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Toro Tole D, Maurel A, Hedger J, Kwan S, Weber D. A systematic review of failed endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding. J Gastrointest Surg 2024; 28:309-315. [PMID: 38446116 DOI: 10.1016/j.gassur.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/13/2023] [Accepted: 12/16/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a surgical emergency, usually managed via endoscopy. Approximately 2% of patients will have another significant bleed after therapeutic endoscopy and may require either transarterial embolization (TAE) or surgery. In 2011, the National Institute for Health and Care Excellence guidelines recommended that TAE should be the preferred option offered in this setting. METHODS This study aimed to conduct an appraisal of guidelines on NVUGIB using the Appraisal of Guidelines for Research and Evaluation II tool. A specific review of their recommendations on the management of adult patients with failed endoscopic hemostasis that required TAE or surgery was conducted. RESULTS The quality of the guidelines was moderate; most could be recommended with changes. However, their recommendations regarding TAE vs surgery were widely heterogeneous. A closer review of the underpinning evidence showed that most studies were retrospective, with a small sample size and missing data. CONCLUSION Because of the heterogeneity in evidence, the decision regarding TAE vs surgery requires further research. Deciding between these modalities is primarily based on TAE availability and patient comorbidities. However, surgery should not be dismissed as a key option after failed endoscopic hemostasis.
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Affiliation(s)
- David Toro Tole
- Department of Surgery, Royal Darwin Hospital, Darwin, Australia.
| | - Amelie Maurel
- Department of Surgery, Royal Darwin Hospital, Darwin, Australia
| | - Joe Hedger
- School of Medicine, Flinders University, Darwin, Australia.
| | - Sherman Kwan
- Department of Surgery, Royal Perth Hospital, Perth, Australia
| | - Dieter Weber
- Department of Surgery, Royal Perth Hospital, Perth, Australia
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Vanhoenacker C, Hufkens E, Laenen A, Bonne L, Claus E, Peluso J, Demedts I, Laleman W, Wilmer A, Maleux G. Factors influencing outcome of angiographic embolization for gastroduodenal hemorrhage related to peptic ulceration. Eur J Radiol 2023; 167:111074. [PMID: 37708676 DOI: 10.1016/j.ejrad.2023.111074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Charlotte Vanhoenacker
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Eva Hufkens
- Department of Gastroenterology and Hepatology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Annouschka Laenen
- Department of Public Health and Primary Care, Leuven Biostatistics and Statistical Bioinformatics Centre, Kapucijnenvoer 35, 3000 Leuven, Belgium.
| | - Lawrence Bonne
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Eveline Claus
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Jo Peluso
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Ingrid Demedts
- Department of Gastroenterology and Hepatology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Alexander Wilmer
- Department of General Internal Medicine, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Geert Maleux
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
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Vanhoenacker C, Hufkens E, Laenen A, Bonne L, Claus E, Peluso J, Demedts I, Laleman W, Wilmer A, Maleux G. Factors influencing outcome of angiographic embolization for gastroduodenal hemorrhage related to peptic ulceration. Eur J Radiol 2023; 166:110970. [PMID: 37463549 DOI: 10.1016/j.ejrad.2023.110970] [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: 04/20/2023] [Revised: 06/19/2023] [Accepted: 07/10/2023] [Indexed: 07/20/2023]
Abstract
PURPOSE Long-term outcome and prognostic factors of transcatheter embolization for gastroduodenal peptic ulcer bleeding are unknown. This study was conducted to evaluate the clinical outcome and factors associated with early recurrent bleeding and 30-day mortality of transcatheter arterial embolization (TAE) for severe, upper gastroduodenal hemorrhage associated with peptic ulcer and refractory to medical and endoscopic therapy. METHODS A monocenter, retrospective study from 2005 to 2020 including 76 consecutive patients who underwent TAE as first-line therapy for bleeding gastroduodenal peptic ulcers refractory to endoscopic therapy. Patient demographics, endoscopy findings, co-morbidities and interventional procedure findings were recorded. The outcome measures were technical and clinical success, procedure related complications, recurrent bleeding, length of hospital stay, 30-day mortality and overall survival. RESULTS The technical success rate was 96% and the clinical success rate was 65,8%. The rebleeding and 30-day mortality rate were 30,7% and 22,4% respectively. A higher international normalized ratio (INR) was a statistically significant risk factor for 30-day mortality (OR, 7.15; 95% CI, 1.67-30.70; p = 0.008). The mean overall survival was 3.76 years (1.16---5.09; 95% CI); a lower Charlson Comorbidity Index (CCI) and a lower Rockall score were significantly associated with a longer overall survival (HR, 1.24; 95% CI, 1.14-1.35; p = 0.0001; HR, 1.32; 95% CI, 1.10-1.59; p = 0.003) respectively. Early rebleeding was significantly associated with a lower overall survival (HR, 2.72; 95% CI, 1.57-4.71; p = 0.0004). CONCLUSION A higher INR was a significant risk factor with a higher 30-day mortality. A lower CCI, a lower Rockall score and the absence of early rebleeding were significantly associated with a longer overall survival.
