Endoscopic Treatment of Upper Gastrointestinal Bleeding

Role of endoscopic ultrasound in non-variceal upper gastrointestinal bleeding management

Non-variceal upper gastrointestinal bleeding (NVUGIB) is one of the challenging situations in clinical practice. Despite that gastric ulcer and duodenal ulcer are still the main causes of acute NVUGIB, there are other causes of bleeding which might not always be detected through the standard endoscopic evaluation. Standard endoscopic management of UGIB consists of injection, thermal coagulation, hemoclips, and combination therapy. However, these methods are not always successful for rebleeding prevention. Endoscopic ultrasound (EUS) has been used recently for portal hypertension management, especially in managing acute variceal bleeding. EUS has been considered a better tool to visualize the bleeding vessel in gastroesophageal variceal bleeding. There have been studies looking at the role of EUS for managing NVUGIB; however, most of them are case reports. Therefore, it is important to review back to see the evolution and innovation of endoscopic treatment for NVUGIB and the role of EUS for possibility to replace the standard endoscopic haemostasis management in daily practice.

[Repeated endoscopic hemostasis as an alternative to surgical treatment of patients with gastroduodenal ulcerative bleeding]

AIM

To define the role of endoscopic hemostasis in treatment of gastroduodenal ulcers complicated by bleeding.

MATERIAL AND METHODS

The results of endoscopic hemostasis in 770 patients with peptic ulcers were analyzed.

RESULTS

Injection hemostasis had the highest efficacy in case of recurrent bleeding. No other method showed significant advantage in its efficiency. The efficacy of injection method was 52%, argon-plasma coagulation - 83.3%, radiowave technique - 78%, combined endoscopic method  - 96%. In case of recurrent bleeding endoscopic hemostasis is effective alternative to surgery especially in high-risk patients. Repeated endoscopic hemostasis significantly decreases mortality from 45% to 23% in case of recurrent bleeding.

Effectiveness comparison of endoscopic methods of non-varicose upper gastrointestinal bleeding treatment

INTRODUCTION

In every case of upper gastrointestinal bleeding suspicion, an endoscopic examination ought to be performed as a matter of urgency. Finding active bleeding, a visible non-bleeding vessel or a lesion with an adherent clot should be followed by application of an available method of endoscopic therapy. The aim of the study was to compare the effectiveness of various endoscopic treatment techniques such as epinephrine injections, coagulation methods and mechanical methods in the treatment of non-varicose upper gastrointestinal bleeding.

MATERIAL AND METHODS

Sixty cases of non-varicose upper gastrointestinal bleeding were analysed in terms of the effectiveness of the above-mentioned procedures used in monotherapy or in combination therapy comprising epinephrine injections and clips application. The choice of the applied procedure depended on morphological features and location of the bleeding source, the patient's general condition, as well as technical equipment and manual skills of the endoscopy staff.

RESULTS

The study confirmed the effectiveness of endoscopic treatment of non-varicose upper gastrointestinal bleeding applying the above-mentioned methods. In most patients, this treatment enabled traumatic surgical intervention to be avoided; it was required in only 3 (5%) out of 60 patients with confirmed upper gastrointestinal bleeding. With the first endoscopy, haemostasis was achieved in 47 cases (78.3%) and the second endoscopy, performed due to bleeding recurrence, was successful in the remaining 10 cases (16.7%).

CONCLUSIONS

In non-varicose upper gastrointestinal bleeding, urgent diagnostic and therapeutic endoscopy should be the first-line management. If the lesion that is the source of bleeding is possible to localize, the endoscopic techniques should be applied. Among the endoscopic procedures used in monotherapy, clips appeared to be the most effective, their effectiveness being comparable to combination therapy. In bleeding from extensive lesions, coagulation methods are considered to be the most efficacious.

Endoscopic hemostasis by using the TriClip for peptic ulcer hemorrhage: a pilot study

BACKGROUND

The feasibility, efficacy, and safety of the TriClip in the management of peptic ulcer hemorrhage in human beings are scarcely reported in the literature.

OBJECTIVE

A pilot study was conducted to assess the feasibility, efficacy, and safety of the TriClip endoscopic clipping device in the control of peptic ulcer hemorrhage.

DESIGN

Prospective evaluation.

SETTING

Regional government hospital.

PATIENTS

From July 2004 to January 2005, patients older than 16 years and with Forrest type I and IIa peptic ulcer hemorrhages were included in the study.

