Acute Peptic Ulcer Hemorrhage Research Articles

Predicting risk factors for rebleeding, infections, mortality following peptic ulcer bleeding in patients with cirrhosis and the impact of antibiotics prophylaxis at different clinical stages of the disease.

BackgroundInfections in cirrhotic patients with upper gastrointestinal bleeding are a common event causing severe complication and mortality. This study aimed to identify risk factors that may predict rebleeding, bacterial infections, and the impact of antibiotic prophylaxis on mortality at different stages of cirrhosis following acute peptic ulcer bleeding (PUB).MethodsA hospital-based retrospective cohort study was conducted on 235 cirrhotic patients with acute peptic ulcer hemorrhage who underwent therapeutic endoscopic procedures between January 2008 and January 2014 (n = 235); of these, 88 patients received prophylactic intravenous ceftriaxone (antibiotic group) and 147 patients did not (nil-antibiotic group). The recorded outcomes were length of hospital stay, bacterial infection, rebleeding, and in-hospital mortality.ResultsForty-eight (20.4 %) patients experienced ulcer rebleeding and 46 (19.6 %) developed bacterial infections. More patients suffered from infection and recurrent bleeding in the nil-antibiotic group than the antibiotic group (25.2 % vs. 10.2 %, p = 0.005 and 30.6 % vs. 3.4 %; p < 0.001, respectively). The predictive risk factors for rebleeding were the Rockall score (p = 0.004), units of blood transfusion (p = 0.031), and no antibiotic prophylaxis (p <0.001); for bacterial infections, they were the Child-Pugh score (p = 0.003), active alcoholism (p = 0.035), and no antibiotic prophylaxis (p = 0.009). Overall, 40 (17 %) patients died during hospitalization. The Rockall score and rebleeding were predictive factors for in-hospital mortality. In subgroup analysis, survival was significantly reduced in decompensated patients (p = 0.034).ConclusionsThis study suggests that antibiotic prophylaxis after endoscopic hemostasis for acute PUB prevented infections and reduced rebleeding events in cirrhotic patients. Antibiotic prophylaxis improved survival among decompensated cohort following PUB. The Rockall score and rebleeding were predictive risk factors for in-hospital mortality.

North vs south differences in acute peptic ulcer hemorrhage in Croatia: hospitalization incidence trends, clinical features, and 30-day case fatality.

AimTo assess the seven-year trends of hospitalization incidence due to acute peptic ulcer hemorrhage (APUH) and associated risk factors, and examine the differences in these trends between two regions in Croatia.MethodsThe study collected sociodemographic, clinical, and endoscopic data on 2204 patients with endoscopically confirmed APUH who were admitted to the Clinical Hospital Center “Sestre Milosrdnice,” Zagreb and Clinical Hospital Center Split between January 1, 2005 and December 31, 2011. We determined hospitalization incidence rates, 30-day case fatality rate, clinical outcomes, and incidence-associated factors.ResultsNo differences were observed in APUH hospitalization incidence rates between the regions. Age-standardized one-year cumulative APUH hospitalization incidence rate calculated using the European Standard Population was significantly higher in Zagreb than in Split region (43.2/100 000 vs 29.2/100,000). A significantly higher APUH hospitalization incidence rates were observed in the above 65 years age group. Overall 30-day case fatality rate was 4.9%.ConclusionThe hospitalization incidence of APUH in two populations did not change over the observational period and it was significantly higher in the Zagreb region. The incidence of acute duodenal ulcer hemorrhage also remained unchanged, whereas the incidence of acute gastric ulcer hemorrhage increased. The results of this study allow us to monitor epidemiological indicators of APUH and compare data with other countries.

The influential roles of antibiotics prophylaxis in cirrhotic patients with peptic ulcer bleeding after initial endoscopic treatments.

