Endoscopic injection therapy of bleeding ulcer: a prospective and randomized comparison of adrenaline alone or with polidocanol

Systematic review with network meta-analysis: dual therapy for high-risk bleeding peptic ulcers

BACKGROUND

Adding a second endoscopic therapy to epinephrine injection might improve hemostatic efficacy in patients with high-risk bleeding ulcers but the optimum modality remains unknown. We aimed to estimate the comparative efficacy of different dual endoscopic therapies for the management of bleeding peptic ulcers through random-effects Bayesian network meta-analysis.

METHODS

Different databases were searched for controlled trials comparing dual therapy versus epinephrine monotherapy or epinephrine combined with another second modality until September, 30 2016. We estimated the ORs for rebleeding, surgery and mortality among different treatments. Adverse events were also evaluated.

RESULTS

Seventeen eligible articles were included in the network meta-analysis. The addition of mechanical therapy (OR 0.19, 95% CrI 0.07-0.52 and OR 0.10, 95% CrI 0.01-0.50, respectively) after epinephrine injection significantly reduced the probability of rebleeding and surgery. Similarly, patients who received epinephrine plus thermal therapy showed a significantly decreased rebleeding rate (OR 0.30, 95% CrI 0.10-0.91), as well as a non-significant reduction in surgery (OR 0.47, 95% CrI 0.16-1.20). Although differing, epinephrine plus mechanical therapy did not provide a significant reduction in rebleeding (OR 0.62, 95% CrI 0.19-2.22) and surgery (OR 0.21, 95% CrI 0.03-1.73) compared to epinephrine plus thermal therapy. Sclerosant failed to confer further benefits and was ranked highest among the 5 treatments in relation to adverse events.

CONCLUSIONS

Mechanical therapy was the most appropriate modality to add to epinephrine injection. Epinephrine plus thermal coagulation was effective for controlling high risk bleeding ulcers. There was no further benefit with sclerosants with regard to rebleeding or surgery, and sclerosants were also associated with more adverse events than any other modality.

Epinephrine injection versus epinephrine injection and a second endoscopic method in high-risk bleeding ulcers

BACKGROUND

Endoscopic therapy reduces the rebleeding rate and the need for surgery in patients with bleeding peptic ulcers.

OBJECTIVES

To determine whether a second procedure improves haemostatic efficacy or patient outcomes or both after epinephrine injection in adults with high-risk bleeding ulcers.

SEARCH METHODS

For our update in 2014, we searched the following versions of these databases, limited from June 2009 to May 2014: Ovid MEDLINE(R) 1946 to May Week 2 2014; Ovid MEDLINE(R) Daily Update May 22, 2014; Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations May 22, 2014 (Appendix 1); Evidence-Based Medicine (EBM) Reviews-the Cochrane Central Register of Controlled Trials (CENTRAL) April 2014 (Appendix 2); and EMBASE 1980 to Week 20 2014 (Appendix 3).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing epinephrine alone versus epinephrine plus a second method. Populations consisted of patients with high-risk bleeding peptic ulcers, that is, patients with haemorrhage from peptic ulcer disease (gastric or duodenal) with major stigmata of bleeding as defined by Forrest classification Ia (spurting haemorrhage), Ib (oozing haemorrhage), IIa (non-bleeding visible vessel) and IIb (adherent clot) (Forrest Ia-Ib-IIa-IIb).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by The Cochrane Collaboration. Meta-analysis was undertaken using a random-effects model; risk ratios (RRs) with 95% confidence intervals (CIs) are presented for dichotomous data.

MAIN RESULTS

Nineteen studies of 2033 initially randomly assigned participants were included, of which 11 used a second injected agent, five used a mechanical method (haemoclips) and three employed thermal methods.The risk of further bleeding after initial haemostasis was lower in the combination therapy groups than in the epinephrine alone group, regardless of which second procedure was applied (RR 0.53, 95% CI 0.35 to 0.81). Adding any second procedure significantly reduced the overall bleeding rate (persistent and recurrent bleeding) (RR 0.57, 95% CI 0.43 to 0.76) and the need for emergency surgery (RR 0.68, 95% CI 0.50 to 0.93). Mortality rates were not significantly different when either method was applied.Rebleeding in the 10 studies that scheduled a reendoscopy showed no difference between epinephrine and combined therapy; without second-look endoscopy, a statistically significant difference was observed between epinephrine and epinephrine and any second endoscopic method, with fewer participants rebleeding in the combined therapy group (nine studies) (RR 0.32, 95% CI 0.21 to 0.48).For ulcers of the Forrest Ia or Ib type (oozing or spurting), the addition of a second therapy significantly reduced the rebleeding rate (RR 0.66, 95% CI 0.49 to 0.88); this difference was not seen for type IIa (visible vessel) or type IIb (adherent clot) ulcers. Few procedure-related adverse effects were reported, and this finding was not statistically significantly different between groups. Few adverse events occurred, and no statistically significant difference was noted between groups.The addition of a second injected method reduced recurrent and persistent rebleeding rates and surgery rates in the combination therapy group, but these findings were not statistically significantly different. Significantly fewer participants died in the combined therapy group (RR 0.50, 95% CI 0.25 to 1.00).Epinephrine and a second mechanical method decreased recurrent and persistent bleeding (RR 0.31, 95% CI 0.18 to 0.54) and the need for emergency surgery (RR 0.20, 95% CI 0.06 to 0.62) but did not affect mortality rates.Epinephrine plus thermal methods decreased the rebleeding rate (RR 0.49, 95% CI 0.30 to 0.78) and the surgery rate (RR 0.20, 95% CI 0.06 to 0.62) but did not affect the mortality rate.Our risk of bias estimates show that risk of bias was low, as, although the type of study did not allow a double-blind trial, rebleeding, surgery and mortality were not dependent on subjective observation. Although some studies had limitations in their design or implementation, most were clear about important quality criteria, including randomisation and allocation concealment, sequence generation and blinding.

