Emergency Endoscopic Hemostasis Research Articles

Risk factors and predictive nomograms for bedside emergency endoscopic treatment following endotracheal intubation in cirrhotic patients with esophagogastric variceal bleeding

Data on emergency endoscopic treatment following endotracheal intubation in patients with esophagogastric variceal bleeding (EGVB) remain limited. This retrospective study aimed to explore the efficacy and risk factors of bedside emergency endoscopic treatment following endotracheal intubation in severe EGVB patients admitted in Intensive Care Unit. A total of 165 EGVB patients were enrolled and allocated to training and validation sets in a randomly stratified manner. Univariate and multivariate logistic regression analyses were used to identify independent risk factors to construct nomograms for predicting the prognosis related to endoscopic hemostasis failure rate and 6-week mortality. In result, white blood cell counts (p = 0.03), Child-Turcotte-Pugh (CTP) score (p = 0.001) and comorbid shock (p = 0.005) were selected as independent clinical predictors of endoscopic hemostasis failure. High CTP score (p = 0.003) and the presence of gastric varices (p = 0.009) were related to early rebleeding after emergency endoscopic treatment. Furthermore, the 6-week mortality was significantly associated with MELD scores (p = 0.002), the presence of hepatic encephalopathy (p = 0.045) and postoperative rebleeding (p < 0.001). Finally, we developed practical nomograms to discern the risk of the emergency endoscopic hemostasis failure and 6-week mortality for EGVB patients. In conclusion, our study may help identify severe EGVB patients with higher hemostasis failure rate or 6-week mortality for earlier implementation of salvage treatments.

Evaluation of the Jichi Medical University diverticular hemorrhage score in the clinical management of acute diverticular bleeding with emergency or elective endoscopy: A pilot study.

Emergency endoscopic hemostasis for colonic diverticular bleeding is effective in preventing serious consequences. However, the low identification rate of the bleeding source makes the procedure burdensome for both patients and providers. We aimed to establish an efficient and safe emergency endoscopy system. We prospectively evaluated the usefulness of a scoring system (Jichi Medical University diverticular hemorrhage score: JD score) based on our experiences with past cases. The JD score was determined using four criteria: CT evidence of contrast agent extravasation, 3 points; oral anticoagulant (any type) use, 2 points; C-reactive protein ≥1 mg/dL, 1 point; and comorbidity index ≥3, 1 point. Based on the JD score, patients with acute diverticular bleeding who underwent emergency or elective endoscopy were grouped into JD ≥3 or JD <3 groups, respectively. The primary and secondary endpoints were the bleeding source identification rate and clinical outcomes. The JD ≥3 and JD <3 groups included 35 and 47 patients, respectively. The rate of bleeding source identification, followed by the hemostatic procedure, was significantly higher in the JD ≥3 group than in the JD <3 group (77% vs. 23%, p <0.001), with a higher JD score associated with a higher bleeding source identification rate. No significant difference was observed between the groups in terms of clinical outcomes, except for a higher incidence of rebleeding at one-month post-discharge and a higher number of patients requiring interventional radiology in the JD ≥3 group than in the JD <3 group. Subgroup analysis showed that successful identification of the bleeding source and hemostasis contributed to a shorter hospital stay. We established a safe and efficient endoscopic scoring system for treating colonic diverticular bleeding. The higher the JD score, the higher the bleeding source identification, leading to a successful hemostatic procedure. Elective endoscopy was possible in the JD <3 group when vital signs were stable.

Novel approach for efficient removal of massive blood clots during emergency endoscopic hemostasis.

Novel approach for efficient removal of massive blood clots during emergency endoscopic hemostasis.

Incidence and risk factors for rebleeding after emergency endoscopic hemostasis for marginal ulcer bleeding

