Predictors of hemostatic failure after adrenaline injection in patients with peptic ulcers with non-bleeding visible vessel

At admission hemodynamic instability is associated with increased mortality and rebleeding rate in acute gastrointestinal bleeding: a systematic review and meta-analysis

BACKGROUND

Acute gastrointestinal bleeding (GIB) is a life-threatening event. Around 20-30% of patients with GIB will develop hemodynamic instability (HI).

OBJECTIVES

We aimed to quantify HI as a risk factor for the development of relevant end points in acute GIB.

DESIGN

A systematic search was conducted in three medical databases in October 2021.

DATA SOURCES AND METHODS

Studies of GIB patients detailing HI as a risk factor for the investigated outcomes were selected. For the overall results, pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated based on a random-effects model. Subgroups were formed based on the source of bleeding. The Quality of Prognostic Studies tool was used to assess the risk of bias.

RESULTS

A total of 62 studies were eligible, and 39 were included in the quantitative synthesis. HI was found to be a risk factor for both in-hospital (OR: 5.48; CI: 3.99-7.52) and 30-day mortality (OR: 3.99; CI: 3.08-5.17) in upper GIB (UGIB). HI was also associated with higher in-hospital (OR: 3.68; CI: 2.24-6.05) and 30-day rebleeding rates (OR: 4.12; 1.83-9.31) among patients with UGIB. The need for surgery was also more frequent in hemodynamically compromised UGIB patients (OR: 3.65; CI: 2.84-4.68). In the case of in-hospital mortality, the risk of bias was high for 1 (4%), medium for 13 (48%), and low for 13 (48%) of the 27 included studies.

CONCLUSION

Hemodynamically compromised patients have increased odds of all relevant untoward end points in GIB. Therefore, to improve the outcomes, adequate emergency care is crucial in HI.

REGISTRATION

PROSPERO registration number: CRD42021285727.

Meta-analysis: predictors of rebleeding after endoscopic treatment for bleeding peptic ulcer

BACKGROUND

Determining the risk of rebleeding after endoscopic therapy for peptic ulcer bleeding (PUB) may be useful for establishing additional haemostatic measures in very high-risk patients.

AIM

To identify predictors of rebleeding after endoscopic therapy.

METHODS

Bibliographic database searches were performed to identify studies assessing rebleeding after endoscopic therapy for PUB. All searches and data abstraction were performed in duplicate. A parameter was considered to be an independent predictor of rebleeding when it was detected as prognostic by multivariate analyses in ≥2 studies. Pooled odds ratios (pOR) were calculated for prognostic variables.

RESULTS

Fourteen studies met the prespecified inclusion criteria. Pre-endoscopic predictors of rebleeding were: (i) Haemodynamic instability: significant in 9 of 13 studies evaluating the variable (pOR: 3.30, 95% CI: 2.57-4.24); (ii) Haemoglobin value: significant in 2 of 10 (pOR: 1.73, 95% CI: 1.14-2.62) and (iii) Transfusion: significant in two of six (pOR not calculable). Endoscopic predictors of rebleeding were: (i) Active bleeding: significant in 6 of 12 studies (pOR: 1.70, 95% CI: 1.31-2.22); (ii) Large ulcer size: significant in 8 of 12 studies (pOR: 2.81, 95% CI: 1.98-4.00); (iii) Posterior duodenal ulcer location: significant in four of eight studies (pOR: 3.83, 95% CI: 1.38-10.66) and (iv) High lesser gastric curvature ulcer location: significant in three of eight studies (pOR: 2.86; 95% CI: 1.69-4.86).

CONCLUSIONS

Major predictors for rebleeding in patients receiving endoscopic therapy are haemodynamic instability, active bleeding at endoscopy, large ulcer size, ulcer location, haemoglobin value and the need for transfusion. These risk factors may be useful for guiding clinical management in patients with PUB.

Epidemiology and demographics of upper gastrointestinal bleeding: prevalence, incidence, and mortality

Despite major advances in diagnosis, prevention, and treatment, nonvariceal upper gastrointestinal bleeding still is a serious problem in clinical practice. Current evidence indicates that most peptic ulcer bleeding-linked deaths are not a direct sequela of the bleeding ulcer itself. Instead, mortality derives from multiorgan failure, cardiopulmonary conditions, or terminal malignancy, suggesting that improving further current treatments for the bleeding ulcer may have a limited impact on mortality unless supportive therapies are developed for the global management of these patients.

[Classification and management of upper gastrointestinal bleeding]

The upper gastrointestinal bleeding remains the most frequent emergency in gastroenterology. Due to the different therapeutic approach a distinction between the variceal and the non-variceal bleeding has been established. A risk assessment for the individual patient is crucial for timing of the endoscopic procedure as well as for the estimation of prognosis. This review gives an overview on modern therapeutic techniques for both, variceal and non-variceal bleeding highlighting on success rates but also on potential complications of the different therapeutic interventions.