The influential roles of antibiotic prophylaxis on cirrhotic patients with peptic ulcer bleeding are still not well documented. The purpose of this study is to clarify these influential roles and to identify the risk factors associated with rebleeding, bacterial infection and in-hospital mortality. A cross-sectional, chart review study was conducted on 210 cirrhotic patients with acute peptic ulcer hemorrhage who underwent therapeutic endoscopic procedures. Patients were divided into group A (with prophylactic intravenous ceftriaxone, n = 74) and group B (without antibiotics, n = 136). The outcomes were length of hospital days, prevention of infection, rebleeding rate and in-hospital mortality. Our results showed that more patients suffered from rebleeding and infection in group B than group A (31.6% vs. 5.4%; p<0.001 and 25% vs. 10.8%; p = 0.014 respectively). The risk factors for rebleeding were active alcoholism, unit of blood transfusion, Rockall score, model for end-stage liver disease score and antibiotic prophylaxis. The risk factors for infection were active alcoholism, Child-Pugh C, Rockall score and antibiotic prophylaxis. Rockall score was the predictive factor for in-hospital mortality. In conclusions, antibiotic prophylaxis in cirrhotic patients after endoscopic interventions for acute peptic ulcer hemorrhage reduced infections and rebleeding rate but not in-hospital mortality. Rockall score was the predictive factor of in-hospital mortality.

The effect of systemic antibiotic prophylaxis for cirrhotic patients with peptic ulcer bleeding after endoscopic interventions.

All previous studies reported the benefit of antibiotic prophylaxis in cirrhotic patients with either a mixture of nonvariceal and variceal bleeding or variceal bleeding alone. Reports on sole peptic ulcers bleeding are lacking. We aimed to assess the effect of antibiotic prophylaxis in cirrhotic patients with peptic ulcer bleeding after endoscopic interventions and the risk factors associated with recurrent bleeding. A cross-sectional retrospective chart review study was conducted on 148 cirrhotic patients with acute peptic ulcer hemorrhage who underwent therapeutic endoscopic procedures. Patients who received prophylactic intravenous ceftriaxone were classified as group A (n=38) and those who did not receive antibiotics were classified as group B (n=110). The outcomes were prevention of infection, length of hospital stay, time of rebleeding, and death. More patients suffered from recurrent bleeding and infection in group B than those in group A (28.2 vs. 5.3%; p=0.003, and 26.4 vs. 10.5%; p=0.043, respectively). The risk factors associated with recurrent bleeding were being male (OR=3.4; p=0.024), those with advanced stage of cirrhosis with Child-Pugh's class C (OR=3.8; p<0.001), and those without antibiotic prophylaxis (OR=8.9; p=0.003). The observed 30-day survival was virtually identical for both groups (p=0.279). Antibiotic prophylaxis in cirrhotic patients after endoscopic interventions for acute peptic ulcer hemorrhage reduced infections and decreased rebleeding. Male gender, cirrhosis Child-Pugh's class C, and no antibiotic prophylaxis were independent predictors of recurrent bleeding. Further studies should be directed to explore ways to improve the overall outcome of these patients.

Giant Peptic Ulcer Hemorrhages: Epidemiology, Treatment, and Outcome in the Teaching Hospital of Tartu

The aim of the study was to analyze the management and outcome in the case of giant peptic ulcer hemorrhage (GPUH). We analyzed the data of all 372 cases of 348 patients treated for acute peptic ulcer hemorrhage during 2005-2007. The source and intensity of hemorrhage was assessed endoscopically according to the Forrest classification: class I+II, persistent hemorrhage or signs of recent hemorrhage; and class III, ulcer without signs of recent hemorrhage. Of the 372 cases, 64 (17%) were GPUH (diameter, ≥2 cm) (group 1) and the remaining 308 (83%) were peptic ulcer hemorrhages of a standard size (SPUH) (diameter, <2 cm), which formed the control group (group 2). Forrest class I+II hemorrhage occurred significantly more frequently in the group 1 as compared with the group 2 (97% [62/64] vs. 77% [238/308]), as well as endoscopic hemostasis, (80% [51/64] vs. 57% [175/308]), repeat hemostasis procedures (22% [11/51] vs 6.3% [11/175]), and operative treatment (27.6% [16/58] vs 1.7% [5/290]) were needed more frequently in the group 1. No postoperative in-hospital deaths occurred in either group. Five patients died: 2 (3.4% [2/58]) in the group 1 and 3 (1.0% [3/290]) in the group 2. GPUHs were more intensive as compared with SPUHs and needed more endoscopic hemostasis, including repeat procedures and operative treatment. Endoscopic hemostasis and operative treatment allowed reducing mortality due to GPUH to 3.4%.

