Factors influencing outcome of angiographic embolization for gastroduodenal hemorrhage related to peptic ulceration

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.

Management of bleeding peptic duodenal ulcer refractory to endoscopic treatment: surgery or transcatheter arterial embolization as first-line therapy? A retrospective single-center study and systematic review

BACKGROUND

The objective of this study was to compare the results of transcatheter arterial embolization (TAE) with surgery in terms of efficacy in the context of bleeding duodenal ulcer (BDU) refractory to endoscopic treatment.

MATERIALS AND METHODS

From January 2006 to December 2016, all patients treated for a BDU refractory to endoscopic treatment were included in this observational, comparative, retrospective, single-center study. Primary endpoint was the overall success of treatment of BDU requiring surgical and/or TAE. The secondary endpoints were pre-interventional data, recurrence rates, feasibility of secondary treatment, morbidity and mortality of surgical and radiological treatment, intensive care unit and length of stay. A systematic review of the literature was performed to compare results of surgery and TAE.

RESULTS

59 out of 396 patients (14.9%) treated for BDU required embolization and/or surgery: 15 patients underwent surgery (group S) including 7 patients after embolization failure and 44 patients underwent TAE (group TAE). The overall treatment success in intention to treat (85.7% vs 67.3%), per protocol (80% vs 79.5%) and bleeding recurrence rates (20% vs 15.9%) were also identical. Mortality (14.2% vs 15.3%) was similar between the two groups. Our study data were pooled with data from eight published studies and suggest that surgery have significant increased overall success (68.3% vs. 55.4%, p < 0.005).

CONCLUSION

The overall success rate was in favour of surgery according our meta-analysis. Our single-center study highlights the fact that predictive factors for recurrent bleeding after TAE must be identified to select good candidates for TAE and/or surgery.

Acute upper gastrointestinal bleed: An audit of the causes and outcomes from a tertiary care center in eastern India

BACKGROUND/PURPOSE OF THE STUDY

Acute upper gastrointestinal (UGI) bleed is a life-threatening emergency carrying risks of rebleed and mortality despite standard pharmacological and endoscopic management. We aimed to determine etiologies of acute UGI bleed in hospitalized patients and outcomes (rebleed rates, 5-day mortality, in-hospital mortality, 6-week mortality, need for surgery) and to determine predictors of rebleed and mortality.

METHODS

Clinical and endoscopic findings were recorded in patients aged > 12 years who presented within 72 h of onset of UGI bleed. Outcomes were recorded during the hospital stay and 6 weeks after discharge.

RESULTS

A total of 305 patients were included in this study, mean age being 44 ± 17 years. Most common etiology of UGI bleed was portal hypertension (62.3%) followed by peptic ulcer disease (PUD) (16.7%). Rebleed rate within 6 weeks was 37.4% (portal hypertension 47.9%, PUD 21.6%, malignancy 71.4%). Five-day mortality was 2.3% (malignancy 14.3%, portal hypertension 3.2%); the in-hospital mortality rate was 3.0% (malignancy 14.3%, portal hypertension 3.2%, PUD 0.0%) and 4.9% at 6 weeks (malignancy 28.6%, portal hypertension 5.8%, PUD 0.0%). Surgery was required in 4.59% patients. On multivariate analysis, post-endoscopy Rockall score was significantly predictive of rebleed in both portal hypertension- and PUD-related rebleed. No factors were found predictive of mortality in multivariate analysis.

CONCLUSION

Portal hypertension remains the commonest cause of UGI bleed in India and carries a higher risk of rebleed and mortality as compared to PUD-related bleed. Post-endoscopy Rockall score is a useful tool for clinicians to assess risk of rebleed.

Endoscopic Doppler US for the prevention of ulcer bleeding after endoscopic submucosal dissection for early gastric cancer: a preliminary study (with video)

BACKGROUND

After endoscopic submucosal dissection (ESD) for early gastric cancer (EGC), delayed bleeding occurs in 1.7% to 38% of cases. Routine coagulation of all nonbleeding visible vessels (NBVVs) in post-ESD ulcers is currently performed as standard practice, but it cannot eliminate bleeding. An endoscopic Doppler US (DOP-US) probe system has possible benefits for the prediction of recurrent bleeding in peptic ulcer hemorrhage.

OBJECTIVE

To establish optimum use and evaluate feasibility of DOP-US for post-ESD ulcers.

DESIGN

Case series study.

SETTING

Cancer referral center.

