1
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Nielsen MM, Schaffalitzky de Muckadell OB, Laursen SB. Doppler-Guided Second-Look Endoscopy in Peptic Ulcer Bleeding: A Randomised Controlled Trial. J Clin Med 2023; 12:6722. [PMID: 37959188 PMCID: PMC10647717 DOI: 10.3390/jcm12216722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/13/2023] [Accepted: 10/19/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Endoscopic treatment guided by Doppler endoscopic probes (DEPs) during index endoscopy may be associated with improved outcome in patients with peptic ulcer bleeding (PUB). As competencies for DEP evaluation are not always available for index endoscopy, we examined the outcome associated with DEP evaluation at second-look endoscopy. METHODS The study was designed as a non-blinded, parallel group, randomised controlled trial. Patients admitted with PUB from Forrest Ia-IIb ulcers, controlled by endoscopic therapy, were randomised (1:1 ratio) to second-look endoscopy <24 h with DEP evaluation of the bleeding ulcer or continued standard treatment. Patients were followed up for 30 days. The primary outcome was rebleeding. Secondary outcomes included the number of transfusions, length of hospital stay, and 30-day mortality. RESULTS A total of 62 patients were included. At second-look endoscopy, 91% (29/32) of patients had a positive DEP signal at the ulcer base and were treated with contact thermal therapy (n = 29), injection of diluted adrenaline (n = 23), and haemoclips (n = 7). Among the 32 patients treated with DEP evaluation, only one rebled (3%) compared to four patients (13%) in the control group (p = 0.20). There were no differences in the secondary outcomes between groups, and there were no complications related to DEP evaluation. CONCLUSIONS Second-look endoscopy with DEP-guided evaluation and treatment is safe and associated with a very low risk of rebleeding (3%) in patients with PUB. Second-look endoscopy with DEP evaluation may be considered in selected PUB patients at high risk of rebleeding, and may represent an alternative to the use of DEP for index endoscopy. Nevertheless, we did not find that second-look endoscopy with DEP evaluation significantly improved patient outcome compared to standard treatment.
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Affiliation(s)
- Michael Milek Nielsen
- Department of Gastroenterology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense, Denmark; (M.M.N.)
| | - Ove B Schaffalitzky de Muckadell
- Department of Gastroenterology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense, Denmark; (M.M.N.)
- Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19, 5000 Odense, Denmark
| | - Stig Borbjerg Laursen
- Department of Gastroenterology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense, Denmark; (M.M.N.)
- Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19, 5000 Odense, Denmark
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2
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Jensen DM. The Importance of Arterial Blood Flow Detection for Risk Stratification and Eradication to Achieve Definitive Hemostasis of Severe Non-Variceal UGI Hemorrhage. J Clin Med 2023; 12:6473. [PMID: 37892610 PMCID: PMC10607067 DOI: 10.3390/jcm12206473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/14/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common medical problem worldwide. Independent endoscopic risk factors for rebleeding and mortality of NVUGIB that are treatable are stigmata of recent hemorrhage (SRH) and arterial blood flow underneath SRH. The specific aims of this paper are to describe the importance of arterial blood flow detection for risk stratification and as a guide to definitive hemostasis of severe NVUGIB. METHODS This is a review of randomized controlled trials and prospective cohort study methodologies and results which utilized a Doppler endoscopic probe (DEP) for the detection of arterial blood underneath SRH, for risk stratification, and as a guide to definitive hemostasis. The results are compared to visually guided hemostasis based upon SRH. RESULTS Although SRH have been utilized to guide endoscopic hemostasis of NVUGIB for 50 years, when most visually guided treatments are applied to lesions with major SRH, arterial blood flow underneath SRH is not obliterated in 25-30% of patients and results in rebleeding. Definitive hemostasis, significantly lower rebleeding rates, and improvements in other clinical outcomes resulted when DEP was used for risk stratification and as a guide to obliteration of arterial blood flow underneath SRH. CONCLUSIONS DEP-guided endoscopic hemostasis is a very effective and safe new method to improve patient outcomes for NVUGIB.
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Affiliation(s)
- Dennis M Jensen
- David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center and The VA Greater Los Angeles Healthcare System, Los Angeles, CA 90095, USA
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3
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Chapelle N, Martel M, Bardou M, Almadi M, Barkun AN. Role of the endoscopic Doppler probe in nonvariceal upper gastrointestinal bleeding: Systematic review and meta-analysis. Dig Endosc 2023; 35:4-18. [PMID: 35598171 DOI: 10.1111/den.14356] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/18/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVES The effectiveness of the Doppler endoscopic probe (DEP) remains unclear in nonvariceal upper gastrointestinal bleeding (NVUGIB). We thus performed a systematic review characterizing the effectiveness of DEP in patients with NVUGIB addressing this question. METHODS A literature search was done until July 2021 using MEDLINE, EMBASE, and ISI Web of Science. A series of meta-analyses were performed assessing outcomes among observational and interventional studies for DEP signal positive and negative lesions as well as DEP-assisted versus standard endoscopies. The primary outcome was "overall rebleeding"; secondary outcomes included all-cause mortality, bleeding-related mortality, need for surgery, length of stay, intensive care unit stay, and angiography. RESULTS Fourteen studies were included from 1911 citations identified. Observational studies compared bleeding lesions with DEP-positive versus DEP-negative signals (11 studies, n = 800 prehemostasis; five studies, n = 148 with posthemostasis data). Three interventional studies (n = 308) compared DEP-assisted to standard endoscopy management. DEP signal positive versus negative lesions either prior to or following any possible hemostasis were at greater risk of overall rebleeding (odds ratio [OR] 6.54 [2.36, 18.11] and OR 25.96 [6.74, 100.0], respectively). The use of DEP during upper endoscopy significantly reduced overall rebleeding rates (OR 0.27 [0.14, 0.54]). When removing outcomes analysis for which only one study was available, all evaluable outcomes were improved with DEP characterization of management guidance except for all-cause mortality. CONCLUSION Although with low certainty evidence, DEP-related information improves on sole visual prediction of rebleeding in NVUGIB, with DEP-guided management yielding decreased overall rebleeding, bleeding-related mortality, and need for surgery.
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Affiliation(s)
- Nicolas Chapelle
- Service de Gastroentérologie, Oncologie Digestive et Assistance Nutritionnelle, Institut des Maladies de l'Appareil Digestif, Nantes, France.,INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes Université, CHU Nantes, Nantes, France
| | - Myriam Martel
- Research Institute of the McGill University Health Center, Montreal, Canada
| | - Marc Bardou
- INSERM CIC 1432, CHU Dijon-Bourgogne, Universite de Bourgogne, Dijon, France
| | - Majid Almadi
- Department of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Alan N Barkun
- Research Institute of the McGill University Health Center, Montreal, Canada.,Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
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4
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Furuichi Y, Sato K, Kato H. Through-the-scope endoscopic Doppler probe method before endoscopic variceal ligation. Dig Endosc 2022; 34:1380-1381. [PMID: 35945165 DOI: 10.1111/den.14395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 06/30/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Yoshihiro Furuichi
- Department of Clinical Laboratory and Endoscopy, Tokyo Women's Medical University, Adachi Medical Center, Tokyo, Japan
| | - Koichiro Sato
- Department of Clinical Laboratory and Endoscopy, Tokyo Women's Medical University, Adachi Medical Center, Tokyo, Japan
| | - Hiroyuki Kato
- Department of Clinical Laboratory and Endoscopy, Tokyo Women's Medical University, Adachi Medical Center, Tokyo, Japan
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5
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Shiratori Y, Ikeya T, Yamamoto K, Takasu A, Suzuki Y, Okada S, Fukuda K, Rateb G. Doppler probe method to reduce delayed bleeding after endoscopic submucosal dissection in the stomach: a propensity-score matched study (with video). Surg Endosc 2022; 36:8663-8671. [PMID: 35697850 DOI: 10.1007/s00464-022-09345-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 05/20/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Prophylactic coagulation after gastric endoscopic submucosal dissection (ESD) decreases the rate of delayed bleeding; however, it cannot prevent bleeding completely, and delayed bleeding may occur from non-exposed vessels that were not detected immediately after ESD or where prophylactic coagulation was inadequate. Doppler monitoring systems which can evaluate vascular flow have been recently introduced in the endoscopic field. We developed the Doppler probe method (DOP) using the novel system and conducted a comparative study. METHODS Data were retrospectively collected at a tertiary hospital between January 2017 and May 2021. Patients who underwent DOP were matched to those who did not (no-DOP, 1:3 ratio). After successful ESD, DOP was performed, and coagulation was additionally performed as necessary. The primary outcome was the rate of 30-day delayed bleeding. RESULTS Fifty DOP patients were matched to 151 no-DOP patients. Although the differences were not statistically significant, the DOP group had lower rates of delayed bleeding (2.0% vs. 8.6%, P = 0.11; risk differences, 6.6%; 95% confidence interval [CI] 1.2-12.1%), readmission due to bleeding (0% vs. 2.7%), and blood transfusion (2.0% vs. 3.3%) compared to the no-DOP group. In the whole study population (n = 245), the log-rank test revealed that DOP was correlated to a lower incidence of delayed bleeding (P = 0.036). The Cox regression model revealed a marginally significant effect on delayed bleeding (hazard ratio = 0.17, 95% CI 0.022-1.26, P = 0.082). No procedure-related adverse events were observed. CONCLUSION DOP is safe and may reduce delayed bleeding; however, further prospective studies are required to validate our findings.
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Affiliation(s)
- Yasutoshi Shiratori
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashi-cho Chuo-ku, Tokyo, Japan.
- Department of Gastroenterology, Sherbrooke University Hospital, Sherbrooke, QC, Canada.