The role of the Doppler ultrasound probe in acute peptic ulcer hemorrhage: preliminary endoscopic results

The role of the Doppler ultrasound probe in acute peptic ulcer hemorrhage: preliminary endoscopic results

Nonvariceal Upper Gastrointestinal Hemorrhage: Probing Beneath the Surface

Looking at the surface of the gastrointestinal (GI) tract has long been the foundation of practice in GI endoscopy. Indeed, many of our day-to-day management decisions are based largely on what the surface looks like, yet it is generally accepted that visual appearances alone can be quite subjective. For many decades, visual stigmata of recent hemorrhage (SRH) formed the basis from which the endoscopist decided whether or not to perform endoscopic hemostasis in patients with nonvariceal upper GI hemorrhage (NVUGIH). The so-called Forrest classification of SRH in peptic ulcer bleeding was published almost 4 decades ago.1 Current recommendations for endoscopic therapy in acute peptic ulcer hemorrhage reside entirely on the surface appearance of the bleeding ulcer.2,3 However, published evidence shows that there is significant interobserver variability in the identification of such SRH. When endoscopists were shown images or videoclips of bleeding peptic ulcers and asked to identify SRH, there was disagreement 25% of the time.4 Moreover, even among international experts, good agreement could only be reached when there was spurting blood.5 Furthermore, some published studies have shown that high-risk stigmata, such as a nonbleeding visible vessel (NBVV), may have uncharacteristic visual appearances (nonpigmented, pale, translucent, or pearl-colored protuberance) and thus may be misinterpreted by the endoscopist as low-risk stigmata.6,7 As Michael V. Sivak, Jr, MD, succinctly noted, “It is well-established that visual assessment alone of an ulcer in a patient with upper GI bleeding is inaccurate, especially with respect to ulcers with SRH. Consequently, the use of the Forrest classification as a guide to the need for endoscopic therapy is necessarily inaccurate” (personal communication, 2006). Indeed, misguided application of endoscopic therapy (either underor overuse) can potentially lead to undesired patient outcomes and to inappropriate use of health care resources. Conceptually, it may be more important to know whether a bleeding lesion still has active blood flow or whether such blood flow has ceased, for instance, as a result of spontaneous intravascular thrombosis. Thus, for any particular bleeding lesion that has stopped bleeding, the risk of recurrent bleeding would theoretically be reduced if active blood flow to the bleeding point had ceased. This theoretical concept has led to the development of novel imaging and nonimaging technologies to try and determine whether blood flow is present or absent beneath a bleeding lesion such as a peptic ulcer. Some of these new technologies may also allow for an assessment of certain physical characteristics of subsurface blood flow, such as relative velocity, and may provide information on anatomic and structural aspects of the surrounding tissue in relation to the bleeding lesion. This

Endoscopic Doppler Ultrasound Versus Endoscopic Stigmata-Directed Management of Acute Peptic Ulcer Hemorrhage: A Multimodel Cost Analysis

Endoscopic Doppler Ultrasound Versus Endoscopic Stigmata-Directed Management of Acute Peptic Ulcer Hemorrhage: A Multimodel Cost Analysis

Endoscopic Doppler Ultrasound Versus Endoscopic Stigmata-Directed Management of Acute Peptic Ulcer Hemorrhage: A Multimodel Cost Analysis

Recurrent bleeding from acute peptic ulcer hemorrhage is problematic. Studies have shown that Doppler ultrasound (DOP-US) is useful in decreasing rebleeding. We analyzed associated costs and outcomes to better define the role of DOP-US versus Conventional (Forrest classification endoscopic stigmata) in the management of acute peptic ulcer bleeding. Two separate decision analyses were constructed. Recurrent bleeding, failed esophagogastroduodenoscopy (EGD) hemostasis, complications, and surgery rates were derived from medical literature. Costs were based on Medicare data. DOP-US is preferred over Conventional in acute peptic ulcer bleeding with average cost savings per patient ranging from 853 dollars (decision-tree modeling) to 1,160 dollars (Monte Carlo simulation). High-dose intravenous proton-pump inhibitors lowered rates of recurrent bleeding for both Conventional and DOP-US, resulting in a lower but still persistent average cost savings per patient for DOP-US (decision-tree modeling = 328 dollars, Monte Carlo simulation = 560 dollars). This decision analyses identified DOP-US as the preferred cost-minimizing strategy in acute peptic ulcer hemorrhage. Results of cost analyses were most dependent on hospitalization costs and recurrent bleeding rates.

