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Shi K, Shen Z, Zhu G, Meng F, Gu M, Ji F. Systematic review with network meta-analysis: dual therapy for high-risk bleeding peptic ulcers. BMC Gastroenterol 2017; 17:55. [PMID: 28424073 PMCID: PMC5395769 DOI: 10.1186/s12876-017-0610-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 04/04/2017] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Keda Shi
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, No. 79 Qingchun Rd, Hangzhou, 310000, Zhejiang, China
| | - Zeren Shen
- Eye Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Guiqi Zhu
- Department of Hepatology, Liver Research Center, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Fansheng Meng
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, No. 79 Qingchun Rd, Hangzhou, 310000, Zhejiang, China
| | - Mengli Gu
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, No. 79 Qingchun Rd, Hangzhou, 310000, Zhejiang, China
| | - Feng Ji
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, No. 79 Qingchun Rd, Hangzhou, 310000, Zhejiang, China.
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Affiliation(s)
- L. Langmead
- Royal London Hospital, Whitechapel, London E1 1BB
| | - P. Swain
- Royal London Hospital, Whitechapel, London E1 1BB
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Khodadoostan M, Karami-Horestani M, Shavakhi A, Sebghatollahi V. Endoscopic treatment for high-risk bleeding peptic ulcers: A randomized, controlled trial of epinephrine alone with epinephrine plus fresh frozen plasma. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2016; 21:135. [PMID: 28331521 PMCID: PMC5348822 DOI: 10.4103/1735-1995.196617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 08/30/2016] [Accepted: 09/05/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Acute upper gastrointestinal bleeding is a common and potentially life-threatening emergency with substantial mortality. Fresh frozen plasma (FFP), a good source of coagulation factors, might be an ideal injection agent based on its physiologic properties. Therefore, we evaluated the role of FFP as a hemostatic agent in patients with high-risk bleeding peptic ulcers. MATERIALS AND METHODS From August 2015 to April 2016, 108 consecutive patients with high-risk bleeding ulcers were admitted to our university hospital. They were randomly assigned to undergo injection of epinephrine alone (A) or epinephrine plus FFP (B). The primary outcomes assessed were the initial hemostasis, recurrent bleeding, hospital stay, blood transfusion, surgery rate, and 14-day mortality. RESULTS Initial hemostasis was achieved in 47 of 50 patients (94%) in the Group A and 49 of 50 patients (98%) in the Group B (P = 0.61). There were no significant differences in the rate of recurrent bleeding between Group A (14%) and Group B (8%) (P = 0.52). We found no significant differences between Group A and Group B with respect to the surgery rate, bleeding death, procedure-related death, and duration of hospitalization (P > 0.05). CONCLUSION It is concluded the injection of epinephrine alone was equally effective as injection of epinephrine plus FFP to endoscopic hemostasis. Epinephrine alone and epinephrine plus FFP were not different in recurrent bleeding, rate of surgery, blood transfusion, or mortality.
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Affiliation(s)
- Mahsa Khodadoostan
- Department of Gastroenterology and Hepatology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Karami-Horestani
- Department of Gastroenterology and Hepatology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ahmad Shavakhi
- Department of Gastroenterology and Hepatology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Vahid Sebghatollahi
- Department of Gastroenterology and Hepatology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Binmoeller KF, Sendino O, Kane SD. Endoscopic ultrasound-guided intravascular therapy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 22:44-50. [PMID: 25366271 DOI: 10.1002/jhbp.183] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The gastrointestinal tract provides a unique "window" to access vascular structures in the mediastinum and abdomen. The advent of interventional endoscopic ultrasound (EUS) has enabled access to these structures with a standard fine-needle aspiration (FNA) needle. Sclerosants, cyanoacrylate, and coils can be delivered through the lumen of the FNA needle. EUS-guided treatment of gastric varices has theoretical advantages over conventional endoscopy-guided treatment. Controlled studies are needed to determine the role of EUS-guided treatment for primary and secondary prevention of variceal bleeding. There is a growing list of novel indications for EUS-guided vascular therapy that include portal vein angiography and pressure measurements, intrahepatic portosystemic shunt placement, and micro coil embolization of vascular structures. Additionally, access and therapy of the heart and surrounding structures appears feasible.
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Affiliation(s)
- Kenneth F Binmoeller
- Paul May and Frank Stein Interventional Endoscopy Services, California Pacific Medical Center, Suite 600, Stanford Building, 2351 Clay Street, San Francisco, CA, 94115, USA.
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Emara MH, Darwiesh EM, Bihery AS, Zaher TI. Endoscopic injection of autologous blood versus diluted epinephrine for control of actively bleeding gastroduodenal ulcers: a randomized-controlled study. Eur J Gastroenterol Hepatol 2014; 26:1267-1272. [PMID: 25171029 DOI: 10.1097/meg.0000000000000180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION A preliminary report showed that autologous blood is an effective and easily applicable technique that can control actively bleeding gastroduodenal ulcers. The aim of this study was to test whether an endoscopic injection of autologous blood is comparable to an endoscopic injection of diluted epinephrine in controlling bleeding from gastroduodenal ulcers. PATIENTS AND METHODS A total of 100 patients with actively bleeding gastroduodenal ulcers were assigned randomly to either an autologous blood injection (group A, n=50) or a diluted epinephrine injection (group B, n=50) along the edges of the ulcers. Groups were compared for rates of initial hemostasis, rebleeding, and complications. RESULTS All patients initially achieved hemostasis (100%). Rebleeding occurred in four patients from group A (8%) and five patients from group B (10%). Two patients in group B developed cardiovascular complications (arrhythmia and ischemic heart attack), whereas none in group A developed complications. CONCLUSION Autologous blood is effective, comparable to diluted epinephrine in achieving initial hemostasis from actively bleeding gastroduodenal ulcers, associated with an 8% rebleeding rate, and led to no complications.
