin methacrylate (PECMA)/gelatin methacryloyl (GelMA) hydrogel for skin hemostasis applications. Int J Biol Macromol 2021; 185:441-450. [PMID: 34197849 DOI: 10.1016/j.ijbiomac.2021.06.162] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/18/2021] [Accepted: 06/24/2021] [Indexed: 12/14/2022]
Abstract
Biomaterials for effective hemorrhage control are urgently needed in clinics as uncontrolled bleeding is associated with high mortality. Herein, we developed an injectable and in situ photo-crosslinkable hybrid hemostatic hydrogel by combining pectin methacrylate (PECMA) and gelatin methacryloyl (GelMA). This modular material system combines ionic- and photo-crosslinking chemistries to design interpenetrating networks (IPN) exhibiting tunable rheology, highly porous structure, and controllable swelling and mechanical properties. By simply changing the calcium (0-15 mM) and polymer (1.5-7%) content used for the sequential crosslinking of hydrogels via calcium gelation and UV-photopolymerization, it was possible to precisely modulate the injectability, degradation, and swelling ratio. Moreover, it is demonstrated that PECMA/GelMA hydrogels present good cytocompatibility and uniquely synergize the hemostatic properties of calcium ions on PECMA, the amine residues on GelMA, and the highly porous network toward rapid blood absorption and fast coagulation effect. An in vitro porcine skin bleeding model confirmed that the hydrogel could be directly injected into the wound and rapidly photo-crosslinked, circumventing the bleeding and decreasing the coagulation time by 39%. Importantly, the crosslinked hydrogel could be easily removed to prevent secondary wound injury. Overall, this injectable hybrid PECMA/GelMA hydrogel stands as a promising hemostatic material.
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Affiliation(s)
- Jing-Han Wang
- Department of Chemical Engineering, Feng Chia University, Taichung, Taiwan
| | - Ching-Wen Tsai
- Taiwan Instrument Research Institute, National Applied Research Laboratories, Hsinchu, Taiwan
| | - Nian-Yun Tsai
- Department of Chemical Engineering, Feng Chia University, Taichung, Taiwan
| | - Chao-Ying Chiang
- Department of Chemical Engineering, Feng Chia University, Taichung, Taiwan
| | - Ru-Sin Lin
- Department of Chemical Engineering, Feng Chia University, Taichung, Taiwan
| | - Rúben F Pereira
- ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal; i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal; INEB - Instituto de Engenharia Biomédica, Universidade do Porto, Porto, Portugal
| | - Yi-Chen Ethan Li
- Department of Chemical Engineering, Feng Chia University, Taichung, Taiwan.
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The Efficacy and Safety of Hemospray for the Management of Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2021; 55:e37-e45. [PMID: 33470608 DOI: 10.1097/mcg.0000000000001379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 05/10/2020] [Indexed: 01/11/2023]
Abstract
GOALS/BACKGROUND Hemospray is a new hemostatic powder recently approved for endoscopic hemostasis in gastrointestinal (GI) bleeding. Data are limited in terms of its clinical outcomes, and its role in the treatment algorithm of GI bleeds. We conducted a systematic review and meta-analysis to study the clinical performance of Hemospray in the management of GI bleeding. STUDY We searched multiple databases from inception through March 2019 to identify studies that reported on the clinical outcomes of Hemospray in GI bleeding. The primary outcome was pooled rates of clinical success after the application of Hemospray in GI bleeding. The secondary outcomes were pooled rebleeding rates and adverse events after use of Hemospray. RESULTS A total of 19 studies, 814 patients, of which 212 patients were treated with Hemospray as monotherapy, and 602 patients were treated with Hemospray with conventional hemostatic techniques. Overall pooled clinical success after the application of Hemospray was 92% [95% confidence interval (95% CI), 87%-96%; I2=70.4%]. Overall pooled early rebleeding rates after application of Hemospray was 20% (95% CI, 16%-26%; I2=54%). Overall pooled delayed rebleeding rates after the application of Hemospray was 23% (95% CI, 16%-31%; I2=34.9%). There was no statistical difference in clinical success (RR, 1.02; 95% CI, 0.96-1.08; P=0.34) and early rebleeding (RR, 0.89; 95% CI, 0.75-1.07; P=0.214) in studies that compared the use of Hemospray as monotherapy versus combination therapy with conventional therapy. CONCLUSIONS Hemospray is highly effective in achieving immediate hemostasis in gastrointestinal bleeding. However, due to significantly high rebleeding rates, Hemospray is not suited for definitive long-term therapy.