BackgroundMarginal ulcer bleeding is a cause of upper gastrointestinal bleeding, but the efficacy of emergency endoscopic hemostasis and risk factors for rebleeding have not been fully explored. The purpose of the current study was to investigate the rebleeding rate and risk factors after emergency endoscopic hemostasis for marginal ulcer bleeding. MethodsWe conducted a retrospective study of 105 patients who underwent emergency endoscopic hemostasis due to marginal ulcer bleeding from January 2015 to July 2021. Patients included in this study were divided into rebleeding and non-rebleeding groups. ResultsAmong the 105 patients, 15.2% (16/105) patients developed rebleeding within 30 days after endoscopic hemostasis, and 87.5% of the patients had rebleeding within 7 days. The mean age of these patients was 60.3 ± 12.3 years, and 95 of them were male. In the univariate analysis, an ulcer size ≥10 mm, a PLT count <100 × 10^9/L and an AIMS65 score ≥2 were risk factors for rebleeding. According to the multivariable analysis, an ulcer size ≥10 mm (OR: 3.715; 95% CIs: 1.060–14.250; p = 0.043) and a PLT count <100 × 10^9/L (OR: 4.480; 95% CIs: 1.099–18.908; p = 0.035) were independent risk factors for rebleeding. ConclusionEmergency endoscopic hemostasis is an effective treatment for marginal ulcer bleeding. An ulcer size ≥10 mm and a PLT count <100 × 10^9/L were independent risk factors for rebleeding within 30 days after endoscopic hemostasis for marginal ulcer bleeding.

Safety and Efficacy of the Noncessation Method of Antithrombotic Agents after Emergency Endoscopic Hemostasis in Patients with Nonvariceal Upper Gastrointestinal Bleeding: A Multicenter Pilot Study.

Background and Aims The present study aimed to clarify the safety and efficacy of the noncessation method of antithrombotic agents after emergency endoscopic hemostasis in patients with nonvariceal upper gastrointestinal bleeding (UGIB). Methods In this multicenter, prospective, pilot study, we performed emergency endoscopic hemostasis for nonvariceal UGIB in patients taking antithrombotic agents and resumed the medications without a cessation period (group A). The clinical characteristics, types of antithrombotic agents, UGIB etiology, treatment outcome, and adverse events were evaluated. We used propensity score matching to compare treatment outcomes and adverse events with our previous cohort (group B) in whom antithrombotic agents were transiently discontinued after emergency endoscopic hemostasis. Results Forty-three consecutive patients were prospectively enrolled. The main antithrombotic agents were low-dose aspirin and direct oral anticoagulants; 11 patients (25.6%) were taking multiple antithrombotics. Peptic ulcers were the main cause of bleeding (95.4%). Endoscopic hemostasis was successful in all patients and the incidence of rebleeding within a month was 7.0%. Propensity score matching created 40 matched pairs. Endoscopic hemostasis was performed by soft coagulation significantly more frequently in group A than in group B (97.5% versus 60.0%, P < 0.001). Neither the rebleeding rate within a month nor thromboembolic event rate was different between the two groups. However, the mean duration of hospitalization was significantly shorter in group A than in group B (8.6 ± 5.2 d versus 14.4 ± 7.1 d, P < 0.001). Conclusions Antithrombotic agents possibly can be continued after successful emergency endoscopic hemostasis for nonvariceal UGIB.

Comparison of various risk scores for the prognosis of hemorrhagic upper gastrointestinal mucosal disorder

BackgroundVarious risk scores have been proposed that are useful for the management of upper gastrointestinal bleeding (UGIB), which is an important disease in emergency medicine. Few studies have examined the usefulness of Charlson Comorbidity index (CCI) in this disease, which evaluates the patient’s general condition by scoring the patient’s underlying disease. There have been no studies investigating the efficacy of CCI compared to other risk scores in the management of UGIB requiring endoscopic hemostasis.MethodsIn addition to the Glasgow-Blatchford score, AIMS65 score, and Rockall score, we investigated the efficacy of the outcome prediction obtained by the original CCI and the updated CCI, scored only with respect to the underlying disease. We also examined the cutoff value when using the risk score. This retrospective study included 265 patients with hemorrhagic upper gastrointestinal mucosal lesions who underwent emergency endoscopic hemostasis during a 6-year period between 2011 and 2016 in our hospital.ResultsThe updated CCI and AIMS65 score correlated with prognosis in multivariate analysis (p = 0.002 and p = 0.003, respectively). In clinical practice, the prognosis might be worse if both updated CCI and AIMS65 score were 3 point or more.ConclusionIn addition to the AIMS65 score, the updated CCI can be a useful tool for managing upper gastrointestinal mucosal disorder bleeding that requires endoscopic hemostasis.

