Treatment and outcome of gastrointestinal bleeding due to peptic ulcers and erosions - (BLUE study)

OBJECTIVES

Peptic ulcers and erosions are the most common causes of upper gastrointestinal bleeding. The aim of this study was to investigate the management and outcomes of these patients.

MATERIALS AND METHODS

A total of 543 patients with endoscopically confirmed bleeding from peptic ulcers and erosions were included from March 2015 to December 2017. The patient characteristics, endoscopic findings, Forrest classification and endoscopic treatment were recorded. Moreover, the rebleeding rates, repeated endoscopies and transcatheter angiographic embolization and surgery incidences were registered. A follow-up endoscopy after discharge from the hospital was scheduled.

RESULTS

Among the patients, high-risk stigmata ulcers were present in 36% (198/543) and low-risk stigmata ulcers and erosions in 60% (327/543) at first endoscopy. Endoscopic therapy was performed in 30% (165/543) of the patients, and hemostasis was achieved in 94% (155/165). The incidence of rebleeding was 9% (49/543) for the whole cohort and 14.8% (23/155) for those patients who had received successful endoscopic treatment. Moreover, rebleeding was significantly more frequent in duodenal ulcers than in gastric ulcers (11.9% vs 4.0%, p = .004). In a multivariable analysis, rebleeding was significantly related to comorbidity and Forrest classification. Transcatheter angiographic embolization and surgery were required in 6% (34/543) and 0.07% (4/543) of patients, respectively. Complete peptic ulcer healing was found at follow-up in 73.3% (270/368) of patients.

CONCLUSIONS

Endoscopic hemostasis was achieved in the majority of patients with high-risk ulceration, although the occurrence of rebleeding is a significant challenge, especially in patients with duodenal ulcers. Clinical trial registration: Bleeding Ulcer and Erosions Study (BLUE Study), ClinicalTrials.gov identifier: NCT03367897.

The recurrent bleeding risk of a Forrest IIc lesion at the second-look endoscopy can be indicated by high Rockall scores ≥ 6

Background

The Forrest classification is widely applied to guide endoscopic hemostasis for peptic ulcer bleeding. Accordingly, practice guidelines suggest medical treatment only for ulcer with a Forrest IIc lesion because it has low rebleeding risk even without endoscopic therapy, ranging from 0 to 13%. However, the risk ranges widely and it is unclear who is at risk of rebleeding with such a lesion. This study assessed whether the Rockall score, which evaluates patients holistically, could indicate the risk of recurrent bleeding among patients with a Forrest IIc lesion at the second-look endoscopy.

Methods

Patients who had peptic ulcer bleeding with Ia-IIb lesions received endoscopic hemostasis at the primary endoscopy, and they were enrolled if their Ia-IIb lesions had been fading to IIc at the second-look endoscopy after 48- to 72-h intravenous proton pump inhibitor (PPI) infusion. Primary outcomes were rebleeding during the 4th–14th day and 4^th–28th day after the first bleeding episode.

Results

The prospective cohort study enrolled 140 patients, who were divided into a Rockall scores ≥ 6 group or a Rockall scores < 6 group. The rebleeding rates in the Rockall scores ≥ 6 group and the Rockall scores < 6 group during the 4th–14th day and the 4th–28th day were 13/70 (18.6%) versus 2/70 (2.9%), p = 0.003 and 17/70 (24.3%) versus 3/70 (4.3%), p = 0.001, respectively, based on an intention-to-treat analysis and 5/62 (8.1%) versus 0/68 (0%), p = 0.023 and 6/59 (10.2%) versus 0/67 (0%), p = 0.009, respectively, based on a per-protocol analysis. The Kaplan–Meier curves showed that the Rockall scores ≥ 6 group had a significantly lower cumulative rebleeding-free proportion than the Rockall scores < 6 group (p = 0.01).

Conclusions

Combined Rockall scores ≥ 6 on arrival with a Forrest IIc lesion at the second-look endoscopy can identify patients at risk of recurrent peptic ulcer bleeding following initial endoscopic and intravenous PPI treatment.

Trial registration Trial registration identifier: NCT01591083

Is the Reinitiation of Antiplatelet Agents Safe at 1 Week after Gastric Endoscopic Submucosal Dissection? Assessment of Bleeding Risk Using the Forrest Classification

Background/Aims

Delayed bleeding after gastric endoscopic submucosal dissection (ESD) commonly occurs within 3 days, but it may also occur after 1 week following ESD, especially in antiplatelet agent users. We evaluated the risk of delayed bleeding in post-ESD ulcers using the Forrest classification.

Methods

Registry data on the Forrest classification of post-ESD ulcers (n=371) at 1 week or 2 weeks after ESD were retrospectively evaluated. The Forrest classification was categorized into two groups: increased risk (Forrest Ia to IIc) or low risk (Forrest III). The odds ratios (ORs) were calculated using logistic regression analysis.

Results

Among 371 post-ESD ulcers, one ulcer (0.3%) was classified as Forrest Ib, two (0.5%) as Forrest IIa, 17 (4.6%) as Forrest IIb, 172 (46.4%) as Forrest IIc, and 179 (48.2%) as Forrest III. The proportion of increased-risk ulcers was 72.2% (140/194) at 1 week after ESD, which decreased to 29.4% (52/177) at 2 weeks after ESD (p<0.001). In the multivariate analysis, a post-ESD ulcer at 1 week after ESD (OR, 7.54), younger age (OR, 2.17), and upper/middle ulcer location (OR, 2.05) were associated with increased-risk ulcers.

Conclusions

One week after ESD, ulcers still have an increased risk of bleeding when assessed using the Forrest classification. This risk should be considered when resuming antiplatelet therapy.