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Affiliation(s)
- Mohamed H Emara
- Tropical Medicine Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Vergara M, Bennett C, Calvet X, Gisbert JP, Cochrane Upper GI and Pancreatic Diseases Group. Epinephrine injection versus epinephrine injection and a second endoscopic method in high-risk bleeding ulcers. Cochrane Database Syst Rev 2014; 2014:CD005584. [PMID: 25308912 PMCID: PMC10714126 DOI: 10.1002/14651858.cd005584.pub3] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Mercedes Vergara
- Hospital de Sabadell & Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)Servei de Malalties DigestivesParc Tauli s/nSabadellBarcelonaSpain
| | | | - Xavier Calvet
- Hospital de Sabadell & Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)Servei de Malalties DigestivesParc Tauli s/nSabadellBarcelonaSpain
| | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)MadridSpain
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Bhat YM, Banerjee S, Barth BA, Chauhan SS, Gottlieb KT, Konda V, Maple JT, Murad FM, Pfau PR, Pleskow DK, Siddiqui UD, Tokar JL, Wang A, Rodriguez SA. Tissue adhesives: cyanoacrylate glue and fibrin sealant. Gastrointest Endosc 2013; 78:209-15. [PMID: 23867370 DOI: 10.1016/j.gie.2013.04.166] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 04/03/2013] [Indexed: 12/11/2022]
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Abstract
The gastrointestinal tract provides a unique window to access vascular structures in the mediastinum and abdomen. The advent of interventional endoscopic ultrasound (EUS) has enabled access to these structures with standard fine-needle aspiration. EUS-guided treatment of varices has been largely reserved as rescue therapy for refractory bleeding but has theoretic advantages over conventional endoscopy-guided treatment. Data are limited and multicenter, prospective controlled trials are needed to show clinical effectiveness and safety in humans. The development of new tools designed for EUS-guided vascular therapy is needed.
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Affiliation(s)
- Frank Weilert
- Peter Stokes Endoscopy Unit, Waikato District Health Board, Waikato Hospital, Pembroke Street, Hamilton 3200, New Zealand
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Epidemiology and demographics of upper gastrointestinal bleeding: prevalence, incidence, and mortality. Gastrointest Endosc Clin N Am 2011; 21:567-81. [PMID: 21944411 DOI: 10.1016/j.giec.2011.07.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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10
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Andriulli A, Merla A, Bossa F, Gentile M, Biscaglia G, Caruso N. How evidence-based are current guidelines for managing patients with peptic ulcer bleeding? World J Gastrointest Surg 2010; 2:9-13. [PMID: 21160828 PMCID: PMC2999192 DOI: 10.4240/wjgs.v2.i1.9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 12/17/2009] [Accepted: 12/24/2009] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Angelo Andriulli
- Angelo Andriulli, Antonio Merla, Fabrizio Bossa, Marco Gentile, Giuseppe Biscaglia, Nazario Caruso, Division of Gastroenterology, "Casa Sollievo Sofferenza" Hospital, IRCCS, viale Cappuccini 1, 71013 San Giovanni Rotondo, Italy
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11
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Tsoi KKF, Chiu PWY, Sung JJY. Endoscopy for upper gastrointestinal bleeding: is routine second-look necessary? Nat Rev Gastroenterol Hepatol 2009; 6:717-22. [PMID: 19946305 DOI: 10.1038/nrgastro.2009.186] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The benefit of routine repeat endoscopy after endoscopic hemostasis in the management of peptic ulcer bleeding is controversial. The aim of this Review is to evaluate the efficacy of second-look endoscopy by examining the evidence from published, randomized, clinical trials. Outcome measurements included recurrent bleeding, surgery, mortality, blood transfusion, and length of hospital stay. Studies were categorized into those in which endoscopy was performed with endoscopic injection or thermal coagulation. On the basis of existing evidence, second-look endoscopy with heater probe reduces the risk of recurrent bleeding, but has no effect on overall mortality or the need for surgery. Therefore, routine second-look endoscopy cannot be recommended. Selected high-risk patients may benefit from second-look endoscopy, but the use of high-dose intravenous PPIs may obviate the need for this procedure.
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Affiliation(s)
- Kelvin K F Tsoi
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong
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Tan VPY, Wong BCY. Management of acute peptic ulcers: how ethnicity, different proton pump inhibitors and mechanism of delivery alter the equation. J Gastroenterol Hepatol 2009; 24:1157-8. [PMID: 19682187 DOI: 10.1111/j.1440-1746.2009.05899.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Javid G, Zargar SA, U-Saif R, Khan BA, Yatoo GN, Shah AH, Gulzar GM, Sodhi JS, Khan MA. Comparison of p.o. or i.v. proton pump inhibitors on 72-h intragastric pH in bleeding peptic ulcer. J Gastroenterol Hepatol 2009; 24:1236-43. [PMID: 19682194 DOI: 10.1111/j.1440-1746.2009.05900.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS After successful endoscopic hemostasis in bleeding peptic ulcer, addition of proton pump inhibitors reduce the rate of recurrent bleeding by maintaining intragastric pH at neutral level. The aim of the present study was to evaluate the effect of various proton pump inhibitors given through different routes on intragastric pH over 72 h after endoscopic hemostasis in bleeding peptic ulcer. METHODS Ninety consecutive patients who had successful endoscopic therapy of bleeding peptic ulcer underwent 72-h continuous ambulatory intragastric pH study, were randomly assigned to receive p.o. omeprazole 80 mg bolus followed by 40 mg every 12 h for 72 h or i.v. 80 mg omeprazole followed by infusion 8 mg/h for 72 h. Oral pantoprazole 80 mg bolus followed by 80 mg every 12 h for 72 h or i.v. 80 mg pantoprazole followed by infusion of 8 mg/h for 72 h. Oral rabeprazole 80 mg bolus followed by 40 mg every 12 h for 72 h or i.v. 80 mg rabeprazole followed by infusion 8 mg/h for 72 h. Five patients received no treatment after successful endoscopic therapy and underwent 72-h pH study. RESULTS Mean 72-h intragastric pH for p.o. omeprazole was 6.56 versus 6.93 for omeprazole infusion (P = 0.48). Mean 72-h intragastric pH for p.o. pantoprazole was 6.34 versus 6.32 for pantoprazole infusion (P = 0.62). Mean 72-h intragastric pH for rabeprazole p.o. was 6.11 versus 6.18 rabeprazole i.v. (P = 0.55). Mean 72-h pH for the no proton pump inhibitor group was 2.04. CONCLUSION There was no significant difference among various proton pump inhibitors given through different routes on raising intragastric pH above 6 for 72 h after successful endoscopic hemostasis in bleeding peptic ulcer.