PATIENTS

Eight patients with mucosal EGC larger than 2 cm without ulceration or scarring and 2 patients with EGC less than 3 cm with scarring.

INTERVENTIONS

We searched for a positive DOP-US signal (DOP-US+), which was defined as pulsatile sound at a depth of 1.5 mm, and NBVVs or areas with DOP-US+ were coagulated with hemostatic forceps. A multibending, double-channel videoendoscope that was fitted with a transparent hood was used.

MAIN OUTCOME MEASUREMENTS

Detectability of DOP-US signals in post-ESD ulcers.

RESULTS

One of 13 oozing bleeding sites, 24 (18%) of 136 NBVVs, and 7 areas without any bleeding stigmata had DOP-US+ and were coagulated until the signal became silent. One hundred twelve NBVVs (82%) and 8 adherent clots without DOP-US signals were left untreated. No delayed bleeding was experienced at 30 days. Median time required for Doppler examination was 34 minutes, but it improved to 18 and 19 minutes in patients 9 and 10, respectively.

CONCLUSIONS

DOP-US might be helpful in the endoscopic management of post-ESD ulcers in EGC. Our setting and maneuver warrant further investigation to clarify whether DOP-US can reduce delayed bleeding and avoid unnecessary coagulation for NBVVs in post-ESD ulcers.

Endoscopic Doppler ultrasound versus endoscopic stigmata-directed management of acute peptic ulcer hemorrhage: a multimodel cost analysis

Recurrent bleeding from acute peptic ulcer hemorrhage is problematic. Studies have shown that Doppler ultrasound (DOP-US) is useful in decreasing rebleeding. We analyzed associated costs and outcomes to better define the role of DOP-US versus Conventional (Forrest classification endoscopic stigmata) in the management of acute peptic ulcer bleeding. Two separate decision analyses were constructed. Recurrent bleeding, failed esophagogastroduodenoscopy (EGD) hemostasis, complications, and surgery rates were derived from medical literature. Costs were based on Medicare data. DOP-US is preferred over Conventional in acute peptic ulcer bleeding with average cost savings per patient ranging from 853 dollars (decision-tree modeling) to 1,160 dollars (Monte Carlo simulation). High-dose intravenous proton-pump inhibitors lowered rates of recurrent bleeding for both Conventional and DOP-US, resulting in a lower but still persistent average cost savings per patient for DOP-US (decision-tree modeling = 328 dollars, Monte Carlo simulation = 560 dollars). This decision analyses identified DOP-US as the preferred cost-minimizing strategy in acute peptic ulcer hemorrhage. Results of cost analyses were most dependent on hospitalization costs and recurrent bleeding rates.

Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding

PURPOSE

To enable accurate transcatheter arterial embolization (TAE) of the target vessel, a new technique to localize the exact position of a bleeding ulcer was tested that involves endoscopic marking of the ulcer with a metallic clip.

MATERIALS AND METHODS

In 13 patients (mean age, 75 years) with acute bleeding ulcers (11 duodenal ulcers, two malignant ulcers), a metallic clip was placed at gastroscopy followed or preceded by routine endoscopic treatment. The metallic clip was placed in the fibrous edge of the ulcer adjacent to the bleeding point. In 10 patients, TAE was indicated as a result of continued or recurrent bleeding. The artery was embolized with microcoils as close as possible to the clip. In three patients, there was no indication for TAE, so plain abdominal radiography was performed to determine whether the marking clip was still in place.

RESULTS

In 11 patients, the clip was still in place on radiography; in two, it had disappeared. Hemostasis was achieved in eight of 10 patients after TAE. In six patients, the clip was essential to identify the bleeding vessel.

CONCLUSION

Marking of the bleeding ulcer with a clip before TAE enhances the possibility that the correct vessel is embolized. This will most likely minimize the risk of recurrent bleeding after embolization, especially in patients who do not show contrast medium extravasation.

Transcatheter arterial embolization in patients with bleeding duodenal ulcer: an alternative to surgery

PURPOSE

To evaluate the efficacy and safety of transcatheter arterial embolization (TAE) in patients with bleeding/rebleeding duodenal ulcers.

MATERIAL AND METHODS

Over a 6-year-period, 40 consecutive patients with bleeding/ rebleeding after endoscopic therapy and/or surgery for duodenal ulcer were included in the study. Superselective angiographic catheterization and coil embolization were performed by the same interventional radiologist.

RESULTS

Lasting hemostasis was achieved in 26 of 40 patients (65%). Transfusion requirement was reduced from median 14 (range 3-35) units of blood before TAE to 2 (range 0-53) units after TAE. Ten patients died, five because of continuous bleeding. No adverse effects as a result of TAE were seen.