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashi-cho Chuo-ku, Tokyo, Japan
| | - Kazuki Yamamoto
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashi-cho Chuo-ku, Tokyo, Japan
| | - Ayaka Takasu
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashi-cho Chuo-ku, Tokyo, Japan
| | - Yuichirou Suzuki
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashi-cho Chuo-ku, Tokyo, Japan
| | - Syuichi Okada
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashi-cho Chuo-ku, Tokyo, Japan
| | - Katsuyuki Fukuda
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashi-cho Chuo-ku, Tokyo, Japan
| | - George Rateb
- Department of Gastroenterology, Sherbrooke University Hospital, Sherbrooke, QC, Canada
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6
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Negm S, Mohamed H, Shafiq A, AbdelKader T, Ismail A, Yassin M, Mousa B, Abozaid M, Orban YA, Al Alawi M, Farag A. Combined endoscopic and radiologic intervention for management of acute perforated peptic ulcer: a randomized controlled trial. World J Emerg Surg 2022; 17:24. [PMID: 35610657 PMCID: PMC9131571 DOI: 10.1186/s13017-022-00429-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/12/2022] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Peptic ulcer perforation is a common life-threatening surgical emergency. Graham omental patch is performed for plugging of perforated peptic ulcer. Many endoscopic methods have been used to treat acute perforated peptic ulcer such as over the scope clips, standard endoscopic clips, endoscopic sewing and metallic stents. The main idea in endoscopic management of acute perforated peptic ulcer is early decontamination and decrease sepsis by interventional radiologic drainage. METHODS This is a prospective randomized controlled clinical trial. This study included patients who were developed acute perforated peptic ulcer manifestations and were admitted to our hospital between December 2019 and August 2021. Sample size was 100 patients divided into 2 equal groups. Endoscopic group (EG): included 50 patients who were subjected to endoscopic management. Surgical group (SG): included 50 patients who were subjected to surgical management. RESULTS One hundred patients were randomized into 2 groups: SG (50) and EG (50). Median age of patients was 36 (range 27:54) and 47 (range 41:50) years-old in SG and EG, respectively. Males constituted 72% and 66% in SG and EG, respectively. Median length of postoperative hospital stay was 1 (range: 1-2) days in EG, while in SG was 7 (range 6-8) days. Postoperative complications in SG patients were 58% in form of fever, pneumonia, leak, abdominal abscess, renal failure and incisional hernia (11%, 5%, 5%, 3%, 2% and 3%, respectively). Postoperative complications in EG patients were 24% in form of fever, pneumonia, leak, abdominal abscess, renal failure and incisional hernia (10%, 0%, 2%, 0%, 0% and 0%, respectively). CONCLUSION Combined endoscopic and interventional radiological drainage can effectively manage acute perforated peptic ulcer without the need for general anesthesia, with short operative time, in high risk surgical patients with low incidence of morbidity & mortality.
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Affiliation(s)
- Said Negm
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hatem Mohamed
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed Shafiq
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | | | - Adel Ismail
- Ismailia Teaching Oncology Hospital, Ismailia, Egypt
| | | | - Bassam Mousa
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | | | | | | | - Ahmed Farag
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
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7
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Wangrattanapranee P, Khrucharoen U, Jensen DM, Wongpongsalee T, Jensen ME. Severe Upper Gastrointestinal Hemorrhage Caused by Reflux Esophagitis. Dig Dis Sci 2022; 67:159-169. [PMID: 33590404 DOI: 10.1007/s10620-021-06828-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 01/06/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND There are few reports about reflux esophagitis (RE) as a cause of severe upper gastrointestinal bleeding (UGIB). AIMS This study aims to evaluate (1) changes in its prevalence over the last three decades and (2) clinical and endoscopic characteristics and 30-day outcomes among RE patients with and without focal esophageal ulcers (EUs) and stigmata of recent hemorrhage (SRH). METHODS A retrospective study of prospectively collected data of esophagitis patients hospitalized with severe UGIB between 1992 and 2020. Descriptive analysis and statistical comparisons were performed. RESULTS Of 114 RE patients, the mean age was 61.1 years and 76.3% were males. 38.6% had prior gastroesophageal reflux disease (GERD) symptoms; overall 36% were on acid suppressants. Over three consecutive decades, the prevalence of RE as a cause of severe UGIB increased significantly from 3.8 to 16.7%. 30-day rebleeding and all-cause mortality rates were 11.4% and 6.1%. RE patients with focal EUs and SRH (n = 23) had worse esophagitis than those with diffuse RE (n = 91) (p = 0.012). There were no differences in 30-day outcomes between RE patients with and without EUs and SRH. CONCLUSIONS For patients with severe UGIB caused by RE, (1) the prevalence has increased significantly over the past three decades, (2) the reasons for this increase and preventive strategies warrant further study, (3) most patients lacked GERD symptoms and did not take acid suppressants, and (4) those with focal ulcers and SRH had more severe esophagitis and were treated endoscopically.
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Affiliation(s)
- Peerapol Wangrattanapranee
- CURE: Digestive Diseases Research Core Center (CURE: DDRCC), Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Gastroenterology Division, Department of Medicine, VA Greater Los Angeles Healthcare System, Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA
| | - Usah Khrucharoen
- CURE: Digestive Diseases Research Core Center (CURE: DDRCC), Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Gastroenterology Division, Department of Medicine, VA Greater Los Angeles Healthcare System, Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - Dennis M Jensen
- CURE: Digestive Diseases Research Core Center (CURE: DDRCC), Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA. .,Gastroenterology Division, Department of Medicine, VA Greater Los Angeles Healthcare System, Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA. .,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA.
| | - Thongsak Wongpongsalee
- CURE: Digestive Diseases Research Core Center (CURE: DDRCC), Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA.,Division of Trauma Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, 13th Floor, Syamindra Building, 2 Prannok Road, Bangkok, 10700, Thailand
| | - Mary Ellen Jensen
- CURE: Digestive Diseases Research Core Center (CURE: DDRCC), Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Gastroenterology Division, Department of Medicine, VA Greater Los Angeles Healthcare System, Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
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8
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Abstract
B. Nulsen D. M. Jensen.
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9
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Jensen DM. Reply. Clin Gastroenterol Hepatol 2021; 19:2679-2680. [PMID: 33465481 DOI: 10.1016/j.cgh.2021.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Dennis M Jensen
- David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
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10
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DM J, TOG K, KA G, M K, J G. Randomized Controlled Trial of Over-the-Scope Clip as Initial Treatment of Severe Nonvariceal Upper Gastrointestinal Bleeding. Clin Gastroenterol Hepatol 2021; 19:2315-2323.e2. [PMID: 32828873 PMCID: PMC7895857 DOI: 10.1016/j.cgh.2020.08.046] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/13/2020] [Accepted: 08/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS No prior randomized controlled trial (RCT) has reported patient outcomes of large over-the-scope clip (OTSC) compared to standard hemostasis as initial endoscopic treatment of severe NVUGIB. This was our study aim. METHODS Patients with bleeding ulcers or Dieulafoy's lesions and major stigmata of hemorrhage - SRH (active spurting bleeding, visible vessel, or clot) - or lesser SRH (oozing bleeding or flat spots - with arterial blood flow by Doppler probe) were randomized to OTSC or standard endoscopic hemostasis (with hemoclips or multipolar electrocoagulation - MPEC). Patients and their healthcare providers were blinded to treatments and made all post-randomization management decisions. Ulcer patients received high dose intravenous infusions of proton pump inhibitors (PPI) for 3 days, then 27 days of oral PPI. 30 day outcomes were prospectively recorded; data management was with SAS; and data analysis was by a statistician. RESULTS 53 patients (25 OTSC, 28 Standard) were randomized, with similar baseline risk factors. However, there were significant differences in OTSC vs. Standard groups in rates of rebleeding (4% vs. 28.6%; p = .017; relative risk 0.10, 95% confidence intervals 0.01, 0.91; number needed to treat 4); severe complications (0 % vs. 14.3%); and post-randomization units of red cell transfusions (0.04 vs. 0.68). All rebleeds occurred in patients with major SRH and none with lesser SRH. CONCLUSION 1. OTSC significantly reduced rates of rebleeding, severe complications, and post-randomization red cell transfusions. 2. Patients with major stigmata benefited significantly from hemostasis with OTSC, but those with lesser stigmata did not. (ClinicalTrials.gov, Number: NCT03065465).