AUTHORS' CONCLUSIONS

Additional endoscopic treatment after epinephrine injection reduces further bleeding and the need for surgery in patients with high-risk bleeding peptic ulcer. The main adverse events include risk of perforation and gastric wall necrosis, the rates of which were low in our included studies and favoured neither epinephrine therapy nor combination therapy. The main conclusion is that combined therapy seems to work better than epinephrine alone. However, we cannot conclude that a particular form of treatment is equal or superior to another.

Predictors of rebleeding after initial hemostasis with epinephrine injection in high-risk ulcers

AIM

To identify the predictors of rebleeding after initial hemostasis with epinephrine injection (EI) in patients with high-risk ulcers.

METHODS

Recent studies have revealed that endoscopic thermocoagulation, or clips alone or combined with EI are superior to EI alone to arrest ulcer bleeding. However, the reality is that EI monotherapy is still common in clinical practice. From October 2006 to April 2008, high-risk ulcer patients in whom hemorrhage was stopped after EI monotherapy were studied using clinical, laboratory and endoscopic variables. The patients were divided into 2 groups: sustained hemostasis and rebleeding.

RESULTS

A total of 175 patients (144, sustained hemostasis; 31, rebleeding) were enrolled. Univariate analysis revealed that older age (≥ 60 years), advanced American Society of Anesthesiology (ASA) status (category III, IV and V), shock, severe anemia (hemoglobin < 80 g/L), EI dose ≥ 12 mL and severe bleeding signs (SBS) including hematemesis or hematochezia were the factors which predicted rebleeding. However, only older age, severe anemia, high EI dose and SBS were independent predictors. Among 31 rebleeding patients, 10 (32.2%) underwent surgical hemostasis, 15 (48.4%) suffered from delayed hemostasis causing major complications and 13 (41.9%) died of these complications.

CONCLUSION

Endoscopic EI monotherapy in patients with high-risk ulcers should be avoided. Initial hemostasis with thermocoagulation, clips or additional hemostasis after EI is mandatory for such patients to ensure better hemostatic status and to prevent subsequent rebleeding, surgery, morbidity and mortality.

How evidence-based are current guidelines for managing patients with peptic ulcer bleeding?

Current guidelines for managing ulcer bleeding state that patients with major stigmata should be managed by dual endoscopic therapy (injection with epinephrine plus a thermal or mechanical modality) followed by a high dose intravenous infusion of proton pump inhibitors (PPIs). This paper aims to review and critically evaluate evidence supporting the purported superiority of a continuous infusion over less intensive regimens of PPIs administration and the need for adding a second hemostatic endoscopic procedure to epinephrine injection. Systematic searches of PubMed, EMBASE and the Cochrane library were performed. There is strong evidence for an incremental benefit of PPIs over H2-receptor antagonists or placebo for the outcome of patients with peptic ulcer bleeding following endoscopic hemostasis. However, the benefit of PPIs is unrelated to either the dosage (intensive vs standard regimen) or the route of administration (intravenous vs oral). There is significant heterogeneity among the 15 studies that compared epinephrine with epinephrine plus a second modality, which might preclude the validity of reported summary estimates. Studies without second look endoscopy plus re-treatment of re-bleeding lesions showed a significant benefit of adding a second endoscopic modality for hemostasis, while studies with second-look and re-treatment showed equal efficacy between endoscopic mono and dual therapy. Inconclusive experimental evidence supports the current recommendation of the use of dual endoscopic hemostatic means and infusion of high-dose PPIs as standard therapy for patients with bleeding peptic ulcers. Presently, the combination of epinephrine monotherapy with standard doses of PPIs constitutes an appropriate treatment for the majority of patients.

Endoscopic hemostasis in peptic ulcer bleeding for patients with high-risk lesions: a series of meta-analyses

BACKGROUND AND OBJECTIVE

Optimal endoscopic hemostasis remains undetermined. This was a systematic review of contemporary methods of endoscopic hemostasis for patients with bleeding ulcers that exhibited high-risk stigmata.

SETTING

Randomized trials that evaluated injection, thermocoagulation, clips, or combinations of these were evaluated from MEDLINE, EMBASE, and CENTRAL (1990-2006).

PATIENTS

A total of 4261 patients were evaluated.

OUTCOMES

Outcomes were rebleeding (primary), surgery, and mortality (secondary). Summary statistics were determined; publication bias and heterogeneity were sought by using funnel plots or by subgroup analyses and meta-regression.

RESULTS

Forty-one trials assessed 4261 patients. All endoscopic therapies decreased rebleeding versus pharmacotherapy alone, including sole intravenous (IV) proton pump inhibition (PPI) (OR 0.56 [95% CI, 0.34-0.92]); only one trial assessed high-dose IV PPI. Injection alone was inferior compared with other methods, except for thermal hemostasis (OR 1.02 [95% CI, 0.74-1.40]), with a strong trend of increased rebleeding if 1 injectate is used rather than 2 (OR 1.40 [95% CI, 0.95-2.05]). Injection followed by thermal therapy did not decrease rebleeding compared with clips (OR 0.82 [95% CI, 0.28-2.38]) or thermal therapy alone (OR 0.79 [95% CI, 0.24-2.62]). Subgroup analysis, however, suggested that injection followed by thermal therapy was superior to thermal therapy alone. Clips were superior to thermal therapy (OR 0.24 [95% CI, 0.06-0.95]) but, when followed by injection, were not superior to clips alone (OR 1.30 [95% CI, 0.36-4.76]). Surgery or mortality was not altered in most comparisons.