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Martines G, Picciariello A, Dibra R, Trigiante G, Jambrenghi OC, Chetta N, Altomare DF. Efficacy of cyanoacrylate in the prevention of delayed bleeding after endoscopic mucosal resection of large colorectal polyps: a pilot study. Int J Colorectal Dis 2020; 35:2141-2144. [PMID: 32577871 DOI: 10.1007/s00384-020-03678-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Postoperative bleeding is a common complication after endoscopic polypectomy, particularly after endoscopic mucosal resection (EMR) of large non-pedunculated polyps, despite prophylactic clipping can reduce its occurrence. Cyanoacrylate glue has recently been proposed as a useful tool in reducing bleeding in surgery because of its adhesive and haemostatic properties. The aim of this study is to evaluate the usefulness of endoscopic application of a modified cyanoacrylate glue in the prevention of early or delayed post EMR bleeding. METHODS This is a pilot study. Inclusion criteria were patients between 18 and 75 years old affected by sessile or flat colonic polyps larger than 2 cm. Patients enrolled in the study were randomized in two groups: group A (EMR) and group B (EMR with the application of 0.3 ml of N-butyl-2-cyanoacrylate + methacryloxysulfolane-Glubran 2®). RESULTS Fifteen patients in both group A and B were enrolled. There were no intraoperative complications but haemostatic clipping was necessary in 3 patients in each group because of active bleeding. Delayed (after 24 h) bleeding occurred in two patients (13.3%) in group A requiring hospital readmission and re-do endoscopy with apposition of haemostatic clips. No case of bleeding was recorded in group B (p = 0.48). CONCLUSION The results of this pilot study suggest a potential role of local spray application of Glubran®2 in reducing post-procedural bleeding.
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Affiliation(s)
- Gennaro Martines
- Department of Emergency and Organ transplantation, Surgical Unit "M.Rubino", Azienda Ospedaliero Universitaria Policlinico, Bari, Italy
| | - Arcangelo Picciariello
- Department of Emergency and Organ transplantation, Surgical Unit "M.Rubino", Azienda Ospedaliero Universitaria Policlinico, Bari, Italy
| | - Rigers Dibra
- Department of Emergency and Organ transplantation, Surgical Unit "M.Rubino", Azienda Ospedaliero Universitaria Policlinico, Bari, Italy
| | - Giuseppe Trigiante
- Department of Emergency and Organ transplantation, Surgical Unit "M.Rubino", Azienda Ospedaliero Universitaria Policlinico, Bari, Italy
| | - O Caputi Jambrenghi
- Department of Emergency and Organ transplantation, Surgical Unit "M.Rubino", Azienda Ospedaliero Universitaria Policlinico, Bari, Italy
| | - Nicola Chetta
- Department of Emergency and Organ transplantation, Surgical Unit "M.Rubino", Azienda Ospedaliero Universitaria Policlinico, Bari, Italy
| | - Donato Francesco Altomare
- Department of Emergency and Organ transplantation, Surgical Unit "M.Rubino", Azienda Ospedaliero Universitaria Policlinico, Bari, Italy. .,IRCCS Istituto Tumori Giovanni Paolo II, Bari, Italy. .,Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Piazza G Cesare, 11, 70124, Bari, Italy.