CONCLUSION

TAE is an effective and safe treatment in a significant proportion of patients with bleeding duodenal/rebleeding ulcers after therapeutic endoscopy and/or surgery.

Endoscopic Doppler ultrasound after injection therapy for peptic ulcer hemorrhage

BACKGROUND/AIMS

A positive Doppler signal in endoscopic Doppler ultrasound at index endoscopy predicts a high risk for rebleeding from peptic ulcer. The aim of this study was to evaluate if a negative Doppler status immediately after injection therapy may exclude a rebleeding from peptic ulcer in a high-risk cohort.

METHODOLOGY

Twenty consecutive patients (pts) (age: 68 (33-91) yrs; 11 female) with peptic ulcer bleeding were enrolled. All patients with an actively bleeding ulcer and those with a non-actively bleeding, but Doppler-positive ulcer were treated by injection of adrenaline (1:10,000 dilution). Treatment was performed during index endoscopy until the Doppler status was negative. Patients were followed-up clinically and endoscopically (including Doppler ultrasound) for bleeding recurrence.

RESULTS

Patients were treated by injection of 12 (6 to 20) mL of adrenaline solution until Doppler scan was negative. During follow-up four pts (20%) had a clinically overt rebleeding episode. At control endoscopy three ulcers were actively bleeding and another two were Doppler positive without rebleeding (total: five of eighteen (27.7%) Doppler-positive ulcers). Two of the twenty pts required surgical therapy due to rebleeding (10%).

CONCLUSIONS

A negative endoscopic Doppler status immediately after injection therapy is not helpful to identify patients with no risk for rebleeding from peptic ulcer.

A fading Meckel's diverticulum: an unusual scintigraphic appearance in a child

We describe the case of a 13-month-old boy with significant rectal bleeding in which the (99m)Tc pertechnetate scan showed an initial focus of uptake in the left iliac fossa, which faded rapidly at 15 min. At surgery an ulcerated Meckel's diverticulum was found. We therefore highlight the need to consider a Meckel's diverticulum in cases where this atypical scintigraphic appearance is seen.

[Arterial embolization can often substitute surgery in bleeding ulcer. When endoscopic hemostasis is not successful an alternative emergency treatment is needed]

Peptic ulcer disease is the most common cause of acute haemorrhage from the upper gastrointestinal tract. Despite therapeutical improvements, the mortality rate remains high. Massive bleeding may, if haemostasis is not achieved by endoscopic treatment, require surgery. Often these patients are elderly with high comorbidity and, hence, are poor surgical candidates. We have therefore used angiography and selective arterial embolisation as an alternative option in 18 patients with massive ulcer bleeding. 13 patients were treated after failed endoscopic treatment, and 5 patients were treated for recurrent bleeding after previous emergency operations for bleeding ulcers. Embolisation of the arterial branch supplying the ulcer was possible in all patients. Permanent haemostasis was achieved in all but one patient, in whom the bleeding was controlled at an emergency operation. Our opinion is that angiographic embolisation is an effective way to control massive bleeding from peptic ulcers. In this way emergency operations in poor surgical candidates can be avoided.

[Prognosis of the stomach and duodenal ulcer complications: endoscopic aspects]

The visual picture of the ulcerous defect was studied in 222 patients by endoscopic and intraoperative methods. The prognostic assessment of the development of complications of ulcer disease of the stomach and duodenum is given on the basis of the characteristics of the ulcer process (diameter, depth, character of the ulcer fundus and margins).

The role of endoscopic Doppler US in patients with peptic ulcer bleeding

BACKGROUND

Stigmata of recent hemorrhage are important prognostic signs for patients with ulcer bleeding, but these are subjective findings. This study evaluated the additional diagnostic value of Doppler US assessment in patients with a bleeding peptic ulcer.

METHODS

A prospective, multicenter study was performed of patients with ulcer bleeding. Stigmata of recent hemorrhage were classified according to the Forrest classification, after which the ulcer was assessed by using an endoscopic Doppler US system. Patients with a Forrest Ib-IIb ulcer with a positive Doppler signal received endoscopic therapy. Patients with a Forrest IIc-III ulcer with a positive Doppler signal were allocated randomly to endoscopic therapy or no therapy. No ulcer without a Doppler signal was treated.

