Forrest Classification Research Articles

ACCURACY OF TRADITIONAL AGE, GENDER AND SYMPTOM BASED PRE-TEST ESTIMATION OF ANGIOGRAPHICALLY SIGNIFICANT CORONARY ARTERY DISEASE IN PATIENTS REFERRED FOR CORONARY CT ANGIOGRAPHY

Determining pre-test probability of angiographically significant coronary artery disease (ASCAD; ≥50p stenosis) in patients with chest pain has traditionally relied on the Diamond & Forrester (DF) classification that incorporates age, gender & symptom description. This data was derived

Short-Term Healing Process of Artificial Ulcers after Gastric Endoscopic Submucosal Dissection

Background/AimsThe relationship between the appearance of an ulcer and postoperative bleeding after gastric endoscopic submucosal dissection (ESD) is not well understood. To explore this potential relationship, we retrospectively analyzed the short-term healing process of ESD.MethodsA total of 520 consecutive lesions in 434 patients seen between January 2004 and December 2009 were retrospectively investigated. At the second-look endoscopy, which occurred between 1 and 8 days after ESD, artificial ulcers were categorized into 6 patterns according to Forrest's classification: spurting bleeding, oozing bleeding, non-bleeding visible vessel, adherent clot, black base/spot, and clean base. From these data, a short-term healing model of the artificial ulcer was generated.ResultsUlcer base changed gradually from a bloody to a clean one. The bleeding or non-bleeding visible vessel categories, which occurred in approximately one quarter of the ulcers within 3 days of ESD, were rarely observed 4 days after ESD.ConclusionsUlcers that occur after gastric ESD heal in line with a specific time course, and it appears that most healing occurs without massive bleeding.

Analysis of etiological and related factors responsible for acute gastrointestinal hemorrhage

To investigate the etiology, related factors and endoscopic characteristics of acute gastrointestinal hemorrhage. The data including age, gender, medical and medication history, and endoscopic characteristics of patients receiving emergency treatment for acute gastrointestinal hemorrhage between February 2006 and February 2010 were collected to analyze the etiological profiles of this disorder. (1) A total of 1415 patients with a 2: 1 male-to-female ratio visited our hospital for acute gastrointestinal hemorrhage in the past 4 years. There was a higher mean age of disease onset in men than in women [(51 +/- 20) years old vs (61 +/- 17) years old, P = 0.000]. The numbers of patients were 399, 361, 242 and 413 for 4 respective quarters in order of sequence. (2) And 1030 patients received endoscopy. Among them, there were 897 (87.1%) with upper gastrointestinal hemorrhage and 133 (12.9%) with lower gastrointestinal hemorrhage. Significant differences existed in the mean age of two groups [(51 +/- 20) years old vs (57 +/- 18) years old, P = 0.000]. The male-to-female ratio was 656: 241 and 65:68 for these 2 groups respectively (P = 0.000). The percentage of patient with a history of NSAID (non-steroidal anti-inflammatory drug) treatment was 22.1% (n = 198) and 12.0% (n = 16) for these 2 groups respectively (P < 0.01). (3) The most common causative diseases of upper gastrointestinal hemorrhage were peptic ulcer (n = 546, 60.8%), esophageal & gastric varices hemorrhage (n = 130, 14.5%) and gastric cancer (n = 40, 4.6%). When the patients were divided into 5 groups of < 12 h, 12-24 h, 24-48 h, 48-72 h and > or = 72 h per time window of gastroscopy, their percentages with endoscopically active hemorrhage were 24.1% (20/83), 14.9% (24/161), 9.6% (16/166), 7.5% (8/106) and 7.6% (29/381) for these groups respectively with statistically significant differences. When peptic ulcer was examined by the Forrest classification, the ratio of grade I a- II c decreased gradually while the ratio of grade III increased gradually among 5 groups (chi2 = 80.414, P = 0.040). (4) The most common causative diseases of lower gastrointestinal hemorrhage were ischemic colitis (n = 44, 33.1%), small intestinal hemorrhage (n = 26, 19.5%) and colonic polyps (n = 18, 13.5%). (5) When the patients were divided into > 65 years old group (n = 277) and < or = 65 years old group (n = 620), the ratio of gastric ulcer and cancer in upper gastrointestinal hemorrhage was higher in the former than in the latter [23.5% (n = 65) vs 8.9% (n = 55) & 9.7% (n = 27) vs 2.1% (n = 13), P < 0.01)]. While the ratio of duodenal ulcer was lower in the former than in the latter [22.4% (n = 62) vs 49.7% (n = 308), P < 0.01]. The ratio of small intestinal hemorrhage in lower gastrointestinal hemorrhage was higher in the former than in the latter (all P < 0.01). At the lowest in the third quarter, the incidence rate of acute gastrointestinal hemorrhage is higher in males than that in females at a lower age of onset. More common than lower gastrointestinal hemorrhage, upper gastrointestinal hemorrhage has a lower mean age of onset. Peptic ulcer is the most common disorder in upper gastrointestinal hemorrhage. Ischemic colitis is the most common disorder in lower gastrointestinal hemorrhage. The rate of gastric ulcer and gastric cancer in the old age group is higher than that in the young group. Emergency gastroscopy is recommended.

