Endoscopic band ligation for control of nonvariceal upper GI hemorrhage: comparison with bipolar electrocoagulation

Guidelines for endoscopic management of nonvariceal upper gastrointestinal bleeding (second edition)

The Japan Gastroenterological Endoscopy Society has prepared Guidelines for Endoscopic Practice in Nonvariceal Upper Gastrointestinal Bleeding as part of the initiative to develop evidence-based endoscopic practice guidelines. Hemorrhagic gastroduodenal (peptic) ulcers are the primary cause of nonvariceal upper gastrointestinal bleeding. With the advent of a super-aged society, the cases caused by Helicobacter pylori are on the decline, whereas those caused by drugs (e.g. aspirin) have been increasing. Endoscopic hemostasis is currently the first-line treatment for nonvariceal upper gastrointestinal bleeding, and various methods have been devised for this purpose. It is recommended to stabilize the vital signs of the patient before and after endoscopic hemostasis with appropriate management based on an assessment of the severity of illness, in addition to the administration of acid secretion inhibitors. These guidelines describe the evaluation and initial treatment of nonvariceal upper gastrointestinal bleeding, as well as the selection of endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding and its management after endoscopic hemostasis. This is achieved by classifying nonvariceal upper gastrointestinal bleeding into two main categories, namely, peptic ulcer and other types of gastrointestinal bleeding. We prepared statements for any available literature with supporting evidence, including the levels of evidence and recommendations. New evidence has been pooled since the publication of the first edition in this area; however, the levels of evidence and recommendations mostly remain low.

Transcatheter Aortic Valve Replacement Reverses Heyde Syndrome: A Case Report of Severe Aortic Stenosis and Gastrointestinal Bleeding

Background: Heyde syndrome is a rare condition characterized by the triad of severe aortic stenosis, gastrointestinal bleeding, and acquired type 2A von Willebrand syndrome. This case report highlights the diagnostic and therapeutic approach for a 72-year-old woman presenting with exertional chest pain, dyspnea, fatigue, and a history of melena. Methods: The diagnostic workup revealed severe microcytic anemia and a reduced vWF ristocetin-to-antigen ratio. Imaging confirmed severe degenerative aortic stenosis, while video capsule endoscopy identified angiodysplasia and telangiectasias in the small bowel as the source of gastrointestinal bleeding. Following evaluation by a multidisciplinary Heart Team, the patient underwent transcatheter aortic valve replacement (TAVR) with an Evolut Fx self-expanding prosthesis. Results: Post-procedural echocardiography showed mild paravalvular regurgitation. The patient's clinical course was favorable, with resolution of anemia and no further gastrointestinal bleeding episodes. Conclusions: Heyde syndrome requires a high index of suspicion for diagnosis in patients with severe aortic stenosis and unexplained anemia or gastrointestinal bleeding. TAVR offers an effective treatment option that not only resolves valvular pathology, but also mitigates associated bleeding risks.

Turn over the new leaf of the treatment in peptic ulcer bleeding: a review of the literature

Peptic ulcer bleeding is the most common cause of upper gastrointestinal bleeding, which has a high mortality risk. The standard therapy for acute peptic ulcer bleeding combines medication administration and endoscopic therapies. Both pharmacologic and endoscopic therapies have developed continuously in the past few decades. Proton pump inhibitors (PPIs) already reached a high efficacy in ulcer healing and have been widely used in the past few decades. Endoscopic hemostasis, which includes local epinephrine injection, heater probe coagulation, use of hemostatic clips, and/or band ligation, is highly effective with an overall hemostatic success rate of 85%-90%. However, 10%-20% of patients could not be cured by the current standard combination treatment. Recurrent ulcer bleeding, despite an initial successful hemostasis, is also a big problem for longer hospitalization stays, higher mortality, and higher complication rates, especially for malignant ulcer bleeding. How to manage all types of peptic ulcer bleeding and how to prevent early recurrent peptic ulcer bleeding remain unresolved clinical problems. Recently, several novel medications and endoscopic methods have been developed. Potassium competitive acid blockers have shown a stronger and longer acid suppression than PPI. Hemostatic powder spray and hemostatic gel emulsion are novel hemostatic weapons with emerging evidence, which are potential missing pieces of the puzzle. This literature review will go through the development of endoscopic hemostasis to the prospects of novel endoscopic treatments.

Outcomes in Severe Upper GI Hemorrhage from Dieulafoy's Lesion with Monitoring of Arterial Blood Flow

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.

A Unique Case of Recurrent Upper Gastrointestinal Bleeding Caused by Two Metachronous Dieulafoy's Lesions: The Role of EUS Evaluation

Introduction

Dieulafoy's lesion (DL) is a rare but important cause of acute, severe, life-threatening, and recurrent upper gastrointestinal bleeding (UGIB). It is frequently difficult to diagnose DL with upper GI endoscopy (UGIE), and endoscopic ultrasonography (EUS) may be valuable. There are only 2 reported bleeding cases caused by two synchronous DL but no reported cases of two metachronous DL.

Case Report

A 28-year-old healthy male presented with acute severe UGIB. UGIE was inconclusive. Systematic EUS mapping identified a gastric DL. After several attempts of EUS-guided hemostasis, DL was marked using a through-the-scope clip and the patient underwent successful transcatheter arterial embolization (TAE). Three years later, a new severe UGIB episode was caused by a second gastric DL in a different location, which was identified and marked by EUS and further successfully treated through TAE. The patient maintained follow-up without evidence of further bleeding.