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Affiliation(s)
- Charlotte Vanhoenacker
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Eva Hufkens
- Department of Gastroenterology and Hepatology, University Hospitals KU Leuven,Herestraat 49, 3000 Leuven, Belgium.
| | - Annouschka Laenen
- Department of Public Health and Primary Care, Leuven Biostatistics and Statistical Bioinformatics Centre, Kapucijnenvoer 35, 3000 Leuven, Belgium.
| | - Lawrence Bonne
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Eveline Claus
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Jo Peluso
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Ingrid Demedts
- Department of Gastroenterology and Hepatology, University Hospitals KU Leuven,Herestraat 49, 3000 Leuven, Belgium.
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospitals KU Leuven,Herestraat 49, 3000 Leuven, Belgium.
| | - Alexander Wilmer
- Department of General Internal Medicine, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Geert Maleux
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
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Kuellmer A, Mangold T, Bettinger D, Maruschke L, Wannhoff A, Caca K, Wedi E, Hosseini ASA, Kleemann T, Schulz T, Jung C, Thimme R, Schmidt A. Over-the-scope clip versus transcatheter arterial embolization for refractory peptic ulcer bleeding-A propensity score matched analysis. United European Gastroenterol J 2021; 9:1048-1056. [PMID: 34432392 PMCID: PMC8598957 DOI: 10.1002/ueg2.12135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/02/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Transcatheter arterial embolization (TAE) or surgery are standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over-the-scope clips (OTSC) have shown superiority to standard endoscopic treatment. OBJECTIVE To compare OTSC treatment to TAE in refractory peptic ulcer bleeding. PATIENTS AND METHODS In this retrospective, multicenter study, 128 patients treated with OTSC (n = 66) or TAE (n = 62) for refractory PUB between 2009 and 2019 in four academic centers were analyzed. Primary endpoint was clinical success (hemostasis + no rebleeding within 7 days). Secondary endpoints were adverse events, length of ICU stay, and mortality. Propensity score matching was performed to adjust for differences in baseline characteristics. RESULTS Patients characteristics were similar in both groups but ulcers in the TAE group were larger, more often located in the duodenal bulb (85.5% vs. 65.2%; p = 0.014), and that the proportion of Forrest Ia bleedings was higher (38.7% vs. 19.7%; p = 0.018). Clinical success was comparable in both groups (74.2% vs. 59.7%; p = 0.092). Stay on the intensive care unit (ICU) was significantly longer in the TAE group (mean 8.0 vs. 4.7 days; p = 0.002). Serious adverse events after re-therapy (12.9% vs. 1.5%; p = 0.042) and in-hospital mortality were significantly higher in the TAE group (9.1 vs. 22.6%, OR 2.92 [95% CI 1.04-8.16]; p = 0.05). After propensity score matching, the differences found regarding ICU stay (4.9± 5.9 and 9.2 ± 11.2; p = 0.009) and in-hospital mortality (5% vs. 22.5%; OR 5.52 [95% CI: 1.11-27.43]; p = 0.048) stayed significant. CONCLUSIONS OTSC treatment for refractory PUB was superior to TAE in terms of ICU stay and in-hospital mortality.
