Ulcers and nonvariceal bleeding

Equivalent clinical outcomes of bleeding peptic ulcers in teaching and non-teaching hospitals: evidence for standardization of medical care in Japan

The clinical outcomes of treatments for several medical conditions are better in teaching hospitals than in non-teaching hospitals. However, there is only limited information for comparisons of the clinical outcomes of bleeding peptic ulcers between teaching and non-teaching hospitals. A total of 4,863 patients treated by endoscopic hemostasis on admission for bleeding peptic ulcers were evaluated in 586 hospitals of the Diagnosis Procedure Combination (DPC) system. We collected their data from the database associated with the DPC system to compare the risk-adjusted length of stay (LOS) and in-hospital mortality within 30 days with respect to the hospital characteristics. The hospitals were categorized into two groups: teaching hospitals that were certified by the Japanese Society of Gastroenterology (3,332 patients in 360 hospitals) and non-teaching hospitals (1,531 patients in 226 hospitals). There was no significant difference with regard to the mean LOS and the crude in-hospital mortality within 30 days between groups (p = 0.181 and 0.174, respectively). Multiple linear regression analyses revealed that the hospital characteristics were not associated with the risk-adjusted LOS. The standardized coefficient for non-teaching hospitals was 0.019 (p = 0.172). Multiple logistic regression analyses further showed no significant difference in the in-hospital mortality within 30 days (non-teaching hospitals, odds ratio = 1.35, 95% confidence interval = 0.786 - 2.319, p = 0.277). In conclusion, both teaching and non-teaching hospitals have equivalent qualities in management of bleeding peptic ulcers. These findings suggest that the standardization of medical treatments for bleeding peptic ulcers has become disseminated in Japan.

Upper Gastrointestinal Haemorrhage: Predictive Factors of In-Hospital Mortality in Patients Treated in the Medical Intensive Care Unit

This prospective, cohort study assessed the independent predictors of in-hospital mortality in patients with acute upper gastrointestinal haemorrhage admitted to the medical intensive care unit (MICU) at the University Clinical Centre Maribor, Slovenia. Using univariate, multivariate and logistic regression methods the predictors of mortality in 54 upper gastrointestinal haemorrhage patients (47 men, mean ± SD age 61.6 ± 14.2 years) were investigated. The mean ± SD duration of treatment in the MICU was 2.8 ± 2.9 days and the mortality rate was 31.5%. Significant differences between non-survivors and survivors were observed in haemorrhagic shock, heart failure, infection, diastolic blood pressure at admission, haemoglobin and red blood cell count at admission, and lowest haemoglobin and red blood cell count during treatment. Heart failure (odds ratio 59.13) was the most significant independent predictor of in-hospital mortality. Haemorrhagic shock and the lowest red blood cell count during treatment were also important independent predictive factors of in-hospital mortality.

Present state of endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding

The subjects of this study were 208 patients who underwent endoscopic hemostasis at the Department of Gastroenterology and Hepatology, Iwate University between January 2004 and December 2008. There were 153 men and 55 women with a mean age of 65.3 years. Among them, 181 patients underwent endoscopic hemostasis in the stomach or duodenum and were divided into the peptic ulcer and artificial ulcer groups. The following were retrospectively analyzed: success rates of endoscopic hemostasis, rates of rebleeding, and devices used during treatment. The overall success rate of endoscopic hemostasis was 97.2%. Hemostasis was achieved in 98.2% of the cases with peptic ulcer bleeding and in 88.9% of the cases with artificial ulcer bleeding. Monotherapy (one hemostatic device) was used in 141 cases (77.9%), combination therapy (multiple hemostatic devices) was used in 39 cases (21.5%), and primary hemostasis was used in one case (0.6%) because of blood flow reduction during the observation period. A heat probe was used in 145 cases (80.1%), making it the most frequently used device. Endoscopic hemostasis is very effective for nonvariceal upper gastrointestinal bleeding.

WITHDRAWN: Argon plasma coagulation therapy for acute non-variceal upper gastrointestinal bleeding

BACKGROUND

Endoscopic treatment is recommended for initial hemostasis in non-variceal upper gastrointestinal bleeding. Many endoscopic hemostatic devices are used. Argon Plasma Coagulation (APC) is an alternative.