CONCLUSIONS

All endoscopic treatments are superior to pharmacotherapy alone; only 1 study assessed high-dose IV PPI. Optimal endoscopic therapies include thermal therapy or clips, either alone or in combination with other methods. Additional data are needed that compare injection followed by thermal therapy to clips alone or clips combined with another method.

Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials

The aim of this study was to determine appropriate endoscopic treatment of patients with bleeding ulcers by synthesizing results of randomized controlled trials. We performed dual independent bibliographic database searches to identify randomized trials of thermal therapy, injection therapy, or clips for bleeding ulcers with active bleeding, visible vessels, or clots, focusing on results from studies without second-look endoscopy and re-treatment. The primary end point was further (persistent plus recurrent) bleeding. Compared with epinephrine, further bleeding was reduced significantly by other monotherapies (relative risk [RR], 0.58 [95% CI, 0.36-0.93]; number-needed-to-treat [NNT], 9 [95% CI, 5-53]), and epinephrine followed by another modality (RR, 0.34 [95% CI, 0.23-0.50]; NNT, 5 [95% CI, 5-7]); epinephrine was not significantly less effective in studies with second-look and re-treatment. Compared with no endoscopic therapy, further bleeding was reduced by thermal contact (heater probe, bipolar electrocoagulation) (RR, 0.44 [95% CI, 0.36-0.54]; NNT, 4 [95% CI, 3-5]) and sclerosant therapy (RR, 0.56 [95% CI, 0.38-0.83]; NNT, 5 [95% CI, 4-13]). Clips were more effective than epinephrine (RR, 0.22 [95% CI, 0.09-0.55]; NNT, 5 [95% CI, 4-9]), but not different than other therapies, although the latter studies were heterogeneous, showing better and worse results for clips. Endoscopic therapy was effective for active bleeding (RR, 0.29 [95% CI, 0.20-0.43]; NNT, 2 [95% CI, 2-2]) and a nonbleeding visible vessel (RR, 0.49; [95% CI, 0.40-0.59]; NNT, 5 [95% CI, 4-6]), but not for a clot. Bolus followed by continuous-infusion proton pump inhibitor after endoscopic therapy significantly improved outcome compared with placebo/no therapy (RR, 0.40 [95% CI, 0.28-0.59]; NNT, 12 [95% CI, 10-18]), but not compared with histamine(2)-receptor antagonists. Thermal devices, sclerosants, clips, and thrombin/fibrin glue appear to be effective endoscopic hemostatic therapies. Epinephrine should not be used alone. Endoscopic therapy should be performed for ulcers with active bleeding and nonbleeding visible vessels, but efficacy is uncertain for clots. Bolus followed by continuous-infusion intravenous proton pump inhibitor should be used after endoscopic therapy.

Endoscopic clipping for acute nonvariceal upper-GI bleeding: a meta-analysis and critical appraisal of randomized controlled trials

BACKGROUND

Acute nonvariceal upper-GI bleeding (NVUGIB) is common, with a high rate of recurrent bleeding and substantial mortality rate. Endoscopic clipping has the theoretical advantage of minimizing tissue injury and is increasingly used.

OBJECTIVE

We conducted a systematic review and meta-analysis to investigate any potential benefits of clipping over other endoscopic techniques for NVUGIB.

DESIGN

Randomized controlled trials (RCT) that compared clipping with other endoscopic hemostatic methods to treat NVUGIB were included. Summary effect size was estimated by odds ratio (OR) with a random-effects model.

RESULTS

Twelve RCTs met inclusion criteria. For peptic ulcer bleeding (PUB), the hemoclip (n = 351 patients) was compared with the heat probe alone, thermal therapy plus injection, and injection alone in 2, 2, and 5 studies, respectively (n = 348 patients). The rate of the initial hemostasis was nonsignificantly increased in the control group compared with the hemoclip group (92% vs 96%, OR 0.58 [95% CI, 0.19-1.75]). The rebleeding rate was nonsignificantly decreased with hemoclips compared with controls (8.5% vs 15.5%, OR 0.56 [95% CI, 0.30-1.05]). Emergency surgery and the mortality rate were not significantly different between the hemoclip and controls. Subgroup analysis conducted in studies that compared hemoclips with injection alone show similar results. Two studies and one study reported outcomes of interest for Dieulafoy's lesions and Mallory-Weiss syndrome, respectively.

CONCLUSIONS

RCTs that compared clipping alone with other endoscopic hemostatic techniques for NVUGIB were limited. Current evidence suggests that the hemoclip is not superior to other endoscopic modalities in terms of initial hemostasis, rebleeding rate, emergency surgery, and the mortality rate for treatment of PUB.

Large-volume endoscopic injection of epinephrine plus normal saline for peptic ulcer bleeding

BACKGROUND AND AIM

Large-volume endoscopic injection of epinephrine has been proven to significantly reduce rates of recurrent peptic ulcer bleeding. Injection of normal saline may be equally effective for the similar hemostatic effect of local tamponade. The aim of our study was to compare the therapeutic effects of large-volume (40 mL) endoscopic injections of epinephrine, normal saline and a combination of the two in patients with active bleeding ulcers.