Obesity is Associated With High Risk Stigmata of Peptic Ulcer Disease

Obesity is a worsening epidemic in the United States (US). National Health and Nutrition Examination Survey (NHANES) data shows that one third of the US population is obese (BMI >30). Patients with obesity are at increased risk for a variety of GI conditions including GERD symptoms, erosive esophagitis, Barrett's esophagus, esophageal adenocarcinoma, gallstones, colonic adenomas, colon cancer, non-alcoholic fatty liver disease, and liver cirrhosis. Population studies suggest that obesity is a risk factor for peptic ulcer disease (PUD). The endoscopic appearance or stigmata of bleeding on initial esophagogastroduodenoscopy (EGD) predicts recurrent bleeding. AIM: To evaluate if obesity is a risk factor for high risk endoscopic stigmata of PUD. METHODS: This study was an IRB-approved protocol. 8050 EGD between 11/17/05 and 2/28/10 were reviewed for the finding of ulcer. Inclusion criteria: 1) Initial EGD with the finding of gastric or duodenal ulcer. Exclusion criteria: 1) malignant ulcer, 2) esophageal ulcer, and 3) incomplete documentation. Data collected: age, sex, BMI, ulcer stigmata, location, size, inpatient/outpatient status, NSAID and aspirin status, and H. pylori status. Ulcer appearance was documented by the Forrest classification. High risk stigmata: active spurting of blood (IA) or oozing blood (IB), a nonbleeding visible vessel or pigmented protuberance (IIA), and an adherent clot (IIB). Low risk stigmata: flat, pigmented spot (IIC), and clean-based ulcer (III). Statistical analysis: Chi square, logistic regression. RESULTS: 350 patients (mean age 64.8) with PUD were included. The mean BMI was 27.8. There were 95.7% males, 32.6% of the patients were obese (BMI >30), 30.3% were positive for H. pylori, and 68.9% were taking NSAIDS. 42% were inpatients and 58% were outpatients. Of all ulcers, the mean size was 8.6 mm, 58.0% were located in the stomach, 87.1% were low risk, and 12.9% were high risk. The distribution of stigmata by the Forrest classification: IA 2.9%(n=10), IB 2.6%(n=9), IIA 5.7%(n=20), IIB 1.7%(n=6), IIC 11.7%(n=41), and III 75.4%(n=264). High risk stigmata was not associated with age, sex, H. pylori status, or use of NSAIDS. However, it was significantly associated with BMI category (BMI ≥35: high risk stigmata 23.3%; BMI < 35: high risk stigmata 11.4% (p = 0.03)) and location (duodenum: high risk stigmata 17.7% vs. stomach: high risk stigmata 9.4% (p = 0.02)). Both BMI category (p=0.03) and PUD location (p=0.02) were significant independent predictors of high risk stigmata. CONCLUSION: A BMI ≥ 35 was associated with a significantly higher risk of stigmata on initial EGD in patients with PUD. A BMI≥ 35 may be helpful in risk stratification of patients with suspected PUD bleeding.