OBJECTIVES

This study reviews all available literature to access the efficacy of APC compared to other endoscopic therapies in the control of acute non-variceal upper GI hemorrhage.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4 2003), MEDLINE 1966 to December 2003, EMBASE 1980 to December 2003, Web of Science for SCISEARCH (1980 to December 2003), BIOSIS (1985 to December 2003), and the National Research Register Issue 4 2003. We also handsearched abstracts from conference proceedings of the United European Gastroenterology Week and Digestive Disease Week.

SELECTION CRITERIA

Randomized, controlled trials of APC compared with other endoscopic hemostasis interventions in the treatment of non-variceal upper gastrointestinal bleeding.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed trial quality and independently extracted data.

MAIN RESULTS

Two trials involving 121 people were included. There was no common intervention to pool. One trial compared APC to heat probe, another trial compared APC to injection sclerotherapy. There was no significant difference between groups in either of these trials.

AUTHORS' CONCLUSIONS

On the basis of the two randomised controlled trials identified in this review, there is no evidence to suggest that APC is superior to other endoscopic therapies. Further randomised controlled trials are needed.

Prognostic factors in gastrointestinal bleeding due to peptic ulcer: construction of a predictive model

OBJECTIVES

The identification of prognostic factors of easy application in clinical practice can improve the diagnostic and therapeutic decision making process in upper gastrointestinal bleeding (UGB). The present study estimates the capacity to predict an unfavorable clinical course (mortality, unstable bleeding, and/or interventional therapy) on the basis of the preendoscopic and endoscopic clinical analytical findings in patients with UGB owing to peptic ulcer.

METHOD

A retrospective cohort study was made of 473 adult patients seen in the Emergency Service of a District Hospital, and diagnosed with UGB secondary to gastroduodenal ulcer. Logistic regression analysis was used to construct different models, with the evaluation of their predictive capacity based on calculation of the area under the receiver operating curve (ROC). The final model was used to calculate the probabilities of an unfavorable clinical course for different profiles, with the purpose of constructing an algorithm of help in the decision making process applied to patients initially considered to be at low risk (Forrest classification IIb and III).

RESULTS

The model with the Forrest variable showed a high predictive capacity: ROCa=0.81 (95% confidence interval, 0.76-0.85). Incorporation to the model of clinical and preendoscopic factors (type of UGB, hematocrit, kidney failure, and liver disease) significantly increased its predictive capacity: ROCa=0.87 (95% confidence interval, 0.83-0.91). This model allows the differentiation of different complication risk levels in patients initially at low risk according to the Forrest classification (IIb and III).

CONCLUSIONS

The Forrest classification is the principal predictive factor for an unfavorable course in patients with gastrointestinal bleeding owing to peptic ulcer, though clinical factors are also important and should complement the decision taking process.

Intratumoral Hydrogen Peroxide Injection During Meningioma Resection

OBJECTIVE:

Meningiomas, although histologically benign, pose a particular challenge to the neurosurgeon because of their extensive and exuberant vascularity. They often bleed extensively during resection until separated from their blood supply. There are a wide variety of hemostatic agents available to the neurosur-geon. Most of these means of hemostasis involve some sort of chemical, electrical, or compressive action. Although anecdotally known to be useful, the use of hydrogen peroxide as an intracranial hemostatic agent in meningioma surgery has not been formally reported. We report a technique of meningioma resection that uses intratumoral hydrogen peroxide injection, reducing the potential for blood loss and shortening resection times.

METHODS:

Seventy-five patients underwent resection of a meningioma using the direct intratumoral H2O2 injection technique. The locations of these meningiomas included convexity and cranial-based lesions. None of the patients underwent preoperative endovascular embolization.

RESULTS:

The use of this technique greatly facilitated the removal of these tumors. No evidence of air embolism occurred during Doppler surveillance and no other significant side effects attributable to H2O2 application were observed. @@CONCLUSION:@@ We demonstrate a previously unreported technique of meningi-oma resection that uses direct intratumoral hydrogen peroxide injection, potentially reducing blood loss, shortening resection times, and obviating the need for preoperative embolization.