RESULTS

A total of 80 patients were enrolled. Of the Forrest Ib-IIb ulcers, 82% had a positive Doppler signal. Of the Forrest IIc-III ulcers, 53% had a positive Doppler signal. There was no difference in the rates of recurrent bleeding, surgery, or mortality between the group with Forrest Ib-IIb ulcers and between the Forrest IIc-III group with and without Doppler signal, but there was little power in the sample size to detect differences. Bleeding recurred in 3 patients without a Doppler signal. Recurrent bleeding was more frequent in the group in which a Doppler signal was still present immediately after endoscopic therapy (3/11 vs. 1/27; p=0.06).

CONCLUSIONS

This study did not substantiate a role for endoscopic Doppler US when this was added to the Forrest classification for making clinical decisions in patients with ulcer bleeding.

Extended surgery for the hepatic artery aneurysm involving duodenum and pancreas--a case report

Hepatic artery aneurysms have been the most frequently reported splanchnic artery aneurysms in the past decade. Due to the complex anatomy and sensitivity of the liver to ischemic injury, a number of therapeutic alternatives exist in repairing aneurysmal hepatic arteries. Excision or obliteration of all hepatic artery aneurysms appears to be the management of choice. However, in managing aneurysms involving the proper hepatic artery and its extrahepatic branches, restoration of normal hepatic blood flow is most crucial. A 49-year-old man was found to have a huge extrahepatic artery aneurysm involving the area from the origin of the common hepatic artery to the distal proper hepatic artery. It ruptured into the duodenal bulb and firmly adhered to the surrounding structures including pancreas and common bile duct. Extended surgery with restoration of normal hepatic flow was performed safely. In cases with huge extrahepatic artery aneurysms, an aggressive approach to restore the hepatic arterial continuity seems appropriate for the prevention of ischemic damage to the liver.

Arterial embolisation in management of massive bleeding from gastric and duodenal ulcers

OBJECTIVE

We have tried angiography and selective arterial embolisation as a complement or another option in patients with massive bleeding from peptic ulcers who were considered poor candidates for surgery.

DESIGN

Prospective, descriptive study.

SETTING

University hospital, Sweden.

PATIENTS

Since 1998, 18 patients (11 women) with a median age of 78 years (range 53-94) had selective arterial embolisation for uncontrollable bleeding from peptic ulcers.

INTERVENTION

Superselective angiographic catheterisation and embolisation of the arterial branch that was supplying the ulcer.

MAIN OUTCOME MEASURES

The success rate of haemostasis and the overall outcome.

RESULTS

13 patients were treated after failed endoscopic treatment to stop bleeding or to control recurrent bleeding after initial arrest, while 5 patients were treated for recurrent bleeding after emergency operations for bleeding ulcers. Most of the ulcers were in the duodenum. The patients were haemodynamically unstable and had a median haemoglobin concentration of 72 g/L (50-98). Embolisation of the arterial branch that was supplying the ulcer was feasible in all patients. Permanent haemostasis was achieved in all but one patient, although two patients needed a second embolisation for recurrent bleeding. One patient had the bleeding controlled at an emergency operation, but eventually died of respiratory complications. There were no serious complications of embolisation.

CONCLUSION

Angiographic embolisation may be an effective way to stop massive bleeding from gastroduodenal ulcers. Emergency operations in poor surgical candidates can therefore be avoided.

Role of Doppler US in acute peptic ulcer hemorrhage: can it predict failure of endoscopic therapy?

BACKGROUND

Recurrent bleeding after successful primary endoscopic hemostasis of acutely bleeding ulcers is a significant problem. This study evaluates endoscopic Doppler ultrasound (US) in assessing risk of recurrent bleeding in patients presenting with acute peptic ulcer hemorrhage.

METHODS

In this prospective, double-blind, nonrandomized trial, patients were enrolled from a single academic institution. Only patients with endoscopically confirmed gastric, duodenal, pyloric, or anastomotic ulcers were enrolled. The therapeutic endoscopist was blinded to the Doppler US signal from the ulcer and based treatment decisions on standard guidelines. A 16 MHz pulsed-wave, linear scanning, US probe was used through the accessory channel of an endoscope to assess for the presence of a Doppler signal.

RESULTS

Fifty-two of 139 screened patients entered the trial (55 Doppler sessions). Endoscopic therapy was performed in 42% (30-day recurrent bleeding rate of 17%). Ulcers that remained persistently Doppler positive immediately after endoscopic therapy had a significantly higher rate of recurrent bleeding than ulcers where the Doppler signal was abolished: 100% versus 11% (p = 0.003). There were no bleeding-related deaths.