Discussion/Conclusion

The authors report a unique case of severe, recurrent UGIB caused by two metachronous gastric DL lesions. The importance of systematic EUS scanning for diagnosis, treatment, and follow-up of DL is emphasized, as well as the potential influence in the outcome of other techniques like angiographic embolization.

Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points

Gastrointestinal angiodysplasias (GIADs), also called angioectasias, are the most frequent vascular lesions. Its precise prevalence is unknown since most of them are asymptomatic. However, the incidence may be increasing since GIADs affect individuals aged more than 60 years and population life expectancy is globally increasing worldwide. They are responsible of about 5% to 10% of all gastrointestinal bleeding (GIB) cases. Most GIADs are placed in small bowel, where are the cause of 50 to 60% of obscure GIB diagnosed with video capsule endoscopy. They may be the cause of fatal severe bleeding episodes; nevertheless, recurrent overt or occult bleeding episodes requiring repeated expensive treatments and disturbing patient's quality-of-life are more frequently observed. Diagnosis and treatment of GIADs (particularly those placed in small bowel) are a great challenge due to insidious disease behavior, inaccessibility to affected sites and limitations of available diagnostic procedures. Hemorrhagic causality out of the actively bleeding lesions detected by diagnostic procedures may be difficult to establish. No treatment guidelines are currently available, so there is a high variability in the management of these patients. In this review, the epidemiology and pathophysiology of GIADs and the status in the diagnosis and treatment, with special emphasis on small bowel angiodysplasias based on multiple publications, are critically discussed. In addition, a classification of GIADs based on their endoscopic characteristics is proposed. Finally, some aspects that need to be clarified in future research studies are highlighted.

Insights into the management of gastric antral vascular ectasia (watermelon stomach)

Gastric antral vascular ectasia (GAVE) is an uncommon but important cause of chronic gastrointestinal bleeding. It is often associated with systemic diseases such as autoimmune diseases, liver cirrhosis, chronic renal insufficiency and cardiovascular disease. The etiology of GAVE has not been fully explored and remains controversial. Diagnosis is mainly based on endoscopic presentation with flat or raised erythematous stripes radiating from the pylorus to the antrum and resembles a watermelon. Clinical presentation may range from iron-deficiency anemia secondary to occult blood loss, melena to hematemesis. In past decades, many therapeutic modalities including medical, endoscopic and surgical intervention have been introduced for GAVE treatment with variable efficacy. Herein, we review the efficacy and safety of these treatment options for GAVE.

Risk Factors for an Iatrogenic Mallory-Weiss Tear Requiring Bleeding Control during a Screening Upper Endoscopy

Background and Aim. In some cases of iatrogenic Mallory-Weiss tears (MWTs), hemostasis is needed due to severe mucosal tearing with bleeding. Therefore, we aimed to evaluate the risk factors for severe iatrogenic MWTs and the methods of endoscopic bleeding control. Materials and Methods. Between January 2008 and December 2012, 426,085 cases of screening upper endoscopy were performed at the Asan Medical Center. We retrospectively analyzed the risk factors for severe iatrogenic MWTs requiring an endoscopic procedure and the treatment modalities of bleeding control. Results. Iatrogenic MWTs occurred in 546 cases (0.13%) of screening upper endoscopy in 539 patients. Bleeding control due to severe bleeding was applied in 71 cases (13.0%), and rebleeding after initial bleeding control occurred in 1 case. Multivariate analysis showed that old age, a history of distal gastrectomy, and a less-experienced endoscopist (fewer than 2,237.5 endoscopic procedures at the time of the MWT) were associated with severe iatrogenic MWTs requiring an endoscopic procedure. Among 71 cases requiring bleeding control, a hemoclip was used in 81.7% (58 cases). Conclusions. Screening endoscopy procedures should be carefully performed when patients are in their old age and have a history of distal gastrectomy, particularly if the endoscopist is less experienced.

Clinical outcome of endoscopic management of duodenal Dieulafoy's lesions: endoscopic band ligation versus endoscopic hemoclip placement

BACKGROUND

The most appropriate type of endoscopic hemostasis for bleeding due to duodenal Dieulafoy's lesions (DLs) is not yet established. The aim of this study was to assess the efficacy of mechanical endoscopic hemostasis for duodenal DLs and long-term outcome after successful hemostasis, as well as to compare the efficacy and safety of endoscopic band ligation (EBL) and endoscopic hemoclip placement (EHP).

METHODS

Patients admitted to the emergency unit with acute upper gastrointestinal bleeding from duodenal DLs were enrolled in this study. The data were collected prospectively, but data analysis was performed retrospectively. Twenty-four patients with duodenal DLs were treated with EBL (n = 11) or EHP (n = 13).

RESULTS

There were no significant differences between groups with respect to clinical or endoscopic characteristics, apart from the number of epinephrine (three cases with EBL vs. 11 cases with EHP; p = 0.011). Primary hemostasis was achieved in all patients. Recurrent bleeding was observed in one patient (9.1 %) from the EBL group and in five patients (38.5 %) from the EHP group (p = 0.166). The recurrent bleeding in the patient from the EBL group was treated by EHP. In the EHP group, all five patients achieved successful secondary hemostasis by endoscopic treatment (EBL in two patients and EHP in three patients). There were no differences in secondary outcomes between the two groups, including the number of endoscopic sessions required, need for angiographic embolization or emergent surgery, transfusion requirements, or length of hospital stay. No complications occurred, and there was no recurrence of bleeding in either group during the follow-up period.