234 The Effects of Pantoprazole IV Drip Versus Pantoprazole IV Bolus on Stigmata of Recent Hemorrhage Among Patients With Nonvariceal Upper Gastrointestinal Bleeding

Gastrointestinal hemorrhage caused by peptic ulcer disease is still one of the most common GI diseases requiring emergency treatment. UGI endoscopy has shown that a bleeding peptic ulcer usually has stigmata of recent hemorrhage indicating the site of the bleeding. Studies have shown that a neutral gastric pH is critical for the stability of clots noted over the bleeding ulcer. This study was done to determine whether PPI IV bolus followed by continuous infusion of 8mh/hr in 72 hours in acute nonvariceal upper gastrointestinal bleeding shows better therapeutic effect than PPI IV bolus of 40mg every 12 hours for 3 days in terms of stigmata of recent hemorrhage as shown in endoscopy done within 48-72 hours after admission as the primary outcome. Secondary outcomes are as follows; rebleeding, need for endoscopic therapy, number of hospital days, need for surgery and mortality. Consecutive patients with upper gastrointestinal bleeding admitted were randomly assigned to receive either Pantoprazole 80mg IV bolus followed by Pantoprazole continuous IV drip at 8mg/hr for 72 hours or Pantoprazole 40mg every 12 hours IV for 3 days. Patients were then scheduled for UGI endoscopy which was done within 48-72 hours. Stigmata of Recent Hemorrhage on initial endoscopy were noted. The rate of rebleeding, number of blood units transfused, number of hospital days, as well as mortality were also noted. Over an 8-month period, total of 193 patients were evaluated; but only 60 were included. Patients were randomly assigned to two groups, Group A Pantoprazole 80mg intravenous bolus injection followed by continuous infusion of 8 mg per hour for 72 hours and Group B Pantoprazole 40mg every 12 hours intravenous for 3 days. There were no significant differences between the two groups in terms of age, smoking history, use of NSAIDS, and co-morbidity. There were more male patients enrolled in Group A The study showed that there was no significant difference in the stigmata of recent hemorrhage (Forrest classification), rate of rebleeding, need for surgey and as well as mortality. However more blood units were transfused in Group A. This study showed that there was no significant difference on the stigmata of recent hemorrhage of bleeding peptic ulcers seen on initial endoscopy after Pantoprazole IV bolus followed by continuous IV drip compared to Pantoprazole IV bolus. There was also no significant difference in the rate of rebleeding, need for surgery, number of hospital days as well as mortality. Since Pantoprazole IV bolus is as effective as Pantoprazole IV bolus followed by continuous IV drip this implies a significant cost saving in proton pump inhibitor therapy for nonvariceal upper gastrointestinal bleeding.Table ICharacteristics of Patients included in the StudyAge in YearsGroup AGroup B64.43 ± 14.8556.83 ± 16.75.068Sex(Males)63%(24)37%(14).007Smoking History %65.2%34.8%.063Use of NSAIDs%53.3%46.7%.606Baseline Disease% Comorbidities45%45%.346 Open table in a new tab Table IIStigmata of Recent HemorrhageSRH* (Forrest)Group AGroup B.0681a (%) (n)1.7% (1)0% (0).0681b (%) (n)1.7 % (1)0 % (0)2a (%) (n)8.3% (5)1.7% (1)2b (%) (n)3.3 % (2)10% (6)2c (%) (n)8.3% (5)1.7% (1)3 (%) (n)26.7% (16)36.7% (22) Open table in a new tab

Randomized controlled trial of standard versus high-dose intravenous omeprazole after endoscopic therapy in high-risk patients with acute peptic ulcer bleeding

Rebleeding from peptic ulcers is a major contributor to death. This study compared standard (40-mg intravenous infusion of omeprazole once daily for 3 days) and high-dose (80-mg bolus of omeprazole followed by 8-mg/h infusion for 72 h) in reducing the rebleeding rate (primary endpoint), need for surgery, duration of hospital stay and mortality in patients with peptic ulcer bleeding after successful endoscopic therapy. This was a single-institution prospective randomized controlled study based on a postulated therapeutic equivalence of the two treatments. All patients who had successful endoscopic haemostasis of a bleeding peptic ulcer (Forrest classification Ia, Ib, IIa or IIb) were recruited. Informed consent was obtained and patients were randomized to receive standard- or high-dose infusions of intravenous omeprazole. Two (3 per cent) of 61 patients in the high-dose group and ten (16 per cent) of 61 in the standard-dose group exhibited rebleeding, a difference of - 13 (95 per cent confidence interval - 25 to - 2) per cent. The upper limit of the one-sided confidence interval exceeded a predefined equivalence absolute difference of 16 per cent. Equivalence of standard- and high-dose omeprazole in preventing rebleeding was not demonstrated. Intravenous standard-dose omeprazole was inferior to high-dose omeprazole in preventing rebleeding after endoscopic haemostasis for peptic ulcer bleeding. NCT00519519 (http://www.clinicaltrials.gov).