CONCLUSIONS

A persistently positive Doppler US signal appears to be a marker of inadequate endoscopic therapy in patients with acutely bleeding peptic ulcers.

[The evaluation of pancreatic blood flow in patients with gastroduodenal ulcer complicated by hemorrhage, according to rheopancreatography]

The results of the pancreatic gland (PG) blood flow was studied up in 121 patients with hemorrhage of different severity using intraoperative rheopancreatography. Under the influence of hemorrhage in the PG the arterial blood flow is lowering, the arteriovenous shunting mechanisms are starting.

Randomized trial of N-butyl-2-cyanoacrylate compared with injection of hypertonic saline-epinephrine in the endoscopic treatment of bleeding peptic ulcers

BACKGROUND AND STUDY AIMS

Theoretically, the injection of cyanoacrylate may be effective for peptic ulcer bleeding, but randomized clinical trials are rare. The aim of this study was to compare the efficacy of N-butyl-2-cyanoacrylate (Histoacryl) and hypertonic saline-epinephrine (HSE) in the endoscopic treatment of major peptic ulcer hemorrhage.

PATIENTS AND METHODS

A total of 126 patients with major peptic ulcer hemorrhage and active bleeding or a nonbleeding visible vessel were randomly allocated to endoscopic injection with HSE (63 patients; group 1) or to injection with Histoacryl (63 patients; group 2). The two groups were well matched for age, sex, initial hemoglobin values, ulcer size and location, and bleeding stigmata.

RESULTS

Initial hemostasis was achieved in 58 cases (92.1%) in group 1 and in 60 cases (95.2%) in group 2 (P=0.717). Rebleeding rates were 16 of 58 in group 1 and seven of 60 in group 2 (P=0.051). There were no significant differences regarding the rates of permanent hemostasis (51 of 63 in group 1 vs. 57 of 63 in group 2, P=0.203), emergency surgery (seven of 58 in group 1 vs. three of 60 in group 2, P=0.200), or hospital mortality due to bleeding (0 in group 1 and 0 in group 2). With regard to the rebleeding rate, there was a significant difference between group 1 and group 2 in the subgroup with active arterial bleeding (11 of 26 in group 1 and four of 29 in group 2, P=0.039) but not in the subgroup with a nonbleeding visible vessel (five of 32 in group 1 and three of 31 in group 2, P=0.708). There were no statistically significant differences in hemostatic results between the two treatment groups in the subgroups with gastric ulcers or duodenal ulcers. Although no complications followed HSE therapy, arterial embolization with infarction occurred in two patients in the Histoacryl group, of whom one died.

CONCLUSIONS

Compared with HSE injection, Histoacryl injection showed no statistically significant differences in hemostatic results, except for decreasing the rebleeding rate in the patients with active arterial bleeding. However, the use of Histoacryl to control peptic ulcer bleeding should be reserved as a last resort before surgery, because of possible embolic complication.

Gastric ulcer bleeding: diagnosis by computed tomography

A case of CT demonstration of a bleeding gastric ulcer is presented, in a patient with confusing clinical manifestations. Abdominal CT was performed without oral contrast medium administration, and showed extravasation of intravenous contrast into a gastric lumen distended with material of mixed attenuation. It is postulated that if radiopaque oral contrast had been given, peptic ulcer bleeding would probably have been masked. CT demonstration of gastric ulcer bleeding, may be of value in cases of differential diagnostic dilemmas.

The role of endoscopic Doppler-sonography

Endoscopic Doppler sonography is a useful method that permits a differentiation to be made between high-risk lesions in danger of rebleeding and prognostically harmless ulcerations. Using this technique, vessels in the base of the ulcer can be reliably identified, and the indication for local endoscopic treatment established. The pulsed Doppler can be used to test the efficacy of prior endoscopic therapy within the framework of follow-up investigations; when arterial blood flow signals are found to persist, treatment needs to be repeated. With the aid of this "programmed" Doppler sonography-controlled endoscopic approach, which in some cases may be repeatable, the number of rebleeds, emergency operations, and probably also mortality, can be permanently lowered. Endoscopic Doppler sonography can also provide important additional information in the area of primary diagnosis and endoscopic treatment of esophageal and gastric varices. The Doppler exploration facilitates the assessment of the sclerosing effect, and is capable of identifying gastric varices and distinguishing these from other submucosal processes. For an assessment of the butyl cyanoacrylate varix, the Doppler is of particular value.