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12
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Aziz M, Weissman S, Mehta TI, Hassan S, Khan Z, Fatima R, Tsirlin Y, Hassan A, Sciarra M, Nawras A, Rastogi A. Efficacy of Hemospray in non-variceal upper gastrointestinal bleeding: a systematic review with meta-analysis. Ann Gastroenterol 2020; 33:145-154. [PMID: 32127735 PMCID: PMC7049242 DOI: 10.20524/aog.2020.0448] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 11/20/2019] [Indexed: 12/16/2022] Open
Abstract
Background Recently, amongst other hemostatic modalities, Hemospray (TC-325) has emerged as an effective method for managing patients with non-variceal upper gastrointestinal bleeding (GIB). We conducted this systematic review and meta-analysis to assess the efficacy of Hemospray in patients with non-variceal upper GIB. Methods Our primary outcomes were clinical and technical success; secondary outcomes were aggregate rebleeding, early rebleeding, delayed rebleeding, refractory bleeding, mortality, and treatment failure. A meta-analysis of proportions was conducted for all reported primary and secondary outcomes. A relative risk meta-analysis was conducted for studies reporting direct comparisons between Hemospray and other hemostatic measures. Results A total of 20 studies with 1280 patients were included in the final analysis. Technical success of Hemospray was seen in 97% of cases (95% confidence interval [CI] 94-98%, I2=52.89%) and a significant trend towards increasing technical success was seen during publication years 2011-2019. Clinical success of Hemospray was seen in 91% of cases (95%CI 88-94%, I2=47.72%), compared to 87% (95%CI 75-94%, I2=0.00%) for other hemostatic measures. The secondary outcomes of aggregate rebleeding, early rebleeding, delayed rebleeding, refractory rebleeding, mortality and treatment failure following the use of Hemospray were seen in 27%, 20%, 9%, 8%, 8%, and 31% of cases, respectively. Conclusion Hemospray is safe, effective and non-inferior to traditional hemostatic measures for the management of non-variceal upper GIB, and can thus be used as an alternative option.
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Affiliation(s)
- Muhammad Aziz
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio (Muhammad Aziz, Zubair Khan, Rawish Fatima)
| | - Simcha Weissman
- Department of Medicine, Hackensack University-Palisades Medical Center, North Bergen, New Jersey (Simcha Weissman)
| | - Tej I Mehta
- Department of Medicine, University of South Dakota Sanford school of Medicine, Sioux Falls, South Dakota (Tej I. Mehta)
| | - Shafae Hassan
- Department of Gastroenterology, University of Toledo Medical Center, Toledo, Ohio (Shafae Hassan, Ali Nawras)
| | - Zubair Khan
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio (Muhammad Aziz, Zubair Khan, Rawish Fatima)
| | - Rawish Fatima
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio (Muhammad Aziz, Zubair Khan, Rawish Fatima)
| | - Yuriy Tsirlin
- Department of Gastroenterology, Maimonides Medical Center, Brooklyn, New York (Yuriy Tsirlin)
| | - Ammar Hassan
- Division of Gastroenterology and Hepatology, Hackensack University-Palisades Medical Center, North Bergen, New Jersey (Ammar Hassan, Michael Sciarra)
| | - Michael Sciarra
- Division of Gastroenterology and Hepatology, Hackensack University-Palisades Medical Center, North Bergen, New Jersey (Ammar Hassan, Michael Sciarra)
| | - Ali Nawras
- Department of Gastroenterology, University of Toledo Medical Center, Toledo, Ohio (Shafae Hassan, Ali Nawras)
| | - Amit Rastogi
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas (Amit Rastogi), USA
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13
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Mujtaba S, Chawla S, Massaad JF. Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives. J Clin Med 2020; 9:jcm9020402. [PMID: 32024301 PMCID: PMC7074258 DOI: 10.3390/jcm9020402] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 01/30/2023] Open
Abstract
Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.