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Affiliation(s)
- Jensen DM
- CURE Digestive Diseases Research Core Center, Los Angeles, CA,David Geffen School of Medicine at UCLA and Ronald Reagan UCLA Medical Center, Los Angeles,,West Los Angeles Veterans Administration Medical Center, Los Angeles, CA
| | - Kovacs TOG
- CURE Digestive Diseases Research Core Center, Los Angeles, CA,David Geffen School of Medicine at UCLA and Ronald Reagan UCLA Medical Center, Los Angeles
| | - Ghassemi KA
- CURE Digestive Diseases Research Core Center, Los Angeles, CA,David Geffen School of Medicine at UCLA and Ronald Reagan UCLA Medical Center, Los Angeles
| | - Kaneshiro M
- CURE Digestive Diseases Research Core Center, Los Angeles, CA,David Geffen School of Medicine at UCLA and Ronald Reagan UCLA Medical Center, Los Angeles
| | - Gornbein J
- David Geffen School of Medicine at UCLA and Ronald Reagan UCLA Medical Center, Los Angeles,,Department of Medicine – GIM - DOMSTATS, UCLA, Los Angeles, CA, United States
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11
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Nulsen B, Jensen DM, Kovacs TOG, Ghassemi KA, Kaneshiro M, Dulai GS, Jutabha R, Gornbein JA. Outcomes in Severe Upper GI Hemorrhage from Dieulafoy's Lesion with Monitoring of Arterial Blood Flow. Dig Dis Sci 2021; 66:3495-3504. [PMID: 33128681 DOI: 10.1007/s10620-020-06679-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 10/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Dieulafoy's lesion (DL) is a rare but increasingly recognized cause of severe upper GI hemorrhage (SUGIH). There is little consensus regarding the endoscopic approach to management of bleeding from DL. AIMS Our purposes were to compare 30-day outcomes of patients with SUGIH from DL with Doppler endoscopic probe (DEP) monitoring of blood flow and guided treatment versus standard visually guided hemostasis (VG). METHODS Eighty-two consecutive DL patients with SUGIH were identified in a large CURE Hemostasis database from previous prospective cohort studies and two recent RCTs at two university-based medical centers. 30-day outcomes including rebleeding, surgery, angiography, death, and severe medical complications were compared between the two treatment groups. RESULTS 40.2% of DL bleeds occurred in inpatients. 43.9% of patients had cardiovascular disease, and 48.7% were taking medications associated with bleeding. For the entire cohort, 41.3% (26/63) of patients treated with VG had a composite 30-day outcome as compared to 10.5% (2/19) of patients treated with DEP (p = 0.017). Rebleeding occurred within 30 days in 33.3% and 10.5% of those treated with VG and DEP, respectively (p = 0.051). After propensity score matching, the adjusted 30-day composite outcome occurred in 39.0% in the VG group compared to 2.6% in the DEP group (p < 0.001). Adjusted 30-day rebleeding occurred in 25.3% in the VG group versus 2.6% in the DEP group (p < 0.001). DISCUSSION DL patients with SUGIH were frequently inpatients and had severe cardiovascular comorbidities and recurrent bleeding. Lesion arterial blood flow monitoring and obliteration are an effective way to treat bleeding from DL which reduces negative 30-day clinical outcomes.
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Affiliation(s)
- B Nulsen
- CURE Hemostasis Research Unit, Los Angeles, CA, USA. .,David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 10945 Le Conte Avenue, Suite 2114, Los Angeles, CA, 90095, USA. .,West Los Angeles Veterans Administration Medical Center, Los Angeles, CA, USA.
| | - D M Jensen
- CURE Hemostasis Research Unit, Los Angeles, CA, USA.,David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 10945 Le Conte Avenue, Suite 2114, Los Angeles, CA, 90095, USA.,West Los Angeles Veterans Administration Medical Center, Los Angeles, CA, USA
| | - T O G Kovacs
- CURE Hemostasis Research Unit, Los Angeles, CA, USA.,David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 10945 Le Conte Avenue, Suite 2114, Los Angeles, CA, 90095, USA
| | - K A Ghassemi
- CURE Hemostasis Research Unit, Los Angeles, CA, USA.,David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 10945 Le Conte Avenue, Suite 2114, Los Angeles, CA, 90095, USA
| | - M Kaneshiro
- CURE Hemostasis Research Unit, Los Angeles, CA, USA.,David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 10945 Le Conte Avenue, Suite 2114, Los Angeles, CA, 90095, USA.,West Los Angeles Veterans Administration Medical Center, Los Angeles, CA, USA
| | - G S Dulai
- CURE Hemostasis Research Unit, Los Angeles, CA, USA.,West Los Angeles Veterans Administration Medical Center, Los Angeles, CA, USA
| | - R Jutabha
- CURE Hemostasis Research Unit, Los Angeles, CA, USA.,David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 10945 Le Conte Avenue, Suite 2114, Los Angeles, CA, 90095, USA.,West Los Angeles Veterans Administration Medical Center, Los Angeles, CA, USA
| | - J A Gornbein
- CURE Hemostasis Research Unit, Los Angeles, CA, USA.,Department of Medicine - GIM - DOMSTATS, UCLA, Los Angeles, CA, USA
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12
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Buddam A, Rao S, Koppala J, Rangray R, Abdussalam A, Mukherjee S, Chandra S. Over-the-scope clip as first-line therapy for ulcers with high-risk bleeding stigmata is efficient compared to standard endoscopic therapy. Endosc Int Open 2021; 9:E1530-E1535. [PMID: 34540546 PMCID: PMC8445675 DOI: 10.1055/a-1526-0754] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/04/2021] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Ulcers with high-risk stigmata have significant rebleeding rates despite standard endoscopic therapy. Data on over-the-scope clip (OTSC) for recurrent bleeding is promising but data on first line therapy is lacking. We report comparative outcomes of OTSC as first-line therapy versus standard endoscopic therapy in ulcers with high-risk stigmata. Patients and methods Consecutive adults who underwent endoscopic therapy for ulcers with high-risk stigmata between July 2019 to September 2020 were included. Patients were grouped into OTSC or standard therapy based on first-line therapy used on index endoscopy. Outcomes measured included: 1) intra-procedural hemostasis based on endoscopic documentation of adequate hemostasis; 2) 7-day rebleeding (> 2 g/dL drop in hemoglobin, hematochezia or hemorrhagic shock); 3) cost of endoscopic interventions; and 4) procedure duration measured as endoscope insertion to removal time. Cost of tools used during the index endoscopy was included. Results Sixty-eight patients were included, 47 were in standard therapy and 21 in the OTSC group. Hemostasis was achieved in 95.2 % in the OTSC group compared to 83.0 % in the standard therapy group ( P = 0.256, number needed to treat [NNT]: 9). Procedure time was shorter in the OTSC group (23 vs. 16 minutes, P = 0.002). Cost of endoscopic interventions were comparable, P = 0.203. Early rebleeding was less often in OTSC group, two (9.5 %) compared to 10 (21.3 %) in standard therapy group, NNT 9. Conclusions Use of OTSCs as first-line treatment for ulcers bleed probably improves hemostasis and decreases early rebleeding. Use of OTSC as first-line therapy shortened procedure duration without increasing the cost of endoscopic interventions.
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Affiliation(s)
- Avanija Buddam
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, Nebraska, United States
| | - Sirish Rao
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, Nebraska, United States
| | - Jahnavi Koppala
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, Nebraska, United States
| | - Rajani Rangray
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, Nebraska, United States
| | - Abdullah Abdussalam
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, Nebraska, United States
| | - Sandeep Mukherjee
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, Nebraska, United States
| | - Subhash Chandra
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, Nebraska, United States
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13
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Jensen DM, Barkun A, Cave D, Gralnek IM, Jutabha R, Laine L, Lau JYW, Saltzman JR, Soetikno R, Sung JJ. Acute gastrointestinal bleeding: proposed study outcomes for new randomised controlled trials. Aliment Pharmacol Ther 2021; 54:616-626. [PMID: 34288017 PMCID: PMC9385213 DOI: 10.1111/apt.16483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/10/2021] [Accepted: 06/02/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute gastrointestinal bleeding (GIB) remains a common cause of hospitalisation. However, interpretation and comparisons of published studies in GIB have been hampered by disparate study methodology. AIMS To make recommendations about outcome measures to be used in future randomised controlled trials (RCTs) of patients with acute bleeding from any GI source (nonvariceal UGI, variceal, small bowel, or colon) and suggest new RCTs in acute GIB for future peer-reviewed funding. METHODS As part of a National Institutes of Health conference entitled "Hemostatic Outcomes in Clinical Trials", a group of GIB experts performed targeted critical reviews of available evidence with the goal of proposing a bleeding outcome that could potentially be applied to different disciplines. In addition, the panel sought to develop a clinically meaningful primary endpoint specifically for acute GIB, potentially allowing a more contemporary regrouping of clinically relevant outcomes. RESULTS The primary endpoint proposed was a composite outcome of further bleeding within 30 days after randomisation leading to red blood cell transfusion, urgent intervention (repeat endoscopy; interventional radiology or surgery), or death. Secondary outcomes may include the individual components of the primary outcome, length of hospitalisation, serious adverse events, and health care resource utilisation. CONCLUSION The proposed endpoint may help move the GIB field forward by focusing on the most clinically relevant outcomes for patients with acute GIB of all types and informing study design and importance of sample size determination for future RCTs in GIB.
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Affiliation(s)
- Dennis M. Jensen
- Division of Gastroenterology, Department of Medicine, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System Los Angeles, CA
| | - Alan Barkun
- Division of Gastroenterology, McGill University and the McGill University Health Centre Montréal, Québec, Canada
| | - David Cave
- UMass Memorial Medical Center, Worcester MA
| | - Ian M. Gralnek
- Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa Israel, Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology Emek Medical Center, Afula, Israel
| | - Rome Jutabha
- Division of Gastroenterology and Hepatology, Keck Hospital of University of Southern California, Los Angeles, CA
| | - Loren Laine
- Yale School of Medicine, New Haven CT; VA Connecticut Healthcare System, West Haven, CT
| | | | | | - Roy Soetikno
- University of California, San Francisco, Department of Medicine, San Francisco, CA
| | - Joseph J.Y. Sung
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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14
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Birda CL, Kumar A, Samanta J. Endotherapy for Nonvariceal Upper Gastrointestinal Hemorrhage. JOURNAL OF DIGESTIVE ENDOSCOPY 2021. [DOI: 10.1055/s-0041-1731962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AbstractNonvariceal upper gastrointestinal hemorrhage (NVUGIH) is a common GI emergency with significant morbidity and mortality. Triaging cases on the basis of patient-related factors, restrictive blood transfusion strategy, and hemodynamic stabilization are key initial steps for the management of patients with NVUGIH. Endoscopy remains a vital step for both diagnosis and definitive management. Multiple studies and guidelines have now defined the optimum timing for performing the endoscopy after hospitalization, to better the outcome. Conventional methods for achieving endoscopic hemostasis, such as injection therapy, contact, and noncontact thermal therapy, and mechanical therapy, such as through-the-scope clips, have reported to have 76 to 90% efficacy for primary hemostasis. Newer modalities to enhance hemostasis rates have come in vogue. Many of these modalities, such as cap-mounted clips, coagulation forceps, and hemostatic powders have proved to be efficacious in multiple studies. Thus, the newer modalities are recommended not only for management of persistent bleed and recurrent bleed after failed initial hemostasis, using conventional modalities but also now being advocated for primary hemostasis. Failure of endotherapy would warrant radiological or surgical intervention. Some newer tools to optimize endotherapy, such as endoscopic Doppler probes, for determining flow in visible or underlying vessels in ulcer bleed are now being evaluated. This review is focused on the technical aspects and efficacy of various endoscopic modalities, both conventional and new. A synopsis of the various studies describing and comparing the modalities have been outlined. Postendoscopic management including Helicobacter pylori therapy and starting of anticoagulants and antiplatelets have also been outlined.