Endoscopic Doppler Ultrasound Probe Vs. Endoscopic Stigmata Directed Management of Acute Peptic Ulcer Hemorrhage: A Multi-Method Cost-Analysis

Endoscopic Doppler Ultrasound Probe Vs. Endoscopic Stigmata Directed Management of Acute Peptic Ulcer Hemorrhage: A Multi-Method Cost-Analysis

Creation of an Effective Porcine Model for the Investigation of High-Intensity Focused Ultrasound for the Treatment of Acute Peptic Ulcer Hemorrhage

Creation of an Effective Porcine Model for the Investigation of High-Intensity Focused Ultrasound for the Treatment of Acute Peptic Ulcer Hemorrhage Jeffrey Marks, Victor Chen, Michael Rosen, Michael Mcgee, Amitabh Chak, Raymond Onders, Ashley Faulx, Steve Schomisch, Jeffrey Ponsky Background: Upper GI bleeding is extremely common and despite advances in endoscopic interventions, it carries a significant mortality rate predominantly secondary to recurrent bleeding. It is theorized that recurrent bleeding is related to the presence of submucosal arterial vessels. We are presently investigating the role of a combination of endoscopic ultrasonography and high intensity focused ultrasound (HIFU) in the management of gastrointestinal bleeding. As there are no natural animate models to mimic submucosal bleeding, we have created a porcine model of submucosal arterial bleeding. Methods: Following delivery of general anesthesia, laparotomy is performed on a 20-25 kg pig. Along the external surface of the greater curvature of the stomach, a seromyotomy is created with cautery parallel to the gastoepiploic vessels for approximately 5 cm. A submucosal space is developed and the gastroepiploic bundle, in continuity, is placed adjacent to the mucosa. The seromuscular tissues are then reapproximated over the vascular bundle with care taken to avoid vessel occlusion. The laparotomy is closed and an endoscope is advanced into the gastric lumen. The site and course of the submucosal vessel is identified with a Doppler EUS probe. A needle knife sphincterotome is then used to sever the overlying mucosa and the underlying submucosal vascular structures. Results: In the first two animals utilizing this technique, the course of the submucosal artery was easily identified with EUS for approximately 2.5 cm using the 0-1.5 mm penetration depth range settings. Arterial bleeding was produced following disruption of the vessles with the needle knife sphincterotome. In one animal, the vessels were found post mortem to be completely transected. Despite this, intragastric rather than intraperitoneal bleeding still occurred due to the presence of the vessels securely placed in the submucosal defect and covered by seromuscular tissues. Conclusion: This study describes a novel technique for the creation of an effective model of submucosal arterial bleeding. This model will be used to investigate the role of HIFU for the treatment of acute peptic ulcer hemorrhage.

Role of Doppler US in acute peptic ulcer hemorrhage: Can it predict failure of endoscopic therapy?

Background: Recurrent bleeding after successful primary endoscopic hemostasis of acutely bleeding ulcers is a significant problem.This study evaluates endoscopic Doppler ultrasound (US) in assessing risk of recurrent bleeding in patients presenting with acute peptic ulcer hemorrhage. Methods: In this prospective, double-blind, nonrandomized trial, patients were enrolled from a single academic institution. Only patients with endoscopically confirmed gastric, duodenal, pyloric, or anastomotic ulcers were enrolled. The therapeutic endoscopist was blinded to the Doppler US signal from the ulcer and based treatment decisions on standard guidelines. A 16 MHz pulsed-wave, linear scanning, US probe was used through the accessory channel of an endoscope to assess for the presence of a Doppler signal. Results: Fifty-two of 139 screened patients entered the trial (55 Doppler sessions). Endoscopic therapy was performed in 42% (30-day recurrent bleeding rate of 17%). Ulcers that remained persistently Doppler positive immediately after endoscopic therapy had a significantly higher rate of recurrent bleeding than ulcers where the Doppler signal was abolished: 100% versus 11% (p = 0.003). There were no bleeding-related deaths. Conclusions: A persistently positive Doppler US signal appears to be a marker of inadequate endoscopic therapy in patients with acutely bleeding peptic ulcers. (Gastrointest Endosc 2000;52:315–21.)