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%.

Medical and Endoscopic Treatment in Peptic Ulcer Bleeding: a National German Survey

Peptic ulcers are the leading cause of upper gastrointestinal (GI) bleeding. The aim of this study was the evaluation of the recent clinical practice in drug therapy and endoscopic treatment of ulcer bleedings in Germany and to compare the results with the medical standard. A structured questionnaire (cross-sectional study) was sent to 1371 German hospitals that provide an emergency service for upper GI bleeding. The project was designed similar to a nationwide inquiry in France in 2001. Forty-four questions concerning the following topics were asked: hospital organisation, organisation of emergency endoscopy service, endoscopic and drug therapy of ulcer bleeding, endoscopic treatment of variceal bleeding. Return of the questionnaires was closed in August 2004. Response rate was 675 / 1371 (49 %). Mean hospitals size was < 200 beds, 49 % (n = 325) had basic care level. 92 % provided a 24-hour endoscopy service, specialized nurses were available in 75 %. Fiberscopes were used only in 15 %. A mean of 10 +/- 12 (range: 0 - 160) bleeding cases/month were treated, 6 +/- 6 cases per month (60 %) were ulcer bleedings. Endoscopy was performed in 72 % immediately after stabilization but in all cases within 24 hours. The Forrest classification was used in 99 % whereas prognostic scores were applied only in 3 %. Forrest Ia,/Ib/IIa/IIb/IIc/III ulcers were indications for endoscopic therapy in 99 %/ 99 %/ 90 %/ 58 %/ 4 %/ 2 % respectively. Favoured initial treatment was injection (diluted epinephrine, mean volume 17 +/- 13 mL/lesion) followed by clipping. In re-bleedings, 93 % tried endoscopic treatment again. Scheduled re-endoscopy was performed in 63 %. PPI were used in 99.6 %, 85 % administered standard dose twice daily. PPI administration was changed from intravenous to oral with the end of fasting in nearly all hospitals. PPI administration schemes can be improved. Indications for Helicobacter pylori eradication followed rational principles. Medical and endoscopic treatment of bleeding ulcers reached a high standard, although some therapeutic strategies leave room for improvement. Bigger hospitals tend to be closer to the medical standard.

Rokcall score versus forrest classification in endoscopic management of bleeding peptic ulcer

Acute upper gastrointestinal bleeding (UGIB) remains an important emergency situation. In the last two decades, major developments took place influencing incidence, etiology and outcome of patients with acute UGIB. Peptic ulcer bleeding is the most significant complication of ulcer disease being responsible for 50% of all cases mortality. Aim of the study: To compare between endoscopic clip application versus argon plasma coagulation in management of bleeding peptic ulcer (BPU). Patients and Methods: Sixty patients suffering from acute UGIB were randomly divided into two groups: group I included 30 patients treated with endoscopic clip application and Group II included 30 patients subjected to endoscopic APC. All patients were classified according to Forrest classification and the clinical Rockall score. Results: There were significant differences between the two groups as regard Forrest classification (P 0.05). Re bleeding was significant with higher Rockall score in group I (P 0.05). Conclusion: Endoscopic application of hemoclips have a less re bleeding rate than Argon plasma coagulation for treatment of bleeding peptic ulcer, although this was statistically insignificant, meanwhile APC is still less cost and easy. Clinical and endoscopic assessment (through Rokcall score and Forrest classification) could help in making best choice for endoscopic management.