Radiological evaluation of complications of intestinal tuberculosis

Complications of intestinal tuberculosis may be masked. This study aims to heighten awareness of these unusual clinical complications and the radiological findings in such cases. Over a period of 5 years, 21 patients with proven intestinal tuberculosis, 13 of whom presented with complications, are presented in this report. Radiological diagnosis was by barium gastrointestinal studies and computed tomographic (CT) evaluation. Surgical specimens and histopathology confirmed the diagnosis. The commonest complication was intestinal obstruction (N = 6). Others were esophagobronchial and duodenocolic fistulas (N = 2), significant gastrointestinal hemorrhage (N = 3) caused by ulcers in the small bowel and colon, and malabsorption syndrome (N = 3) caused by diffuse small bowel infiltration in 2 cases and duodenocolic fistula in the third case. None of the patients presented were immunocompromised. Though uncommon, tuberculosis should be considered in patients presenting clinically with intestinal obstruction, significant gastrointestinal hemorrhage and malabsorption state.

Angiographic evaluation and management of nonvariceal upper gastrointestinal bleeding

Endoscopy is the primary diagnostic and therapeutic tool used in the evaluation and treatment of patients with upper gastrointestinal bleeding. When endoscopy is unsuccessful in identifying or controlling GI hemorrhage, however, arteriography is useful in both the evaluation and treatment of upper GI hemorrhage.

[X-ray diagnostic features of giant bleeding ulcers in stomach and duodenum]

The study was based on the analysis of clinical, X-ray, and morphological examinations made in 64 patients with giant gastric and duodenal ulcers. All the patients were admitted for gastroduodenal hemorrhage. Among the examinees, there were 28 patients with giant ulcer of the stomach and 26 with that of the duodenum. The authors present the methods of X-ray examinations and the X-ray symptomatology of giant ulcers of the stomach and duodenum. Gastroscopic and X-ray examinations were comparatively analyzed. The paper gives evidence that the X-ray examination has many advantages in estimating the size and ratio of ulcers to the adjacent organs and tissues. The paper outlines giant duodenal ulcers. The authors identify two groups of patients with giant ulcers of the duodenal bulb, which differ in its size and the extent of deformity. One of valid signs of the penetration of giant ulcers is not only their size, but their depth and fixation to the adjacent organs and tissues.

[Segmental "portal hypertension". A rare cause of severe tractable variceal bleeding]

We present a 33 year-old man with massive upper gastrointestinal bleeding caused by a rare form of segmental portal hypertension. The patient developed a pancreatic abscess, which caused an isolated thrombosis in the splenic vein and the development of pronounced collaterals and bleeding fundus varices. The patient underwent splenectomy and recovered quickly hereafter. The literature is sparse on severe bleeding complications due to acute pancreatitis. The present case emphasizes the importance of recognition of unusual manifestations of common clinical conditions.

Sonographic detection of intragastric blood clot

An intragastric blood clot suggested by sonography and later confirmed at upper gastrointestinal series and at gastroscopy is reported. Sonographic findings were a moveable mass within stomach presenting as an arc-like hyperechoic surface with a strong posterior resonance artifact. Compression of the mass with a transducer induced the mass to move from antrum to corpus within stomach. We think that the demonstration of a blood clot within stomach can be suggested on the basis of typical sonographic findings as a secondary sign of a bleeded gastric or duodenal ulcer.

[X-ray diagnosis features of acute bleeding ulcers of the stomach and duodenum]

The paper is based on the analysis of clinical, X-ray, and morphological studies in 74 patients with massive gastrointestinal hemorrhage who were treated at the hospitals of the N.V. Sklifosofsky Research Institute of Emergency Care, in 1991-1994. Among the examinees, there were 28 with medio-gastric ulcer and 44 with parapyloric ulcers. In 2 patients bleeding occurred with the anastomosis ulcers of the stomach operated on. The paper presents the specific features of X-ray studies of patients with bleeding gastroduodenal ulcers. X-ray studies should be twice performed in these patients. The first study is conducted if gastroscopic findings are unclear, the repeated one is carried out while assessing changes in disease regression. The emergency gastroscopic and subsequent X-ray studies have demonstrated that acute ulcers may be at various sites and multiple. X-ray diagnosis of bleeding ulcers is determined by their sites and the nature of an ulcerous process. The X-ray diagnosis of chronic callous gastric ulcers accompanied by hemorrhage was based on the detection of two direct symptoms of a "niche" on the gastric outlines and configuration and an inflammatory mound on the gastric outline and configuration. That of chronic bleeding ulcers of the duodenal bulb is based not only on searches for the basic symptom of peptic ulcer -"niche", but other signs of the disease-the deformed organ, and the magnitude of a periprocess. Gastroduodenoscopy is applied not only for the primary diagnosis of a hemorrhagic source, but a therapeutical technique. However, the use of endoscopy alone in patients with gastroduodenal hemorrhage did not give a comprehensive idea of the magnitude of ulcerous changes, organ-specific deformity, and a periprocess.