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Affiliation(s)
- Gul Javid
- Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir, India.
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Barkun AN, Martel M, Toubouti Y, Rahme E, Bardou M. Endoscopic hemostasis in peptic ulcer bleeding for patients with high-risk lesions: a series of meta-analyses. Gastrointest Endosc 2009; 69:786-99. [PMID: 19152905 DOI: 10.1016/j.gie.2008.05.031] [Citation(s) in RCA: 135] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Accepted: 05/10/2008] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Alan N Barkun
- Divisions of Gastroenterology, the McGill University Health Centre, Montreal General Hospital site, Montréal, Québec, Canada.
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Levy MJ, Chak A. EUS 2008 Working Group document: evaluation of EUS-guided vascular therapy. Gastrointest Endosc 2009; 69:S37-42. [PMID: 19179168 DOI: 10.1016/j.gie.2008.11.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Accepted: 11/09/2008] [Indexed: 02/07/2023]
Affiliation(s)
- Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine Rochester, Minnesota 55905, USA
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Laine L, McQuaid KR. Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials. Clin Gastroenterol Hepatol 2009; 7:33-47; quiz 1-2. [PMID: 18986845 DOI: 10.1016/j.cgh.2008.08.016] [Citation(s) in RCA: 225] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Revised: 08/06/2008] [Accepted: 08/08/2008] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Loren Laine
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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Cappell MS, Friedel D. Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy. Med Clin North Am 2008; 92:511-viii. [PMID: 18387375 DOI: 10.1016/j.mcna.2008.01.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, William Beaumont Hospital, MOB 233, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA.
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18
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Abstract
Acute upper gastrointestinal bleeding is an important emergency situation. Population-based epidemiology data are important to get insight in the actual healthcare problem. There are only few recent epidemiological surveys regarding acute upper gastrointestinal bleeding. Several surveys focusing on peptic ulcer disease showed a significant decrease in admission and mortality of peptic ulcer disease. Several more recent epidemiological surveys show a decrease in incidence of all cause upper gastrointestinal bleeding. The incidence of peptic ulcer bleeding remained stable. Peptic ulcer bleeding is the most common cause of upper gastrointestinal bleeding, responsible for about 50% of all cases, followed by oesophagitis and erosive disease. Variceal bleeding is the cause of bleeding in cirrhotic patients in 50-60%. Rebleeding in upper gastrointestinal bleeding occurs in 7-16%, despite endoscopic therapy. Rebleeding is especially high in variceal bleeding and peptic ulcer bleeding. Mortality ranges between 3 and 14% and did not change in the past 10 years. Mortality is increasing with increasing age and is significantly higher in patients who are already admitted in hospital for co-morbidity. Risk factors for peptic ulcer bleeding are NSAIDs use and H. pylori infection. In patients at risk for gastrointestinal bleeding and using NSAIDs, a protective drug was only used in 10%. COX-2 selective inhibitors do cause less gastroduodenal ulcers compared to non-selective NSAIDs, however, more cardiovascular adverse events are reported. H. pylori infection is found in about 50% of peptic ulcer bleeding patients. H. pylori should be tested for in all ulcer patients and eradication should be given.
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19
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Levy MJ, Wong Kee Song LM, Farnell MB, Misra S, Sarr MG, Gostout CJ. Endoscopic ultrasound (EUS)-guided angiotherapy of refractory gastrointestinal bleeding. Am J Gastroenterol 2008; 103:352-9. [PMID: 17986314 DOI: 10.1111/j.1572-0241.2007.01616.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are well-established methods for treating gastrointestinal (GI) bleeding, although some lesions prove refractory to conventional techniques. Little consideration has been directed toward the use of endoscopic ultrasound (EUS) in the management of refractory bleeding. AIMS To discuss patient selection, technique, and clinical outcomes for EUS-guided angiotherapy for severe refractory bleeding after conventional therapies. METHODS The EUS database was reviewed to identify all patients who underwent EUS-directed angiotherapy. RESULTS Five patients, four with severe bleeding from hemosuccus pancreaticus, Dieulafoy lesion, duodenal ulcer, or gastrointestinal stromal tumor (GIST) and one with occult GI bleeding, had an average of three prior episodes (range 2-4) of severe bleeding and had received 18 (range 14-25) units of packed red blood cells (PRBC). All had failed in at least two conventional attempts to control the bleeding. Under EUS guidance, 99% alcohol was injected (4-7 mL) in two patients, one each with a pancreatic pseudoaneurysm and a duodenal Dieulafoy lesion. In three other patients, cyanoacrylate (3-5 mL) was injected into a duodenal ulcer, and in two patients with a GIST. No patient rebled and no complications were reported. CONCLUSIONS EUS-guided angiotherapy appears safe and effective in managing selected patients with clinically severe or occult GI bleeding from lesions potentially refractory to standard endoscopic and/or angiographic techniques. Further studies are needed to confirm the safety and efficacy and to refine the selection criteria in an effort to improve patient care.