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Affiliation(s)
- Armin Kuellmer
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Tobias Mangold
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Dominik Bettinger
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
- Berta‐Ottenstein‐ProgrammeUniversity of FreiburgFreiburgGermany
| | - Lars Maruschke
- Department of RadiologySt.‐Josef HospitalRkK‐KlinikumFreiburgGermany
| | - Andreas Wannhoff
- Department of Internal Medicine and GastroenterologyHospital LudwigsburgLudwigsburgGermany
| | - Karel Caca
- Department of Internal Medicine and GastroenterologyHospital LudwigsburgLudwigsburgGermany
| | - Edris Wedi
- Medizinische Klinik II / IVSana Klinikum OffenbachOffenbachGermany
| | - Ali Seif Amir Hosseini
- Department of Diagnostic and Interventional RadiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Tobias Kleemann
- Medinische Klinik IVCarl‐Thiem‐Klinikum CottbusCottbusGermany
| | - Thomas Schulz
- Institut für RadiologieCarl‐Thiem‐Klinikum CottbusCottbusGermany
| | - Carlo Jung
- Gastroenterology and Digestive Endoscopy UnitForlì‐Cesena HospitalsAUSL RomagnaForlì‐CesenaItaly
| | - Robert Thimme
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Arthur Schmidt
- Department of Medicine IIMedical CenterFaculty of MedicineUniversity of FreiburgFreiburgGermany
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Park S, Jeong B, Shin JH, Jang EH, Hwang JH, Kim JH. Transarterial embolisation for gastroduodenal bleeding following endoscopic resection. Br J Radiol 2021; 94:20210062. [PMID: 33861138 DOI: 10.1259/bjr.20210062] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Transcatheter arterial embolisation (TAE) is widely used to treat gastrointestinal bleeding. This paper reports the safety and efficacy of TAE for bleeding following endoscopic resection, including endoscopic mucosal resection and endoscopic submucosal dissection. METHODS Fifteen consecutive patients (13 males, two females; mean age 62.2 years) from two tertiary medical centres who underwent TAE for gastroduodenal bleeding after endoscopic resection from November 2001 to December 2020 were included. Patient demographics, clinical presentations, angiographic findings, and TAE details were retrospectively reviewed. RESULTS Immediate bleeding during endoscopic resection was noted in four patients. Delayed bleeding 1-30 days after endoscopic resection in nine patients presented with haematochezia (n = 4), haematemesis (n = 6) and melaena (n = 1). Endoscopic haemostasis was attempted in 11 patients (73.3%) but failed due to continued bleeding despite haemostasis (n = 6), failure to secure endoscopic field (n = 3) and unstable vital signs (n = 2). Eleven patients had positive angiographic findings for bleeding, and all bleeding arteries were embolised except one owing to failed superselection of the bleeder. In the other four patients with negative angiographic findings, the left gastric artery with/without the right gastric artery or the accessory left gastric artery was empirically embolised using gelatin sponge particles. Both technical and clinical success rates were 93.3% (14/15). No procedure-related complications occurred during follow-up. CONCLUSIONS TAE is safe and effective in the treatment of immediate and delayed bleeding after endoscopic resection procedures. ADVANCES IN KNOWLEDGE This is the first and largest 20-year bicentric study published in English on this topic. Empirical TAE for angiographically negative bleeding sites was also effective without significant complications.