METHOD

A total of 216 patients with actively bleeding ulcers (spurting or oozing) were randomly assigned to three groups (1:10,000 epinephrine, normal saline or diluted epinephrine plus normal saline). The hemostatic effects and clinical outcomes were compared between the three groups.

RESULTS

The initial hemostatic rate was significantly lower in the normal saline group (P < 0.05). The volume of injected solution required for the arrest of bleeding was significantly larger in the normal saline group (P < 0.01). Mean duration for arrest of bleeding was significantly longer in the normal saline group (P < 0.01). There were no significant differences between the three groups with respect to the rates of recurrent bleeding, surgical intervention, 30-day mortality, amount of transfusion and duration of hospitalization. Significant elevation of systolic blood pressure (P < 0.05) and persistent high pulse rate after endoscopic injection were observed in the epinephrine group.

CONCLUSIONS

For patients with active bleeding ulcers (spurting or oozing), we recommend a large-volume (40 mL) combination injection using diluted epinephrine to cease bleeding, followed by injection of normal saline to achieve sustained hemostasis.

Epinephrine injection versus epinephrine injection and a second endoscopic method in high risk bleeding ulcers

BACKGROUND

Endoscopic therapy reduces rebleeding rate, need for surgery, and mortality in patients with bleeding peptic ulcers. Injection of epinephrine is the most popular therapeutic method. Guidelines disagree on the need for a second haemostatic procedure immediately after epinephrine.

OBJECTIVES

The objective of this review was to determine whether the addition of a second procedure improves efficacy or patient outcomes or both after epinephrine injection in adults with high risk bleeding ulcers.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials - CENTRAL (which includes the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register) (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006) and reference lists of articles. We also contacted experts in the field.

SELECTION CRITERIA

Randomised studies comparing endoscopic treatment: epinephrine alone versus epinephrine associated with a second haemostatic method in adults with haemorrhage from peptic ulcer disease with major stigmata of bleeding as defined by the Forrest classification. Bleeding must have been confirmed by endoscopy.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

Seventeen studies including 1763 people were included. Adding a second procedure reduced further bleeding rate from 18.8% to 10.4%; Peto Odds Ratio 0.51; 95% confidence interval (CI) 0.39 to 0.66, and emergency surgery from 10.8% to 7.1%; OR 0.63; 95% CI 0.45 to 0.89. Mortality fell from 5% to 2.5% OR 0.50; 95% CI 0.30 to 0.82. Subanalysis showed that the risk of further bleeding decreased regardless of which second procedure was applied. In addition, the risk was reduced in all subgroups.

AUTHORS' CONCLUSIONS

Additional endoscopic treatment after epinephrine injection reduces further bleeding, the need for surgery and mortality in patients with bleeding peptic ulcer.

Dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers: a meta-analysis of controlled trials

BACKGROUND

There is no definite recommendation on the use of dual endoscopic therapy in patients with severe peptic ulcer bleeding. A systematic review and meta-analysis were performed to determine whether the use of two endoscopic hemostatic procedures improved patient outcomes compared with monotherapy.

METHODS

A search for randomized trials comparing dual therapy (i.e., epinephrine injection plus other injection or thermal or mechanical method) versus monotherapy (injection, thermal, or mechanical alone) was performed between 1990 and 2006. Heterogeneity between studies was tested with chi(2) and explained by metaregression analysis.

RESULTS

Twenty studies (2,472 patients) met inclusion criteria. Compared with controls, dual endoscopic therapy reduces the risk of recurrent bleeding (OR [odds ratio] 0.59 [0.44-0.80], P= 0.0001) and the risk of emergency surgery (OR 0.66 [0.49-0.89], P= 0.03) and showed a trend toward a reduction in the risk of death (OR 0.68 [0.46-1.02], P= 0.06). Subcategory analysis showed that dual therapy was significantly superior to injection therapy alone for all the outcomes considered, but failed to demonstrate that any combination of treatments is better than either mechanical therapy alone (OR 1.04 [0.45-2.45] for rebleeding, 0.49 [0.50-4.87] for surgery, and 1.28 [0.34-4.86] for death) or thermal therapy alone (OR 0.67 [0.40-1.20] for rebleeding, 0.89 [0.45-1.76] for surgery, and 0.51 [0.24-1.10] for death).

CONCLUSIONS

Dual endoscopic therapy proved significantly superior to epinephrine injection alone, but had no advantage over thermal or mechanical monotherapy in improving the outcome of patients with high-risk peptic ulcer bleeding.

Non-surgical approach to bleeding gastric ulcer

Bleeding gastric ulcers is a common reason for emergency upper endoscopy in Emergency Center of Clinical Center of Serbia. Randomized controlled trials have shown that endoscopic hemostasis is beneficial for patients with a bleeding peptic ulcer. Aim of this study was to analyze the frequency, etiological factors and localization of bleeding gastric ulcer. At the same time we were evaluated a degree of bleeding activity according to Forrest?s classification and modality of performed endoscopic hemostasis. All patients who underwent upper gastrointestinal (UGI) endoscopy for bleeding gastric ulcer in Emergency Center (January 2001.- December 2005.) were identified from an endoscopy database and the clinical records were reviewed retrospectivel. A total of 3954 patients underwent UGI endoscopy for presumed acute UGI hemorrhage. More than thirty % of them(31,1)- 1230 had an endoscopic diagnosis of bleeding gastric ulcer. We observed 1230 bleeding patients (60 % male and 40 % female) with a mean age of 64,3. The commonest localization of bleeding gastric ulcers was antrum (54 - 15%). Percentage of patients who received non-steroidal anti-inflammatory drugs (NSAIDs) and/or salicilates before bleeding was 54, 6%. The main symptom was melaena, which was observed in 82, 44% of patients with bleeding gastric ulcer. According to Forrest?s classification of bleeding activity, the most of patients had F IB and F III degree (23, 41% and 22, 76%). Injection endoscopic hemostasis was performed in 26,34% patients, which had active bleeding (F IA, F IB) Hemostasis was initially obtained in 96% of bleeding patients. Bleeding gastric ulcer is one of the commonest endoscopic diagnosis in Emergency Center of Clinical Center of Serbia. The most frequent etiology factor was no - steroid antinflamatory drugs and/or salicilates. Injection endoscopic hemostasis is a safe procedure with a low cost, and, if successful, substantially reduces the need for emergency surgery.