Free radial forearm flap for reconstruction of postoperative defects in combined and complex treatment of patients with locally-advanced squamous cell carcinoma of the oral cavity

The study objectiveis to assess immediate and long-term results of replacing complex defects with a free radial forearm flap in the multimodal treatment of patients with locally advanced oral cavity squamous cell carcinoma.Materials and methods.Twenty eight patients (20 women and 8 men aged 23 to 71 years) with locally advanced oral cavity squamous cell carcinoma (including 10 buccal cancers, 8 carcinomas of tongue, 6 carcinomas of the floor of the mouth, 2 retromolar area carcinomas, 1 carcinoma of the hard palate and 1 carcinoma of alveolar region of the lower jaw) underwent tumor surgery with simultaneous plastic reconstruction of the defect using radial forearm free flap at the department of head and neck tumors of N. N. Blokhin National Medical Research Center of Oncology within 2010–2018. Primary tumors were detected in 2 patients and 11 patients had residual (n = 7) or recurrent (n = 4) tumors after radiotherapy or chemoradiotherapy.Results.An overall success rate was 96.4 %. Postoperative histology revealed that there were no tumor cells at the resection edges. Postoperative complications included: complete flap necrosis in 1 patient with severe concomitant diseases, marginal flap necrosis in 2 patients (in both cases after the necrotic tissue had rejected, wounds were healed by secondary intention), sural veins thrombosis in 1 patient, acute peptic ulcer bleeding on the 6th day after surgery in 1 patient treated with emergency endoscopic hemostasis. No lethal outcomes were reported. Postoperative period lasted in average 14 days. Upon subsequent observation tumor relapse in the oral cavity occurred in 4 (14.3 %) patients, relapses of regional metastases – in 2 (7.1 %). Good aesthetic and functional results were noted. Adequate restoration of breathing, chewing, swallowing and speaking resulted in a full patients’ rehabilitation. In all cases, the radial flap adapted well to the oral cavity organs and corresponded to the surrounding tissues in thickness and consistency.Conclusion.Use of a radial forearm free flap makes it possible to successfully reconstruct extensive and complex defects after surgery of locally advanced primary and recurrent forms of oral cavity squamous cell cancer of various locations. Due to flap’s high regenerative capabilities, preoperative radiation therapy does not affect the frequency of local complications. It allows restoring vital functions of the oral cavity and achieving good aesthetic and functional results.

Risk Factors for Delayed Hemorrhage after Colonic Endoscopic Mucosal Resection in Patients Not on Antithrombotic Therapy: Retrospective Analysis of 3,844 Polyps of 1,660 Patients

Background/Aims: Colonic endoscopic mucosal resection (EMR) is safe for patients without antithrombotic therapy; however, EMR is associated with several risks. This study was performed to evaluate the risk of delayed hemorrhage in patients undergoing EMR without antithrombotic therapy. Methods: In the present retrospective single-center study, 1,792 patients without antithrombotic therapy underwent colonic EMR from March 2012 to December 2016 at the Saga Medical Centre Koseikan. Risk factors were evaluated with respect to patient and lesion characteristics, the endoscopist’s experience, and preventive hemoclips. Delayed hemorrhage was defined as bleeding for which emergency endoscopic hemostasis was applied >24 h after EMR. Results: Among the 1,792 patients, 1,660 with 3,844 tumors were evaluated. Delayed hemorrhage occurred in 43 patients (2.6%) and 46 polyps (1.2%). Preventive hemoclips were applied in 996 patients (60.0%). Univariate analysis indicated that delayed hemorrhage occurred more frequently in young patients (3–39 years, p < 0.001, 40–59 years, p = 0.005) compared to > 60 years and in association with large polyps (> 10 mm, p = 0.003), hemoclip (p = 0.019), and pedunculated polyps (p = 0.024). Multivariate analysis indicated that risk factors for hemorrhage were young age (age of 3–39 years p < 0.001, 40–59 years, p = 0.005) and large polyps (> 10 mm, p < 0.001). The risk of delayed hemorrhage was increased by an estimated 8% with a 1-mm increase in polyp size. Conclusion: The present study suggests that young age (under 60 years old) and large polyp size are risk factors for causing delayed hemorrhage after colonic EMR in patients without antithrombotic therapy.