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Affiliation(s)
- Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic Foundation, Rochester, MN 55905, USA
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20
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Park WG, Yeh RW, Triadafilopoulos G. Injection therapies for nonvariceal bleeding disorders of the GI tract. Gastrointest Endosc 2007; 66:343-54. [PMID: 17643711 DOI: 10.1016/j.gie.2006.11.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Accepted: 11/09/2006] [Indexed: 02/08/2023]
Affiliation(s)
- Walter G Park
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California 94305, USA
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21
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Liou TC, Chang WH, Wang HY, Lin SC, Shih SC. Large-volume endoscopic injection of epinephrine plus normal saline for peptic ulcer bleeding. J Gastroenterol Hepatol 2007; 22:996-1002. [PMID: 17608844 DOI: 10.1111/j.1440-1746.2006.04544.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
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.
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Affiliation(s)
- Tai-Cherng Liou
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan.
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22
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Vergara M, Calvet X, Gisbert JP. Epinephrine injection versus epinephrine injection and a second endoscopic method in high risk bleeding ulcers. Cochrane Database Syst Rev 2007:CD005584. [PMID: 17443601 DOI: 10.1002/14651858.cd005584.pub2] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
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.
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Affiliation(s)
- M Vergara
- Hospital de Sabadell, Unitat de Malaties Digestives, Institut Universitari Parc Tauli, Universitat Autonoma de Barcelona. Parc Tauli s/n, Sabadell, Spain, 08208.
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23
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Marmo R, Rotondano G, Piscopo R, Bianco MA, D'Angella R, Cipolletta L. Dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers: a meta-analysis of controlled trials. Am J Gastroenterol 2007; 102:279-89; quiz 469. [PMID: 17311650 DOI: 10.1111/j.1572-0241.2006.01023.x] [Citation(s) in RCA: 155] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Riccardo Marmo
- Department of Medicine, Division of Gastroenterology, Hospital L. Curto, Polla, Italy
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24
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Mijalković NS, Djuranović S, Popović D, Pavlović A, Culafić D, Jovanović I, Sokić-Milutinović A, Krstić M. Non-surgical approach to bleeding gastric ulcer. ACTA ACUST UNITED AC 2007; 54:151-5. [PMID: 17633877 DOI: 10.2298/aci0701151m] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- N S Mijalković
- Institut za bolesti digestivnog sistema, Klinika za gastroenterologiju i hepatologiju, KCS, Beograd
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25
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Waterman M, Gralnek IM. Preventing complications of endoscopic hemostasis in acute upper gastrointestinal hemorrhage. Gastrointest Endosc Clin N Am 2007; 17:157-67, viii. [PMID: 17397782 DOI: 10.1016/j.giec.2006.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Matti Waterman
- Department of Gastroenterology, Rambam Medical Center, Haifa, Israel
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26
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Abstract
PURPOSE The pharmacology, clinical efficacy, adverse effects and toxicities, drug interactions, dosage and administration, and safety issues related to the use of absorbable hemostatic agents are reviewed. SUMMARY Absorbable hemostatic agents exert their pharmacologic effects at various points within the coagulation cascade. These agents are indicated for use during surgical procedures as adjunctive therapy when bleeding is not controlled by conventional methods. Early clinical data on absorbable hemostatic agents revealed a beneficial effect with regard to controlling capillary bleeding, achieving hemostasis during vascular surgery, and controlling bleeding from fistula-puncture sites. Few randomized controlled clinical trials have directly compared available agents, but case reports describing the efficacy of absorbable hemostatic agents in specific situations, especially unlabeled uses of thrombin, abound. Existing trials have compared the efficacy of established agents with newer agents, including fibrin sealants, with varying results. A variety of rarely occurring adverse effects have been reported with the administration of absorbable hemostatic agents; some of these rare effects, such as paralysis, are quite severe. No standardized dosing regimens are available for these agents, although surgeons may have a preference for a particular regimen based on their own clinical experience. No drug interactions involving absorbable hemostatic agents have been published; however, the use of these agents with other medications that affect hemostasis may disrupt clot formation. CONCLUSION Absorbable hemostatic agents are useful as adjunctive therapy during surgical procedures when conventional methods do not control bleeding. Although rare adverse effects have occurred with these agents, their careful administration will prevent serious adverse outcomes.
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Affiliation(s)
- Michael Gabay
- College of Pharmacy, University of Illinois Medical Center at Chicago, 833 South Wood Street, M/C 886, Chicago, IL 60612, USA.
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27
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Liou TC, Lin SC, Wang HY, Chang WH. Optimal injection volume of epinephrine for endoscopic treatment of peptic ulcer bleeding. World J Gastroenterol 2006; 12:3108-13. [PMID: 16718798 PMCID: PMC4124392 DOI: 10.3748/wjg.v12.i19.3108] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Tai-Cherng Liou
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Section 2, Chungshan North Road, Taipei, Taiwan, China.