CONCLUSIONS

Mechanical endoscopic treatments are effective and safe for the treatment of bleeding duodenal DLs. A large-scale, randomized, controlled study is required to confirm the efficacy and safety of EBL and EHP for the management of bleeding duodenal DLs.

Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding

Japan Gastroenterological Endoscopy Society (JGES) has compiled a set of guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding using evidence-based methods. The major cause of non-variceal upper gastrointestinal bleeding is peptic gastroduodenal ulcer bleeding. As a result, these guidelines mainly focus on peptic gastroduodenal ulcer bleeding, although bleeding from other causes is also overviewed. From the epidemiological aspect, in recent years in Japan, bleeding from drug-related ulcers has become predominant in comparison with bleeding from Helicobacter pylori (HP)-related ulcers, owing to an increase in the aging population and coverage of HP eradication therapy by national health insurance. As for treatment, endoscopic hemostasis, in which there are a variety of methods, is considered to be the first-line treatment for bleeding from almost all causes. It is very important to precisely evaluate the severity of the patient's condition and stabilize the patient's vital signs with intensive care for successful endoscopic hemostasis. Additionally, use of antisecretory agents is recommended to prevent rebleeding after endoscopic hemostasis, especially for gastroduodenal ulcer bleeding. Eighteen statements with evidence and recommendation levels have been made by the JGES committee of these guidelines according to evidence obtained from clinical research studies. However, some of the statements that are supported by a low level of evidence must be confirmed by further clinical research.

The Dieulafoy's Lesion: An Update on Evaluation, Diagnosis, and Management

Dieulafoy's lesion (DL) is a persistently wide caliber artery that is observed more frequently at the fifth decade of life in the male population with multiple comorbidities. There are a variety of endoscopic therapies that have been used to treat DL; however, there are no clear guidelines on the best treatment modality. This article systematically reviews the diagnosis, the most commonly reported therapies of DL, and offers a suggested algorithm based upon efficacy of treatment such as initial hemostasis, rebleeding rates, and mortality.

Mechanical Hemostasis Techniques in Nonvariceal Upper Gastrointestinal Bleeding

One of the most important advances in gastroenterology has been the use of endoscopic hemostasis techniques to control nonvariceal upper gastrointestinal bleeding, particularly when high-risk stigmata are present. Several options are available, including injection therapy, sprays/topical agents, electrocautery, and mechanical methods. The method chosen depends on the nature of the lesion and experience of the endoscopist. This article reviews the available mechanical hemostatic modalities.

Endoscopic Management of Dieulafoy's Lesion

A Dieulafoy's lesion is a vascular abnormality consisting of a large caliber-persistent tortuous submucosal artery. A small mucosal defect with the eruption of this protruding vessel can cause bleeding. In fact, a Dieulafoy's lesion is a relatively rare but potentially life-threatening condition. It accounts for 1% to 2% of cases of acute gastrointestinal bleeding. Although there is no consensus on the treatment of Dieulafoy's lesions; treatment options depend on the mode of presentation, site of the lesion, and available expertise. Endoscopic therapy is usually successful in achieving primary hemostasis, with hemostasis success rates reaching 75% to 100%. Although various therapeutic endoscopic methods are used to control bleeding in Dieulafoy's lesions, the best method for endoscopic intervention is not clear. Combination endoscopic therapy is known to be superior to monotherapy because of a lower rate of recurrent bleeding. In addition, mechanical therapies including hemostatic clipping and endoscopic band ligation are more effective and successful in controlling bleeding than other endoscopic methods. Advances in endoscopic techniques have reduced mortality in patients with Dieulafoy's lesion-from 80% to 8%-and consequently, the need for surgical intervention has been reduced. Currently, surgical intervention is used for cases that fail therapeutic endoscopic or angiographic interventions.

Management of upper gastrointestinal bleeding emergencies: evidence-based medicine and practical considerations

Acute upper gastrointestinal (GI) bleeding remains one of the most common encounters in emergency medicine. The increased use of non-steroid anti-inflammatory drugs by the general population and the increased prescription of anti-platelet agents and anti-coagulants after cardiovascular interventions and for prevention of cerebral vascular accidents may have aggravated the situation. Significant progress has been made in the past decade or so in the non-surgical management of acute upper GI bleeding emergencies. This article will review the current standard treatment of the most common upper GI bleeding emergencies in adults as supported by evidence-based medicine with practical considerations from the authors' own practice experience.

Review article: gastrointestinal angiodysplasia - pathogenesis, diagnosis and management

BACKGROUND

Angiodysplasia (AD) of the gastrointestinal (GI) tract is an important condition that can cause significant morbidity and -rarely - mortality.

AIM

To provide an up-to-date comprehensive summary of the literature evaluating this disease entity with a particular focus on pathogenesis as well as current and emerging diagnostic and therapeutic modalities. Recommendations for treatment will be made on the basis of the current available evidence and consensus opinion of the authors.

METHODS

A systematic literature search was performed. The search strategy used the keywords 'angiodysplasia' or 'arteriovenous malformation' or 'angioectasia' or 'vascular ectasia' or 'vascular lesions' or 'vascular abnormalities' or 'vascular malformations' in the title or abstract.

RESULTS

Most AD lesions (54-81.9%) are detected in the caecum and ascending colon. They may develop secondary to chronic low-grade intermittent obstruction of submucosal veins coupled with increased vascular endothelial growth factor-dependent proliferation. Endotherapy with argon plasma coagulation resolves bleeding in 85% of patients with colonic AD. In patients who fail (or are not suitable for) other interventions, treatment with thalidomide or octreotide can lead to a clinically meaningful response in 71.4% and 77% of patients respectively.