Outcomes of Patients Undergoing Endoscopic Hemostasis for the Upper Gastrointestinal Bleeding Were Not Influenced by the Timing of Hospital Emergency Visits: A Situation Prevailing in Japan

Background: The aim of the present study was to determine differences in the prognosis of patients in Japan who underwent emergency endoscopic hemostasis (i) during regular hours versus off hours and (ii) as outpatients versus hospitalized patients. Methods: The present retrospective study included 443 patients who underwent emergency endoscopic hemostasis for non-variceal upper gastrointestinal bleeding from January 2008 to December 2014. These patients were classified into 2 groups: hospitalized patients and outpatients. The outpatients were further subclassified into those who visited the hospital during regular hours and those who visited during off hours. Results: The outcomes of outpatients who underwent emergency hemostasis during off hours did not differ from patients treated during regular hours. Multivariate analysis revealed that outcomes of hospitalized patients, including mortality, need for blood transfusion and length of hospitalization, were worse than those of outpatients; it also revealed that patient age, malnutrition rate and prevalence of diabetes and neoplasms were higher among hospitalized patients than those in outpatients. Conclusions: The clinical outcomes of patients who underwent emergency endoscopic hemostasis for upper gastrointestinal bleeding during off hours did not differ from those of patients treated during regular hours. Outcomes were worse among hospitalized patients, mainly because of their bad general condition.

Risk Factors for Delayed Hemorrhage After Colonic Endoscopic Mucosal Resection (EMR) Focused on Patients who did not Receive Antithrombotic Therapy: A Retrospective Pilot Chart Review

Introduction: Antithrombotic agents are one of major risk factors for delayed hemorrhage after colonic EMR. Whereas the patients without antithrombotic therapy can be performed colonic EMR relatively safe, there are several risks to receive colonic EMR. The aim of present study was to evaluate the risk factors of the delayed hemorrhage after colonic EMR in patients without antithrombotic therapy. Methods: The present study included 995 patients with colonic EMR from January 2013 to December 2016 in Saga Medical Centre Koseikan. The patients who received antithrombotic therapy were excluded from the study. The risk factors were evaluated regarding the patient-characteristics, the lesion-characteristics, and prevented hemoclips. Delayed hemorrhage was defined that the emergency endoscopic hemostasis was applied for bleeding more than 24 h after the EMR procedure. Results: Totally, 2,034 polyps of 995 patients were evaluated in the present study. The average of age was 68.0 years old and the average polyp size was 7.6 mm. Delayed hemorrhage occurred in 14 patients (1.4%). Multivariate analysis indicated that delayed hemorrhage occurred more frequently in the young patients (age <70 years old, P<0.01), and in the large polyp (size >10mm, P=0.01). Prevented hemoclips were applied for the 284 patients (28.5%), and the clips were not statistically effective for delayed bleeding. Conclusion: The present pilot retrospective chart review suggested that the relatively young age (age <70 years old) and the relatively large polyps (size >10 mm) might be risks for the patients without antithrombotic therapy, which warrant a further clinical trial with multicenter study in Japan.

Effectiveness of Endoscopic Hemostasis with Soft Coagulation for Non-Variceal Upper Gastrointestinal Bleeding over a 12-Year Period

Background/Aims: In this study, investigations were carried out to ascertain whether soft coagulation hemostasis for non-variceal upper gastrointestinal bleeding (UGIB) has ever been performed in a time-dependent manner. Methods: Medical records of 502 patients who had undergone emergency endoscopic hemostasis for non-variceal UGIB from 2003 to 2014 were checked and the modalities were used to achieve hemostasis compared between the first period from 2003 to 2008 (197 patients) and the second period from 2009 to 2014 (305 patients). Results: Endoscopic hemostasis was successfully achieved in 96.0% of study patients. Peptic ulcers were the main cause of bleeding (89.4%). Endoscopic hemostasis was performed by soft coagulation significantly more frequently during the second (71.1%) than the first period (11.7%; p < 0.001). Endoscopic hemostasis was mainly achieved by trainees during the second period (76.1%); these trainees comprised a significantly greater proportion of endoscopists than during the first period (56.3%; p < 0.001). Endoscopic-related complications did not differ between the 2 periods. The only risk factor for rebleeding after hemostasis was Helicobacter pylori infection; the use of soft coagulation and the fact that endoscopists were just trainees were not risk factors. Conclusion: Our findings suggest that using soft coagulation to achieve endoscopic hemostasis for non-variceal UGIB is safe and effective, even when it is performed by trainees.