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Affiliation(s)
- Suyoung Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Centre, University of Ulsan College of Medicine, Olympic-ro 43gil, Seoul, Republic of Korea
| | - Boryeong Jeong
- Department of Radiology and Research Institute of Radiology, Asan Medical Centre, University of Ulsan College of Medicine, Olympic-ro 43gil, Seoul, Republic of Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Centre, University of Ulsan College of Medicine, Olympic-ro 43gil, Seoul, Republic of Korea
| | - Eun Ho Jang
- Department of Radiology, Ulsan City Hospital, 1007, Saneop-ro, Buk-gu, Ulsan, Republic of Korea
| | - Jung Han Hwang
- Department of Radiology, Gil Medical Centre, Gachon University College of Medicine, 21, Namdong-daero 774beon-gil, Namdong-gu, Incheon, Republic of Korea
| | - Jeong Ho Kim
- Department of Radiology, Gil Medical Centre, Gachon University College of Medicine, 21, Namdong-daero 774beon-gil, Namdong-gu, Incheon, Republic of Korea
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Mille M, Engelhardt T, Stier A. Bleeding Duodenal Ulcer: Strategies in High-Risk Ulcers. Visc Med 2021; 37:52-62. [PMID: 33718484 PMCID: PMC7923890 DOI: 10.1159/000513689] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/09/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Acute peptic ulcer bleeding is still a major reason for hospital admission. Especially the management of bleeding duodenal ulcers needs a structured therapeutic approach due to the higher morbidity and mortality compared to gastric ulcers. Patient with these bleeding ulcers are often in a high-risk situation, which requires multidisciplinary treatment. SUMMARY This review provides a structured approach to modern management of bleeding duodenal ulcers and elucidates therapeutic practice in high-risk situations. Initial management including pharmacologic therapy, risk stratification, endoscopy, surgery, and transcatheter arterial embolization are reviewed and their role in the management of bleeding duodenal ulcers is critically discussed. Additionally, a future perspective regarding prophylactic therapeutic approaches is outlined. KEY MESSAGES Beside pharmacotherapeutic and endoscopic advances, bleeding management of high-risk duodenal ulcers is still a challenge. When bleeding persists or rebleeding occurs and the gold standard endoscopy fails, surgical and radiological procedures are indicated to manage ulcer bleeding. Surgical procedures are performed to control hemorrhage, but they are still associated with a higher morbidity and a longer hospital stay. In the meantime, transcatheter arterial embolization is recommended as an alternative to surgery and more often replaces surgery in the management of failed endoscopic hemostasis. Future studies are needed to improve risk stratification and therefore enable a better selection of high-risk ulcers and optimal treatment. Additionally, the promising approach of prophylactic embolization in high-risk duodenal ulcers has to be further investigated to reduce rebleeding and improve outcomes in these patients.
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Affiliation(s)
- Markus Mille
- Department of General and Visceral Surgery, HELIOS Hospital Erfurt, Erfurt, Germany
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Transcatheter Arterial Embolization Compared With Surgery for Uncontrolled Peptic Ulcer Bleeding. Ann Surg 2019; 269:304-309. [PMID: 29064894 DOI: 10.1097/sla.0000000000002565] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Tarasconi A, Baiocchi GL, Pattonieri V, Perrone G, Abongwa HK, Molfino S, Portolani N, Sartelli M, Di Saverio S, Heyer A, Ansaloni L, Coccolini F, Catena F. Transcatheter arterial embolization versus surgery for refractory non-variceal upper gastrointestinal bleeding: a meta-analysis. World J Emerg Surg 2019; 14:3. [PMID: 30733822 PMCID: PMC6359767 DOI: 10.1186/s13017-019-0223-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 01/22/2019] [Indexed: 12/19/2022] Open
Abstract
Background Nowadays, very few patients with non-variceal upper gastrointestinal bleeding fail endoscopic hemostasis (refractory NVUGIB). This subset of patients poses a clinical dilemma: should they be operated on or referred to transcatheter arterial embolization (TAE)? Objectives To carry out a systematic review of the literature and to perform a meta-analysis of studies that directly compare TAE and surgery in patients with refractory NVUGIB. Materials and methods We searched PubMed, Ovid MEDLINE, and Embase. A combination of the MeSH terms “gastrointestinal bleeding”; “gastrointestinal hemorrhage”; “embolization”; “embolization, therapeutic”; and “surgery” were used ((“gastrointestinal bleeding” or “gastrointestinal hemorrhage”) and (“embolization” or “embolization, therapeutic”) and “surgery”)). The search was performed in June 2018. Studies were retrieved and relevant studies were identified after reading the study title and abstract. Bibliographies of the selected studies were also examined. Statistical analysis was performed using RevMan software. Outcomes considered were all-cause mortality, rebleeding rate, complication rate, and the need for further intervention. Results Eight hundred fifty-six abstracts were found. Only 13 studies were included for a total of 1077 patients (TAE group 427, surgery group 650). All selected papers were