Bleeding esophageal duplication detected in utero

Peptic complications in duplications of the alimentary tract may occur when the duplication is lined by gastric mucosa. These complications commonly develop in the first year of life. We report a case of a bleeding esophageal duplication in a fetus.

[Bleeding peptic ulcers--concept for acute therapy]

Acute ulcer bleeding still is a life-threatening event. The therapeutic goal is to establish intensity, activity and location of the bleeding and to assess primary hemostasis by consequent endoscopic therapy, also preventing recurrence significantly. With the injection method, primary hemostasis accounts for over 90% success. Also recurrent bleeding can be stopped to the same extent. Endoscopic doppler allows a qualitative and quantitative registration of potentially dangerous vessels on the ulcer base. Drug therapy does serve for the acute treatment to a lesser extent; it is more valid for the initiation of the conservative ulcer therapy. Surgical interventions therefore confined to risk patients in whom a primary hemostasis failed or the ulcer is located in a dangerous site, for instance in the back wall of the duodenal bulb.

[Leiomyosarcoma of the stomach]

Leiomyosarcoma of the stomach is a rare occurrence, amounting to only 0.5-3% of all stomach malignancies. Because of its extragastral growth, it produce clinical symptoms, mostly with bleeding, only at a late stage. The decisive method of examination is computed tomography which demonstrates the extraluminal tumor lying apparently in the mesenterium with contrast medium up-take at the borders and central necrosis. A secure differential diagnosis to leiomyoma is not possible by angiography or by computed tomography; this distinction is even difficult by histology.

Does Doppler ultrasound improve the prognosis of acute ulcer bleeding?

The visible vessel in the floor of the ulcer seen on endoscopy is one of the most important prognostic factors of ulcer bleeding. With the ultimate aim of improving the purely visual interpretation of the base of the ulcer, we investigated the utility of an innovative pulsed endoscopic Doppler procedure in 140 patients with acute ulcer bleeding. Agreement between the endoscopic appearance and the Doppler ultrasonographic findings was observed in only 59% of the ulcers. In all Doppler-positive ulcers, injection therapy was performed irrespective of the endoscopic appearance of the ulcer. This was repeated if the ulcer was still Doppler-positive on repeat examination. With this strategy, only 9% recurrent hemorrhages were seen, and there was no hemorrhage-associated mortality. Among the Doppler-negative lesions, which received only medical treatment, no rebleeding was observed. On the basis of these results, it would appear that a Doppler ultrasound oriented classification of ulcer bleeding is superior to the Forrest classification based on a purely visual interpretation. The endoscopic Doppler verifies the visual impression of the ulcer, identifies the indication for operative endoscopy, and can monitor the effectiveness of the latter.

Bleeding peptic ulcer: surgical therapy

The management of bleeding peptic ulcer disease varies with multiple clinical and endoscopic variables. For the patient with rapid hemorrhage and hemodynamic instability refractory to endoscopic control, operation clearly is indicated. For patients with a low probability of recurrent ulcer hemorrhage because of the absence of endoscopic stigmata or clinical predictors of further ulcer bleeding, nonoperative management with selective use of endoscopic hemostasis is appropriate. For the remaining patients with a moderate risk of recurrent ulcer hemorrhage, the clinician must use what is known of the clinical and endoscopic predictors of recurrent hemorrhage and arrive at a judgment regarding the selective use of endoscopic hemostasis and subsequent early operation. For elderly patients with a large duodenal or gastric ulcer who have experienced significant blood loss precipitating an episode of hypovolemic shock and who have endoscopic stigmata of ulcer hemorrhage, early elective operation after endoscopic hemostasis is the most judicious course. Surgery also is the wise choice for those patients in whom an initially successful attempt at endoscopic hemostasis fails and who rebleed while hospitalized. Recommendations for the surgical management of bleeding peptic ulcer disease include Immediate operation for (1) patients with rapidly exsanguinating ulcer hemorrhage and (2) patients with active bleeding and failure of endoscopic hemostasis to control the bleeding. Early elective operation after initial endoscopic hemostasis for (1) elderly patients with comorbid disease and/or hemodynamic instability who have active arterial ulcer hemorrhage (Forrest Ia) controlled with endoscopic hemostasis; (2) elderly patients with comorbid disease and/or hemodynamic instability who have a visible vessel in an ulcer crater (Forrest IIa) treated with endoscopic hemostasis: surgery is particularly advised in this circumstance for those with a positive arterial Doppler signal in the ulcer crater or a large posterior duodenal ulcer or a large lesser-curvature gastric ulcer; and (3) elderly patients with comorbid disease and/or hemodynamic instability who develop recurrent ulcer bleeding while hospitalized or with a total blood transfusion requirement exceeding 5 U.