Ендоскопічний гемостаз у комплексному лікуванні гострих шлунково-кишкових кровотеч

Авторами досліджено результати спостережень 92 хворих із гастродуоденальними кровотечами при виразковій хворобі шлунка і дванадцятипалої кишки, лікування яких здійснювали відповідно до запропонованої авторами на підставі патогенезу крововтрати активно-альтернативної тактики: проведення екстреного і превентивного ендоскопiчного гемостазу, інфузійно-трансфузійної терапії. Здійснено 104 гемостази. Остаточно зупинку кровотечi ендоскопiчними методами виконано в 90 пацiєнтiв (97,8 %). Представлено методи і можливості ендоскопічного гемостазу, що підтверджує його ефективність.

Efficacy of Endoscopic Hemostasis with Soft Coagulation Using Hemostatic Forceps for Upper Gastrointestinal Bleeding over a 12-year Period: 2016 ACG Presidential Poster Award

Introduction: The endoscopic submucosal dissection (ESD) technique was introduced to obtain en bloc specimens of early gastric cancer. Endoscopic high-frequency soft coagulation is used to manage visible bleeding and/or nonbleeding vessels during ESD. Upper gastrointestinal bleeding (UGIB) is the most common gastroenterological emergency, and has a considerable morbidity and mortality. This study aimed to compare the etiology and clinical outcome of nonvariceal UGIB between two periods during the last 12 years. Methods: The present retrospectively study evaluated the medical records of patients who underwent emergency endoscopic hemostasis for nonvariceal UGIB from 2003 to 2014. The patients were divided into two periods: the first period was from 2003 to 2008 and the second period was from 2009 to 2014. The study revealed the characteristics of these patients and compared the treatment outcome of endoscopic hemostasis between soft coagulation and other modalities. In addition, endoscopic hemostasis rate was compared between specialists and trainees. The specialists already had the fundamental skills and knowledge needed for ESD, and each specialist assisted more than 40 gastric ESD procedures. Results: 566 patients underwent emergency endoscopy with nonvariceal UGIB. Among the 502 out of 566 patients who underwent endoscopic hemostasis, 197 were in the first period and 305 patients were in the second period. Whereas peptic ulcer lesions were the main cause of bleeding (89.4%) during the whole study period, small and multiple ulcers in addition to duodenal ulcers significantly increased in the second period. Endoscopic hemostasis was successfully performed in 97.0% in the first period and in 95.4% in the second period with no significant difference between the periods. In the modality of hemostasis, the rate of endoscopic hemostasis with soft coagulation using the ESD technique significantly increased in the second period compared to the first period (71.1% vs.11.7%, p < 0.001). The rate of endoscopic hemostasis performed by trainees was significantly higher in the second period than in the first period (76.1% vs.56.3%, p < 0.001). Rebleeding after endoscopic hemostasis decreased in the second period (9.8%) compared to the first period (15.7%). Conclusion: This retrospective study suggested that endoscopic hemostasis with soft coagulation using the ESD technique was safe even performed by trainees and might lead to a lower rebleeding rate after endoscopic hemostasis for UGIB.

Effects evaluation of rapid response first-aid case on bedside emergency endoscopic hemostasis therapy

Objective To explore the effects of rapid response first-aid case on bedside emergency gastroscopy hemostatic treatment. Methods A total of 52 patients with esophageal-fundal varices in liver cirrhosis from January 2014 to June 2015 were divided into control group (n=25) and experimental group (n=27). The patients of control group received the routine nursing; then we summarized the experience and mistakes of operation cooperation, optimized process; next we designed rapid response first-aid case and used in the experimental group. The blood transfusion time, goods preparation time, blood loss, blood transfusion volume were compared in two groups. Results The data of the experimental group in average bleeding to transfusion time (90.22±36.47)min, materials preparation time (14.66±3.48) min, the average amount of bleeding (369.62±158.90) ml, average blood transfusion amount (322.40±117.82) ml were lower than those of the control group [average bleeding to blood transfusion time (123.60±51.87) min, materials preparation time (22.44±2.59) min, average bleeding volume (660.20±181.82) ml, average blood transfusion amount (458.00±140.63)ml](P<0.05). Conclusions The implementation of rapid response first-aid case can effectively shorten the rescue time, reduce bleeding and blood transfusion time, the blood loss, the wastage of human resources and medical resources, improve the efficiency of nursing work in the department and the success rate of rescue. Key words: First aid; Endoscopy; Hemostasis; Rapid response first-aid case