Optimal injection volume of epinephrine for endoscopic treatment of peptic ulcer bleeding

AIM: To define the optimal injection volume of epinephrine with high efficacy for hemostasis and low complication rate in patients with actively bleeding ulcers.

METHODS: This prospective, randomized, comparative trial was conducted in a medical center. A total of 228 patients with actively bleeding ulcers (spurting or oozing) were randomly assigned to three groups with 20, 30 and 40 mL endoscopic injections of an 1:10 000 solution of epinephrine. The hemostatic effects and clinical outcomes were compared between the three groups.

RESULTS: There were no significant differences in all background variables between the three groups. Initial hemostasis was achieved in 97.4%, 98.7% and 100% of patients respectively in the 20, 30 and 40 mL epinephrine groups. There were no significant differences in the rate of initial hemostasis between the three groups. The rate of peptic ulcer perforation was significantly higher in the 40 mL epinephrine group than in the 20 and 30 mL epinephrine groups (P < 0.05). The rate of recurrent bleeding was significantly higher in the 20 mL epinephrine group (20.3%) than in the 30 (5.3%) and 40 mL (2.8 %) epinephrine groups (P < 0.01). There were no significant differences in the rates of surgical intervention, the amount of transfusion requirements, the days of hospitalization, the deaths from bleeding and 30 d mortality between the three groups. The number of patients who developed epigastric pain due to endoscopic injection, was significantly higher in the 40 mL epinephrine group (51/76) than in the 20 (2/76) and 30 mL (5/76) epinephrine groups (P < 0.001). Significant elevation of systolic blood pressure after endoscopic injection was observed in the 40 mL epinephrine group (P < 0.01). Significant decreasing and normalization of pulse rates after endoscopic injections were observed in the 20 mL and 30 mL epinephrine groups (P < 0.01).

CONCLUSION: Injection of 30 mL diluted epinephrine (1:10 000) can effectively prevent recurrent bleeding with a low rate of complications. The optimal injection volume of epinephrine for endoscopic treatment of an actively bleeding ulcer (spurting or oozing) is 30 mL.

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.

[Endoscopic treatment of bleeding ulcers: has everything been said and done?]

Endoscopic treatment reduces bleeding recurrence, the need for surgery and mortality in patients with bleeding ulcers. However endoscopic treatment fails in 10-15% of patients, leading to high morbidity and mortality. The therapeutic measures with demonstrated effectiveness in reducing the risk of hemorrhagic recurrence and its complications are combined endoscopic treatment (adrenaline plus a second hemostatic intervention) and proton pump inhibitors. Also useful, although there is less evidence, are immediate resuscitation and <<second look>> endoscopy. Some studies suggest that activated recombinant factor VII infusion or supra-selective arterial embolization can be useful in severe hemorrhage. Further studies are required to determine optimal treatment according to the characteristics of each patient.

Acute endoscopic intervention in non-variceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding is one of the commonest emergencies encountered by general physicians. Once haemodynamic stability has been achieved, therapeutic endoscopy is vital in control and arrest of bleeding. Various methods are available and the evidence is reviewed as to the most optimal approach. Clinical parameters including timing of endoscopy, risk stratification, and predictors of failure will also be discussed together with a summary of recommendations based on current available evidence.

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

BACKGROUND

Non-bleeding visible vessel (NBVV) in patients with bleeding peptic ulcer is associated with a high risk of rebleeding. The aim of this study was to define factors associated with failure of endoscopic hemostasis and rebleeding in patients with NBVV.

METHODS

Clinical and endoscopic parameters related to failure of endoscopic hemostasis with adrenaline in 191 bleeding peptic ulcer patients with NBVV were evaluated.

RESULTS

Endoscopic hemostasis was permanently successful in 154 patients (80.6%). Emergency surgical hemostasis for rebleeding was required in 37 patients (19.4%). Univariate analysis showed that therapeutic failure was significantly related to the presence of shock on admission (P=0.003), posterior duodenal ulcers (P=0.001), peptic ulcer history (P=0.001), previous peptic ulcer bleeding (P=0.002), or lack of history of non-steroidal anti-inflammatory drugs consumption, when compared to use of such drugs (P=0.04). Patients where therapy failed had lower hemoglobin levels at admission (7.8+/-1.9 g/dL versus 10+/-2.4 g/dL, P=0.005). In a multivariate analysis low hemoglobin (P<0.001) as well as history of previous peptic ulcer bleeding (P=0.002) and posterior duodenal ulcers (P=0.001) were negative predictors. Using the mean value of hemoglobin as the cut-off point, it is noteworthy that only 2 out of 81 patients (2.5%) who had none of these predictive factors required emergency surgical hemostasis, whereas 34 out of 110 patients (30.9%) with at least one predictive factor required emergency surgery.