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15
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[Treatment of nonvariceal upper gastrointestinal bleeding: endoluminal-endovascular-surgical]. Chirurg 2019; 90:607-613. [PMID: 31392464 DOI: 10.1007/s00104-019-0948-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Nonvariceal upper gastrointestinal bleeding (UGIB) has a high mortality. Hematemesis sometimes with melena are the leading clinical symptoms. Peptic ulcers and (erosive) inflammation are common, whereas Mallory-Weiss syndrome, neoplasms, angiodysplasia and diffuse UGIB are less common. PROBLEM A risk stratification is based on the medical history, clinical presentation and laboratory tests, which are considered in the Glasgow-Blatchford score; however, which treatment approach is optimal? RESULTS After stabilisation under restricted transfusion indications, temporary stoppage of anticoagulants and optimized coagulation is beneficial and proton pump inhibitors (PPI) should be started. Prokinetics improve the endoscopic conditions in UGIB. The use of an endoscopic Doppler probe optimizes localization of the bleeding site. The use of the Forrest classification and Helicobacter pylori diagnostics are recommended. Mechanical (clips, injection), thermal (argon plasma coagulation, APC) and topical (hemostatic powder) endoscopic treatment procedures are available. Endoluminal hemostasis is very effective. Only clip application is suitable as monotherapy whereas all other endoscopic options should be combined. Angiography followed by transarterial embolization (TAE) can be used for therapy. Despite the high primary success rate, the risk of rebleeding is high. Surgery as the primary treatment is rarely necessary, although effective. Compared to TAE complications are higher, but there is no difference regarding mortality. CONCLUSION Endoscopy remains the gold standard for the initial diagnostics and treatment of UGIB. In cases of rebleeding repeated endoscopy is recommended. With persistent UGIB an endovascular procedure should be evaluated. Surgery remains an important salvage option.
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Siau K, Chapman W, Sharma N, Tripathi D, Iqbal T, Bhala N. Management of acute upper gastrointestinal bleeding: an update for the general physician. J R Coll Physicians Edinb 2019; 47:218-230. [PMID: 29465096 DOI: 10.4997/jrcpe.2017.303] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Acute upper gastrointestinal bleed (AUGIB) is one of the most common medical emergencies in the UK, with roughly one presentation every 6 min. Despite advances in therapeutics and endoscopy provision, mortality following AUGIB over the last two decades has remained high, with over 9,000 deaths annually in the UK; consequently, several national bodies have published UK-relevant guidelines. Despite this, the 2015 UK National Confidential Enquiry into Patient Outcome and Death in AUGIB highlighted variations in practice, raised concerns regarding suboptimal patient care and released a series of recommendations. This review paper incorporates the latest available evidence and UK-relevant guidelines to summarise the optimal pre-endoscopic, endoscopic, and post-endoscopic approach to and management of non-variceal and variceal AUGIB that will be of practical value to both general physicians and gastroenterologists.
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Affiliation(s)
- K Siau
- N Bhala, Department of Gastroenterology, University Hospital, Birmingham, Mindelsohn Way, Birmingham B15 2TH, UK.
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17
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Bang B, Lee E, Maeng J, Kim K, Hwang JH, Hyon SH, Hyon W, Lee DH. Efficacy of a novel endoscopically deliverable muco-adhesive hemostatic powder in an acute gastric bleeding porcine model. PLoS One 2019; 14:e0216829. [PMID: 31185029 PMCID: PMC6559629 DOI: 10.1371/journal.pone.0216829] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 04/29/2019] [Indexed: 02/07/2023] Open
Abstract
This study investigated the effectiveness of new hemostatic adhesive powder (UI-EWD) in a swine mode of acute gastric bleeding. Gastric ulcer bleeding was induced endoscopically at two locations in each of eight heparinized mini-pigs. UI-EWD and saline were sprayed endoscopically in the experimental (n = 5) and control groups (n = 3), respectively. The hemostatic effect and hydrogel persistence on ulcers were periodically evaluated endoscopically. Initial hemostasis was achieved successfully in all lesions in the experimental group. Follow-up endoscopy showed minor delayed bleeding in 10% at 6 hours in the experimental group, whereas re-bleeding was observed in 50% at 6 hours in the control group. UI-EWD gel persisted at 90%, 80%, and 50% of ulcer bases at 6, 18, and 42 hours post-application, respectively. This study suggests that muco-adhesive UI-EWD may be effective in the endoscopic treatment of active ulcer bleeding.