[Not Available]

Zusammenfassung. Gastrointestinale Blutungen stellen sowohl auf der internistischen Notfallstation als auch in der hausärztlichen Praxis ein häufiges Krankheitsbild dar. Die klinische Präsentation ist breit und hängt ab von der Lokalisation sowie dem zeitlichen Auftreten der Blutung. Am gefürchtetsten, weil auch mit der höchsten Mortalitätsrate verbunden, sind akute obere gastrointestinale Blutungen. Untere gastrointestinale Blutungen sistieren hingegen meist spontan. Es ist daher unerlässlich für den Kliniker, anhand Anamnese, klinischer Untersuchung sowie einem Basislabor die Lokalisation und den zeitlichen Verlauf der Blutung zu eruieren sowie deren Risiko bezüglich ernsthafter Komplikationen abzuschätzen. Für Letzteres sind neben der aktuellen Klinik v.a. die Komorbiditäten des Patienten entscheidend. Klinische Scores helfen bei der Einschätzung der Akutspitalbedürftigkeit sowie bei der Bestimmung des optimalen Endoskopie-Zeitpunktes. Je nach Endoskopie-Befund ist eine ambulante Weiterbetreuung möglich, bei hoher Rezidivblutungsrate wie bei gewissen gastroduodenalen Ulzera ist jedoch eine stationäre, in Einzelfällen gar eine intensivmedizinische, Überwachung unerlässlich. In der folgenden Zusammenstellung werden die gängigsten Einteilungen der gastrointestinalen Blutungen, deren Klinik und Behandlungsoptionen sowie die Prognosen respektive Rezidivraten beschrieben.

Effective endoscopic treatment of Mallory-Weiss syndrome using Glasgow-Blatchford score and Forrest classification

OBJECTIVES

There is limited data on whether scoring systems can be used to predict clinical outcomes in patients with upper gastrointestinal bleeding due to Mallory-Weiss syndrome (MWS). We aimed to evaluate whether the Glasgow-Blatchford score (GBS) could be effective in predicting clinical outcomes of bleeding MWS and to investigate the predictive ability of the Forrest classification for rebleeding and assess the effective endoscopic modalities for bleeding control in MWS.

METHODS

From January 2004 to December 2012 168 patients were diagnosed with MWS in the Asan Medical Center Emergency Department. We analyzed their clinical outcomes, including endoscopic treatment, transfusion and admission as well as the rates of rebleeding and mortality using GBS and the Forrest classification, retrospectively.

RESULTS

Endoscopic treatment was applied to patients. The GBS was significantly higher in patients treated with endoscopic therapy than in the conservative treatment group (6.8 ± 3.7 vs 5.1 ± 4.7, P = 0.011). In patients with a GBS of >6 the rates of endoscopic treatment and rebleeding and the need for transfusion and admission were significantly higher (all P < 0.05). The Forrest classification was able to predict recurrent bleeding (area under the receiver operating characteristic curve 0.723, 95% confidence interval 0.609-0.836, P = 0.025). Hemoclip-based therapy and band ligation achieved higher success rates than did injection therapy alone in preventing rebleeding (96.4%, 88.9% and 71.4%, P = 0.013).

CONCLUSION

In MWS, GBS might be useful for predicting clinical outcomes and the Forrest classification in predicting recurrent bleeding.

Second-look endoscopy with prophylactic hemostasis is still effective after endoscopic submucosal dissection for gastric neoplasm

AIM: The clinical value of second-look endoscopy (SLE) after endoscopic submucosal dissection (ESD) has been doubted continuously. The aim of this study was to assess the effectiveness of SLE based on the risk of delayed bleeding after ESD.

METHODS: A total of 310 lesions of gastric epithelial neoplasms treated by ESD were reviewed. The lesions were divided into two groups based on the risk of post-procedural bleeding estimated by Forrest classification. The high risk of rebleeding group (Forrest Ia, Ib and IIa) required endoscopic treatment, while the low risk of rebleeding group (Forrest IIb, IIc and III) did not. Delayed bleeding after ESD was investigated.

RESULTS: Sixty-six lesions were included in the high risk of rebleeding group and 244 lesions in the low risk of rebleeding group. There were no significant differences in delayed bleeding between the high risk group (1/66) and the low risk group (1/244) (P = 0.38). The high risk of rebleeding group tended to be located more often in the mid-third and had higher appearance of flat or depressed shape than the low risk group (P = 0.004 and P = 0.006, respectively).

CONCLUSION: SLE with pre-emptive prophylactic endoscopic treatment is still effective in preventing delayed bleeding after ESD.

Patient characteristics with high or low blood urea nitrogen in upper gastrointestinal bleeding

AIM: To examine characteristics of patients with blood urea nitrogen (BUN) levels higher and lower than the normal limit.

METHODS: Patient records between April 2011 and March 2014 were analyzed retrospectively. During this time, 3296 patients underwent upper endoscopy. In total, 50 male (69.2 ± 13.2 years) and 26 female (72.3 ± 10.2 years) patients were assessed. Patients were divided into two groups based on BUN levels: higher than the normal limit (21.0 mg/dL) (H) and lower than the normal limit (L). One-way analysis of variance was performed to reveal differences in the variables between the H and L groups. Fisher’s exact test was used to compare the percentage of patients with gastric ulcer or gastric cancer in the H and L groups.

RESULTS: White blood cell count was higher in the H group than in the L group (P = 0.0047). Hemoglobin level was lower in the H group than in the L group (P = 0.0307). Glycated hemoglobin was higher in the H group than in the L group (P = 0.0264). The percentage of patients with gastric ulcer was higher in the H group (P = 0.0002). The H group contained no patients with gastric cancer.

CONCLUSION: Patients with BUN ≥ 21 mg/dL might have more severe upper gastrointestinal bleeding.