non-randomized studies: ten were single-center and two were double-center retrospective comparative studies, while only one was a multicenter prospective cohort study. No comparative randomized clinical trial is reported in the literature. Mortality. Pooled data (1077 patients) showed a tendency toward improved mortality rates after TAE, but this trend was not statistically significant (OD = 0.77; 95% CI 0.50, 1.18; P = 0.05; I2 = 43% [random effects]). Significant heterogeneity was found among the studies. Rebleeding rate. Pooled data (865 patients, 211 events) showed that the incidence of rebleeding was significantly higher for patients undergoing TAE (OD = 2.44; 95% CI 1.77, 3.36; P = 0.41; I2 = 4% [fixed effects]). Complication rate. Pooling of the data (487 patients, 206 events) showed a sharp reduction of complications after TAE when compared with surgery (OD = 0.45; 95% CI 0.30, 0.47; P = 0.24; I2 = 26% [fixed effects]). Need for further intervention. Pooled data (698 patients, 165 events) revealed a significant reduction of further intervention in the surgery group (OD = 2.13; 95% CI 1.21, 3.77; P = 0.02; I2 = 56% [random effects]). A great degree of heterogeneity was found among the studies. Conclusions The present study shows that TAE is a safe and effective procedure; when compared to surgery, TAE exhibits a higher rebleeding rate, but this tendency does not affect the clinical outcome as shown by the comparison of mortality rates (slight drift toward lower mortality for patients undergoing TAE). The present study suggests that TAE could be a viable option for the first-line therapy of refractory NVUGIB and sets the foundation for the design of future randomized clinical trials. Limitations The retrospective nature of the majority of included studies leads to selection bias. Furthermore, the decision of whether to proceed with surgery or refer to TAE was made on a case-by-case basis by each attending surgeon. Thus, external validity is low. Another limitation involves the variability in etiology of the refractory bleeding. TAE techniques and surgical procedure also differ consistently between different studies. Frame time for mortality detection differs between the studies. These limitations do not impair the power of the present study that represents the largest and most recent meta-analysis currently available.
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Affiliation(s)
- Antonio Tarasconi
- 1Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| | - Gian Luca Baiocchi
- 2Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Vittoria Pattonieri
- 1Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| | - Gennaro Perrone
- 1Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| | - Hariscine Keng Abongwa
- 1Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| | - Sarah Molfino
- 2Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Nazario Portolani
- 2Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | | | - Salomone Di Saverio
- 4Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Arianna Heyer
- 5Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA USA
| | - Luca Ansaloni
- 6General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Federico Coccolini
- 6General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Fausto Catena
- 1Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
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Outcomes of patients hospitalized with peptic ulcer disease diagnosed in acute upper endoscopy. Eur J Gastroenterol Hepatol 2017; 29:1251-1257. [PMID: 28857894 DOI: 10.1097/meg.0000000000000951] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The incidence and complications of peptic ulcer disease (PUD) have declined, but mortality from bleeding ulcers has remained unchanged. The aims of the current study were to evaluate the significance of PUD among patients admitted for acute upper endoscopy and to evaluate the survival of PUD patients. PATIENTS AND METHODS In this prospective, observational cohort study, data on 1580 acute upper endoscopy cases during 2012-2014 were collected. A total of 649 patients were included with written informed consent. Data on patients' characteristics, living habits, comorbidities, drug use, endoscopy and short-term and long-term survival were collected. RESULTS Of all patients admitted for endoscopy, 147/649 (23%) had PUD with the main symptom of melena. Of these PUD patients, 35% had major stigmata of bleeding (Forrest Ia-IIb) in endoscopy. Patients with major stigmata had significantly more often renal insufficiency, lower level of blood pressure with tachycardia and lower level of haemoglobin, platelets and ratio of thromboplastin time. No differences in drug use, Charlson comorbidity class, BMI, smoking or alcohol use were found. Of the PUD patients, 31% were Helicobacter pylori positive. The 30-day mortality was 0.7% (95% confidence interval: 0.01-4.7), 1-year mortality was 12.9% (8.4-19.5) and the 2-year mortality was 19.4% (13.8-26.8), with no difference according to major or minor stigmata of bleeding. Comorbidity (Charlson>1) was associated with decreased survival (P=0.029) and obesity (BMI≥30) was associated with better survival (P=0.023). CONCLUSION PUD is still the most common cause for acute upper endoscopy with very low short-term mortality. Comorbidity, but not the stigmata of bleeding, was associated with decreased long-term survival.