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Affiliation(s)
- Chhagan L. Birda
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Antriksh Kumar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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15
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Cañamares-Orbís P, Lanas Arbeloa Á. New Trends and Advances in Non-Variceal Gastrointestinal Bleeding-Series II. J Clin Med 2021; 10:jcm10143045. [PMID: 34300211 PMCID: PMC8303152 DOI: 10.3390/jcm10143045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/03/2021] [Accepted: 07/05/2021] [Indexed: 12/12/2022] Open
Abstract
The gastrointestinal tract is a long tubular structure wherein any point in the mucosa along its entire length could be the source of a hemorrhage. Upper (esophagel and gastroduodenal) and lower (jejunum, ileum, and colon) gastrointestinal bleeding are common. Gastroduodenal and colonic bleeding are more frequent than bleeding from the small bowel, but nowadays the entire gastrointestinal tract can be explored endoscopically and bleeding lesions can be locally treated successfully to stop or prevent further bleeding. The extensive use of antiplatelet and anticoagulants drugs in cardiovascular patients is, at least in part, the cause of the increasing number of patients suffering from gastrointestinal bleeding. Patients with these conditions are usually older and more fragile because of their comorbidities. The correct management of antithrombotic drugs in cases of gastrointestinal bleeding is essential for a successful outcome for patients. The influence of the microbiome in the pathogenesis of small bowel bleeding is an example of the new data that are emerging as potential therapeutic target for bleeding prevention. This text summarizes the latest research and advances in all forms of acute gastrointestinal bleeding (i.e., upper, small bowel and lower). Diagnosis is approached, and medical, endoscopic or antithrombotic management are discussed in the text in an accessible and comprehensible way.
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Affiliation(s)
- Pablo Cañamares-Orbís
- Gastroenterology, Hepatology and Nutrition Unit, San Jorge University Hospital, 22004 Huesca, Spain
- Correspondence:
| | - Ángel Lanas Arbeloa
- IIS Aragón, CIBERehd, 50009 Zaragoza, Spain;
- Service of Digestive Diseases, University Clinic Hospital Lozano Blesa, 50009 Zaragoza, Spain
- University of Zaragoza, 500009 Zaragoza, Spain
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16
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Lan T, Tong H, Qian S, Wei B, Huang Z, Wu H, Tan Q, Gao J, Bai S, Gong H, Jiang T, Yang J, Zhang Q, Hu B, Tang C. Prophylactic transcatheter angiographic embolization reduces Forrest IIa ulcer rebleeding: A retrospective study. Medicine (Baltimore) 2021; 100:e23855. [PMID: 33725926 PMCID: PMC7982249 DOI: 10.1097/md.0000000000023855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/31/2020] [Indexed: 02/07/2023] Open
Abstract
The application of transcatheter angiographic embolization (TAE) is controversial in the treatment of ulcer bleeding. This study aims to determine rebleeding risk factors and evaluate the efficacy of prophylactic TAE (p-TAE) following endoscopic hemostasis in rebleeding prevention of Forrest lla ulcers.The medical records of Forrest lla ulcer patients who underwent endoscopic hemostasis (E group) and endoscopic hemostasis plus p-TAE (E + p-TAE group) in West China Hospital from May 2009 to May 2018 were retrospectively reviewed. Baseline characteristics, clinical efficacy, and rebleeding risk factors were analyzed.As a result, a total of 102 patients were included, with 75 and 27 patients in E and E + p-TAE group, respectively. Most of the baseline data in E and E + p-TAE group were similar except for the proportion of protruded non-bleeding visible vessel (NBVV) (E group vs E + p-TAE group, 50.7% vs 74.1%, P = .035). The rebleeding rate of E + p-TAE group (3.7%) was significantly lower than E group (24.0%) (P = .02). The protruded NBVV (OR: 6.896, 95% confidence interval [CI]: 1.532-30.642, P = .01) and employment of p-TAE (OR: 0.038, 95% CI: 0.003-0.448, P = .009) were identified as independent risk factors for Forrest IIa ulcer rebleeding. Additionally, log-rank test indicated the rebleeding occurrence was greatly reduced by p-TAE in patients with protruded NBVVs (P = .006).In conclusion, the protruded NBVV and employment of p-TAE were the independent risk factors tightly associated with rebleeding of Forrest IIa ulcer. P-TAE following endoscopic hemostasis could effectively prevent Forrest IIa ulcer from rebleeding.
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Affiliation(s)
- Tian Lan
- Department of Gastroenterology
- Lab. of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital
| | | | - Shuaijie Qian
- West China School of Medicine, Sichuan University, Chengdu
| | - Bo Wei
- Department of Gastroenterology
| | | | - Hao Wu
- Department of Gastroenterology
| | | | - Jinhang Gao
- Lab. of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital
| | | | | | - Ting Jiang
- Department of Gastroenterology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jinhui Yang
- Department of Gastroenterology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | | | - Bing Hu
- Department of Gastroenterology
| | - Chengwei Tang
- Department of Gastroenterology
- Lab. of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital
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17
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Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, Laursen SB, Radaelli F, Papanikolaou IS, Cúrdia Gonçalves T, Dinis-Ribeiro M, Awadie H, Braun G, de Groot N, Udd M, Sanchez-Yague A, Neeman Z, van Hooft JE. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021; 53:300-332. [PMID: 33567467 DOI: 10.1055/a-1369-5274] [Citation(s) in RCA: 172] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
1: ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3-5 days.Strong recommendation, moderate quality evidence. 3: ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4: ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5: ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6: ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 : ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8: ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9: ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (A): PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (B): High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10: ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.
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Affiliation(s)
- Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - A John Morris
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Marine Camus
- Sorbonne University, Endoscopic Unit, Saint Antoine Hospital Assistance Publique Hopitaux de Paris, Paris, France
| | - James Lau
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Angel Lanas
- Digestive Disease Services, University Clinic Hospital, University of Zaragoza, IIS Aragón (CIBERehd), Spain
| | - Stig B Laursen
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Franco Radaelli
- Department of Gastroenterology, Valduce Hospital, Como, Italy
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Tiago Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- School of Medicine, University of Minho, Braga/Guimarães, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Mario Dinis-Ribeiro
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Portugal
| | - Halim Awadie
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Georg Braun
- Medizinische Klinik 3, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Marianne Udd
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Andres Sanchez-Yague
- Gastroenterology Unit, Hospital Costa del Sol, Marbella, Spain
- Gastroenterology Department, Vithas Xanit International Hospital, Benalmadena, Spain
| | - Ziv Neeman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Diagnostic Imaging and Nuclear Medicine Institute, Emek Medical Center, Afula, Israel
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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18
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Shiratori Y, Ikeya T, Oguri N, Takasu A, Okamoto T, Fukuda K. Endoscopic Doppler probe ultrasonography for detecting blood flow at post-endoscopic submucosal dissection ulcers of the stomach. Endosc Int Open 2020; 8:E1086-E1090. [PMID: 32743062 PMCID: PMC7373657 DOI: 10.1055/a-1197-6177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/18/2020] [Indexed: 12/21/2022] Open
Abstract
Background and study aims The rate of early rebleeding after endoscopic submucosal dissection (ESD) for early gastric cancer ranges from 5 % to 38 %, despite application of preventive methods. Post-ESD rebleeding may be caused by "invisible" vessels that may not be detectable using ultrasonographic techniques. Recently, Doppler probe ultrasonography (DOP) has been used in endoscopy. Because little is known about the usefulness of DOP for decreasing the post-ESD rebleeding rate, we performed a preliminary case series study. Patients and methods Twelve patients underwent DOP for post-ESD ulcer evaluation after visible vessel coagulation. In this study, the novel DOP system used in the vascular surgery department was used. DOP-positive invisible vessels were shown as a pulse wave on the monitor. Results No (0 %) cases of post-ESD rebleeding occurred. Twenty invisible vessels were detected, and 13 were subjected to additional coagulation up to a depth of 3 mm. Mean DOP procedure time was 11.6 minutes (range: 8-18 minutes). In these latter cases, disappearance of the Doppler pulse wave was confirmed. No early rebleeding or other adverse events were experienced. Conclusion DOP is a safe and feasible method for detecting invisible vessels in post-ESD ulcers. Further investigation of the clinical relevance is warranted.