Prognosis for Off-Hour Patients of Hemorrhagic Gastroduodenal Ulcers Treated by Endoscopic Hemostasis Is Equivalent to That of Office-Hour Patients in Japan

Introduction: Efficacy of emergency endoscopic hemostasis on peptic ulcer bleeding is well established. One of the problems in the emergency endoscopy is timing in hospital visit of outpatients. This study aimed i) to compare the characteristics and outcome between office-hour outpatients and off-hour outpatients, and ii) to reveal risk factors for re-bleeding. Methods: This study included 145 outpatients who received emergency endoscopic hemostasis in Karatsu Red Cross Hospital from January, 2008 to April, 2015. The patients were divided into two groups with hospital visiting time: group A of 70 patients; outpatients who visited the hospital during officehour (8:30 to 17:00 on weekdays), and group B of 75 patients; outpatients who visited the hospital during off-hour (17:00 to 8:30 on weekdays or holidays). Characteristics and outcomes were compared between the two groups. In addition, risk factors for re-bleeding were evaluated. Results: Background characteristics of the patients including age, gender, underlying disease, medication, chief complaint, location of ulcer, and Forrest classification were not different between groups A and B. Treatment outcomes of endoscopic hemostasis including primary hemostasis, re-bleeding, endoscopy related complications, and number of deaths within 30 days were not different between the two groups. Anti-platelet agent was a only risk factor for re-bleeding (p = 0.024). Conclusion: Treatment outcomes did not depend on the visiting time to the hospital, suggesting a small number of medical staffs during overtime of the hospital appropriately treated the patients with bleeding ulcers in Japan. In addition, the results suggested that more careful care was required in the patients taking anti-platelet agent.

Case with a Nonreassuring Fetal Status Induced by Massive Hematemesis due to Mallory-Weiss Tear That Required Emergency Cesarean Section at 38 Weeks' Gestation.

We describe a rare case of Mallory-Weiss tear with massive hematemesis at 38 weeks' gestation. A 35-year-old woman presented with epigastralgia followed by massive hematemesis. An emergency endoscopy indicated active pulsatile bleeding at the esophagocardial junction. Although an emergency endoscopic hemostasis was successful, late decelerations without acceleration on cardiotocogram were observed. Therefore, the patient underwent emergency cesarean section, along with blood transfusion, following the endoscopic hemostasis. The hemoglobin level just before the operation was 5.1 g/dL. We suspected that massive hematemesis induced maternal acute anemia and hypovolemia, which resulted in a nonreassuring fetal status. Hence, urgent endoscopic hemostasis, adequate blood transfusion, and emergency cesarean section were needed. Mallory-Weiss tear during the third trimester may have a possibility of massive hematemesis and urgent blood transfusion, emergency endoscopic hemostasis, and emergency cesarean section may be needed.

An effective and safe gastric endoscopic submucosal dissection in the right lateral position using an inverted overtube

Previously, we reported the efficacy of a newly developed inverted overtube in shortening the hemostatic time and obtaining a clear endoscopic view in emergency endoscopic hemostasis. This device also helped us to perform gastric endoscopic submucosal dissection (ESD) more safely by changing the direction of gravity in the right lateral position. To perform a safe ESD, it is important to make an appropriate angle and distance between the electric knife and the gastric mucosa. In this position, the distance to gastric mucosa is reduced, and the angle of the electric knife changes from vertical to somewhat oblique, facilitating safer cutting.