CONCLUSION

It is possible, by employing specific characteristics, to define a subgroup of high-risk patients for rebleeding in patients with NBVV despite therapeutic endoscopy and thus candidates for a complementary endoscopic method of hemostasis or emergency surgical intervention.

The effect of octreotide as an adjunct treatment in active nonvariceal upper gastrointestinal bleeding

GOALS

The aim of this study was to determine the effect ofoctreotide on active or recent gastrointestinal bleeding from benign peptic ulcers.

STUDY

This is a prospective, randomized study including 110 patients with gastric or duodenal peptic ulcers presenting with active spurting or oozing bleeding or nonbleeding visible vessel. All patients were subjected to endoscopic hemostasis by injection of noradrenaline, and they were then randomized to either receive octreotide (55 patients) or placebo (55 patients). The groups did not differ with respect to age, sex, use of nonsteroidal antiinflammatory drugs, previous history of ulcer or bleeding, Helicobacter pylori infection, site, and severity of bleeding.

RESULTS

The rebleeding rate was 36% in placebo and 32% in octreotide group, which does not present a statistically significant difference. Surgical intervention was required for 18 patients (32.7%) in the placebo group and for 16 patients (29%) in the octreotide group. The mortality rate was 2 patients (3.6%) in the placebo and 4 patients (7.2%) in the octreotide group. All the above presented no statistical difference. In addition, there was no statistically significant difference between the 2 groups with respect to the number of blood units transfused and hospital stay.

CONCLUSIONS

The use of octreotide as an adjunct treatment in patients with acutely bleeding benign peptic ulcer or/and visible vessel did not seem to offer significant benefits regarding their outcome.

Addition of a second endoscopic treatment following epinephrine injection improves outcome in high-risk bleeding ulcers

BACKGROUND & AIMS

Endoscopic therapy reduces the rebleeding rate, the need for surgery, and the mortality in patients with peptic ulcer and active bleeding or visible vessel. Injection of epinephrine is the most popular therapeutic method. Guidelines disagree on the need for a second hemostatic procedure immediately after epinephrine; although it seems to reduce further bleeding, its effects on morbidity, surgery rates, and mortality remain unclear. The aim of this study was to perform a systematic review and meta-analysis to determine whether the addition of a second procedure improves hemostatic efficacy and/or patient outcomes after epinephrine injection.

METHODS

An extensive search for randomized trials comparing epinephrine alone vs. epinephrine plus a second method was performed in MEDLINE and EMBASE and in the abstracts of the AGA Congresses between 1990 and 2002. Selected articles were included in a meta-analysis.

RESULTS

Sixteen studies including 1673 patients met inclusion criteria. Adding a second procedure reduced the further bleeding rate from 18.4% to 10.6% (Peto odds ratio 0.53, 95% CI: 0.40-0.69) and emergency surgery from 11.3% to 7.6% (OR: 0.64, 95% CI: 0.46-0.90). Mortality fell from 5.1% to 2.6% (OR: 0.51, 95% CI: 0.31-0.84). Subanalysis showed that the risk of further bleeding decreased regardless of which second procedure was applied. In addition, the risk was reduced in all subgroups, although reduction was more evident in high-risk patients and when no scheduled follow-up endoscopies were performed.

CONCLUSIONS

Additional endoscopic treatment after epinephrine injection reduces further bleeding, need for surgery, and mortality in patients with bleeding peptic ulcer.

Nonvariceal upper gastrointestinal bleeding

Nonvariceal UGI bleeding is one of the most common emergencies that gastroenterologists encounter, and continues to be a significant cause of morbidity and mortality. The keys to management are rapid resuscitation and stabilization; appropriate triage based on pre-endoscopic risk factors; early endoscopy to achieve prompt diagnosis and implement hemostatic therapy to high-risk lesions; and aggressive antisecretory therapy (in the case of peptic ulcer bleeding) to reduce the risk of continued or recurrent bleeding.

Minimizing recurrent peptic ulcer hemorrhage after endoscopic hemostasis: the cost-effectiveness of competing strategies

OBJECTIVES

Controversy exists regarding the optimal strategy to minimize recurrent ulcer hemorrhage after successful endoscopic hemostasis. Our objective was to evaluate the cost-effectiveness of competing strategies for the posthemostasis management of patients with high risk ulcer stigmata.

METHODS

Through decision analysis, we calculated the cost-effectiveness of four strategies: 1) follow patients clinically after hemostasis and repeat endoscopy only in patients with evidence of rebleeding (usual care); 2) administer intravenous proton pump inhibitors (i.v. PPIs) after hemostasis and repeat endoscopy only in patients with clinical signs of rebleeding; 3) perform second look endoscopy at 24 h in all patients with successful endoscopic hemostasis; and 4) perform selective second look endoscopy at 24 h only in patients at high risk for rebleeding as identified by the prospectively validated Baylor Bleeding Score. Probability estimates were derived from a systematic review of the medical literature. Cost estimates were based on Medicare reimbursement. Effectiveness was defined as the proportion of patients with rebleeding, surgery, or death prevented.

RESULTS

The selective second look endoscopy strategy was the most effective and least expensive of the four competing strategies, and therefore dominated the analysis. The i.v. PPI strategy required 50% fewer endoscopies than the competing strategies, and became the dominant strategy when the rebleed rate with i.v. PPIs fell below 9% and when the cost of i.v. PPIs fell below 10 dollars/day.

CONCLUSIONS

Compared with the usual practice of "watchful waiting," performing selective second look endoscopy in high risk patients may prevent more cases of rebleeding, surgery, or death at a lower overall cost. However, i.v. PPIs are likely to reduce the need for second look endoscopy and may be preferred overall if the rebleed rate and cost of i.v. PPIs remains low.