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Affiliation(s)
- ByoungWook Bang
- Division of Gastroenterology, Department of Internal Medicine, Inha University College of Medicine, Incheon, Republic of Korea
| | - Eunhye Lee
- Utah-Inha DDS and Advanced Therapeutics Research Center, Incheon, Republic of Korea
| | - JinHee Maeng
- Utah-Inha DDS and Advanced Therapeutics Research Center, Incheon, Republic of Korea
| | - Keunsu Kim
- Utah-Inha DDS and Advanced Therapeutics Research Center, Incheon, Republic of Korea
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California, United States of America
| | | | - Woogi Hyon
- BMG Incorporated, Kyoto, Japan
- School of Materials Science, Japan Advanced Institute of Science and Technology, Nomi, Ishikawa, Japan
| | - Don Haeng Lee
- Division of Gastroenterology, Department of Internal Medicine, Inha University College of Medicine, Incheon, Republic of Korea
- Utah-Inha DDS and Advanced Therapeutics Research Center, Incheon, Republic of Korea
- * E-mail:
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18
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Abstract
Upper gastrointestinal bleeding (UGIB) is a common medical emergency, with a reported mortality of 2-10%. Patients identified as being at very low risk of either needing an intervention or death can be managed as outpatients. For all other patients, intravenous fluids as needed for resuscitation and red cell transfusion at a hemoglobin threshold of 70-80 g/L are recommended. After resuscitation is initiated, proton pump inhibitors (PPIs) and the prokinetic agent erythromycin may be administered, with antibiotics and vasoactive drugs recommended in patients who have cirrhosis. Endoscopy should be undertaken within 24 hours, with earlier endoscopy considered after resuscitation in patients at high risk, such as those with hemodynamic instability. Endoscopic treatment is used for variceal bleeding (for example, ligation for esophageal varices and tissue glue for gastric varices) and for high risk non-variceal bleeding (for example, injection, thermal probes, or clips for lesions with active bleeding or non-bleeding visible vessel). Patients who require endoscopic therapy for ulcer bleeding should receive high dose proton pump inhibitors after endoscopy, whereas those who have variceal bleeding should continue taking antibiotics and vasoactive drugs. Recurrent ulcer bleeding is treated with repeat endoscopic therapy, with subsequent bleeding managed by interventional radiology or surgery. Recurrent variceal bleeding is generally treated with transjugular intrahepatic portosystemic shunt. In patients who require antithrombotic agents, outcomes appear to be better when these drugs are reintroduced early.
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Affiliation(s)
- Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow G4 OSF, UK
| | - Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Connecticut, CT 06520, USA
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Saltzman JR. Hemostatic Spray for the Management of Gastrointestinal Bleeding. Gastroenterol Hepatol (N Y) 2019; 15:40-43. [PMID: 30899208 PMCID: PMC6423688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- John R Saltzman
- Professor of Medicine Harvard Medical School Boston, Massachusetts
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20
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CEGP-003 Spray Has a Similar Hemostatic Effect to Epinephrine Injection in Cases of Acute Upper Gastrointestinal Bleeding. Dig Dis Sci 2018; 63:3026-3032. [PMID: 30054842 DOI: 10.1007/s10620-018-5208-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/10/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopically applicable hemostatic agents have been demonstrated to have high initial hemostasis rates in cases of upper gastrointestinal bleeding (UGIB). AIMS The authors developed a new hemostatic powder (CEGP-003) and evaluated its hemostatic and ulcer healing effects in UGIB. METHODS Patients with peptic ulcer or post-endoscopic resection bleeding were randomly assigned to be treated by epinephrine injection or CEGP-003 spray. All patients were placed under observation for 3 days and underwent second-look endoscopy. The primary outcome was initial hemostasis rate, and the secondary outcomes were rebleeding rate and ulcer healing effect. RESULTS Seventy-two patients with UGIB were enrolled in this study. Causes of bleeding were peptic ulcer (15, 20.5%), post-endoscopic mucosal resection (11, 15.1%), and post-endoscopic submucosal dissection bleeding (47, 64.4%). Initial hemostasis was achieved in 89.2% (34/37) of patients in the epinephrine group and in 100% (35/35) in the CEGP-003 group (p = 0.115). Rebleeding occurred in 2.7% (1/37) and 8.6% (3/35) in the epinephrine and CEGP-003 groups, respectively (p = 0.35). Three days after endoscopic hemostasis, the ulcer healing effects of epinephrine and CEGP-003 were similar (p = 0.79). CONCLUSION This study shows that CEGP-003 spray has a hemostatic effect similar to epinephrine in terms of initial hemostasis and rebleeding rates. The authors consider CEGP-003 a potential therapeutic tool for UGIB as a definitive or bridge therapy and that it is particularly useful for oozing lesions after endoscopic resection.