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Tonolini M, Ierardi AM, Bracchi E, Magistrelli P, Vella A, Carrafiello G. Non-perforated peptic ulcer disease: multidetector CT findings, complications, and differential diagnosis. Insights Imaging 2017; 8:455-469. [PMID: 28677101 PMCID: PMC5621988 DOI: 10.1007/s13244-017-0562-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 06/10/2017] [Accepted: 06/12/2017] [Indexed: 12/12/2022] Open
Abstract
Abstract Despite availability of effective therapies, peptic ulcer disease (PUD) remains a major global disease, resulting from a combination of persistent Helicobacter pylori infection and widespread use of nonsteroidal anti-inflammatory drugs. Albeit endoscopy definitely represents the mainstay diagnostic technique, patients presenting to emergency departments with unexplained abdominal pain generally undergo multidetector CT as an initial investigation. Although superficial ulcers generally remain inconspicuous, careful multiplanar CT interpretation may allow to detect deep ulcers, secondary mural and extraluminal signs of peptic gastroduodenitis, thereby allowing timely endoscopic verification and appropriate treatment. This pictorial essay aims to provide radiologists with an increased familiarity with CT diagnosis of non-perforated PUD, with emphasis on differential diagnosis. Following an overview of current disease epidemiology and complications, it explains the appropriate CT acquisition and interpretation techniques, and reviews with several examples the cross-sectional findings of uncomplicated PUD. Afterwards, the CT features of PUD complications such as ulcer haemorrhage, gastric outlet obstruction, biliary and pancreatic fistulisation are presented. Teaching points • Gastric and duodenal peptic ulcers are increasingly caused by nonsteroidal anti-inflammatory drugs • Multiplanar CT interpretation allows detecting deep ulcers and secondary signs of gastroduodenitis • CT diagnosis of uncomplicated peptic disease relies on direct and indirect signs • Currently the commonest complication, haemorrhage may be treated with transarterial embolisation • Other uncommon complications include gastric outlet obstruction and biliopancreatic fistulisation
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Affiliation(s)
- Massimo Tonolini
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy.