Variable use of endoscopic haemostasis in the management of bleeding peptic ulcers

BACKGROUND

Randomised controlled trials (RCTs) have shown that endoscopic haemostasis is beneficial for patients with a bleeding peptic ulcer. The relevance of such data to management outside of RCTs is unclear. Therefore we examined management of patients with a bleeding peptic ulcer in a UK teaching hospital.

METHODS

All patients who underwent upper gastrointestinal (UGI) endoscopy for bleeding peptic ulcer between 1997 and 1999 were identified from an endoscopy database and the clinical records reviewed retrospectively.

RESULTS

A total of 872 patients underwent UGI endoscopy for presumed acute UGI haemorrhage; 179 (21%) had an endoscopic diagnosis of bleeding peptic ulcer. Seventy nine patients had a peptic ulcer with stigmata of recent haemorrhage (SRH) but only 61 (77%) of these patients received endoscopic haemostasis (77% adrenaline, 23% combination therapy). Re-bleeding occurred in 24 patients with SRH in whom transfusion requirement was the sole predictor of re-bleeding. The re-bleeding rate among patients who received adrenaline was 25% (n=12), compared with 57% (n=8) in the combination group and 31% (n=4) in those who did not receive endoscopic haemostasis. Patients who received combination endoscopic haemostasis had an increased incidence of active bleeding (p=0.007) and an increased transfusion requirement (p=0.002). Eleven of 20 patients who re-bled had repeat endoscopic haemostasis, with 45% eventually requiring surgery.

CONCLUSIONS

Results of endoscopic management of bleeding peptic ulcers in the unit studied differ markedly from those published by specialised centres. The data reported here suggest that increased standardisation of endoscopic haemostasis is required, especially in units with provision for emergency "out-of-hours" endoscopy, performed by several individuals of different grades.

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.

Current status of endoscopic therapy for ulcer bleeding

This article provides an overview of the therapeutic endoscopic modalities available for the treatment of peptic ulcer bleeding. The benefits of endoscopic haemostasis have been fully demonstrated by three meta-analyses, which included most of the controlled trials published until 1992. In this review, an emphasis is placed on randomized, prospective comparative trials published during the past 20 years. Using an evidence-based medicine approach, the results of meta-analyses are translated into efficacy measures known as relative and absolute risk reductions, and number needed to treat. Single-modality treatments with injection agents such as epinephrine, sclerosants and thrombogenic substances, or with thermal therapies, are efficacious and comparable. Combination therapy involving injection and thermal techniques may offer an advantage over single-method therapy. The differences in the results between clinical trials and routine clinical practice, and among the various randomized studies, are probably related to operators' experience and variations in technique rather than to inconsistency of endoscopic haemostasis.

Combination therapies for the endoscopic treatment of gastrointestinal bleeding

This review discusses the background and analysis of data in the literature regarding the effect of a combination of endoscopic therapies on the treatment of bleeding gastroduodenal ulcers. Although these techniques are commonly used, convincing data to support combinations of injection therapies are scarce, and various studies give somewhat conflicting results. In one study, a combination of the injection of adrenaline and a high dose of thrombin was superior to using adrenaline alone. The combination of injection therapy with a thermal method tends to give better results than injection therapy alone in several studies, but the difference is only statistically significant in one study (which uses the gold probe). The data regarding a combination of injection therapy with haemostatic clips are somewhat discordant regarding the effect of the haemoclip itself, but none of the studies found an advantage of combining the two modalities. Some studies suggest that subgroups may exist, such as ulcers with spurting haemorrhage, in which combined treatment might be more useful.

Injection therapy for endoscopic haemostasis

Endoscopic injection is widely used for the arrest of active ulcer bleeding and for prevention of re-bleeding from ulcers with visible vessels. Although of proven value in clinical trials, mechanisms of action are unclear; tamponade, vasoconstriction, endarteritis and a direct effect upon the clotting process at the site of the arterial defect have been proposed. Clinical trials show that dilute adrenaline is an effective agent and that the addition of sclerosants or alcohol confirms no extra benefit, yet risks serious side-effects. The best results are associated with injection of fibrin glue or thrombin which stimulate formation of a stable blood clot. The efficacy of injection, thermal modalities such as the heater probe and electrocoagulation using BICAP are comparable. In general, there is an advantage in combining injection with a thermal modality, although this may have merit in patients with severe, active ulcer bleeding. Patients who re-bleed following successful primary haemostatic injection treatment can be considered for further endoscopic intervention, but the decision to undertake a surgical operation or repeat endoscopic therapy is a matter of clinical judgement.

Is endoscopic paravascular injection of sclerosing agents reasonable in the control of GI bleeding?

BACKGROUND

The pharmacologic response and microvascular effects associated with the endoscopic injection of sclerosing agents around vessels (paravascular injection) to stop bleeding from the digestive tract remain to be clarified.

METHODS

Using in vivo microscopy, we directly visualized submucosal microvessels of the rat stomach and intestine. We studied differences among sclerosing agents in thrombus formation and vascular diameter change that occur through a pharmacologic response and/or local compression after topical application or paravascular injection of the agents.

RESULTS

Except for absolute ethanol, topical application of the agents did not cause constriction or thrombi in either arterioles or venules. Polidocanol topical application and paravascular injection significantly dilated arterioles. Injecting ethanolamine oleate near venules constricted them the longest and most effectively, but vasoconstriction in arterioles was transient. Injecting absolute ethanol formed long-lasting thrombi and caused vasoconstriction in venules, but arteriole thrombi persisted no more than 3 minutes. The vascular response to thrombin did not significantly differ from that to physiologic saline.