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Affiliation(s)
- Yasutoshi Shiratori
- Division of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
| | - Takashi Ikeya
- Division of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
| | - Noriaki Oguri
- Division of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
| | - Ayaka Takasu
- Division of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
| | - Takeshi Okamoto
- Division of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
| | - Katsuyuki Fukuda
- Division of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
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19
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Burgos-Santamaría D, Rodríguez de Santiago E. Response. Gastrointest Endosc 2020; 91:956-957. [PMID: 32204819 DOI: 10.1016/j.gie.2019.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/26/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Diego Burgos-Santamaría
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
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- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
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20
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Vellanki M, Gapp J, Chandra S. Hemostatic spray powder TC-325 for endoscopic hemostasis, bridge, or definitive intervention. Gastrointest Endosc 2020; 91:956. [PMID: 32204820 DOI: 10.1016/j.gie.2019.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 11/19/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Meghana Vellanki
- Division of Gastroenterology, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Jonathan Gapp
- Division of Gastroenterology, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Subhash Chandra
- Division of Gastroenterology, Creighton University School of Medicine, Omaha, Nebraska, USA
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21
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Tarasconi A, Coccolini F, Biffl WL, Tomasoni M, Ansaloni L, Picetti E, Molfino S, Shelat V, Cimbanassi S, Weber DG, Abu-Zidan FM, Campanile FC, Di Saverio S, Baiocchi GL, Casella C, Kelly MD, Kirkpatrick AW, Leppaniemi A, Moore EE, Peitzman A, Fraga GP, Ceresoli M, Maier RV, Wani I, Pattonieri V, Perrone G, Velmahos G, Sugrue M, Sartelli M, Kluger Y, Catena F. Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg Surg 2020; 15:3. [PMID: 31921329 PMCID: PMC6947898 DOI: 10.1186/s13017-019-0283-9] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 12/18/2019] [Indexed: 02/08/2023] Open
Abstract
Background Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment. Methods The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached. Conclusions The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
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Affiliation(s)
- Antonio Tarasconi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | | | - Matteo Tomasoni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Sarah Molfino
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Dieter G. Weber
- Royal Perth Hospital, Perth, Australia & The University of Western Australia, Crawley, Australia
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Fabio C. Campanile
- Division of Surgery, ASL VT - Ospedale “Andosilla”, Civita Castellana, Italy
| | - Salomone Di Saverio
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Claudio Casella
- Department of Molecular and Translational Medicine, Surgical Clinic, University of Brescia, Brescia, Italy
| | - Michael D. Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Andrew W. Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta Canada
| | | | - Ernest E. Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO USA
| | - Andrew Peitzman
- University of Pittsburgh, School of Medicine, UPMC – Presbyterian, Pittsburgh, PA USA
| | - Gustavo Pereira Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | - Marco Ceresoli
- Department of General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Ronald V. Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Imtaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | | | - Gennaro Perrone
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - George Velmahos
- Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, USA
| | - Michael Sugrue
- Letterkenny University Hospital, Donegal Clinical Research Academy Centre for Personalized Medicine, Donegal, Ireland
| | | | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fausto Catena
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
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22
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Yang E, Chang MA, Savides TJ. New Techniques to Control Gastrointestinal Bleeding. Gastroenterol Hepatol (N Y) 2019; 15:471-479. [PMID: 31787854 PMCID: PMC6875875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
For decades, the mainstay of endoscopic hemostasis for a wide variety of gastrointestinal bleeding etiologies was limited to a few tools and techniques, including epinephrine injection, thermal probes, and through-the-scope hemostatic clips. Several novel approaches have recently emerged to control acute gastrointestinal hemorrhage. The concepts behind these approaches are diverse, ranging from upgrading current techniques (eg, over-the-scope clips and endoscopic ultrasound-guided treatment of gastric varices) to developing new technologies (eg, hemostatic powders) and repurposing current tools (eg, Doppler endoscopic probe). This article presents an evidence-based review of the major advancements in endoscopic hemostasis techniques.
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Affiliation(s)
- Edward Yang
- Dr Yang is a gastroenterology fellow, Dr Chang is an assistant professor of medicine
- Dr Savides is a professor of clinical medicine in the Division of Gastroenterology in the Department of Medicine at the University of California San Diego in La Jolla, California
| | - Michael A Chang
- Dr Yang is a gastroenterology fellow, Dr Chang is an assistant professor of medicine
- Dr Savides is a professor of clinical medicine in the Division of Gastroenterology in the Department of Medicine at the University of California San Diego in La Jolla, California
| | - Thomas J Savides
- Dr Yang is a gastroenterology fellow, Dr Chang is an assistant professor of medicine
- Dr Savides is a professor of clinical medicine in the Division of Gastroenterology in the Department of Medicine at the University of California San Diego in La Jolla, California
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Friedel D. Potential role of new technological innovations in nonvariceal hemorrhage. World J Gastrointest Endosc 2019; 11:443-453. [PMID: 31523376 PMCID: PMC6715570 DOI: 10.4253/wjge.v11.i8.443] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 06/16/2019] [Accepted: 07/20/2019] [Indexed: 02/06/2023] Open
Abstract
The present armamentarium of endoscopic hemostatic therapy for non-variceal upper gastrointestinal hemorrhage includes injection, electrocautery and clips. There are newer endoscopic options such as hemostatic sprays, endoscopic suturing and modifications of current options including coagulation forceps and over-the-scope clips. Peptic hemorrhage is the most prevalent type of nonvariceal upper gastrointestinal hemorrhage and traditional endoscopic interventions have demonstrated significant hemostasis success. However, the hemostatic success rate is less for other entities such as Dieulafoy’s lesions and bleeding from malignant lesions. Novel innovations such as endoscopic submucosal dissection and peroral endoscopic myotomy has spawned a need for dependable hemostasis. Gastric antral vascular ectasias are associated with chronic gastrointestinal bleeding and usually treated by standard argon plasma coagulation (APC), but newer modalities such as radiofrequency ablation, banding, cryotherapy and hybrid APC have been utilized as well. We will opine on whether the newer hemostatic modalities have generated success when traditional modalities fail and should any of these modalities be routinely available in the endoscopic toolbox.
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Affiliation(s)
- David Friedel
- Department of Gastroenterology, New York University Winthrop Hospital, Mineola, NY 11501, United States
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24
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Ali H, Sharif M, Yasmin M, Rehmani MH, Riaz F. A survey of feature extraction and fusion of deep learning for detection of abnormalities in video endoscopy of gastrointestinal-tract. Artif Intell Rev 2019. [DOI: 10.1007/s10462-019-09743-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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25
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Parsi MA, Schulman AR, Aslanian HR, Bhutani MS, Krishnan K, Lichtenstein DR, Melson J, Navaneethan U, Pannala R, Sethi A, Trikudanathan G, Trindade AJ, Watson RR, Maple JT. Devices for endoscopic hemostasis of nonvariceal GI bleeding (with videos). VideoGIE 2019; 4:285-299. [PMID: 31334417 PMCID: PMC6616320 DOI: 10.1016/j.vgie.2019.02.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Endoscopic intervention is often the first line of therapy for GI nonvariceal bleeding. Although some of the devices and techniques used for this purpose have been well studied, others are relatively new, with few available outcomes data. Methods In this document, we review devices and techniques for endoscopic treatment of nonvariceal GI bleeding, the evidence regarding their efficacy and safety, and financial considerations for their use. Results Devices used for endoscopic hemostasis in the GI tract can be classified into injection devices (needles), thermal devices (multipolar/bipolar probes, hemostatic forceps, heater probe, argon plasma coagulation, radiofrequency ablation, and cryotherapy), mechanical devices (clips, suturing devices, banding devices, stents), and topical devices (hemostatic sprays). Conclusions Endoscopic evaluation and treatment remains a cornerstone in the management of nonvariceal upper- and lower-GI bleeding. A variety of devices is available for hemostasis of bleeding lesions in the GI tract. Other than injection therapy, which should not be used as monotherapy, there are few compelling data that strongly favor any one device over another. For endoscopists, the choice of a hemostatic device should depend on the type and location of the bleeding lesion, the availability of equipment and expertise, and the cost of the device.
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Key Words
- ABS, Ankaferd blood stopper
- APC, argon plasma coagulation
- ASGE, American Society for Gastrointestinal Endoscopy
- CPT, Current Procedural Terminology
- CSEMS, covered self-expandable metallic stent
- EBL, endoscopic band ligation
- EDP, endoscopic Doppler probe
- GAVE, gastric antral vascular ectasia
- HP, heater probe
- LGIB, lower GI bleeding
- MPEC, multipolar electrocoagulation
- OTSC, over-the-scope clip
- PTFE, polytetrafluoroethylene
- RCT, randomized controlled trial
- TTS, through-the-scope
- U.S. FDA, United States Food and Drug Administration
- UGIB, upper GI bleeding
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Affiliation(s)
| | - Mansour A Parsi
- Section for Gastroenterology & Hepatology, Tulane University Health Sciences Center, New Orleans, LA
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Harry R Aslanian
- Section of Digestive Diseases, Department of Internal Medicine, Yale University, New Haven, CT
| | - Manoop S Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Kuman Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, IL
| | | | - Rahul Pannala
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, New York-Presbyterian/Columbia University Medical Center, New York, NY
| | | | - Arvind J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, NY
| | - Rabindra R Watson
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, CA
| | - John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Gölder S, Neuhas L, Freuer D, Probst A, Ebigbo A, Braun G, Brueckner J, Stueckle J, Meier A, Messmann H. Over-the-scope clip in peptic ulcer bleeding: clinical success in primary and secondary treatment and factors associated with treatment failure. Endosc Int Open 2019; 7:E846-E854. [PMID: 31206010 PMCID: PMC6565427 DOI: 10.1055/a-0898-3357] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 03/25/2019] [Indexed: 02/07/2023] Open
Abstract
Background and study aims It is unclear if the clinical success rate of the over-the-scope-clip (OTSC) in peptic ulcer bleeding (PUB) is comparable when it is used in the first- or in the second-line of treatment. Patients and methods Data on endoscopic treatment (first- vs. second-line) in PUB with OTSC and clinical data were analyzed. The primary outcome was the clinical success of hemostasis, defined as the absence of recurrent bleeding or further intervention. Secondary outcomes were factors associated with OTSC failure. Results From April 2014 to March 2018, 100 patients (age 72 [20 - 98] y, female 36 %) with PUB in the stomach or the duodenum were treated endoscopically with the OTSC. The OTSC was used as a first-line procedure (primary-OTSC) in 66 pts. Successful hemostasis could be achieved in 90.9 %. After failure of an initial endoscopic treatment, 34 patients were treated with the OTSC (secondary-OTSC) and the treatment was successful in 94.1 %. Recurrent bleeding occurred in n = 10 for primary-OTSC (16.7 %) and in n = 7 pts in the secondary-OTSC (21.9 %) ( P = 0.81). Clinical success in the primary-OTSC was 75.8 % and 73.5 % in the secondary-OTSC respectively. Conclusions The OTSC has a high rate of initial bleeding control in first- and second line treatment of PUB. OTSC failure occurs more often in the duodenum than in the stomach and results in longer intensive care unit stay, higher amount of transfusions, and a higher reimbursement per case.