Do we need more technology to reduce recurrence of bleeding from ulcers?

Do we need more technology to reduce recurrence of bleeding from ulcers?

The Efficacy of Proton-pump Inhibitors in Acute Ulcer Bleeding

Despite remarkable progress in the treatment of chronic peptic ulcer disease, acute gastroduodenal ulcer hemorrhage remains a therapeutic challenge. Numerous trials of H-2 receptor antagonists have not consistently shown a significant benefit in such patients. Proton-pump inhibitors, which more profoundly suppress gastric acid, are being increasingly evaluated. We have performed a qualitative systematic review to analyze the results of these trials to determine if a reasonable consensus can be reached. We searched for all published, randomized, controlled studies that evaluated proton-pump inhibitors in patients with acute peptic ulcer hemorrhage. The primary outcomes evaluated were: (A) persistent or recurrent bleeding; (B) need for surgery; and (C) mortality. Sixteen trials were evaluated, enrolling 3154 patients. Four of the sixteen studies showed a statistically significant decrease in overall rebleeding rate, and two described specific benefit in patients with Type IIa and IIb endoscopic stigmata. Four studies also showed a significantly decreased surgery rate, but none demonstrated a significant mortality reduction. Proton-pump inhibitors may improve outcome in acute peptic ulcer bleeding, but the available clinical data remain inconsistent. Further study is necessary to define the optimal dosage, route of administration, duration of therapy, and subsets of patients most likely to benefit.

The baylor score does not predict rebleeding following endoscopic therapy for acute peptic ulcer hemorrhage

The baylor score does not predict rebleeding following endoscopic therapy for acute peptic ulcer hemorrhage

Effect of somatostatin on splanchnic hemodynamics in patients with cirrhosis of the liver and in normal subjects

The effect of somatostatin on splanchnic hemodynamics was determined in 8 patients with cirrhosis of the liver and in 18 normal subjects using arterial-hepatic-venous catheterization. Estimated hepatic blood flow determined by indocyanine green infusion was 1.36 ± 0.23 L/min (± SEM) in patients with cirrhosis and remained unaffected during 30 min of somatostatin (250 μg/h) administration. Wedged hepatic venous pressure which was elevated to 23 ± 1.8 mmHg was also uninfluenced. In contrast to somatostatin, an infusion of vasopressin (12 U/h for 30 min) given to the same patients, lowered estimated hepatic blood flow by 28% (p < 0.05) and wedged hepatic venous pressure by 18% (p < 0.02). Arterial gastrin and insulin levels were lowered during somatostatin infusion by 33% (p < 0.02) and by 75% (p < 0.005), respectively. In contrast to the cirrhotics, infusion of 250 μg/h somatostatin into normal subjects was associated with a decrease of estimated hepatic blood flow from 1.20 ± 0.16 to 0.88 ± 0.12 L/min (p < 0.01) representing a 27% decline. Arterial gastrin and insulin concentrations were lower (p < 0.01) than in cirrhotics, but the basal levels were lowered by somatostatin to a similar degree in both groups of patients. A higher dose of somatostatin (500 μg/h) administered to normal subjects resulted in a similar decrease of gastrin and of estimated hepatic blood flow as that seen with 250 μg/h, whereas a lower dose (125 μg/h) decreased gastrin but failed to influence estimated hepatic blood flow. Thus, somatostatin at a dose which has been used in the treatment of acute peptic ulcer hemorrhage (250 μg/h) failed to influence estimated hepatic blood flow and wedged hepatic venous pressure in patients with cirrhosis but lowered splanchnic blood flow in normal subjects. Assuming that this effect contributes to somatostatin's therapeutic efficacy, these results cast doubt on its potential value in the treatment of upper gastrointestinal bleeding of cirrhotics with portal hypertension.