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

The value of routine second-look endoscopy in the management of the acute gastroduodenal ulcer bleeding

The role of routine second-look endoscopy in the management of patients with acute peptic ulcer bleeding is controversial. A more precise identification of higher risk patient group, based on both clinical and endoscopic criteria, is needed to determine whether there are high-risk patients who may benefit from this management strategy. Or aim was to find out whether scheduled second-look endoscopy has any beneficial effect in the clinical outcome. Both endoscopic and clinical data were analyzed in 274 acute gastroduodenal ulcer bleeding patients. The need for repeated endoscopic haemostatic intervention was used as a measure to evaluate the potential beneficial effect of the second look endoscopy. Patients were categorized according to the Forrest classification detected during the emergency endoscopy. In the subgroup of actively bleeding patients (Forrest Ia, Ib) a second endoscopic haemostasis was performed in 23.8% of cases. In the patient subgroup with visible vessel ulcers (Forrest IIa) and in those with adherent clot covered ulcers (Forrest IIb) the needs for a repeated haemostasis were 13.0% and 13.3% respectively. Despite the not statistically significant differences, remarkable clinical impact was noted favoring scheduled second look endoscopy in patients with initially active ulcer bleeding. In the light of the retrospective study results it may be concluded that the scheduled second look endoscopy strategy offers a beneficial clinical outcome for selected patients estimated to be a very high risk of re-bleeding following the initial endoscopic therapy for active bleeding.

Inter-Observer Agreement On Assessment of Photo Documentation in Bleeding Peptic Ulcer

Background: Photo documentation is readily available at many endoscopic units. To date, however, there are few published evaluations on the utility of this technique in confirming the main findings of the endoscopy. Methods: In order to study the level of inter-observer agreement in assessment of photo documentation, all endoscopists who contributed to a large multinational study in peptic ulcer bleeding (PUB study; NCT00251979) were invited to assess the photo documentation of 25 cases from the study. Each case was classified by assessing the stigmata of recent bleeding according to the Forrest classification (6 classes) or as ‘not assessable’. The assessments were made without knowledge about the classification previously performed by the original endoscopist and, independently, by the two members of the Endpoint Committee (EpC). Thirteen of the 25 cases selected were deemed ‘excellent’ (i.e. agreement between the two EpC members and the original investigator). The remaining 12 cases yielded some degree of disagreement. Kappa scores were calculated for each Forrest grade, for all assessors combined and according to the level of assessor experience with endoscopic procedures (>10y, ‘experienced’; and ≤10y, ‘less experienced’). Results: A total of 115 assessors (endoscopists/investigators) completed the survey. The majority specialized in gastroenterology (n=83); the remainder were primarily surgeons (n=23). 52 assessors were experienced with endoscopic procedures (>10y), while 59 assessors were considered less experienced (≤10y); experience status was unknown for 4 assessors. For the 13 cases considered excellent, 70% of the assessors agreed with the classification made by the original investigator. For the remaining 12 cases, the corresponding value was 21%. The mean (95% CI) kappa score between all assessors was 0.51 (0.51, 0.52). The mean (95% CI) kappa score for each Forrest grade were: Ia (spurting), 0.68 (0.67, 0.68); Ib (oozing), 0.51 (0.51, 0.52); IIa (non-bleeding visible vessel), 0.35 (0.34, 0.35); and IIb (adherent clot), 0.39 (0.39, 0.40). Similar findings were apparent when kappa scores were examined according to the assessors' level of endoscopic experience. Conclusions: Bleeding peptic ulcer can be adequately documented by endoscopic photos, the highest inter-observer agreement being apparent in Forrest class Ia. Supported by AstraZeneca R&D, Mölndal, Sweden.

Predictors Related to Need for Additional Bleeding Control During Follow-Up Endoscopic Examination After Gastric Endoscopic Submucosal Dissection and Efficacy of Routine Preventive Electrocoagulation