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28
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Zargar SA, Javid G, Khan BA, Yattoo GN, Shah AH, Gulzar GM, Sodhi JS, Mujeeb SA, Khan MA, Shah NA, Shafi HM. Pantoprazole infusion as adjuvant therapy to endoscopic treatment in patients with peptic ulcer bleeding: prospective randomized controlled trial. J Gastroenterol Hepatol 2006; 21:716-721. [PMID: 16677158 DOI: 10.1111/j.1440-1746.2006.04292.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND AIM Following successful endoscopic therapy in patients with peptic ulcer bleeding, rebleeding occurs in 20% of patients. Rebleeding remains the most important determinant of poor prognosis. We investigated whether or not administration of pantoprazole infusion would improve the outcome in ulcer bleeding following successful endoscopic therapy. METHODS In this double-blind, placebo-controlled, prospective trial, patients who had gastric or duodenal ulcers with active bleeding or non-bleeding visible vessel received combined endoscopy therapy with injection of epinephrine and heater probe application. Patients who achieved hemostasis were randomly assigned to receive pantoprazole (80 mg intravenous bolus followed by an infusion at a rate of 8 mg per hour) or placebo for 72 h. The primary end-point was the rate of rebleeding. RESULTS Rebleeding was lower in the pantoprazole group (8 of 102 patients, 7.8%) than in the placebo group (20 of 101 patients, 19.8%; P = 0.01). Patients in the pantoprazole group required significantly fewer transfusions (1 +/- 2.5 vs 2 +/- 3.3; P = 0.003) and days of hospitalization (5.6 +/- 5.3 vs 7.7 +/- 7.3; P = 0.0003). Rescue therapies were needed more frequently in the placebo group (7.8% vs 19.8%; P = 0.01). Three (2.9%) patients in the pantoprazole group and eight (7.9%) in the placebo group required surgery to control their bleeding (P = 0.12). Two patients in the pantoprazole group and four in the placebo group died (P = 0.45). CONCLUSION In patients with bleeding peptic ulcers, the use of high dose pantoprazole infusion following successful endoscopic therapy is effective in reducing rebleeding, transfusion requirements and hospital stay.
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Affiliation(s)
- Showkat Ali Zargar
- Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India.
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29
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Ferguson CB, Mitchell RM. Nonvariceal upper gastrointestinal bleeding: standard and new treatment. Gastroenterol Clin North Am 2005; 34:607-21. [PMID: 16303573 DOI: 10.1016/j.gtc.2005.08.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Charles B Ferguson
- Department of Gastroenterology, Belfast City Hospital, Belfast, Northern Ireland
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30
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Calvet X, Vergara M, Brullet E. [Endoscopic treatment of bleeding ulcers: has everything been said and done?]. GASTROENTEROLOGIA Y HEPATOLOGIA 2005; 28:347-53. [PMID: 15989817 DOI: 10.1157/13076353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- X Calvet
- Unitat de Malalties Digestives, Hospital de Sabadell, Institut Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Barcelona, España.
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31
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Arasaradnam RP, Donnelly MT. Acute endoscopic intervention in non-variceal upper gastrointestinal bleeding. Postgrad Med J 2005; 81:92-8. [PMID: 15701740 PMCID: PMC1743205 DOI: 10.1136/pgmj.2004.020867] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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.
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32
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Abstract
Endoscopic therapy for nonvariceal bleeding should only be used if major stigmata of hemorrhage such as active bleeding and nonbleeding visible vessel are present. Treatment of peptic ulcers with adherent clots is currently controversial. Combination of epinephrine injection and coaptive coagulation is most effective in achieving endoscopic hemostasis. Hemoclips may be preferable for very deep ulcers and large visible blood vessels if coaptive coagulation is anticipated to have a high risk of perforation or bleeding. Adrenaline injection or hemoclip application should be used in bleeding Mallory-Weiss tears, as the safety of thermal methods is not well established. Argon plasma coagulation is the mainstay of endoscopic treatment for superficial lesions such as angiodysplasia and gastric antral vascular ectasia. Both sclerotherapy and band ligation are effective in acute hemostasis of bleeding esophageal varices. Variceal band ligation is preferred due to its superior safety profile and shorter procedure time. Due to the early recurrence of varices after banding ligation, there may be a role for metachronous combination therapy of ligation followed by sclerotherapy. Histoacryl glue is the preferred method of endoscopic hemostasis in gastric varices.
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Affiliation(s)
- Aric J Hui
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, N. T., Hong Kong SAR, China.
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Chua TS, Fock KM, Ng TM, Teo EK, Tan JYL, Ang TL. Epinephrine injection therapy versus a combination of epinephrine injection and endoscopic hemoclip in the treatment of bleeding ulcers. World J Gastroenterol 2005; 11:1044-7. [PMID: 15742412 PMCID: PMC4250769 DOI: 10.3748/wjg.v11.i7.1044] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the efficacy of hemoclip application in combination with epinephrine injection in the treatment of bleeding peptic ulcers and to compare the clinical outcomes between patients treated with such a combination therapy and those treated with epinephrine injection alone.
METHODS: A total of 293 patients (211 males, 82 females) underwent endoscopic therapy for bleeding peptic ulcers. Of these, 202 patients (152 males, 50 females) received epinephrine injection therapy while 91 patients (59 males, 32 females) received combination therapy. The choice of endoscopic therapy was made by the endoscopist. Hemostatic rates, rebleeding rates, need for emergency surgery and 30-d mortality were the outcome measures studied.
RESULTS: Patients who received combination therapy were significantly older (mean age 66±16 years, range 24-90 years) and more suffered from chronic renal failure compared to those who received epinephrine injection therapy alone (mean age 61±17 years, range 21-89 years). Failure to achieve permanent hemostasis was 4% in the group who received epinephrine injection alone and 11% in the group who received combination therapy. When the differences in age and renal function between the two treatment groups were taken into account by multivariate analysis, the rates of initial hemostasis, rebleeding rates, need for surgery and 30-d mortality for both treatment options were not significantly different.