CONCLUSIONS

Angiodysplasia is a rare, but important, cause of both overt and occult GI bleeding especially in the older patients. Advances in endoscopic imaging and therapeutic techniques have led to improved outcomes in these patients. The choice of treatment should be decided on a patient-by-patient basis. Further research is required to better understand the pathogenesis and identify potential therapeutic targets.

Intravenous albumin shortens the duration of hospitalization for patients with hypoalbuminemia and bleeding peptic ulcers: a pilot study

BACKGROUND

Patients with hypoalbuminemia have an increased risk of ulcer rebleeding and longer length of hospitalization.

AIMS

This study aimed to test whether intravenous albumin can decrease the incidence of rebleeding or shorten the duration of hospitalization in patients with bleeding peptic ulcers and hypoalbuminemia.

METHODS

Sixty-two patients with bleeding peptic ulcers and Rockall scores ≥ 6 were prospectively enrolled after having received endoscopic therapy. The enrolled patients were divided into a normal albumin group (serum albumin ≥ 3 g/dL, n = 39) or an intervention group (<3 g/dL, n = 23) to receive a 3-day course of omeprazole infusion and 25-day oral esomeprazole. Patients (n = 29) with bleeding ulcers and hypoalbuminemia who received the same dose of intravenous and oral omeprazole but did not receive albumin therapy were enrolled from a previous study as the control group. In the intervention group, patients received albumin infusion (10 g q8h) for 1 day (serum albumin levels 2.5-2.9 g/dL) and 2 days (<2.5 g/dL), respectively.

RESULTS

The 28-day cumulative rebleeding rates were similar between the intervention group and the control group (39.1 vs. 42.3 %, p = 0.99). The intervention group had a shorter duration of hospitalization (9 vs. 15 days, p = 0.02) than cohort controls. The risk of rebleeding developed after discharge were similar (normal albumin group vs. intervention group vs. control group, 1/5 [20 %] vs. 2/9 [22.2 %] vs. 1/11 [9.1 %], p = 0.7).

CONCLUSIONS

Albumin administration shortens the duration of hospitalization for patients with peptic ulcer bleeding and hypoalbuminemia, but does not decrease the incidence of rebleeding.

Mini-loop ligation of a bleeding duodenal Dieulafoy's lesion

Two percent of gastrointestinal hemorrhages are caused by Dieulafoy’s lesions, which are located in duodenum in only 15% of cases. There are no recommendations regarding the prime endoscopic treatment technique for this condition. A 61-year-old woman presented with melena without signs of hemodynamic instability. During an urgent upper endoscopy, blood oozing from the normal mucosa of the duodenum was seen and this was classified as a Dieulafoy’s lesion. A mini-loop was opened at the rim of a transparent ligation chamber, at the end of the endoscope, and after aspiration of the lesion, closed and detached. Complete hemostasis was achieved without early or postponed complications. In every day clinical practice, mini-loop ligation is rarely used because of possible complications, such as site ulceration, organ perforation, re-bleeding and possible inexperience of the operator. To the best of our knowledge this is the first case of successful treatment of bleeding duodenal Dieulafoy’s lesion by mini-loop ligation.

Endoscopic band ligation versus argon plasma coagulation for gastric antral vascular ectasia associated with liver diseases

AIM

The aim of the present study was to evaluate the clinicopathological features and the efficacy of endoscopic treatments in treating gastric antral vascular ectasia (GAVE) in association with liver diseases.

METHODS

Thirty-four patients with the characteristic endoscopic findings of GAVE were enrolled. Endoscopic treatments were carried out for all 34 patients, including argon plasma coagulation (APC) in 22 patients and endoscopic band ligation (EBL) in 12 patients.

RESULTS

All 34 patients had iron-deficiency anemia and 21 patients also had a history of tarry stools. The underlying pathologies of chronic liver diseases were liver cirrhosis in 26 patients, liver cirrhosis associated with hepatocellular carcinoma in six, and idiopathic portal hypertension in two. The liver function was classified by Child-Pugh classification: class A (n=6), class B (n=21), and class C (n=7). Antral motility was frequent and intense in all 34 GAVE patients. In the 22 patients who received APC, endoscopies revealed the recurrence of GAVE in 15 patients requiring further treatment by APC (recurrence rate, 68.2%). Seven patients died during the follow-up period, including two cases with bleeding-related deaths. In the 12 patients who received EBL, endoscopies revealed the recurrence of GAVE in one patient requiring further treatment by EBL (recurrence rate, 8.3%). Two patients died during the follow-up period, neither were bleeding-related deaths.

CONCLUSIONS

The results suggest that GAVE is related to severe liver damage and portal hypertension. APC has a high recurrence rate of GAVE in the medium term after treatment. EBL may be useful as a treatment for GAVE.

Mallory-Weiss syndrome: clinical and endoscopic characteristics

BACKGROUND

Mallory-Weiss syndrome is defined by upper gastrointestinal bleeding from vomiting-induced mucosal lacerations at the esophago-gastric junction. This study was purposed to investigate the incidence, location, clinical manifestation, diagnosis and effectiveness of treatment (including endoscopic treatment and conservative medical treatment) of Mallory-Weiss syndrome in China.

METHODS

All patients who received emergency upper gastrointestinal endoscopy due to Mallory-Weiss syndrome from September 2007 to August 2011 at gastrointestinal endoscopy center of Renmin Hospital of Wuhan University were included in this study. The clinical presentation, medical history, location and characteristics of Mallory-Weiss syndrome methods and effectiveness of therapy of patients with Mallory-Weiss syndrome were retrospectively analyzed by chart reviews. Long-term follow-up data were collected at outpatient clinics or telephone interviews.