Severe acute haemorrhagic gastritis controlled by hydrogen peroxide

A 92-year-old woman presented with severe acute haemorrhagic gastritis due to abuse of non-steroidal anti-inflammatory drugs (NSAIDs). She was treated with instillation of 150 ml 3% hydrogen peroxide (H2O2) every 2 h via a nasogastric tube. The copious amount of bright red blood through the nasogastric tube started to decline substantially after the first administration of H2O2 and continued to reveal clear material during the second and third instillation of H2O2. The total amount of H2O2 administered was 600 ml. No rebleeding and only a few flame-shaped intramucosal haemorrhages were observed on the following four consecutive daily endoscopic evaluations. These are promising observations which will have to be confirmed with respect to the safety and efficacy of H2O2 treatment by further controlled studies.

Nonvariceal upper gastrointestinal bleeding: standard and new treatment

Nonvariceal upper gastrointestinal bleeding remains a challenging problem with a significant morbidity and mortality. In recent years endoscopic techniques have evolved, resulting in improved primary hemostasis and a reduction in the risk of rebleeding. Combination endoscopic therapy followed by high-dose proton pump inhibitor shows improved outcomes. Innovative endoscopic therapies hold promise but are as yet unproved. An aging population with significant medical comorbidities has a major influence on the overall outcome from upper gastrointestinal bleeding.

Argon plasma coagulation therapy for acute non-variceal upper gastrointestinal bleeding

BACKGROUND

Endoscopic treatment is recommended for initial hemostasis in non-variceal upper gastrointestinal bleeding. Many endoscopic hemostatic devices are used. Argon Plasma Coagulation (APC) is an alternative.

OBJECTIVES

This study reviews all available literature to access the efficacy of APC compared to other endoscopic therapies in the control of acute non-variceal upper GI hemorrhage.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4 2003), MEDLINE 1966 to December 2003, EMBASE 1980 to December 2003, Web of Science for SCISEARCH (1980 to December 2003), BIOSIS (1985 to December 2003), and the National Research Register Issue 4 2003. We also handsearched abstracts from conference proceedings of the United European Gastroenterology Week and Digestive Disease Week.

SELECTION CRITERIA

Randomized, controlled trials of APC compared with other endoscopic hemostasis interventions in the treatment of non-variceal upper gastrointestinal bleeding.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed trial quality and independently extracted data.

MAIN RESULTS

Two trials involving 121 people were included. There was no common intervention to pool. One trial compared APC to heat probe, another trial compared APC to injection sclerotherapy. There was no significant difference between groups in either of these trials.

AUTHORS' CONCLUSIONS

On the basis of the two randomised controlled trials identified in this review, there is no evidence to suggest that APC is superior to other endoscopic therapies. Further randomised controlled trials are needed.

Risk factors for mortality in severe upper gastrointestinal bleeding

BACKGROUND AND AIMS

Factors related to mortality after upper gastrointestinal (GI) bleeding may differ in importance in high- and low-risk populations. This retrospective study was undertaken to define risk factors of mortality in patients needing endoscopy for upper gastrointestinal bleeding at a tertiary care centre.

PATIENTS/METHODS

Three hundred and sixty-two patients with upper gastrointestinal bleeding were identified from endoscopy charts. Patients' characteristics, bleeding parameters, clinical presentation, pre-existing medication and laboratory data were retrieved from hospital charts and patients who survived and those who died in hospital were compared.

RESULTS/FINDINGS

The mean Rockall score was 6.6+/-1.3 with 92.5% of patients belonging to a Rockall high-risk group. In hospital, mortality was 26.5%, with 6.4% of patients dying as a direct consequence of bleeding. Variceal bleeding was associated with a high risk of recurrent bleeding and death. Renal disease, liver disease, coagulopathy and immunosuppression were more frequently found in non-survivors than in survivors. Accordingly, serological tests of renal or liver function and coagulation were more disturbed in non-survivors. On average, heart rate was higher, and blood pressure and haemoglobin levels lower in non-survivors. Heparin, glucocorticoids, and anti-ulcer drugs were more frequently used in patients dying in hospital. By logistic regression analysis, in-patient status at the time of bleeding, renal disease and coagulopathy, as well as glucocorticoid use, were risk factors for hospital mortality.