Endoscopic injection therapy of Forrest II and III gastroduodenal ulcers guided by endoscopic Doppler ultrasound

Endoscopic Doppler ultrasound enables the reliable identification of vessels in the base of gastroduodenal ulcers. In a prospective study including 114 patients with acute ulcer bleeding, pulsed Doppler ultrasound was able to demonstrate superficial blood vessels in the ulcer base in 62% of 106 cases where complete Doppler assessment was possible (93%). Agreement between the endoscopic pattern of visible vessels and the Doppler ultrasound findings was attained in only 52% of the cases. Doppler positive ulcers (n = 66) were treated with injection therapy (if necessary, repeated), irrespective of their Forrest classification. Using such an approach, the rebleeding rate in this group decreased to less than 8% and none of the patients died of causes related to the hemorrhage. All Doppler negative ulcers (n = 40) healed without complications or the need for endoscopic treatment; among these were 11 cases with Forrest IIa and b. We conclude that endoscopic Doppler appears to be a valuable diagnostic procedure in the assessment of bleeding ulcers, thus modifying the Forrest classification. Our concept is that Doppler positive ulcers require local endoscopic treatment, whereas Doppler negative ulcers can be treated conservatively.

[Significance of the ulcer vessel in acute ulcer hemorrhage--value of local endoscopic therapy in combination with endoscopic Doppler ultrasound]

The acute ulcer hemorrhage is one of the most frequent diagnoses in Gastroenterology. In addition to the active hemorrhage the visible ulcer vessel, even if not bleeding at present, is one of the most important prognostic criteria. Numerous controlled studies have shown that with this sign recurrent hemorrhages will occur in up to 81%, resulting in emergency surgery in up to 56% with an associated mortality of up to 21%. By a meta-analysis we could show that prophylactic endoscopic therapy can significantly reduce both the rate of recurrent hemorrhage as well as emergency surgery. If the endoscopic doppler is used as well, as diagnostic as well as follow-up examination, the effectiveness of endoscopic treatment is greatly improved. The numbers we present show that active local endoscopic therapy should be undertaken in a visible ulcer vessel.

[Endoscopic Doppler ultrasound in gastroduodenal ulcer hemorrhage]

AIMS

Investigation of the information value of endoscopic Doppler ultrasonography of the base of the ulcer in comparison with visual endoscopic assessment of bleeding gastroduodenal ulcers using the Forrest classification.

STUDY DESIGN

Open prospective comparative study involving 30 patients with acutely bleeding gastroduodenal ulcers. Where Doppler ultrasonography revealed an artery in the base of the ulcer, injection with epinephrine and polidocanol was administered. Follow-up examinations were performed on day 2 and after 4 weeks.

RESULTS

Endoscopic Doppler ultrasonography reliably identifies the vessels responsible for bleeding from gastroduodenal ulcers, in particular in lesions with stigmata of recent bleeding (Forrest II), but also in ulcers with no such stigmata but a history of bleeding (Forrest III). In addition, Doppler ultrasonography also allows the results of injection therapy to be determined.

CONCLUSION

Endoscopic Doppler ultrasonography makes possible the rapid and efficient identification of invisible vessels in the ulcer floor responsible for bleeding.

Chronic duodenal ulcer in children and response to highly selective vagotomy

The effectiveness of highly selective vagotomy (HSV) in adult duodenal ulcer surgery is confirmed by absence of peroperative mortality or postoperative morbidity and by ulcer healing in the majority of cases. Whether it could be used in children with the same result was the subject of our study in 13 successive cases of complicated duodenal ulcer treated between 1974 and 1987. There was complete ulcer healing in 4 cases. Pain relapsed in 5 cases and there was recurrence of hemorrhage in 2 cases. Although immediate good results lasted for at least 3 years, 2 patients were lost to follow-up. Still, we consider HSV as a safe procedure available for children as it does not "queer the pitch" for a subsequent treatment if it fails.