RESULTS

Sixteen patients were diagnosed with Mallory-Weiss syndrome, which account for 3.08% of 519 patients with acute non-variceal upper gastrointestinal bleeding. Common comorbidities were found in one patient with hepatic cirrhosis. Conservative medical treatment, local injection, hemoclipping, or multipolar electrocoagulation produced primary hemostasis in 87.5% (14/16) of patients.

CONCLUSION

Mallory-Weiss syndrome is uncommon in China in comparison with reported experience in the west when the same group of patients is selected. Different approaches to treatment are to be recommended depending on whether or not active hemorrhage is present.

Bleeding from gastric body varices effectively treated with endoscopic band ligation

A 55-year-old man with alcoholic liver cirrhosis was admitted to hospital with tarry stools. Videoendoscopy examination on admission revealed blood oozing from the greater curvature of the gastric body (ectopic varices). Endoscopic ultrasonography and computed tomography were used in making the diagnosis. Endoscopic band ligation (EBL) was performed for the bleeding site of these varices. The patient experienced no further episodes of bleeding during the 6 months following treatment with EBL. EBL was very effective in treating the bleeding from gastric body varices.

Hemostatic efficacy and clinical outcome of endoscopic treatment of Dieulafoy's lesions: comparison of endoscopic hemoclip placement and endoscopic band ligation

BACKGROUND

The most suitable mechanical endoscopic hemostasis for a bleeding Dieulafoy's lesion (DL) is not yet well established.

OBJECTIVE

To compare the hemostatic efficacy and clinical outcome of endoscopic hemoclip placement (EHP) and endoscopic band ligation (EBL).

DESIGN

Retrospective, single-center study.

SETTING

A tertiary-care referral university hospital.

PATIENTS

Sixty-six patients who received mechanical endoscopic hemostasis for bleeding DLs.

INTERVENTIONS

Endoscopic hemostasis.

MAIN OUTCOME MEASUREMENT

Primary hemostasis and rebleeding rates.

RESULTS

DLs accounted for 3.8% of cases of acute nonvariceal upper GI bleeding during the study period. Active bleeding from DLs was noted in 34 patients (51.5%). EHP and EBL were performed as a method of endoscopic hemostasis in 34 and 32 patients, respectively. There were no significant differences between the 2 groups with respect to baseline characteristics (except comorbidities) and endoscopic features of DLs. Primary hemostasis was achieved in all 66 patients (100%). There were 6 cases of recurrent bleeding: 5 (14.7%) and 1 (3.1%) in the EHP and EBL groups, respectively. Secondary hemostasis was achieved with endoscopic treatment and angiographic embolization in 5 patients and 1 patient, respectively, and no patients required surgery. The mean procedure time of endoscopic hemostasis was significantly longer in the EHP group (19.1 vs 11.5 minutes, P = .015). There was no bleeding-related mortality.

LIMITATIONS

Retrospective analysis.

CONCLUSIONS

Both EHP and EBL are suitable for the treatment of bleeding DLs. EBL can be used as an initial hemostatic method for bleeding DLs because of a favorable clinical outcome comparable to that with EHP and a shorter procedure time.

Endoscopic band ligation for refractory gastric antral vascular ectasia associated with liver cirrhosis

An 84-year-old woman with unknown liver cirrhosis was admitted to our hospital in October 2008 with anemia due to recurrent gastric antral vascular ectasia (GAVE). At 78 years of age, argon plasma coagulation (APC) was performed for GAVE, and between 79 and 83 years of age, APC was carried out five times for recurrent episodes of GAVE presenting as anemia. Upon hospitalization, she was found to have anemic conjunctivae and the laboratory findings were red blood cells 245 × 10(4)/mm(3) and hemoglobin 7.7 g/dL. During this period, endoscopic band ligation (EBL) was performed for the recurrent refractory GAVE. EBL was first applied to the most distal antrum, and subsequent EBLs were performed more proximally. Two weeks after initial EBL treatment, endoscopy revealed both ulcers and shrinking of GAVE in the stomach. Fourteen months later, no further recurrence of GAVE was observed by endoscopy. This patient had no episodes of bleeding during the 20 month period since she was treated with EBL, and has a hemoglobin value of 10.1 g/dL. The histologic changes that occur with GAVE exist in the mucosal and submucosal region of the stomach; therefore, EBL may be effective for refractory GAVE because of obliterating submucosal vascular plexus.

Endoscopic band ligation could decrease recurrent bleeding in Mallory-Weiss syndrome as compared to haemostasis by hemoclips plus epinephrine

BACKGROUND

Mallory-Weiss syndrome (MWS) with active bleeding at endoscopy may require endoscopic haemostasis the modalities of which are not well-defined.

AIM

To compare the efficacy of endoscopic band ligation vs. hemoclip plus epinephrine (adrenaline) in bleeding MWS.

METHODS

From 2001 to 2008, 218 consecutive patients with a MWS at endoscopy were hospitalized in our Gastrointestinal Bleeding Unit. In 56 patients (26%), an endoscopic haemostasis was required because of active bleeding. Band ligation was performed in 29 patients (Banding group), while hemoclip application plus epinephrine injection was performed in 27 patients (H&E group). Treatment efficacy and early recurrent bleeding were retrospectively compared between the two groups.