INTERVENTIONS

TriClips were used for initial hemostasis. Salvage procedures, including adrenalin injection, heat probe application, argon plasma coagulation, or surgery will be carried out appropriately if TriClip failed to control bleeding alone. An endoscopy was repeated 24 hours later for the security of the TriClip and for any endoscopic evidence of recurrent bleeding. A follow-up endoscopy was performed 8 weeks later to assess ulcer healing.

MAIN OUTCOME MEASUREMENTS

Procedure time, successful hemostatic rate, number of clips used, ulcer recurrent bleeding rate, complications, and ulcer healing rate were measured.

LIMITATIONS

No comparative arm; pilot study only.

RESULT

A total of 27 cases (11 women, 16 men) were included in the study, with a median age of 70 years (range 18-88 years). There were 19 cases of duodenal ulcer and 8 cases of gastric ulcer, with median size of 8 mm (range 2-20 mm). The rate of successful hemostasis in the first endoscopy by TriClips alone was 81.5% (22/27), with a median procedure time of 10 minutes (range 3-30 minutes). In the second endoscopy, the endoscopic recurrent bleeding rate was 14.8% (4/27) and the TriClips were found dislodged in 11 patients (40.7%). The permanent hemostasis rate was 67% (18/27). The overall failure rate was 33% (9/27). Three patients required blood transfusion before the first endoscopy. There was no morbidity or mortality observed in all cases. All ulcers healed after 8 weeks.

CONCLUSIONS

The use of the TriClip is feasible in the initial control of peptic ulcer hemorrhage. However, we could not detect any obvious advantages in arresting bleeding vessels by using this new clipping device.

An economic evaluation of vasoactive agents used in the United Kingdom for acute bleeding oesophageal varices in patients with liver cirrhosis

OBJECTIVE

To conduct an economic evaluation of terlipressin, octreotide and placebo in the treatment of bleeding oesophageal varices (BOV) where endotherapy could be used concomitantly.

METHODS

A discrete event simulation model was created with transition states: bleeding, no bleeding, no bleeding post transjugular intrahepatic portosystemic shunt, post-salvage surgery, and death. Efficacy data on survival, re-bleeding and control of bleeding were obtained from high quality studies reported in Cochrane meta-analyses. Baseline outcomes related to the course of disease and health-state utilities were derived from published sources. Vasoactive treatment costs and all related BOV costs were obtained from published UK sources.

RESULTS

The average aggregated treatment cost per person for all medical interventions at 1 year was lower for terlipressin-treated patients (2623 pounds sterling) compared with those treated using octreotide (2758 pounds sterling) or placebo (2890 pounds sterling). The incremental analysis comparing terlipressin with octreotide and placebo using a cost per quality adjusted life year (QALY) and cost per life year gained (LYG) approach indicated that terlipressin was the dominant BOV treatment option (i.e. it cost less and it was more effective). Based on a maximum willingness to pay of 20,000 pounds sterling/QALY terlipressin was more effective and cost-saving compared to octreotide and placebo for simulations ranging from 42 days to 2 years. In point estimation analyses octreotide was dominant compared to placebo; however, probabilistic sensitivity analysis indicated that octreotide was unlikely to be cost-effective compared to placebo.

CONCLUSIONS

The findings indicated that vasoactive treatment in BOV was cost-saving compared to no vasoactive treatment. Furthermore, terlipressin was the more cost-effective vasoactive treatment for BOV in cirrhotic patients.

Emergency management of bleeding esophageal varices: drugs, bands or sleep?

Variceal bleeding is a severe complication of cirrhosis leading to significant morbidity and mortality. Treatment of acute variceal bleeding has improved dramatically since the era of the mechanical balloon tamponade. These advances include endoscopic band ligation or sclerotherapy, and vasoactive pharmacological options such as somatostatin, octreotide, vasopressin and terlipressin. Evidence from a multitude of clinical trials and meta-analyses comparing endoscopic and pharmacological treatments suggests near equivalence in efficacy for initial hemostasis, mortality and rate of rebleeding. This raises the question of whether on-call gastroenterologists should be performing emergency endoscopic treatment in the middle of the night or start pharmacological treatment and delay endoscopy until optimal patient and working conditions the next morning. The present review analyzes the available comparative data between endoscopic and pharmacological treatment options. Although the literature cannot yet definitively answer the question posed, the authors suggest that delaying endoscopic treatment until the next morning may be the most reasonable practical approach.