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21
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Cho YS. New endoscopic techniques in treating gastrointestinal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Young Sin Cho
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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22
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Ng JL, Marican M, Mathew R. Topical haemostatic powder as a novel endoscopic therapy for severe colonic diverticular bleeding. ANZ J Surg 2018; 89:E56-E60. [DOI: 10.1111/ans.14895] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 08/28/2018] [Accepted: 09/03/2018] [Indexed: 01/07/2023]
Affiliation(s)
- Jia Lin Ng
- Department of Colorectal Surgery; Singapore General Hospital; Singapore
| | - Musfirah Marican
- Department of Colorectal Surgery; Singapore General Hospital; Singapore
| | - Ronnie Mathew
- Department of Colorectal Surgery; Singapore General Hospital; Singapore
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23
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The Use and Safety of a Novel Haemostatic Spray in the Endoscopic Management of Acute Nonvariceal Upper Gastrointestinal Bleeding in Children. J Pediatr Gastroenterol Nutr 2018; 67:e47-e50. [PMID: 29570557 DOI: 10.1097/mpg.0000000000001967] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
AIMS AND BACKGROUND Advanced endohaemostatic technique performance and experience is extremely variable in distribution amongst paediatric endoscopists. Haemostatic spray (Hemospray), a novel endohaemostatic topically applied powder has the advantage of extreme ease of use and; hence may lower the threshold of competency required by the endoscopist thereby potentially reducing mortality. The aim of the study is to prospectively evaluate the efficacy and the safety of haemostatic spray in paediatric patients with acute upper gastrointestinal bleeding (AUGIB). METHODS Prospective enrolment of children with AUGIB (Group 1) occurred, either as primary therapy or as an adjunct to standard endohaemostatic therapeutic techniques. Patients were assessed for likely need for endohaemostatic intervention of >8 of 24 of the paediatric Sheffield AUGIB score.A follow-up endoscopy occurred in those deemed to have clinical need pre-discharge. For comparison, another group (Group 2) of patients, who received conventional endohaemostatic treatment in the preceding 36 months, were reviewed. RESULTS A total of 20 applications of Hemospray occurred in 17 patients (8 boys, median (range) age: 6.5 years (2 days to 17.75 years) and a total of 29 patients were enrolled in Group 2 (16 boys, median [range] age: 5.1 [0.25-17.0]). All patients tolerated haemostatic spray applications with no adverse events. The haemostatic spray group achieved 100% initial haemostasis with 18% rebleeding rate, although only a 6% failure rate after re-application. In the conventional group, similar 100% initial haemostasis was achieved with 24% rebleeding rate and 7% failure rate necessitating surgical interventions. CONCLUSIONS This paediatric series suggests that monotherapy with haemostatic spray is as effective as conventional approaches in the management of AUGIB.
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Mourad FH, Leong RW. Role of hemostatic powders in the management of lower gastrointestinal bleeding: A review. J Gastroenterol Hepatol 2018; 33:1445-1453. [PMID: 29405446 DOI: 10.1111/jgh.14114] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 01/15/2018] [Accepted: 01/22/2018] [Indexed: 12/14/2022]
Abstract
Despite the recent advances in endoscopic hemostatic techniques, the management of lower gastrointestinal bleeding could be sometimes challenging. Hemostatic powders such as Hemospray, EndoClot, and Ankaferd Blood Stopper have found their way into digestive endoscopy and are licenced in many countries especially for use in upper gastrointestinal bleeding. We reviewed the literature on the use of these hemostatic powders in different situations in lower gastrointestinal bleeding and looked at the success rate and rebleeding rate. Most of the data are derived from case reports, retrospective and prospective case series with absence of any randomized controlled trials. Hemostatic powders were used as primary or salvage therapy to control bleeding from polypectomy site, colonic tumors, diverticula, arteriovenous malformations, radiation proctitis, ischemic colitis, and surgical intestinal anastomosis. The rate of immediate control of bleeding is in the range of 88-100% with a recurrence rate of 3-13% except for radiation proctitis bleeding where rebleeding rate can be as high as 77%. Although there are many advantages for the use of local hemostatic agents in lower gastrointestinal bleeding, future randomized controlled trials comparing them with conventional methods are needed.