| | - Anna Maria Ierardi
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo e Carlo, Via A di Rudinì 8, 20142, Milan, Italy
| | - Elena Bracchi
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Paolo Magistrelli
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Adriana Vella
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Gianpaolo Carrafiello
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo e Carlo, Via A di Rudinì 8, 20142, Milan, Italy
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Nykänen T, Peltola E, Kylänpää L, Udd M. Bleeding gastric and duodenal ulcers: case-control study comparing angioembolization and surgery. Scand J Gastroenterol 2017; 52:523-530. [PMID: 28270041 DOI: 10.1080/00365521.2017.1288756] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To compare the safety, efficacy and feasibility of transcatheter arterial embolization (TAE) and surgery in the treatment of bleeding gastric and duodenal ulcers (BGDUs). MATERIALS AND METHODS The study group comprised patients receiving TAE or surgery for BGDUs after failed endoscopic hemostasis in Helsinki University Hospital (HUH) during 2000-2015. Hospital medical records provided study data. 30-d mortality and rebleeding rates were the primary outcomes. Postoperative complications, blood transfusion rate, and the durations of intensive care and hospital admissions were the secondary outcomes. RESULTS During the study period, BGDUs lead to 1583 hospital admissions. TAE or surgery was necessary on 85 (5.4%) patients, 43 receiving surgery and 42 TAE. Out of 42, 16 received prophylactic TAE. Two underwent angiography and TAE to localize the bleeding. The remaining 24 received TAE for active or recurrent bleeding after endoscopy. The comparison of TAE (n = 24) and surgery (n = 43) included only patients with active or recurrent bleeding. Mortality rate was 12.5% after TAE and 25.6% after surgery (p = 0.347). Rebleeding rate was 25% after TAE and 16.3% after surgery (p = 0.641). Postprocedural complications were less frequent after TAE than surgery (37.5 vs. 67.4%, p = 0.018). Other secondary outcomes did not differ. Out of 85 procedures, 14 (16.5%) took place between midnight and 8 a.m., all nighttime interventions being surgeries. CONCLUSIONS Mortality and rebleeding rates did not differ between TAE and surgery. With less postoperative complications, TAE should be the preferred hemostatic method when endoscopy fails.
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Affiliation(s)
- Taina Nykänen
- a Gastrointestinal surgery, Abdominal Center , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Erno Peltola
- b Department of Radiology, Helsinki Medical Imaging Center , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Leena Kylänpää
- c Gastrointestinal surgery, Abdominal Center , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Marianne Udd
- d Gastrointestinal surgery, Abdominal Center , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
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Malmi H, Kautiainen H, Virta LJ, Färkkilä MA. Increased short- and long-term mortality in 8146 hospitalised peptic ulcer patients. Aliment Pharmacol Ther 2016; 44:234-45. [PMID: 27240732 DOI: 10.1111/apt.13682] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 11/09/2015] [Accepted: 05/09/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Incidence and complications of peptic ulcer disease (PUD) have declined, but mortality from peptic ulcer bleeding has remained unchanged. The few recent studies on mortality associated with both uncomplicated and complicated patients with peptic ulcer disease provide contradictory results. AIMS To evaluate short- and long-term mortality, and the main causes of death in peptic ulcer disease. METHODS In this retrospective epidemiologic cohort study, register data on 8146 adult patients hospitalised with peptic ulcer disease during 2000-2008 were collected in the capital region of Finland. All were followed in the National Cause of Death Register until the end of 2009. The data were linked with the nationwide Drug Purchase Register of the Finnish Social Insurance Institution. RESULTS Mean follow-up time was 4.9 years. Overall mortality was substantially increased, standardised mortality ratio 2.53 (95% CI: 2.44-2.63); 3.7% died within 30 days, and 11.8% within 1 year. At 6 months, the survival of patients with perforated or bleeding ulcer was lower compared to those with uncomplicated ulcer; hazard ratios were 2.06 (1.68-2.04) and 1.32 (1.11-1.58), respectively. For perforated duodenal ulcers, both the short- and long-term survival was significantly impaired in women. The main causes of mortality at 1 year were malignancies and cardiovascular diseases. Previous use of statins was associated with significant reduction in all-cause mortality. CONCLUSIONS One-year mortality in patients hospitalised with peptic ulcer disease remained high with no change. This peptic ulcer disease cohort had a clearly decreased survival rate up to 10 years, especially among women with a perforated duodenal ulcer, most likely explained by poorer survival due to underlying comorbidity.
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Affiliation(s)
- H Malmi
- Gastrointestinal Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H Kautiainen
- Department of General Practice and Primary Health Care, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Department of General Practice and Primary Health Care, University of Eastern Finland, Kuopio, Finland
| | - L J Virta
- Research Department, The Social Insurance Institution of Finland, Turku, Finland
| | - M A Färkkilä
- Helsinki University Clinic of Gastroenterology, University of Helsinki, Helsinki, Finland
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