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Affiliation(s)
- Stefan Gölder
- University Hospital Augsburg, Department of Internal Medicine III, Augsburg, Germany,Corresponding author Dr. Stefan Karl Gölder University Hospital Augsburg – Department of Internal Medicine IIIStenglinstraße 2Augsburg 86156Germany+498214003331
| | - Lukas Neuhas
- Klinikum Dritter Orden, Department of Internal Medicine I, Munich, Germany
| | - Denis Freuer
- Chair of Epidemiology of the LMU Munich at UNIKA-T, Augsburg, Germany
| | - Andreas Probst
- University Hospital Augsburg, Department of Internal Medicine III, Augsburg, Germany
| | - Alanna Ebigbo
- University Hospital Augsburg, Department of Internal Medicine III, Augsburg, Germany
| | - Georg Braun
- University Hospital Augsburg, Department of Internal Medicine III, Augsburg, Germany
| | - Juliane Brueckner
- Klinikum Dritter Orden, Department of Internal Medicine I, Munich, Germany
| | - Johannes Stueckle
- Klinikum Dritter Orden, Department of Internal Medicine I, Munich, Germany
| | - Alexander Meier
- Klinikum Dritter Orden, Department of Internal Medicine I, Munich, Germany
| | - Helmut Messmann
- University Hospital Augsburg, Department of Internal Medicine III, Augsburg, Germany
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27
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Kantowski M, Schoepfer AM, Settmacher U, Stallmach A, Schmidt C. Assessment of endoscopic Doppler to guide hemostasis in high risk peptic ulcer bleeding. Scand J Gastroenterol 2019; 53:1311-1318. [PMID: 30394134 DOI: 10.1080/00365521.2018.1509121] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Rebleeding or emergency surgery in failed endoscopic therapy of peptic ulcer bleeding are associated with high rates of morbidity and mortality. The clinical benefit of an endoscopic Doppler (ED) examination prior to endoscopic injection therapy was evaluated in high risk ulcer patients for rebleeding episode. Standard injection therapy (non-Doppler (ND)) was compared with targeted injection therapy after examination of the supplying vessel in the ulcer base by the ED. MATERIALS AND METHODS Sixty patients with peptic ulcer bleeding (Forrest Ia-IIa; Rockall score of 5 or higher) were included in the study. Patients were assigned to ED or ND group with conventional therapy by chance. In the ND group injection was directed by the visual aspect of the ulcer, whereas in ED therapy was directed by ED. RESULTS Thirty-five patients were allocated to the ED group, and 25 to the ND group, respectively. No significant differences in patient or ulcer characteristics were observed regarding ulcer size, localization, Forrest classification or endoscopic treatment. Recurrent bleeding was observed in 7/35 (20%) in the ED group and in 13/25 (52%) of patients in the ND group (p = .013). Fewer ED patients needed surgery for rebleeding (1/35 vs. 6/25; p = .017). Bleeding related, but not all-cause mortality was significantly lower in the ED group (1/35 vs. 6/25, p = .017). DISCUSSION In this comparative analysis, use of ED to guide hemostatic therapy was associated with a significant reduction in recurrence of bleeding, surgical intervention and bleeding associated mortality.
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Affiliation(s)
- Marcus Kantowski
- a Clinic for Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases) , Jena University Hospital , Jena , Germany.,b Department of Interdisciplinary Endoscopy , University Hospital Hamburg-Eppendorf , Hamburg , Germany
| | - Alain M Schoepfer
- c Division of Gastroenterology and Hepatology , Centre Hospitalier Universitaire Vaudois/CHUV , Lausanne , Switzerland
| | - Utz Settmacher
- d Clinic for General, Visceral und Vascular Surgery , Jena University Hospital , Jena , Germany
| | - Andreas Stallmach
- a Clinic for Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases) , Jena University Hospital , Jena , Germany
| | - Carsten Schmidt
- a Clinic for Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases) , Jena University Hospital , Jena , Germany.,e Department of Gastoenterology, Hepatology, Endocrinology, Diabetology and Infectiology , Clinic Fulda , Fulda , Germany
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28
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Gweon TG, Kim J. Comprehensive review of outcomes of endoscopic treatment of gastrointestinal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Tae-Geun Gweon
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Jinsu Kim
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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29
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Sung JJY, Chiu PCY, Chan FKL, Lau JYW, Goh KL, Ho LHY, Jung HY, Sollano JD, Gotoda T, Reddy N, Singh R, Sugano K, Wu KC, Wu CY, Bjorkman DJ, Jensen DM, Kuipers EJ, Lanas A. Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018. Gut 2018; 67:1757-1768. [PMID: 29691276 PMCID: PMC6145289 DOI: 10.1136/gutjnl-2018-316276] [Citation(s) in RCA: 158] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 12/14/2022]
Abstract
Non-variceal upper gastrointestinal bleeding remains an important emergency condition, leading to significant morbidity and mortality. As endoscopic therapy is the 'gold standard' of management, treatment of these patients can be considered in three stages: pre-endoscopic treatment, endoscopic haemostasis and post-endoscopic management. Since publication of the Asia-Pacific consensus on non-variceal upper gastrointestinal bleeding (NVUGIB) 7 years ago, there have been significant advancements in the clinical management of patients in all three stages. These include pre-endoscopy risk stratification scores, blood and platelet transfusion, use of proton pump inhibitors; during endoscopy new haemostasis techniques (haemostatic powder spray and over-the-scope clips); and post-endoscopy management by second-look endoscopy and medication strategies. Emerging techniques, including capsule endoscopy and Doppler endoscopic probe in assessing adequacy of endoscopic therapy, and the pre-emptive use of angiographic embolisation, are attracting new attention. An emerging problem is the increasing use of dual antiplatelet agents and direct oral anticoagulants in patients with cardiac and cerebrovascular diseases. Guidelines on the discontinuation and then resumption of these agents in patients presenting with NVUGIB are very much needed. The Asia-Pacific Working Group examined recent evidence and recommends practical management guidelines in this updated consensus statement.
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Affiliation(s)
- Joseph JY Sung
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Philip CY Chiu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Francis K L Chan
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - James YW Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Khean-lee Goh
- Department of Gastroenterology and Hepatology, University of Malaya, Kuala Lumpur, Malaysia
| | - Lawrence HY Ho
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Jose D Sollano
- UST Hospital, University of Santo Tomas, Manila, Philippines
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Nihon University School of Medicine, Tokyo, Japan
| | - Nageshwar Reddy
- Asian Institute of Gastroenterology, Asian Healthcare Foundation, Hyderabad, India
| | - Rajvinder Singh
- Department of Medicine, Lyell McEwin Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Kentaro Sugano
- Department of Medicine, Jichi Medical School, Shimotsuke, Japan
| | - Kai-chun Wu
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, Xi’an, China
| | | | | | | | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Angel Lanas
- Department of Gastroenterology, University Hospital, Zaragoza, Spain
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30
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Abstract
Peptic ulcer bleeding remains an important medical emergency. Important recent advances are reviewed. These include further support for a more restrictive transfusion strategy aiming for a target haemoglobin of 70-90 g/L. The Glasgow-Blatchford score remains the most useful assessment score for identifying the lowest risk patients suitable for outpatient management and predicting the need for intervention. Newer scores such as the AIMS65 and Progetto Nazionale Emorragia Digestive score (PNED) may be more accurate in predicting mortality. Pre-endoscopy erythromycin improves outcomes and is underused. A new disposable Doppler probe appears to provide more accurate determination of both rebleeding risk and the success of endoscopic therapy than purely visual guidance. Over-the-scope clips and haemostatic powders appear to have some role as endoscopic salvage therapies. Non- H. pylori, non-aspirin/non-steroidal anti-inflammatory drug (NSAID) ulcers contribute to an increasing percentage of bleeding peptic ulcers and are associated with a high rebleeding rate. The optimal management of these ulcers remains to be determined.
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Affiliation(s)
- Ian LP Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
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31
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Ghassemi KA, Jensen DM. The Cutting Edge: Doppler Probe in Guiding Endoscopic Hemostasis. Gastrointest Endosc Clin N Am 2018; 28:321-330. [PMID: 29933778 DOI: 10.1016/j.giec.2018.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This article examines use of the Doppler endoscopic probe (DEP) for risk stratification and as a guide to definitive hemostasis of nonvariceal upper gastrointestinal (NVUGI) bleeding and colonic diverticular hemorrhage. Studies report that lesions with high-risk stigmata of recent hemorrhage (SRH) have a higher rate of a positive DEP signal compared with those without such SRH. Lesions with a persistently positive DEP signal after endoscopic hemostasis have a higher 30-day rebleeding rate. Studies document arterial blood flow underneath stigmata of recent hemorrhage as a risk factor for rebleeding of focal nonvariceal gastrointestinal lesions. With DEP probe as a guide, rates of definitive endoscopic hemostasis and clinical outcomes are improved compared with standard visually guided treatment.