RESULTS

Primary endoscopic haemostasis was achieved in all patients. Recurrent bleeding occurred in 0% in Banding group vs. 18% in H&E group (P = 0.02). The use of hemoclips plus epinephrine (OR = 3; 95% CI = 1.15-15.8) and active bleeding at endoscopy (OR = 1.9; 95% CI = 1.04-5.2) were independent predictive factors of early recurrent bleeding.

CONCLUSIONS

Haemostasis by hemoclips plus epinephrine was an independent predictive factor of rebleeding. This result suggests that band ligation could be the first choice endoscopic treatment for bleeding MWS, but requires further prospective assessment.

Endoscopic hemostasis with metallic hemoclips for iatrogenic Mallory-Weiss tear caused by endoscopic examination

AIM

Applied endoscopic techniques including mucosal resection, sclerotherapy and endoscopic retrograde cholangiopancreatography (ERCP) have been advanced and iatrogenic complications including Mallory-Weiss tear (MWT) occasionally occur in daily endoscopic procedures. The present study aimed to examine the advantages of clipping for MWT complications that occur during endoscopic examination.

METHODS

Over 10 years, we experienced 47 patients with bleeding caused by MWT. Metallic hemoclips were applied for 38 patients for hemostasis. These patients were categorized into two groups: 18 patients in group A whose bleeding tear occurred during endoscopic examination in an iatrogenic condition, and 20 patients in group B visited the emergency unit due to other etiology of MWT.

RESULTS

The background characteristics, including length of tears, were not different between the two groups. Initial hemostasis was 100% in groups A and B. Rebleeding was 0/18 (0%) in group A and 1/20 (5 %) in group B. Number of patients who received blood transfusion was significantly higher in group B (group A: 0/18, group B: 4/20). Hemoglobin level before hemostasis was 12.5 g/dL in group A which was not different to that in group B, 10.9 g/dL.

CONCLUSION

Application of hemoclips was effective for bleeding MWT during endoscopic procedures, which warranted prophylactic application of hemoclips on MWT during endoscopic examination.

Treatment of gastric antral vascular ectasia (watermelon stomach) with endoscopic band ligation

BACKGROUND

Gastric antral vascular ectasia (GAVE) is characterized by mucosal and submucosal vascular ectasia causing recurrent GI hemorrhage. Treatment of GAVE with endoscopic thermal therapy (ETT) requires multiple sessions for destruction of vascular ectasia and control of bleeding. Endoscopic band ligation (EBL) has become the standard treatment of varices because it effectively obliterates the submucosal plexus of esophageal varices with an acceptably low rate of complications. Additionally, EBL has been used for control of bleeding from other GI vascular lesions. In patients with GAVE and recurrent GI hemorrhage, EBL may offer an alternative to ETT for treatment of large areas of diseased mucosa and submucosa.

OBJECTIVE

Our purpose was to compare EBL (n = 9) with ETT (n = 13) for the treatment of bleeding from GAVE.

DESIGN

Observational comparative study.

PATIENTS

Patients with gastric antral vascular ectasia with occult or overt bleeding.

SETTING

Mayo Clinic Arizona, a multispecialty academic medical center.

INTERVENTION

EBL or ETT with argon plasma coagulation or electrocautery.

MAIN OUTCOME AND MEASUREMENTS

Number of treatments to cessation of bleeding and posttreatment hemoglobin, hospitalization, and transfusion requirement.

RESULTS

There were no significant differences in the demographics, clinical presentation, associated portal hypertension, or mean hemoglobin values or the mean number of transfusions or hospitalizations between the 2 groups before treatment. Four patients in the EBL group had failed prior ETT. Compared with ETT, in exploratory statistical testing EBL had a significantly higher rate of bleeding cessation (67% vs 23%, P = .04), fewer treatment sessions required for cessation of bleeding (1.9 vs 4.7, P = .05), a greater increase in hemoglobin values (2.8 g/dL vs 0.9 g/dL, P = .05), a greater decrease in transfusion requirements (-12.7 vs -5.2, P = .02), and a greater decrease in hospital admissions (-2.6 vs -0.5, P = .02) during the follow-up period. Analysis of covariance showed significantly superior efficacy of EBL for cessation of bleeding, postprocedure transfusion, and hospitalization. One patient in the EBL group had postprocedure emesis and 1 in the ETT group had immediate post procedure bleeding. All patients in the EBL group had complete mucosal healing with minimal residual GAVE at follow-up endoscopy failed post-EBL.

CONCLUSIONS

Our initial experience suggests that EBL is superior to ETT for the management of GAVE. EBL required fewer treatment sessions for control of bleeding, had higher rates for cessation of bleeding, had a reduction in hospitalizations and transfusion requirements, and allowed for a significant increase in hemoglobin values.

Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy

Acute upper gastrointestinal bleeding is a relatively common,potentially life-threatening condition that causes more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper gastrointestinal bleeding lesions. Endoscopic therapy is indicated for lesions with high risk stigmata of recent hemorrhage, including active bleeding, oozing, a visible vessel, and possibly an adherent clot. Endoscopic therapies include injection therapy, such as epinephrine or sclerosant injection; ablative therapy, such as heater probe or argon plasma coagulation; and mechanical therapy, such as endoclips or endoscopic banding. Endoscopic therapy reduces the risk of rebleeding,the need for blood transfusions, the requirement for surgery, and patient morbidity.

Hemostasis of Dieulafoy's lesions by argon plasma coagulation (with video)

BACKGROUND

A Dieulafoy's lesion is a submucosal artery that may erode the epithelium and lead to severe hemorrhages. The safety and efficacy of argon plasma coagulation (APC) for the hemostasis of these lesions has not been studied.