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Affiliation(s)
- Fadi H Mourad
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Rupert W Leong
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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25
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Abstract
Peptic ulcer bleeding remains an important medical emergency. Important recent advances are reviewed. These include further support for a more restrictive transfusion strategy aiming for a target haemoglobin of 70-90 g/L. The Glasgow-Blatchford score remains the most useful assessment score for identifying the lowest risk patients suitable for outpatient management and predicting the need for intervention. Newer scores such as the AIMS65 and Progetto Nazionale Emorragia Digestive score (PNED) may be more accurate in predicting mortality. Pre-endoscopy erythromycin improves outcomes and is underused. A new disposable Doppler probe appears to provide more accurate determination of both rebleeding risk and the success of endoscopic therapy than purely visual guidance. Over-the-scope clips and haemostatic powders appear to have some role as endoscopic salvage therapies. Non- H. pylori, non-aspirin/non-steroidal anti-inflammatory drug (NSAID) ulcers contribute to an increasing percentage of bleeding peptic ulcers and are associated with a high rebleeding rate. The optimal management of these ulcers remains to be determined.
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Affiliation(s)
- Ian LP Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
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26
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Abstract
Acute upper gastrointestinal haemorrhage due to peptic ulcer bleeding remains an important cause of emergency presentation and hospital admission. Despite advances in many aspects of management, peptic ulcer bleeding is still associated with significant morbidity, mortality, and healthcare costs. Comprehensive international guidelines have been published, but advances as well as controversies continue to evolve. Important recent advances include the evidence supporting a more restrictive transfusion strategy aiming for a target haemoglobin of 70–90 g/l. Comparative studies have confirmed that the Glasgow–Blatchford score remains the most useful score for predicting the need for intervention as well as for identifying the lowest-risk patients suitable for outpatient management. New scores, including the AIMS65 and Progetto Nazionale Emorragia Digestiva score, may be more accurate in predicting mortality. Pre-endoscopy erythromycin appears to improve outcomes and is probably underused. High-dose oral proton pump inhibition (PPI) for 11 days after PPI infusion is advantageous in those with a Rockall score of 6 or more. Oral is as effective as parenteral iron at restoring haemoglobin levels after a peptic ulcer bleed and both are superior to placebo in this respect. Within endoscopic techniques, haemostatic powders and over-the-scope clips can be used when other methods have failed. A disposable Doppler probe appears to provide more accurate determination of both rebleeding risk and the success of endoscopic therapy than purely visual guidance. Non-
Helicobacter pylori, non-aspirin/non-steroidal anti-inflammatory drug ulcers contribute an increasing percentage of bleeding peptic ulcers and are associated with a poor prognosis and high rebleeding rate. The optimal management of these ulcers remains to be determined.
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Affiliation(s)
- Ian Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
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27
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Nabi Z. Complications of therapeutic gastroscopy/colonoscopy other than resection. Best Pract Res Clin Gastroenterol 2016; 30:719-733. [PMID: 27931632 DOI: 10.1016/j.bpg.2016.10.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/07/2016] [Accepted: 10/21/2016] [Indexed: 01/31/2023]
Abstract
Gastrointestinal (GI) endoscopy is profoundly utilized for diagnostic and therapeutic purposes. The therapeutic potential of GI endoscopy has amplified many folds with the evolution of novel techniques as well as equipments. However, with the augmentation of therapeutic endoscopy, the extent, likelihood and severity of adverse events have increased as well. The attendant risks and adverse events with therapeutic endoscopy are many folds that of diagnostic endoscopy. Besides endoscopic resection, therapeutic endoscopy is widely utilized for hemostasis in GI bleeds, dilatation of stenosis, enteral stenting, foreign body removal, ablation of Barrett's esophagus etc. Major adverse events associated with interventional endoscopic procedures include bleeding and perforation. Adverse events of endoscopic interventions are diverse and related to the underlying disease, therapeutic modality used and operator's experience. Many of these adverse events can be prevented. Early recognition of an unavoidable adverse event is important to minimize the associated morbidity and mortality.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India.