INTERPRETATION/CONCLUSION

In tertiary care, a high mortality rate is observed in upper GI bleeding. Teams involved in treating such patients should be aware of the setting in which treatment is performed and its related risk factors.

Endoscopic therapy for upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is one of the most common medical emergencies and remains a major cause of morbidity and mortality among patients. Although initially employed diagnostically, endoscopy has steadily replaced surgery as a first-line treatment in all but the haemodynamically unstable patient. A vast selection of techniques and devices are now available to the dedicated therapeutic endoscopist, including injection therapy, electrical or thermal coagulation and mechanical banding or clipping. The use of endoscopic ultrasound for targeting treatment is increasing and the development of new technologies, such as capsule endoscopy, is likely to play an important role in future protocols. However, despite numerous randomized controlled trials and meta-analyses comparing the efficacy of different endoscopic interventions, the implementation of obtained results into treatment regimes has so far failed to impact significantly on overall UGIB mortality, which remains stubbornly at 10-14%. Reducing this continues to be one of the main challenges facing the therapeutic endoscopist.

Dieulafoy lesion in a one-year-old child

The Dieulafoy lesion is a rare cause of severe upper gastrointestinal bleeding associated with a significant mortality. Rebleeding from undiscovered lesions is frequent and often fatal. The outcome depends on a high degree of suspicion for the condition. In any age group, the entity may be underdiagnosed rather than truly rare. It is particularly uncommon in infants. The authors report the case of the youngest patient so far to suffer from a Dieulafoy lesion.

Argon plasma coagulation of hemorrhagic solitary rectal ulcer syndrome

Solitary ulcer syndrome (SUS) is a rare disorder that may provoke hematochezia. Argon plasma coagulation (APC) is used in a wide range of gastrointestinal bleeding. We experienced APC in a patient with a bleeding gigantic SUS: a 64-year-old woman who developed a SUS at 60. After 3 years, recurrent hematochezia, secondary anemia, and rectal pain occurred. Endoscopy revealed a large rectal bleeding ulcer. Moreover, the pain led the patient to assume analgesics. These conditions stimulated us to treat this ulcer with APC within 4 sessions; each session spaced out at 30-day intervals. The patient experienced and maintained the following benefits: (1) resolution of bleeding and secondary anemia after the first session, (2) reduction of ulcer depth, disappearance of pain and analgesic withdrawal at the end of the cycle, (3) almost complete endoscopic healing of the ulcer after 9 months of follow-up. This experience suggests that APC may represent a therapeutic approach for bleeding SUS even if controlled studies are necessary before recommending it as acceptable treatment.

Adrenaline plus cyanoacrylate injection for treatment of bleeding peptic ulcers after failure of conventional endoscopic haemostasis

BACKGROUND

Endoscopic therapy is a safe and effective method for treating non-variceal upper gastrointestinal bleeding. However failure of therapy, in terms of continuing bleeding or rebleeding, is seen in up to 20%. Cyanoacrylate is a tissue glue used for variceal bleeding that has occasionally been reported as an alternative haemostatic technique in non-variceal haemorrhage.

AIM

To retrospectively describe personal experience using cyanoacrylate injection in the management of bleeding ulcers after failure of first-line endoscopic modalities.

PATIENTS AND METHODS

Between January 1995 and March 1998, 18 [12 M/6 F, mean age 68.1 years) out of 176 patients, referred to our Unit for non-variceal upper gastrointestinal bleeding, were treated with intralesional injection of adrenaline plus undiluted cyanoacrylate. Persistent bleeding after endoscopic haemostasis or early rebleeding were the indications for cyanoacrylate treatment.

RESULTS

Definitive haemostasis was achieved in 17 out of 18 patients treated with cyanoacrylate. One patient needed surgery. No early or late rebleeding occurred during the follow-up. No complications or instrument lesions related to cyanoacrylate were recorded.

CONCLUSIONS

In our retrospective series, cyanoacrylate plus adrenaline injection was found to be a potentially safe and effective alternative to endoscopic haemostasis when conventional treatment modalities fail in controlling bleeding from gastroduodenal ulcers.