OBJECTIVE

To evaluate efficacy of APC alone in the hemostasis of Dieulafoy's lesions.

DESIGN

A retrospective analysis of hemostasis by chart review, with long-term follow-up by outpatient visit or phone interview.

SETTING

An academic hospital with 24-hour endoscopic service availability.

PATIENTS

All patients with acute bleeding from a Dieulafoy's lesion treated with APC.

INTERVENTIONS

Hemostasis was attempted with 2.3-mm APC probes, with settings varying from 40 W to 60 W, according to lesion location.

MAIN OUTCOME MEASUREMENTS

Initial hemostasis, recurrent bleeding, and 30-day mortality rates.

RESULTS

Twenty-three Dieulafoy's lesions were treated with APC, which represented 85% of all such lesions observed. Severe comorbidities and abnormal coagulation were present in 39% and 22%, respectively. Dieulafoy's lesions were located in the upper-GI tract in 20 patients (87%). Active bleeding was found in 20 patients (87%), a nonbleeding visible vessel was found in 2 patients (9%), and a minute mucosal defect below an adherent clot was found in 1 (4%). Initial hemostasis was achieved in all patients, without complications. An injection of an average volume of 3 mL of 1:10,000 epinephrine solution preceded APC in 3 cases for the identification of the bleeding lesion. Recurrent bleeding occurred in a patient after 48 hours; no bleeding-related deaths were observed during a median follow-up of 29 months.

LIMITATIONS

Retrospective study.

CONCLUSIONS

Dieulafoy's lesions can be successfully managed by APC alone.

Preventing complications of endoscopic hemostasis in acute upper gastrointestinal hemorrhage

Over the last 20 years, endoscopic hemostasis has become the primary method of controlling acute, overt upper gastrointestinal hemorrhage (UGIH) and prevent rebleeding. Although uncommon, procedure-related complications may occur. This article reviews the risks attributable to endoscopic hemostasis in acute UGIH and how to help prevent these complications.

Endoscopic band ligation therapy for upper gastrointestinal bleeding related to Mallory-Weiss syndrome

BACKGROUND

No consensus exists as to the best endoscopic treatment for Mallory-Weiss syndrome. Endoscopic band ligation is a readily available and easily learned technique. This prospective study evaluated the efficacy and safety of endoscopic band ligation therapy for Mallory-Weiss syndrome.

METHODS

From August 1998 to June 2005, a clinical trial assessed 37 patients with a diagnosis of Mallory-Weiss syndrome who had active bleeding, exposed vessels, or both. Their lesions were treated using endoscopic band ligation.

RESULTS

Endoscopic band ligation was successful in 36 of 37 cases, with a follow-up period ranging from 1 to 24 months. The remaining patient had severe liver failure and disseminated intravascular coagulation. The patient bled again at 12 h and subsequently died. Except for this case, no recurrent bleeding, perforation, or other complications occurred.

CONCLUSIONS

The study results suggest that endoscopic band ligation is an effective, safe, and easily learned procedure for treating upper gastrointestinal bleeding related to Mallory-Weiss syndrome.

Quality in colonoscopy: cecal intubation first, then what?

In 2002, the U.S. MultiSociety Task Force on Colorectal Cancer proposed multiple quality indicators for use in the continuous quality improvement (CQI) process for colonoscopy. The quality indicators were not prioritized for implementation in clinical practice. This editorial reviews evidence suggesting that after cecal intubation rates, two quality indicators should be the priorities for the CQI process for colonoscopy: (1) measurement of individual endoscopists' adenoma detection rates and (2) recommended intervals for postpolypectomy surveillance colonoscopy.

Dieulafoy’s lesion: A case series study

AIM: Dieulafoy’s lesion (DL) accounts for 1-5.8% of cases of acute upper gastrointestinal bleeding (GIB). Its mortality is high, approaching 20%, despite recent advances in endoscopic therapy. We aimed to report our experience in the treatment of DL.

METHODS: A retrospective case study of all patients with DL between January 1993 and January 2003 was done. Characteristics, treatment methods, success rates and 30-d mortality of the patients were analyzed.

RESULTS: Thirty-six patients were noted to have DL in the study period. Thirty-three records were available for assessment in which 35 DL were identified. The median age of the patients was 67 years with male to female ratio of 5.6:1. Significant comorbidities existed in 69% of the patients. Eighty-nine percent of the DL was found at first endoscopy, three DL at laparotomy. Significant coexistent endoscopic findings existed in 23%. Hemostasis was achieved in 88% by using adrenaline injection, or in combination with heater probe application at first endoscopy. Four cases had re-bleeding, all were successfully treated endoscopically. The 30-d mortality rate was 23%.

CONCLUSION: Successful endoscopic hemostasis could be achieved in 100% of cases of DL. The overall mortality may still remain high, mainly due to the comorbidities and age of these patients.

170 degrees wide-angle colonoscope: effect on efficiency and miss rates

BACKGROUND

Small polyps are routinely missed during colonoscopy even with careful examination.

AIM

To determine and compare endoscopic efficiency and polyp miss rate between a prototype 170 degrees wide-angle (WA) colonoscope and a standard (S) colonoscope.

METHODS

Two consecutive same-day colonoscopies were performed in 50 patients with intact colons. The patients were randomized to undergo the first colonoscopy with either the prototype WA 170 degrees angle of view colonoscope or an S adult 140 degrees angle of view colonoscope.