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Affiliation(s)
- Kevin A Ghassemi
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 100 Medical Plaza Driveway, Los Angeles, CA 90095, USA; CURE: Digestive Diseases Research Center, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA.
| | - Dennis M Jensen
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 100 Medical Plaza Driveway, Los Angeles, CA 90095, USA; CURE: Digestive Diseases Research Center, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA; Department of Medicine, VA West Los Angeles Medical Center, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA
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32
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Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is bleeding that develops in the oesophagus, stomach or proximal duodenum. Peptic ulcers, caused by Helicobacter pylori infection or use of NSAIDs and low-dose aspirin (LDA), are the most common cause. Although the incidence and mortality associated with NVUGIB have been decreasing owing to considerable advances in the prevention and management of NVUGIB over the past 20 years, it remains a common clinical problem with an annual incidence of ∼67 per 100,000 individuals in the United States in 2012. NVUGIB is a medical emergency, and mortality is in the range ∼1-5%. After resuscitation and initial assessment, early (within 24 hours) diagnostic and therapeutic endoscopy together with intragastric pH control with proton pump inhibitors (PPIs) form the basis of treatment. With a growing ageing population treated with antiplatelet and/or anticoagulant medications, the clinical management of NVUGIB is complex as the risk between gastrointestinal bleeding events and adverse cardiovascular events needs to be balanced. The best clinical approach includes identification of risk factors and prevention of bleeding; available strategies include continuous treatment with PPIs or H. pylori eradication in those at increased risk of developing NVUGIB. Treatment with PPIs and/or use of cyclooxygenase-2-selective NSAIDs should be implemented in those patients at risk of NVUGIB who need NSAIDs and/or LDA.
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33
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Abstract
Acute upper gastrointestinal haemorrhage due to peptic ulcer bleeding remains an important cause of emergency presentation and hospital admission. Despite advances in many aspects of management, peptic ulcer bleeding is still associated with significant morbidity, mortality, and healthcare costs. Comprehensive international guidelines have been published, but advances as well as controversies continue to evolve. Important recent advances include the evidence supporting a more restrictive transfusion strategy aiming for a target haemoglobin of 70–90 g/l. Comparative studies have confirmed that the Glasgow–Blatchford score remains the most useful score for predicting the need for intervention as well as for identifying the lowest-risk patients suitable for outpatient management. New scores, including the AIMS65 and Progetto Nazionale Emorragia Digestiva score, may be more accurate in predicting mortality. Pre-endoscopy erythromycin appears to improve outcomes and is probably underused. High-dose oral proton pump inhibition (PPI) for 11 days after PPI infusion is advantageous in those with a Rockall score of 6 or more. Oral is as effective as parenteral iron at restoring haemoglobin levels after a peptic ulcer bleed and both are superior to placebo in this respect. Within endoscopic techniques, haemostatic powders and over-the-scope clips can be used when other methods have failed. A disposable Doppler probe appears to provide more accurate determination of both rebleeding risk and the success of endoscopic therapy than purely visual guidance. Non-
Helicobacter pylori, non-aspirin/non-steroidal anti-inflammatory drug ulcers contribute an increasing percentage of bleeding peptic ulcers and are associated with a poor prognosis and high rebleeding rate. The optimal management of these ulcers remains to be determined.
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Affiliation(s)
- Ian Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
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34
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Jensen DM. Reply. Gastroenterology 2017; 153:868-869. [PMID: 28781222 DOI: 10.1053/j.gastro.2017.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Dennis M Jensen
- David Geffen School of Medicine at UCLA, Los Angeles, California
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35
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Abstract
In this narrative review, invited by the Editors of Gastroenterology, we summarize recent advances in the field of gastrointestinal endoscopy. We have chosen articles published primarily in the past 2-3 years. Although a thorough literature review was performed for each topic, the nature of the article is subjective and systematic and is based on the authors' experience and expertise regarding articles we believed were most likely to be of high clinical and scientific importance.
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Affiliation(s)
| | | | | | - Amit Rastogi
- University of Kansas Medical Cancer, Kansas City, Kansas
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36
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Jensen DM, Kovacs TOG, Ohning GV, Ghassemi K, Machicado GA, Dulai GS, Sedarat A, Jutabha R, Gornbein J. Doppler Endoscopic Probe Monitoring of Blood Flow Improves Risk Stratification and Outcomes of Patients With Severe Nonvariceal Upper Gastrointestinal Hemorrhage. Gastroenterology 2017; 152:1310-1318.e1. [PMID: 28167214 PMCID: PMC5613762 DOI: 10.1053/j.gastro.2017.01.042] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 01/22/2017] [Accepted: 01/26/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS For 4 decades, stigmata of recent hemorrhage in patients with nonvariceal lesions have been used for risk stratification and endoscopic hemostasis. The arterial blood flow that underlies the stigmata rarely is monitored, but can be used to determine risk for rebleeding. We performed a randomized controlled trial to determine whether Doppler endoscopic probe monitoring of blood flow improves risk stratification and outcomes in patients with severe nonvariceal upper gastrointestinal hemorrhage. METHODS In a single-blind study performed at 2 referral centers we assigned 148 patients with severe nonvariceal upper gastrointestinal bleeding (125 with ulcers, 19 with Dieulafoy's lesions, and 4 with Mallory Weiss tears) to groups that underwent standard, visually guided endoscopic hemostasis (control, n = 76), or endoscopic hemostasis assisted by Doppler monitoring of blood flow under the stigmata (n = 72). The primary outcome was the rate of rebleeding after 30 days; secondary outcomes were complications, death, and need for transfusions, surgery, or angiography. RESULTS There was a significant difference in the rates of lesion rebleeding within 30 days of endoscopic hemostasis in the control group (26.3%) vs the Doppler group (11.1%) (P = .0214). The odds ratio for rebleeding with Doppler monitoring was 0.35 (95% confidence interval, 0.143-0.8565) and the number needed to treat was 7. CONCLUSIONS In a randomized controlled trial of patients with severe upper gastrointestinal hemorrhage from ulcers or other lesions, Doppler probe guided endoscopic hemostasis significantly reduced 30-day rates of rebleeding compared with standard, visually guided hemostasis. Guidelines for nonvariceal gastrointestinal bleeding should incorporate these results. ClinicalTrials.gov no: NCT00732212 (CLIN-013-07F).
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Affiliation(s)
- Dennis M. Jensen
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA,David Geffen School of Medicine at UCLA, Los Angeles, CA,Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Thomas OG Kovacs
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA,David Geffen School of Medicine at UCLA, Los Angeles, CA,Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Gordon V. Ohning
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA,David Geffen School of Medicine at UCLA, Los Angeles, CA,Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Kevin Ghassemi
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA,David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Gustavo A. Machicado
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA,David Geffen School of Medicine at UCLA, Los Angeles, CA,Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Gareth S. Dulai
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA,David Geffen School of Medicine at UCLA, Los Angeles, CA,Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Alireza Sedarat
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA,David Geffen School of Medicine at UCLA, Los Angeles, CA,Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Rome Jutabha
- CURE Digestive Diseases Research Center (DDRC) - GI Hemostasis Unit, Los Angeles, CA,David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Jeffrey Gornbein
- Department of Biomathematics at the David Geffen School of Medicine at UCLA
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Nayor J, Saltzman JR. Should We All Be Using the Doppler Endoscopic Probe in Nonvariceal Upper Gastrointestinal Bleeding? Gastroenterology 2017; 152:1280-1282. [PMID: 28351653 DOI: 10.1053/j.gastro.2017.03.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Jennifer Nayor
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts.
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What Does Lesion Blood Flow Tell Us About Risk Stratification and Successful Management of Non-variceal UGI Bleeding? Curr Gastroenterol Rep 2017; 19:17. [PMID: 28374310 DOI: 10.1007/s11894-017-0556-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW There has been a decline in mortality associated with upper gastrointestinal (UGI) hemorrhage as the use of urgent endoscopy has increased. This review will examine endoscopic risk stratification of non-variceal UGI bleeding (e.g., ulcers, Dieulafoy lesions, and Mallory-Weiss tears), including the use of the Doppler endoscopic probe (DEP). RECENT FINDINGS Prospective studies evaluating the use of DEP in non-variceal UGI hemorrhage showed that lesions with high-risk stigmata of recent hemorrhage (SRH) have a higher rate of a positive DEP signal compared to those with intermediate-risk SRH. Additionally, lesions with a persistently positive DEP signal after endoscopic hemostasis were seen with high-risk SRH and had a higher 30-day rebleeding rate. Residual arterial blood flow underneath ulcers is a significant risk factor for rebleeding. However, if more endoscopic treatment is applied, clinical outcomes for patients with severe non-variceal UGI hemorrhage are improved, as documented by a recent CURE Hemostasis randomized controlled trial (RCT).
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Reassessment of Rebleeding Risk of Forrest IB (Oozing) Peptic Ulcer Bleeding in a Large International Randomized Trial. Am J Gastroenterol 2017; 112:441-446. [PMID: 28094314 PMCID: PMC5612665 DOI: 10.1038/ajg.2016.582] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 10/01/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Our aims were to assess risks of early rebleeding after successful endoscopic hemostasis for Forrest oozing (FIB) peptic ulcer bleeding (PUBs) compared with other stigmata of recent hemorrhage (SRH). METHODS These were post hoc multivariable analyses of a large, international, double-blind study (NCT00251979) of patients randomized to high-dose intravenous (IV) esomeprazole (PPI) or placebo for 72 h. Rebleeding rates of patients with PUB SRH treated with either PPI or placebo after successful endoscopic hemostasis were also compared. RESULTS For patients treated with placebo for 72 h after successful endoscopic hemostasis, rebleed rates by SRH were spurting arterial bleeding (FIA) 22.5%, adherent clot (FIIB) 17.6%, non-bleeding visible vessel (FIIA) 11.3%, and oozing bleeding (FIB) 4.9%. Compared with FIB patients, FIA, FIIB, and FIIA had significantly greater risks of rebleeding with odds ratios (95% CI's) from 2.61 (1.05, 6.52) for FIIA to 6.66 (2.19, 20.26) for FIA. After hemostasis, PUB rebleeding rates for FIB patients at 72 h were similar with esomeprazole (5.4%) and placebo (4.9%), whereas rebleed rates for all other major SRH (FIA, FIIA, FIIB) were lower for PPI than placebo, but the treatment by SRH interaction test was not statistically significant. CONCLUSIONS After successful endoscopic hemostasis, FIB patients had very low PUB rebleeding rates irrespective of PPI or placebo treatment. This implies that after successful endoscopic hemostasis the prognostic classification of FIB ulcers as a high-risk SRH and the recommendation to treat these with high-dose IV PPI's should be re-evaluated.