[Mallory-Weiss syndrome: diagnosis and treatment]

Mallory-Weiss syndrome is relatively common and is involved in 3 to 10% of cases of upper gastrointestinal bleeding. Most of the time, the hemorrhage is mild and stops spontaneously. Clinical suspicion requires confirmation by an upper gastrointestinal endoscopy, which must be performed rapidly after the first hematemesis. Mallory-Weiss syndrome is diagnosed when it shows a longitudinal mucosal tear at the esophagogastric junction. Patients with active bleeding or signs of recent bleeding at endoscopy need immediate endoscopic treatment for hemostasis. Band ligation seems to be the most efficient procedure for primary hemostasis and for preventing recurrent bleeding. The use of proton pump inhibitors and antiemetics seems logical in all cases, although nothing in the literature demonstrates their efficacy.

Comparison of hemostatic efficacy for argon plasma coagulation and distilled water injection in treating high-risk bleeding ulcers

GOALS AND BACKGROUND

Endoscopic treatment is recommended for initial hemostasis in nonvariceal upper gastrointestinal bleeding. Many endoscopic devices have been demonstrated to be effective in the hemostasis of bleeding ulcers. However, the hemostatic efficacy of argon plasma coagulation (APC) has not been widely investigated.

STUDY

From February 2007 to February 2008, 271 consecutive patients with high-risk bleeding ulcers, characterized by active bleeding, nonbleeding visible vessels and adherent clots, were admitted to our hospital. Among these patients, 135 nonrandomly underwent either APC therapy or distilled water injection. Pantoprazole infusion was conducted during the fasting period after endoscopy and orally for 8 weeks to encourage ulcer healing. Episodes of rebleeding were retreated with endoscopic combination therapy. Patients who did not benefit from retreatment underwent emergency surgery.

RESULTS

In all,135 patients were enrolled, among whom 6 with gastric malignancy, acute severe illness or multiple bleeding sites were excluded. Finally, hemostatic efficacy in 59 patients treated with APC was prospectively compared with 70 patients treated with distilled water injection. The two treatment groups were similar with respect to all baseline characteristics. Initial hemostasis was accomplished in 57 patients treated with APC, and 64 patients with distilled water injection therapy (97% vs. 91%, P=0.29). Bleeding recurred in 6 patients treated with APC, and in 17 patients treated with distilled water injection (11% vs. 27%, P=0.03). No significant differences were observed between the 2 groups in hospital stay, transfusion requirements, surgery and mortality.

CONCLUSIONS

Endoscopic therapy with APC is more effective than distilled water injection for preventing rebleeding in the treatment of high-risk bleeding ulcers.

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.

Systematic review of the predictors of recurrent hemorrhage after endoscopic hemostatic therapy for bleeding peptic ulcers

BACKGROUND

An increased knowledge regarding the predictors of rebleeding after endoscopic therapy for bleeding ulcers should improve clinical management and outcomes. The aim of this systematic review was to identify the strongest and most consistent predictors of rebleeding to assist in the development of tools to stratify and appropriately manage patients after endoscopic therapy.

METHODS

Bibliographic database searches for prospective studies assessing rebleeding after endoscopic therapy for bleeding ulcers were performed. Relevant studies were identified, and data were abstracted in a duplicate and independent fashion. The primary outcomes sought were significant independent predictors of rebleeding by multivariable analyses in > or =2 studies.

RESULTS

Ten articles met the prespecified inclusion criteria. The pooled rate of rebleeding after endoscopic therapy was 16.4%. The independent pre-endoscopic predictors of rebleeding were hemodynamic instability (significant in 5 of 5 studies; summary odds ratio [OR] 2.75, 95% confidence interval [CI] 1.99-3.51) and comorbid illness (significant in 2 of 7 studies; insufficient data to calculate summary OR or report OR range). The independent endoscopic predictors of rebleeding were active bleeding at endoscopy (significant in 5 of 8 studies; summary OR 1.93, 95% CI 1.30-2.55), large ulcer size (significant in 4 of 5 studies; summary OR 2.01, 95% CI 1.21-2.80), posterior duodenal ulcer (significant in 2 of 3 studies; insufficient data to calculate summary OR or report OR range), and lesser gastric curvature ulcer (significant in 2 of 2 studies; insufficient data to calculate summary OR or report OR range).

CONCLUSIONS

The independent predictors of recurrent hemorrhage after endoscopic therapy, particularly those that are the strongest and most consistent in the literature, may be used to select patients who are most likely to benefit from aggressive post-hemostasis care, including intensive care unit (ICU) observation and second-look endoscopy. Prospective studies designed to formally assess the relative utilities of these factors in predicting rebleeding and dictating management are needed.

Model to predict rebleeding following endoscopic therapy for non-variceal upper gastrointestinal hemorrhage

BACKGROUND AND AIM

Following endoscopic therapy, up to 20% of patients with non-variceal upper gastrointestinal hemorrhage experience rebleeding. The aim of the present study was to determine risk factors for recurrent hemorrhage in these patients.