Background and Aim: Many reports suggested that gastric endoscopic submucosal dissection (ESD) technique was associated with higher complication rate compared with conventional endoscopic mucosal resection methods, and immediate or delayed bleeding was a most common complication. Previous studies have also showed the association of several factors such as patient's age, size of specimen, location of the lesion with frequency of bleeding. The purpose of this study was to evaluate the risk factors for additional endoscopic bleeding control during follow-up endoscopy after routine post-ESD coagulation. Methods: We analyzed data of 194 consecutive patients with 216 gastric neoplastic lesions from March 2007 to November 2008. All patients underwent a strict preventive hemostasis with electrocoagulation using coagulation forceps for all visible vessles as well as active bleeding focuses in the resected area. Follow-up endoscopy was performed within 24 to 48 hours after gastric ESD to identify the presence of delayed bleeding. Additional endoscopic bleeding control was performed in cases of active oozing, spurting and exposed large vessels. Various factors related to patients, endoscopic findings, resected specimen and the histologic diagnosis were analyzed as potential risk factors. Results: Additional endoscopic bleeding control was performed in 30 gastric lesions (13.9% of all lesions and 14.4% of patients). Among 30 lesions, 13 lesions (6.0% of all lesions) presented as a significant bleeding, defined as Forrest classification Ia and Ib. Three patients (1.5% of all patients) developed delayed bleeding during 9∼13 days after the procedure. Cancerous lesion was significantly associated with higher rate of significant bleeding during follow-up endoscopy compared with benign lesions such as adenoma and hyperplasic polyp (P = 0.045). Other variables was not associated with frequency of additional bleeding control during follow-up endoscopy. Conclusion: Routine preventive electrocoagulation alleviate known risk factors for delayed bleeding after gastric ESD, and therefore may lead to a lower delayed bleeding rate. In the case of cancer compared with benign lesion, more strict preventive bleeding control may be required because of higher rate of delayed bleeding.

Les hémorragies digestives ulcéreuses au CHU Hassan-II de Fès: approche épidémiologique

AimEvaluate and refine the epidemiological profile of patients presenting bleeding peptic ulcers at the Fez Hassan-II Teaching Hospital, in order to improve their health care.Patients and methodsOver a period of three-years, all patients presenting a bleeding peptic ulcer were included in this study. An identification form was elaborated. The form includes different variables such as: presence of comorbidity, medicines taken, different therapies and rates of hemorrhagic relapse and death.ResultsTwo hundred ninety identification forms were analysed. Male predominance (75.86%) was noted, with an average age of 47 ± 17 years and the use of non-steroidal anti-inflammatory drugs by 21 patients (9.5%). Ninety-one percent of the ulcers were located in the bulb. Bleeding ulcers at Forrest stages Ia, Ib and II were noted in 15.1% of cases. Anti-secretory treatment was most often omeprazole, taken orally. Thirty-four patients (14.5%) had relapsed, 17 (7%) had undergone haemostatic surgery, and no patient was treated by endoscopic hemostasia. Eleven patients (3.7%) died. Only age and Forrest stages were the factors predicting relapse.ConclusionCases of bleeding peptic ulcers at the Fez Hassan-II Teaching Hospital were less severe than in developed nations and this is because of a different epidemiological profile. Age and Forrest classification are predictive factors of relapse bleeding.

Endoscopic Treatment of Dieulafoy Lesions and Risk Factors for Rebleeding

Background/AimsDieulafoy lesions are an important cause of upper gastrointestinal bleeding. The purpose of this study was to assess the efficacy of endoscopic treatment for these lesions and to identify the possible predictive factors for rebleeding associated with clinical and endoscopic characteristics.MethodsRecords from 44 patients admitted with Dieulafoy bleeding between January 2006 and December 2007 were reviewed. We retrospectively analyzed the clinical and endoscopic findings and then correlated the rebleeding risk factors with Dieulafoy lesions.ResultsPrimary hemostasis was achieved by endoscopic treatment in 39 patients (88.6%). There were no significant differences between the rebleeding and non-rebleeding groups with respect to age, gender, initial hemoglobin levels, presence of shock, concurrent disease, location of bleeding, or initial hemostatic treatment methods. However, the use of non-steroidal anti-inflammatory drugs or anticoagulants (p=0.02) and active stages in the Forrest classification (p<0.01) were risk factors for rebleeding after endoscopic therapy.ConclusionsEndoscopic therapy is effective and safe for treating Dieulafoy lesions, and it has both short- and long-term benefits. Early identification of risk factors such as the use of non-steroidal anti-inflammatory drugs or anticoagulants and the Forrest classification of bleeding predict the outcome of Dieulafoy lesions.