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Camus M, Jensen DM, Kovacs TO, Jensen ME, Markovic D, Gornbein J. Independent risk factors of 30-day outcomes in 1264 patients with peptic ulcer bleeding in the USA: large ulcers do worse. Aliment Pharmacol Ther 2016; 43:1080-9. [PMID: 27000531 PMCID: PMC4837138 DOI: 10.1111/apt.13591] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 05/30/2015] [Accepted: 03/01/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Predictors of worse outcomes (rebleeding, surgery and death) of peptic ulcer bleeds (PUBs) are essential indicators because of significant morbidity and mortality rates of PUBs. However those have been infrequently reported since changes in medical therapy (PPI, proton pump inhibitors) and application of newer endoscopic haemostatic technique. AIMS To determine: (i) independent risk factors for 30-day rebleeding, surgery, and death and (ii) whether ulcer size is an independent predictor of major outcomes in patients with severe PUB after successful endoscopic haemostasis and treatment with optimal medical (high dose IV PPI) vs. prior treatment (high dose IV histamine 2 antagonists - H2RAs). METHODS A large prospectively followed population of patients hospitalised with severe PUBs between 1993 and 2011 at two US tertiary care academic medical centres, stratified by stigmata of recent haemorrhage (SRH) was studied. Using multivariable logistic regression analyses, independent risk factors for each outcome (rebleeding, surgery and death) up to 30 days were analysed. Effects for medical treatment (H2RA patients 1993-2005 vs. PPIs 2006-2011) were also analysed. RESULTS A total of 1264 patients were included. For ulcers ≥10 mm, the odds of 30-day rebleeding increased 6% per each 10% increase in ulcer size (OR 1.06, 95% CI 1.02-1.10, P = 0.0053). Other risk factors for 30-day rebleeding were major SRH, in-patient start of bleeding, and prior GI bleeding. Major SRH and ulcer size≥10 mm were predictors of 30-day surgery. Risk factors for 30-day death were major SRH, in-patient bleeding, and any initial platelet transfusion or fresh frozen plasma transfusion ≥2 units. Among patients with major SRH and out-patient start of bleeding, larger ulcer size was also a risk factor for death (OR 1.08 per 10% increase in ulcer size, 95% CI 1.02-1.14, P = 0.0095). Ulcer size was a significant independent variable for both time periods. CONCLUSIONS Ulcer size is a risk factor for worse outcomes after PUB and should be carefully recorded at initial endoscopy to improve patient triage and management.
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Affiliation(s)
- Marine Camus
- CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
- Division of Digestive Diseases at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States
- Department of Gastroenterology, Cochin Hospital, APHP, University Paris 5, France
| | - Dennis M. Jensen
- CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
- Division of Digestive Diseases at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States
- Gastroenterology Division at VA GLAHC, Los Angeles, CA, United States
| | - Thomas O. Kovacs
- CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
- Division of Digestive Diseases at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States
- Gastroenterology Division at VA GLAHC, Los Angeles, CA, United States
| | - Mary Ellen Jensen
- CURE Hemostasis Research Group, CURE Digestive Diseases Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
- Division of Digestive Diseases at UCLA Ronald Reagan Medical Center, Los Angeles, CA, United States
| | - Daniela Markovic
- Department of Biomathematics, University of California, Los Angeles, California
| | - Jeffrey Gornbein
- Department of Biomathematics, University of California, Los Angeles, California
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Jensen DM, Ohning GV, Kovacs TOG, Jutabha R, Ghassemi K, Dulai GS, Machicado GA. Natural history of definitive diverticular hemorrhage based on stigmata of recent hemorrhage and colonoscopic Doppler blood flow monitoring for risk stratification and definitive hemostasis. Gastrointest Endosc 2016; 83:416-23. [PMID: 26227931 PMCID: PMC4715947 DOI: 10.1016/j.gie.2015.07.033] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 07/17/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Few prospective reports describe the short-term natural history of colon diverticular hemorrhage based on stigmata of recent hemorrhage, and none include blood flow detection for risk stratification or as a guide to definitive hemostasis. Our purposes were to report the 30-day natural history of definitive diverticular hemorrhage based on stigmata and to describe Doppler probe blood flow detection as a guide to definitive hemostasis. METHODS Different cohorts of patients with severe diverticular bleeding and stigmata on urgent colonoscopy are reported. For 30-day natural history, patients were treated medically. If severe rebleeding occurred, they had surgical or angiographic treatment. We report natural history with major stigmata (active bleeding, visible vessel, or adherent clot) and no stigmata or flat spots after clots were washed away. We also report Doppler probe detection of arterial blood flow underneath stigmata before and after hemostasis in a recent cohort. RESULTS For natural history, patients with major stigmata treated medically had 65.8% (25/38) rebleeding rates, and 44.7% (17/38) had intervention for hemostasis. Patients with spots or clean bases had no rebleeding. A Doppler probe detected arterial blood flow in 92% of major stigmata--none after hemostasis--and there was no rebleeding. CONCLUSIONS (1) Patients with major stigmata treated medically had high rates of rebleeding and intervention for hemostasis. (2) Patients with clean diverticula or only flat spots had no rebleeding. (3) High rates of arterial blood flow were detected under major stigmata with a Doppler probe, but with obliteration by hemostasis no rebleeding occurred.
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Affiliation(s)
- Dennis M Jensen
- Center for Ulcer Research and Education Digestive Diseases Research Center, Veterans Affairs Greater Los Angeles Healthcare System, David Geffen School of Medicine at the University of California at Los Angeles, Departments of Medicine at the Ronald Reagan UCLA and Veterans Affairs West Los Angeles Medical Centers, Los Angeles, California, USA
| | - Gordon V Ohning
- Center for Ulcer Research and Education Digestive Diseases Research Center, Veterans Affairs Greater Los Angeles Healthcare System, David Geffen School of Medicine at the University of California at Los Angeles, Departments of Medicine at the Ronald Reagan UCLA and Veterans Affairs West Los Angeles Medical Centers, Los Angeles, California, USA
| | - Thomas O G Kovacs
- Center for Ulcer Research and Education Digestive Diseases Research Center, Veterans Affairs Greater Los Angeles Healthcare System, David Geffen School of Medicine at the University of California at Los Angeles, Departments of Medicine at the Ronald Reagan UCLA and Veterans Affairs West Los Angeles Medical Centers, Los Angeles, California, USA
| | - Rome Jutabha
- Center for Ulcer Research and Education Digestive Diseases Research Center, Veterans Affairs Greater Los Angeles Healthcare System, David Geffen School of Medicine at the University of California at Los Angeles, Departments of Medicine at the Ronald Reagan UCLA and Veterans Affairs West Los Angeles Medical Centers, Los Angeles, California, USA
| | - Kevin Ghassemi
- Center for Ulcer Research and Education Digestive Diseases Research Center, Veterans Affairs Greater Los Angeles Healthcare System, David Geffen School of Medicine at the University of California at Los Angeles, Departments of Medicine at the Ronald Reagan UCLA and Veterans Affairs West Los Angeles Medical Centers, Los Angeles, California, USA
| | - Gareth S Dulai
- Center for Ulcer Research and Education Digestive Diseases Research Center, Veterans Affairs Greater Los Angeles Healthcare System, David Geffen School of Medicine at the University of California at Los Angeles, Departments of Medicine at the Ronald Reagan UCLA and Veterans Affairs West Los Angeles Medical Centers, Los Angeles, California, USA
| | - Gustavo A Machicado
- Center for Ulcer Research and Education Digestive Diseases Research Center, Veterans Affairs Greater Los Angeles Healthcare System, David Geffen School of Medicine at the University of California at Los Angeles, Departments of Medicine at the Ronald Reagan UCLA and Veterans Affairs West Los Angeles Medical Centers, Los Angeles, California, USA
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Nayor J, Saltzman JR. Determining the endpoint of endoscopic therapy for upper GI bleeding: Are our eyes as good as our ears? Gastrointest Endosc 2016; 83:137-9. [PMID: 26706302 DOI: 10.1016/j.gie.2015.08.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 08/30/2015] [Indexed: 02/08/2023]
Affiliation(s)
- Jennifer Nayor
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Ghassemi KA, Jensen DM. Evolving techniques for gastrointestinal endoscopic hemostasis treatment. Expert Rev Gastroenterol Hepatol 2016; 10:615-23. [PMID: 26651414 PMCID: PMC6063521 DOI: 10.1586/17474124.2016.1130623] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
With mortality due to gastrointestinal (GI) bleeding remaining stable, the focus on endoscopic hemostasis has been on improving other outcomes such as rebleeding rate, need for transfusions, and need for angiographic embolization or surgery. Over the past few years, a number of devices have emerged to help endoscopically assess and treat bleeding GI lesions. These include the Doppler endoscopic probe, hemostatic powder, and over-the-scope clip. Also, new applications have been described for radiofrequency ablation. In this article, we will discuss these evolving tools and techniques that have been developed, including an analysis of their efficacy and limitations.
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Affiliation(s)
- Kevin A. Ghassemi
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA,CURE Hemostasis Research Group
| | - Dennis M. Jensen
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA,CURE Hemostasis Research Group,Division of Gastroenterology, VA Greater Los Angeles Healthcare Center, Los Angeles, CA, USA
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