CONCLUSION

The paravascular injection of ethanolamine oleate, because of its long-lasting vasoconstriction, or of absolute ethanol, because of its thrombogenic effect, is a valid therapeutic approach to treating venous bleeding. The efficacy of paravascular injection of sclerosing agents for treating acute arterial bleeding, however, is not supported in this experimental model.

The effect of endoscopic injection therapy on the clinical outcome of patients with benign peptic ulcer bleeding

BACKGROUND

Our aim was to investigate the effect of endoscopic injection therapy on the clinical outcome of patients with benign peptic ulcer bleeding.

METHODS

In this study 1203 patients admitted with peptic ulcer bleeding over a 5-year period (January 1987 to April 1991) before endoscopic therapy and 1028 patients admitted with peptic ulcer bleeding after introduction of endoscopic therapy (May 1991 to March 1996) were assessed. Endoscopic therapy was performed in all patients with active bleeding or non-bleeding visible vessels during emergency endoscopy with injection of adrenaline, 1:10,000 in 0.9% saline.

RESULTS

The introduction of injection therapy was associated with a reduction in transfusion requirements (from 5.1 +/- 2.6 to 3.4 +/- 1.8 units), hospitalization days (from 10.8 +/- 6.5 to 7.8 +/- 5.1 days), surgical interventions (from 50.6% to 23.6%), and mortality (from 12.9% to 4.6%) in patients with active bleeding or non-bleeding visible vessels (P < 0.05) but remained unchanged in the rest. Patients with gastric ulcer had a more pronounced reduction in emergency surgical haemostasis and mortality than patients with duodenal ulcer. There were no deaths or procedure-related complications.

CONCLUSION

Endoscopic injection therapy with adrenaline/saline is a simple, low-cost, and safe method that improves the clinical outcome and reduces the mortality in patients with peptic ulcer bleeding.

Role of endoscopic injection therapy in the treatment of bleeding peptic ulcer

Of patients with peptic ulceration who are actively bleeding at endoscopy, 80 per cent will continue to bleed or rebleed in hospital; 50 per cent of those who have a non-bleeding visible vessel will also rebleed. Endoscopic injection treatment stops active bleeding and prevents further haemorrhage in most of these patients. The mechanism of action may include tamponade, vasoconstriction, sclerosis, tissue dehydration and thrombogenesis; substances injected include adrenaline, sclerosants, alcohol, thrombin, or a combination of agents. Although trials often define the need for surgery as an injection treatment failure, an alternative view is that endoscopic control may facilitate safe, early, elective surgery. A successful outcome may require a combination of endoscopic and operative approaches.

Factors predicting failure of endoscopic injection therapy in bleeding duodenal ulcer

BACKGROUND

The aim of this study was to assess the factors that may cause failure of endoscopic injection in patients bleeding from a duodenal ulcer.

METHODS

One hundred twenty patients admitted for a bleeding duodenal ulcer with active arterial hemorrhage or a nonbleeding visible vessel were included.

RESULTS

Endoscopic injection was not feasible in 14 of 120 (11.6%) patients because of inaccessibility or massive hemorrhage. The remaining 106 patients underwent endoscopic therapy by injection of adrenaline and polidocanol. The efficacy (achievement of definitive hemostasis) of endoscopy therapy was 83% (88 of 106). Univariate analysis showed that failure of endoscopic injection was related to age, presence of shock, ulcer size greater than 2 cm, and hemoglobin level. Multivariate analysis showed that ulcer size greater than 2 cm (p = 0.005) and the presence of shock (p = 0.03) were factors predictive of endoscopic treatment failure. Failure to achieve hemostasis (p < 0.001) and poor physical status measured by American Society of Anesthesiology classification (p = 0.02) were significantly related to mortality.

CONCLUSIONS

Ulcer size and severity of hemorrhage are predictive of endoscopic injection failure in patients bleeding from high-risk duodenal ulcers. Survival is determined by clinical status and associated diseases.

Value of second-look endoscopy after injection therapy for bleeding peptic ulcer: a prospective and randomized trial

A prospective and randomized trial involving 104 patients was performed to assess whether second-look endoscopy could improve the efficacy of injection therapy for bleeding ulcers. The inclusion criteria were the presence of active arterial bleeding or a non-bleeding visible vessel at emergency endoscopy. All the patients received emergency injection of 1:10,000 adrenaline and were subsequently randomized (52 patients in each group) according to whether or not they would receive a second elective endoscopy within the first 24 hours with repeated injection if a visible vessel was still identified. Both groups were well matched for clinical and endoscopic data. A tendency towards better results was noted in the group that received a second-look endoscopy; the two groups were compared in regard to further bleeding (21% versus 29%, 95% confidence interval of the difference = -24.3 to 8.5), need for emergency surgery (8% versus 15%, 95% confidence interval of the difference = -19.9 to 4.5), transfusion requirements (1.7 +/- 1.9 versus 2.5 +/- 2.5 units, 95% confidence interval of the difference = -1.6 to 0.07), length of hospital stay (9.3 +/- 8.6 versus 11.8 +/- 10.8 days, 95% confidence interval of the difference = -6.2 to 1.4), and mortality rate (2% versus 4%). Although these trends did not achieve statistical significance, a type II error cannot be ruled out. However, according to our results, several hundred patients would be required to demonstrate statistically these relatively small differences.(ABSTRACT TRUNCATED AT 250 WORDS)