Clinical characteristics of dieulafoy lesion: analysis of 15 cases

Objective To investigate the clinical characteristic and treatment of dieulafoy lesion in order to improve the early diagnosis and treatment.Methods A retrospective review of clinical records of 15 cases of dieulafoy lesion admitted to our emergency department from October 2005 to August 2012 was carried out.Results The male patients were more vulnerable to this disease than female patients,thereby the ratio of male to female patients was 6.5∶ 1,and the mean age was 48.3 years.The precipitating factors were often obscure,and some possible factors were related with certain amount of wine (1/15),using nonsteroidal anti-inflammatory drugs (2/15),and eating irritant food (2/15),and a few patients had a past history of hypertension (3/15) or diabetes mellitus (5/15) and no patient had past history of peptic lesion and cirrhosis of liver.The Dieulafoy' s lesion occurred suddenly without premonitory symptoms such as pain or upset of stomach,presented with the episodes of hematemesis or hemafecia,and the patients were in a stage of shock and moderate to severe anemia because of massive blood loss.The majority of lesions located at the posterior wall of the stomach (9/15) or adjacent to the lesser curvature (10/15).Endoscopy was of prime importance for confirming the diagnosis of Dieulafoy's lesions.Endoscopic treatments included hemostasis with clipping combined with epinephrine submucosa injection and successfully excising the lesion in 14 patients (14./15).Surgical treatment was done in 1 patient after failure of endoscopic treatments.Conclusions Dieulafoy lesion is characterized by sudden massive hemorrhage of the alimentary tract,it most commonly locates in the pars posterior of stomach adjacent to the lesser curvature in the middle-aged and the elderly males.Endoscopy is the most simple and essential method to confirm the diagnosis,and emergency endoscopic hemostasis with clipping for treating Dieulafoy lesion is an effective therapeutic strategy. Key words: Dieulafoy lesion; Clinical characteristic; Diagnosis; Treatment

Sp711 Emergency Endoscopic Diagnosis and Hemostasis for Delayed Bleeding of Submucosal Tunnel after Peroral Endoscopic Myotomy (POEM)

Postoperative delayed bleeding of submucosal tunnel is a rare complication after peroral endoscopic myotomy (POEM) for esophageal achalasia. However, once it occurs it can be fatal. Thus, early diagnosis and managements are most critical for patient outcome. Here, we showed emergency endoscopic diagnosis and hemostasis for delayed bleeding of submucosal tunnel after POEM in a 25-year-old male. This patient did not have any coagulation disorder before POEM and underwent POEM successfully. After discharge, he complained of progressive serious retrosternal pain from the first day after surgery and also suddenly had vomiting of fresh blood on the third day. Emergency gastroscopy was performed immediately for exploration. Hematoma was found along the submucosal tunnel and the covering mucosa was very swelling. After removing the metal clips of mucosal entry, a large number of blood clots were discovered in the submucosal tunnel, and were removed. The active bleeding points were identified and coagulated with hemostatic forceps. However, on the third day after first endoscopic hemostasis, there was major blood drainage from nasogastric tuble. A Sengstaken–Blakemore tube was placed into the stomach and lower part of the esophagus to compress the bleeding spot. Intermittence deflation of the balloons was done every 24 hours. The gastric balloon of Sengstaken–Blakemore tube was finally deflated on the first day after placement, and the esophageal balloon was finally released on the second day. Successful hemostasis was achieved and no blood transfusion was necessary. This case may provide a better understanding of delayed bleeding after POEM with an emphasis on its early features and effective managements. Vomiting of fresh blood and progressive serious retrosternal pain were the major early manifestations in patients with delayed bleeding of submucosal tunnel. Emergency endoscopic diagnosis and hemostasis should be taken as early as possible. It should be worth mentioning that a Sengstaken–Blakemore tube is particularly effective for hemostasis by compression.

The Acute Management of Nonvariceal Upper Gastrointestinal Bleeding

Background. The mortality from nonvariceal upper gastrointestinal bleeding is still around 5%, despite the increased use of proton-pump inhibitors and the advancement of endoscopic therapeutic modalities. Aim. To review the state-of-the-art management of acute non variceal upper gastrointestinal bleeding from the presentation to the emergency department, risk stratification, endoscopic hemostasis, and postendoscopic consolidation management to reduce the risk of recurrent bleeding from peptic ulcers. Methods. A PubMed search was performed using the following key words acute management, non variceal upper gastrointestinal bleeding, and bleeding peptic ulcers. Results. Risk stratifying patients with acute non variceal upper gastrointestinal bleeding allows the categorization into low risk versus high risk of rebleeding, subsequently safely discharging low risk patients early from the emergency department, while achieving adequate hemostasis in high-risk lesions followed by continuous proton-pump inhibitors for 72 hours. Dual endoscopic therapy still remains the recommended choice in controlling bleeding from peptic ulcers despite the emergence of new endoscopic modalities such as the hemostatic powder. Conclusion. The management of nonvariceal upper gastrointestinal bleeding involves adequate resuscitation, preendoscopic risk assessment, endoscopic hemostasis, and post endoscopic pharmacological and nonpharmacological treatment.