METHODS

This was a retrospective cohort study of consecutive patients admitted to a tertiary care hospital between 1 July 1999 and 30 June 2004, with non-variceal upper gastrointestinal hemorrhage. Patients were evaluated for rebleeding within 30 days of successful therapeutic endoscopy. Using the hospital's endoscopic database, 236 patients were identified. Risk factors were identified using multivariable logistic regression with backward selection. Internal validation was carried out using bootstrapping.

RESULTS

Six risk factors were identified: failure to use a proton pump inhibitor post-procedure (P = 0.056), Endoscopically demonstrated bleeding (P = 0.053), peptic ulcer as the bleeding source (P = 0.018), treatment with epinephrine monotherapy (P = 0.0026), post-procedure intravenous or low molecular weight heparin use (P = 0.0014), and moderate or severe cirrhosis (P = 0.032) (PEPTIC). The risk of rebleeding increased as the number of risk factors present increased. The observed rates of rebleeding were: 7.1%, 16.4%, 37.0%, 75.0% and 100% for zero, one, two, three or four risk factors, respectively (no patients had five or six risk factors present). The bias-adjusted area under the receiver-operator characteristic curve for the number of risk factors predicting rebleeding was 0.69.

CONCLUSIONS

We have identified six easily remembered risk factors, which, when summed, predict recurrent hemorrhage following endoscopic therapy for non-variceal upper gastrointestinal hemorrhage.

Continuous infusion of high-dose omeprazole is more effective than standard-dose omeprazole in patients with high-risk peptic ulcer bleeding: a retrospective study

High-dose omeprazole reduces the rate of recurrent bleeding after endoscopic treatment of peptic ulcer bleeding. However, the effectiveness of high-dose vs. standard-dose omeprazole in peptic ulcer bleeding has never been shown.

AIM

To compare the benefits of high-dose vs. standard-dose omeprazole in peptic ulcer bleeding.

METHODS

We reviewed the medical files of patients admitted between 1997 and 2004 for high-risk peptic ulcer bleeding who had undergone successful endoscopic treatment. We distinguished 2 periods: before 2001, standard-dose omeprazole (40 mg/day intravenously until alimentation was possible, then 40 mg/day orally for 1 week); after 2001, high-dose omeprazole (80 mg bolus injection, then 8 mg/h continuous infusion for 72 h, then 40 mg/day orally for 1 week). During both periods, patients subsequently received omeprazole, 20 mg/day, orally for 3 weeks.

RESULTS

We enrolled 114 patients (period 1, n = 45, period 2, n = 69). Therapy with high-dose omeprazole significantly decreased the occurrence of poor outcome (27 vs. 12%, P = 0.04), rebleeding (24 vs. 7%, P = 0.01), mortality due to haemorrhagic shock (11 vs. 0%, P < 0.001) and need for surgery (9 vs. 1%, P = 0.05).

CONCLUSIONS

In this retrospective study, high-dose omeprazole reduced the occurrence of rebleeding, need for surgery and mortality due to hemorrhagic shock in patients with high-risk peptic ulcer bleeding, as compared with standard-dose omeprazole.

Factors associated with failure of initial endoscopic hemoclip hemostasis for upper gastrointestinal bleeding

BACKGROUND

Endoscopic hemoclip is widely used for the management of bleeding peptic ulcers. The major difficulty in clinical application of the hemoclip is deployment to the lesion during initial hemostasis. The aim of this study was to define factors associated with the failure of endoscopic hemoclip for initial hemostasis of upper GI bleeding.

PATIENTS AND METHODS

From January to December 2003, we prospectively studied 77 randomized patients with clinical evidence of upper GI bleeding due to either active bleeding or a visible vessel identified by upper GI endoscopy in our emergency department.

RESULTS

Among the 77 patients, 13 (16.9%) failed treatment (Group 1) and 64 (83.1%) were successfully (Group 2) treated by endoscopic hemoclip for lesions related to upper GI bleeding. There were no differences due to gender, blood pressure, initial heart rate, and hemoglobulin before or after endoscopic treatment, platelet count, serum creatinine, and albumin between groups. The mean age of Group 1 was higher than that of Group 2 (73.31+/-9.38 years vs. 65.41+/-16.45 years, respectively; P=0.083). Most patients who did not achieve initial hemostasis by endoscopic hemoclip had upper GI lesions over the gastric antrum and duodenal bulb. Among the 13 patients who failed to achieve endoscopic hemoclip initial hemostasis, four lesions were located over the posterior wall of the antrum, and four lesions over the lesser curvature side of the duodenal bulb.

CONCLUSION

Endoscopic hemoclip is an effective hemostatic method for upper GI bleeding. Age, gastric antrum, and duodenal bulb lesions may be associated with the failure of initial hemostasis by endoscopic hemoclip.