CONCLUSION: Combination therapy of epinephrine injection with endoscopic hemoclip application is an effective method of achieving hemostasis in bleeding peptic ulcer diseases. However, superiority of combination therapy over epinephrine injection alone, could not be demonstrated.
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Affiliation(s)
- Tju-Siang Chua
- Changi General Hospital, 2 Simei Street 3, Singapore 529889, Republic of Singapore.
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34
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Salm R, Grund KE. Fibrinklebung – Einsatz in der endoskopischen Akutbehandlung der Ulkusblutung. Visc Med 2005. [DOI: 10.1159/000087187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Abstract
Acute upper gastrointestinal bleeding is a common medical emergency which carries hospital mortality in excess of 10%. The most important causes are peptic ulcer and varices. Varices are treated by endoscopic band ligation or injection sclerotherapy and management of the underlying liver disease. Ulcers with major stigmata are treated by injection with dilute adrenaline, thrombin, or fibrin glue; application of heat using the heater probe, multipolar electrocoagulation, or Argon plasma coagulation; or endoclips. Intravenous omeprazole reduces the risk of re-bleeding in ulcer patients undergoing endoscopic therapy. Repeat endoscopic therapy or operative surgery are required if bleeding recurs.
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Affiliation(s)
- K Palmer
- Department of Gastroenterology, Western General Hospital, Edinburgh EH4 2XU, UK.
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Abstract
Acute upper gastrointestinal bleeding is a common medical emergency which carries hospital mortality in excess of 10%. The most important causes are peptic ulcer and varices. Varices are treated by endoscopic band ligation or injection sclerotherapy and management of the underlying liver disease. Ulcers with major stigmata are treated by injection with dilute adrenaline, thrombin, or fibrin glue; application of heat using the heater probe, multipolar electrocoagulation, or Argon plasma coagulation; or endoclips. Intravenous omeprazole reduces the risk of re-bleeding in ulcer patients undergoing endoscopic therapy. Repeat endoscopic therapy or operative surgery are required if bleeding recurs.
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Affiliation(s)
- K Palmer
- Department of Gastroenterology, Western General Hospital, Edinburgh EH4 2XU, UK.
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37
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Petersen B, Barkun A, Carpenter S, Chotiprasidhi P, Chuttani R, Silverman W, Hussain N, Liu J, Taitelbaum G, Ginsberg GG. Tissue adhesives and fibrin glues. Gastrointest Endosc 2004; 60:327-33. [PMID: 15332018 DOI: 10.1016/s0016-5107(04)01564-0] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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38
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Exon DJ, Sydney Chung SC. Endoscopic therapy for upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2004; 18:77-98. [PMID: 15123086 DOI: 10.1016/s1521-6918(03)00102-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2003] [Accepted: 06/01/2003] [Indexed: 01/31/2023]
Abstract
Upper gastrointestinal bleeding (UGIB) is one of the most common medical emergencies and remains a major cause of morbidity and mortality among patients. Although initially employed diagnostically, endoscopy has steadily replaced surgery as a first-line treatment in all but the haemodynamically unstable patient. A vast selection of techniques and devices are now available to the dedicated therapeutic endoscopist, including injection therapy, electrical or thermal coagulation and mechanical banding or clipping. The use of endoscopic ultrasound for targeting treatment is increasing and the development of new technologies, such as capsule endoscopy, is likely to play an important role in future protocols. However, despite numerous randomized controlled trials and meta-analyses comparing the efficacy of different endoscopic interventions, the implementation of obtained results into treatment regimes has so far failed to impact significantly on overall UGIB mortality, which remains stubbornly at 10-14%. Reducing this continues to be one of the main challenges facing the therapeutic endoscopist.
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Affiliation(s)
- David J Exon
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
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39
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Calvet X, Vergara M, Brullet E, Gisbert JP, Campo R. Addition of a second endoscopic treatment following epinephrine injection improves outcome in high-risk bleeding ulcers. Gastroenterology 2004; 126:441-50. [PMID: 14762781 DOI: 10.1053/j.gastro.2003.11.006] [Citation(s) in RCA: 147] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Xavier Calvet
- Unitat de Malaties Digestives, Hospital de Sabadell/UDIAT, Institut Universitari Parc Taulí, Universitat Autónoma de Barcelona, Spain.
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40
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Pais SA, Yang R. Diagnostic and therapeutic options in the management of nonvariceal upper gastrointestinal bleeding. Curr Gastroenterol Rep 2003; 5:476-81. [PMID: 14602055 DOI: 10.1007/s11894-003-0036-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
Upper gastrointestinal bleeding from peptic ulcers is common. Advances in prognostication, therapeutic endoscopy, and medical management have evolved rapidly. Patients most likely to rebleed after therapy can now be identified and monitored more closely, and patients with ulcers of low risk for rebleeding can be managed on an outpatient basis. High-risk patients include those with ulcers containing a visible vessel or who are actively bleeding. Endoscopic therapy is mandatory in high-risk patients and involves at least two hemostatic techniques. Second-look endoscopy and repeated hemostasis should be performed promptly in patients who rebleed. Adjunctive treatment includes intravenous proton pump inhibitor administered in high doses for the first 72 hours after endoscopic therapy. Further studies are needed to determine the optimal combination of hemostatic techniques to better target patients who are at risk for ulcer rebleeding.
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Affiliation(s)
- Shireen Andrade Pais
- Division of Gastroenterology and Endoscopy, Keck School of Medicine, University of Southern California, Building 1, Room 12-137, 1200 North State Street, Los Angeles, CA 90033, USA.
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41
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Abstract
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.
