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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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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: 62] [Impact Index Per Article: 8.9] [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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Jensen DM, Ohning GV, Kovacs TOG, Ghassemi KA, Jutabha R, Dulai GS, Machicado GA. Doppler endoscopic probe as a guide to risk stratification and definitive hemostasis of peptic ulcer bleeding. Gastrointest Endosc 2016; 83:129-36. [PMID: 26318834 PMCID: PMC4691549 DOI: 10.1016/j.gie.2015.07.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 07/03/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS For more than 4 decades endoscopists have relied on ulcer stigmata for risk stratification and as a guide to hemostasis. None used arterial blood flow underneath stigmata to predict outcomes. For patients with severe peptic ulcer bleeding (PUB), we used a Doppler endoscopic probe (DEP) for (1) detection of blood flow underlying stigmata of recent hemorrhage (SRH), (2) quantitating rates of residual arterial blood flow under SRH after visually directed standard endoscopic treatment, and (3) comparing risks of rebleeding and actual 30-day rebleed rates for spurting arterial bleeding (Forrest [F] IA) and oozing bleeding (F IB). METHODS Prospective cohort study of 163 consecutive patients with severe PUB and different SRH. RESULTS All blood flow detected by the DEP was arterial. Detection rates were 87.4% in major SRH-spurting arterial bleeding (F IA), non-bleeding visible vessel (F IIA), clot (F IIB)-and were significantly lower at 42.3% (P < .0001) for an intermediate group of oozing bleeding (F IB) or flat spot (F IIC). For spurting bleeding (F IA) versus oozing (F IB), baseline DEP arterial flow was 100% versus 46.7%, residual blood flow detected after endoscopic hemostasis was 35.7% versus 0%, and 30-day rebleed rates were 28.6% versus 0% (all P < .05). CONCLUSIONS (1) For major SRH versus oozing or spot, the arterial blood flow detection rate by the DEP was significantly higher, indicating a higher rebleed risk. (2) Before and after endoscopic treatment, spurting (F IA) PUB had significantly higher rates of blood flow detection than oozing (F IB) PUB and a significantly higher 30-day rebleed rate. (3) The DEP is recommended as a new endoscopic guide with SRH to improve risk stratification and potentially definitive hemostasis for PUB.
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Affiliation(s)
- Dennis M Jensen
- CURE Hemostasis Research Group of the CURE Digestive Diseases Research Center, Divisions of Digestive Diseases and Departments of Medicine, Ronald Reagan University of California at Los Angeles Medical Center, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, Calif, USA; West Los Angeles Veterans Administration Medical Center, Los Angeles, Calif, USA
| | - Gordon V Ohning
- CURE Hemostasis Research Group of the CURE Digestive Diseases Research Center, Divisions of Digestive Diseases and Departments of Medicine, Ronald Reagan University of California at Los Angeles Medical Center, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, Calif, USA; West Los Angeles Veterans Administration Medical Center, Los Angeles, Calif, USA
| | - Thomas O G Kovacs
- CURE Hemostasis Research Group of the CURE Digestive Diseases Research Center, Divisions of Digestive Diseases and Departments of Medicine, Ronald Reagan University of California at Los Angeles Medical Center, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, Calif, USA; West Los Angeles Veterans Administration Medical Center, Los Angeles, Calif, USA
| | - Kevin A Ghassemi
- CURE Hemostasis Research Group of the CURE Digestive Diseases Research Center, Divisions of Digestive Diseases and Departments of Medicine, Ronald Reagan University of California at Los Angeles Medical Center, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, Calif, USA
| | - Rome Jutabha
- CURE Hemostasis Research Group of the CURE Digestive Diseases Research Center, Divisions of Digestive Diseases and Departments of Medicine, Ronald Reagan University of California at Los Angeles Medical Center, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, Calif, USA
| | - Gareth S Dulai
- CURE Hemostasis Research Group of the CURE Digestive Diseases Research Center, Divisions of Digestive Diseases and Departments of Medicine, Ronald Reagan University of California at Los Angeles Medical Center, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, Calif, USA; West Los Angeles Veterans Administration Medical Center, Los Angeles, Calif, USA
| | - Gustavo A Machicado
- CURE Hemostasis Research Group of the CURE Digestive Diseases Research Center, Divisions of Digestive Diseases and Departments of Medicine, Ronald Reagan University of California at Los Angeles Medical Center, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, Calif, USA; West Los Angeles Veterans Administration Medical Center, Los Angeles, Calif, USA
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