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28
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Abstract
Recent studies could demonstrate that neoadjuvant chemotherapy and radiochemotherapy for esophageal and gastric cancer do not significantly increase the risk of postoperative morbidity and mortality as compared to surgery alone. With respect to patient safety and effectiveness of neoadjuvant concepts, quality assured performance of each treatment modality and close interdisciplinary cooperation play an important role. The majority of potential side effects and complications, which might occur during neoadjuvant therapy can be adequately controlled by correct prophylaxis and professional medical complication management. Complications before, during and after neoadjuvant therapy of upper gastrointestinal tract tumors can also be caused by the tumor itself or by medicinal therapy. These comprise bleeding, fistulas, perforations and stenoses. Modern endoscopic techniques are the therapy of choice in these situations. Preoperative conditioning during the period of neoadjuvant therapy opens the possibility of reduced postoperative complications to patients with tumors of the upper gastrointestinal tract.
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Beg S, Al-Bakir I, Bhuva M, Patel J, Fullard M, Leahy A. Early clinical experience of the safety and efficacy of EndoClot in the management of non-variceal upper gastrointestinal bleeding. Endosc Int Open 2015; 3:E605-9. [PMID: 26716120 PMCID: PMC4683139 DOI: 10.1055/s-0034-1393087] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 08/11/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND STUDY AIMS EndoClot is a novel topical hemostatic powder approved for use in non-variceal upper gastrointestinal bleeding. This study examines its impact as rescue therapy in the management of gastrointestinal bleeding for which standard endoscopic therapy failed to achieve hemostasis. METHODS This observational study covered a 24-month period. Data were collated from patients treated with EndoClot for comparison with a cohort of patients managed with standard endoscopic therapy. End points of this study included immediate hemostasis, 30-day rebleed rate, 30-day mortality rate, and adverse events. RESULTS Between April 1, 2012, and March 31, 2014, gastroscopic procedures were performed in 1009 patients, of whom 173 required endoscopic therapy. EndoClot was used in 21 patients, with immediate hemostasis achieved in all cases, a 30-day rebleed rate of 4.8 % (95 % confidence interval [95 %CI] - 4.34 % to 3.94 %), and a 30-day mortality rate of 19.0 % (95 %CI 2.29 % - 35.91 %). Despite higher risk bleeds in this cohort of patients, Fisher's exact test demonstrated no significant difference between their 30-day mortality rate (P = 0.51) and rebleed rate (P = 0.31) and those of the patients treated with standard endoscopic hemostatic techniques. CONCLUSIONS This study demonstrates that EndoClot can be used both safely and effectively in the management of non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Sabina Beg
- Gastroenterology, West Hertfordshire Hospitals NHS Trust, Hertfordshire, United Kingdom
| | - Ibrahim Al-Bakir
- Gastroenterology, West Hertfordshire Hospitals NHS Trust, Hertfordshire, United Kingdom
| | - Meha Bhuva
- Gastroenterology, West Hertfordshire Hospitals NHS Trust, Hertfordshire, United Kingdom
| | - Jay Patel
- Gastroenterology, West Hertfordshire Hospitals NHS Trust, Hertfordshire, United Kingdom
| | - Mark Fullard
- Gastroenterology, West Hertfordshire Hospitals NHS Trust, Hertfordshire, United Kingdom
| | - Anthony Leahy
- Gastroenterology, West Hertfordshire Hospitals NHS Trust, Hertfordshire, United Kingdom,Corresponding author Anthony Leahy, MD West Hertfordshire Hospitals NHS Trust – GastroenterologyWatfordVicarage RoadHertfordshire WD18 0HBUnited Kingdom
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