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Affiliation(s)
- Christopher S Huang
- Section of Gastroenterology, Boston Medical Center, 88 East Newton Street, D-408, Boston, MA 02118, USA
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42
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van Leerdam ME, Rauws EAJ, Geraedts AAM, Tijssen JGP, Tytgat GNJ. The role of endoscopic Doppler US in patients with peptic ulcer bleeding. Gastrointest Endosc 2003; 58:677-84. [PMID: 14595300 DOI: 10.1016/s0016-5107(03)02033-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Stigmata of recent hemorrhage are important prognostic signs for patients with ulcer bleeding, but these are subjective findings. This study evaluated the additional diagnostic value of Doppler US assessment in patients with a bleeding peptic ulcer. METHODS A prospective, multicenter study was performed of patients with ulcer bleeding. Stigmata of recent hemorrhage were classified according to the Forrest classification, after which the ulcer was assessed by using an endoscopic Doppler US system. Patients with a Forrest Ib-IIb ulcer with a positive Doppler signal received endoscopic therapy. Patients with a Forrest IIc-III ulcer with a positive Doppler signal were allocated randomly to endoscopic therapy or no therapy. No ulcer without a Doppler signal was treated. RESULTS A total of 80 patients were enrolled. Of the Forrest Ib-IIb ulcers, 82% had a positive Doppler signal. Of the Forrest IIc-III ulcers, 53% had a positive Doppler signal. There was no difference in the rates of recurrent bleeding, surgery, or mortality between the group with Forrest Ib-IIb ulcers and between the Forrest IIc-III group with and without Doppler signal, but there was little power in the sample size to detect differences. Bleeding recurred in 3 patients without a Doppler signal. Recurrent bleeding was more frequent in the group in which a Doppler signal was still present immediately after endoscopic therapy (3/11 vs. 1/27; p=0.06). CONCLUSIONS This study did not substantiate a role for endoscopic Doppler US when this was added to the Forrest classification for making clinical decisions in patients with ulcer bleeding.
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Affiliation(s)
- Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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43
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Sung JJ. The role of acid suppression in the management and prevention of gastrointestinal hemorrhage associated with gastroduodenal ulcers. Gastroenterol Clin North Am 2003; 32:S11-23. [PMID: 14556432 DOI: 10.1016/s0889-8553(03)00058-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Peptic ulcer bleeding remains a substantial source of morbidity and mortality in the ICU setting. Endoscopic injection with adrenaline and thermocoagulation is the mainstay of treatment for peptic ulcer bleeds. To enhance healing and overcome limitations of endoscopic therapies, acid suppression therapy is recommended. Although results from a few studies do not support their use fully following an episode of acute UGI bleeding, PPIs have been used successfully to lower transfusion requirements and additional surgical procedures, reduce hospital stays, and lower medical costs. H2RAs and PPIs have a rapid onset of action when given intravenously; however, patients quickly become tolerant to the effects of H2RAs, generally requiring increased doses of medication after the first day of administration. PPIs provide persistent acid suppression, maintaining neutral gastric pH, especially during the critical first 72 hours following a bleed. Recent clinical studies further support their use in preventing bleeding in the clinical setting. Controversy exists over the utility of pharmacologically induced acid suppression in critically ill patients at risk for stress ulcers. Comparative pH studies, however, suggest that i.v. PPIs such as pantoprazole are more effective in raising intragastric pH than are H2RAs. Although the clinical benefits of PPIs for stress ulcer prophylaxis have not been established, there is a theoretical framework suggesting that they should be beneficial. Ongoing clinical studies should show whether the theoretical advantage translates into clinically meaningful benefits.
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Affiliation(s)
- Joseph J Sung
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Shatin, Hong Kong, China.
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44
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Church NI, Dallal HJ, Masson J, Mowat NAG, Johnston DA, Radin E, Turner M, Fullarton G, Prescott RJ, Palmer KR. A randomized trial comparing heater probe plus thrombin with heater probe plus placebo for bleeding peptic ulcer. Gastroenterology 2003; 125:396-403. [PMID: 12891541 DOI: 10.1016/s0016-5085(03)00889-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND & AIMS This multicenter, double-blind, controlled trial compared the efficacy of combined endoscopic hemostatic treatment using the heater probe plus thrombin injection with that of the heater probe plus placebo injection as treatment for peptic ulcers with active bleeding or nonbleeding visible vessels. Efficacy was defined in terms of primary hemostasis, prevention of rebleeding, and need for urgent surgery. METHODS Two hundred forty-seven patients presenting with major peptic ulcer bleeding were randomized to heater probe plus thrombin or to heater probe plus placebo. The groups were well matched for all risk categories including age, endoscopic stigmata, shock, and severity of comorbid diseases. Endoscopic therapy was applied using the heater probe followed by injection of thrombin or placebo. RESULTS Successful primary hemostasis was achieved in 97% of patients. Rebleeding developed in 19 (15%) of thrombin plus heater probe patients and 17 (15%) of placebo plus heater probe patients. Emergency surgery was necessary in 16 and 13 patients, respectively. Eight patients in the thrombin group had adverse events compared with 4 in the placebo group. Eight (6%) of thrombin plus heater probe patients and 14 (12%) of placebo plus heater probe patients died (P = 0.21). CONCLUSIONS The combination of thrombin and the heater probe does not confer an additional benefit over heater probe and placebo as endoscopic treatment for bleeding peptic ulcer. Our trial does not support the use of this combination of hemostatic therapy.
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Affiliation(s)
- N I Church
- Gastroenterology Department, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, United Kingdom.