RESULTS

The mean time for insertion was 2.09 (1.09) min versus 2.53 (1.47) min (p= 0.002) for the WA colonoscope and the S colonoscope, respectively. Similarly, the mean time for examination during withdrawal was shorter with the WA colonoscope (4.98 (0.94) vs 5.74 (1.12) min; p < 0.0001). The mean insertion time for the second examination was shorter than the insertion time for the first examination, irrespective of the colonoscope (p= 0.006). However, the withdrawal times were not significantly different between the first and second examinations (p= 0.11). The miss rate for all polyps with the WA colonoscope (19%) was similar to the miss rate with the S colonoscope (27%; p= 0.19). The miss rates for adenomas with the WA (10/33; 30.3%) and the S scope (15/50; 30%) were similar (p= 0.98).

CONCLUSIONS

The use of the WA colonoscope was associated with a reduction in insertion time to the cecum, as well as examination time during withdrawal. No evidence was found that the accuracy of the two colonoscopes differs.

Upper gastrointestinal bleeding

PURPOSE OF REVIEW

This review discusses key issues in the management of upper gastrointestinal bleeding including patient preparation, sedation, hemostatic techniques, disposition, and recommended pharmacologic interventions.

RECENT FINDINGS

Optimal resuscitation before endoscopy and proper pharmacologic interventions after endoscopy seem to be as crucial to the management of patients with upper gastrointestinal bleeding as meticulous hemostatic techniques during the procedure. In a retrospective evaluation of patients with upper gastrointestinal bleeding, multivariate analysis demonstrated significantly reduced morbidity and mortality in those who underwent aggressive preendoscopic resuscitation. In a prospective, randomized clinical trial, patients who received intravenous proton pump inhibitor therapy after endoscopic intervention had a significantly reduced rebleeding rate compared with their placebo control group.

SUMMARY

The algorithms described in this review can be applied clinically today and should directly lead to improved outcome. Nevertheless, even with the latest care available, results are not optimal. This review points to two major areas where we can benefit from improvement: primary hemostasis and recurrent bleeding. By pointing to these limitations, it is hoped that this review can help stimulate research in the field by applying new technologies to solve these problems. Endoscopic ultrasound, for example, could be used to help identify feeding vessels that can be treated endoscopically, thus potentially decreasing the incidence of failed primary hemostasis. Endoscopic suturing, when more fully developed, may provide a better hemostatic technique that can reduce the incidence of recurrent bleeding. It is only through these reviews that our state of knowledge in the field can be constantly reevaluated to update today's clinician with the latest knowledge and stimulate tomorrow's researchers with challenging problems.

A prospective, randomized trial comparing mechanical methods of hemostasis plus epinephrine injection to epinephrine injection alone for bleeding peptic ulcer

BACKGROUND

The hemostatic efficacy of mechanical methods of hemostasis, together with epinephrine injection, was compared with that of epinephrine injection alone in bleeding peptic ulcer.

METHODS

Ninety patients with a peptic ulcer with active bleeding or a non-bleeding visible vessel were randomly assigned to undergo a mechanical method of hemostasis (23 hemoclip application, 22 band ligation) plus epinephrine injection, or epinephrine injection alone.

RESULTS

The two groups were similar with respect to all background variables. Initial hemostasis was achieved in 44/45 (97.8%) patients in both groups. The mean number of hemoclips and elastic bands applied were 2.8: 95% CI[2.5, 3.1] and 1.1: 95% CI[1.0, 1.2], respectively, and the mean volume of epinephrine injected was 19.9 mL: 95% CI[19.3 mL, 20.5 mL]. The rate of recurrent bleeding in the combination group (2/44, 4.5%) was significantly lower in comparison with the injection group (9/44, 20.5%, p < 0.05). The mean number of therapeutic endoscopic sessions needed to achieve permanent hemostasis in the combination group (1.04: 95% CI[1.01, 1.07]) was significantly lower vs. the injection group (1.22: 95% CI[1.15, 1.30]).

CONCLUSIONS

The combination of an endoscopic mechanical method of hemostasis plus epinephrine injection is more effective than epinephrine injection alone for the treatment of bleeding peptic ulcer.

A prospective, randomized trial of endoscopic band ligation vs. epinephrine injection for actively bleeding Mallory-Weiss syndrome

BACKGROUND

Effective hemostatic treatment is mandatory for patients with actively bleeding Mallory-Weiss syndrome. This study evaluated the respective efficacy and the safety of endoscopic band ligation and endoscopic epinephrine injection in Mallory-Weiss syndrome.

METHODS

Thirty-four consecutive patients with actively bleeding Mallory-Weiss syndrome were prospectively enrolled and were randomly assigned to undergo endoscopic band ligation or endoscopic injections of a 1:10,000 solution of epinephrine. Demographic characteristics, endoscopic variables, and outcome parameters, including rates of hemostasis and recurrent bleeding, were analyzed.

RESULTS

The number of elastic bands applied was one or two; the mean volume of epinephrine injected was 18.0 mL: 95% CI[16.8, 19.2]. There was no significant difference between the groups with respect to age, gender, alcohol ingestion, presenting symptoms, Hb level, shock, comorbid diseases, coagulopathy, tear location, blood transfusion, or duration of hospitalization. Primary hemostasis was achieved in all 17 patients in the band ligation group and in 16 of 17 patients (94.1%) in the epinephrine injection group. There was no recurrence of bleeding or major complication in either group.

CONCLUSIONS

In this small study, no difference was detected in the efficacy or the safety of band ligation vs. epinephrine injection for the treatment of actively bleeding Mallory-Weiss syndrome.