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45
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Nietsch H, Lotterer E, Fleig WE. [Acute upper gastrointestinal hemorrhage. Diagnosis and management]. Internist (Berl) 2003; 44:519-28, 530-2. [PMID: 12966782 DOI: 10.1007/s00108-003-0918-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Upper gastrointestinal hemorrhage calls for a team approach. Early endotracheal intubation of unconscious patients helps to prevent aspiration. Erythromycin i.v. 20 min. before emergency endoscopy improves the diagnostic yield. Patients without increased risk of rebleeding may be treated on an outpatient basis. Band ligation is the gold standard for acute variceal bleeding. Terlipressin, somatostatin and octreotide are equally effective but require additional measures for prevention of late recurrence. Somatostatin and analogues used as adjunct to ligation slightly reduce the risk of rebleeding but not of death. Three to seven days of prophylactic antibiotics decrease the risk of uncontrolled or recurrent bleeding. Therapeutic failures are rescued by transjugular intrahepatic portosystemic shunting (TIPS). Patients with nonvaricose bleeding should only be treated when active hemorrhage or a "visible vessel" is found. First line treatment is endoscopic injection of diluted adrenalin or isotonic saline. Thermal coagulation is an alternative. Tissue-destructing sclerosants should be avoided. Clipping and injection of fibrin glue are second and third line measures. Proton pump inhibitors improve endoscopic hemostasis, however, it is unclear whether high i.v. doses are required. H. pylori must be eradicated to prevent late recurrence. Rebleeding is treated endoscopically with angiographic intervention or surgery as rescue measures.
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Affiliation(s)
- H Nietsch
- Universitätsklinik und Poliklinik für Innere Medizin I, Martin-Luther-Universität Halle-Wittenberg, Halle/Saale
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Marmo R, Rotondano G, Bianco MA, Piscopo R, Prisco A, Cipolletta L. Outcome of endoscopic treatment for peptic ulcer bleeding: Is a second look necessary? A meta-analysis. Gastrointest Endosc 2003; 57:62-7. [PMID: 12518133 DOI: 10.1067/mge.2003.48] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endoscopic therapy for GI bleeding is highly effective. Nevertheless, bleeding recurs in 10% to 25% of cases, irrespective of the method of treatment used. Whether a second-look endoscopy with retreatment after initial hemostasis is of clinical value is controversial. A meta-analysis was performed to assess whether systematic second-look endoscopy with retreatment reduces the risks of recurrent bleeding, salvage surgery, and death in patients with peptic ulcer bleeding. METHODS A systematic review was performed of randomized controlled studies of the value of second-look endoscopy in patients with peptic ulcer bleeding published between 1990 and 2000. Four studies were selected according to predefined criteria. Two investigators extracted the data independently. Pooled risk estimates and number need to treat were calculated for each procedure. Heterogeneity of effects was tested. RESULTS The absolute risk reduction in clinical recurrent bleeding was 6.2% (p < 0.01). Absolute risk reduction for surgery and mortality were, respectively, 1.7% and 1.0% (not significant). The second look with retreatment significantly reduced the risk of recurrent bleeding compared with control patients (OR 0.64; 95% CI [0.44, 0.95]; p < 0.01), with a number needed to treat of 16. There was no heterogeneity among studies. The risk of surgery as well as the risk of death were not significantly influenced by the second-look endoscopy with retreatment (number needed to treat, respectively, 58 and 97). CONCLUSIONS Systematic second-look endoscopy with retreatment significantly reduces the risk of recurrent bleeding in patients with peptic ulcer bleeding compared with control patients, but it does not substantially reduce the risk of salvage surgery or mortality.
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Affiliation(s)
- Riccardo Marmo
- U.O. di Gastroenterologia Ospedale Maresca-Torre Del Greco, Italy
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48
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Spiegel BMR, Ofman JJ, Woods K, Vakil NB. Minimizing recurrent peptic ulcer hemorrhage after endoscopic hemostasis: the cost-effectiveness of competing strategies. Am J Gastroenterol 2003; 98:86-97. [PMID: 12526942 DOI: 10.1111/j.1572-0241.2003.07163.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Brennan M R Spiegel
- Department of Digestive Diseases, University of California at Los Angeles School of Medicine, Los Angeles, California, USA
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49
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50
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Lin HJ, Hsieh YH, Tseng GY, Perng CL, Chang FY, Lee SD. Endoscopic injection with fibrin sealant versus epinephrine for arrest of peptic ulcer bleeding: a randomized, comparative trial. J Clin Gastroenterol 2002; 35:218-21. [PMID: 12192196 DOI: 10.1097/00004836-200209000-00004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND endoscopic epinephrine and fibrin injection in the treatment of bleeding peptic ulcer are reported to be safe, effective, and easy to use. However, a wide range of rebleeding rates has been reported with epinephrine injection. GOALS to compare the hemostatic effects of endoscopic injection with fibrin sealant versus epinephrine. STUDY between December 1998 and July 2000, 51 patients with active bleeding or nonbleeding visible vessels entered this trial. The clinical parameters were comparable between both groups. In the epinephrine group, we injected 5 to 10 mL of 1:10,000 epinephrine, surrounding the bleeder. In the fibrin sealant group, we injected fibrin sealant 4 mL, surrounding the bleeder. RESULTS initial hemostasis was obtained in all enrolled patients. Rebleeding was more in the epinephrine group than in the fibrin sealant group (4 [15%] of 26 vs. 14 [56%] of 25, = 0.003 on the intention-to-treat basis, and 4 [16.7%] of 24 vs. 14 [58.3%] of 24, = 0.003 on the per protocol basis, respectively). Volume of blood transfusion, number of surgeries, hospital stay, and number of deaths were similar between both groups. CONCLUSION fibrin sealant injection is more effective in preventing rebleeding than epinephrine after endoscopic therapy, but this study showed no difference in outcomes with either therapy.
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Affiliation(s)
- Hwai-Jeng Lin
- Division of Gastroenterology, Department of Medicine, VGH-TAIPEI, Taipei, Taiwan, ROC.
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