Comparison of Scoring Systems for the Prediction of Outcomes in Patients with Nonvariceal Upper Gastrointestinal Bleeding: A Prospective Study

The authors aimed to compare the clinical utility of five scoring systems for the prediction of rebleeding and death in patients with nonvariceal upper gastrointestinal bleeding (UGIB). A total of 239 consecutive patients who had undergone endoscopy due to nonvariceal UGIB were prospectively investigated on the basis of five scoring systems (Forrest classification, Rockall scoring system, Cedars-Sinai Medical Centre Predict Index, Blatchford scoring system, and Baylor college scoring system). Thirty-five patients (14.6%) experienced rebleeding and 20 patients (8.4%) died. Comparison of the high-risk categories of the four predictive systems showed that the Forrest classification was superior to the others in predicting rebleeding and death. The Cedars-Sinai Medical Centre Predict Index and the Rockall scoring system showed high positive predictive values for predicting rebleeding and death, respectively. We concluded that the Forrest classification was the most useful scoring system for the prediction of rebleeding and death in patients with nonvariceal UGIB.

Clarifying the Relationship Between ABO/Rhesus Blood Group Antigens and Upper Gastrointestinal Bleeding

The relationship between blood group antigens and peptic ulcer disease has been widely evaluated in the past. Data concerning the same association with upper gastrointestinal bleeding are very limited. We aimed to evaluate this association and we thought it was worthwhile to try to determine whether these components take some part in this complication. The study population consisted of 1,098 adults (364 patients and 734 volunteer blood donors as controls). Demographic features, comorbid illnesses, and use of aspirin/nonsteroidal anti-inflammatory drugs (NSAIDs) were recorded. Blood groups were examined by gel centrifugation method. We included only patients with bleeding from peptic ulcer disease and erosive gastropathy. Ulcers were classified by using Forrest's classification system in terms of rebleeding risk. Helicobacter pylori was examined by histology. The gender distribution was similar in both groups. The ABO blood group phenotype distribution in patients and controls (respectively) was as follows: 46.2% versus 34.9% for group O, 32.4% versus 39.5% for group A, 15.7% versus 18.4% for group B, and 5.8% versus 7.2% for group AB. Blood group O was found to have higher frequency in the patient group than in the control group (P=0.004). Rh positivity was also higher in patients than in controls (P=0.007). H. pylori positivity was similar between blood groups among patients. The rebleeding and mortality rates between blood groups were also similar. ABO blood group O had an important role in patients with upper gastrointestinal bleeding. The impact of blood group on rebleeding and mortality may be a focus for further studies.

Prognostic Factors in Gastrointestinal Bleeding Due to Peptic Ulcer

The identification of prognostic factors of easy application in clinical practice can improve the diagnostic and therapeutic decision making process in upper gastrointestinal bleeding (UGB). The present study estimates the capacity to predict an unfavorable clinical course (mortality, unstable bleeding, and/or interventional therapy) on the basis of the preendoscopic and endoscopic clinical analytical findings in patients with UGB owing to peptic ulcer. A retrospective cohort study was made of 473 adult patients seen in the Emergency Service of a District Hospital, and diagnosed with UGB secondary to gastroduodenal ulcer. Logistic regression analysis was used to construct different models, with the evaluation of their predictive capacity based on calculation of the area under the receiver operating curve (ROC). The final model was used to calculate the probabilities of an unfavorable clinical course for different profiles, with the purpose of constructing an algorithm of help in the decision making process applied to patients initially considered to be at low risk (Forrest classification IIb and III). The model with the Forrest variable showed a high predictive capacity: ROCa=0.81 (95% confidence interval, 0.76-0.85). Incorporation to the model of clinical and preendoscopic factors (type of UGB, hematocrit, kidney failure, and liver disease) significantly increased its predictive capacity: ROCa=0.87 (95% confidence interval, 0.83-0.91). This model allows the differentiation of different complication risk levels in patients initially at low risk according to the Forrest classification (IIb and III). The Forrest classification is the principal predictive factor for an unfavorable course in patients with gastrointestinal bleeding owing to peptic ulcer, though clinical factors are also important and should complement the decision taking process.

Treatment of Acute Ulcer Bleeding in the Upper Gastrointestinal Tract with Fibrin Adhesion

Introduction: Various endoscopic therapies such as cauterization, epinephrine injection, and clip deployment are used to treat patients with gastroduodenal ulcer hemorrhage. Fibrin adhesion with its biologic properties is another potential modality. The aim of this study is to examine its efficacy in the management of acute ulcer bleeds of the UGI tract. Methods: 266 patients underwent endoscopic fibrin adhesion therapy during the period 1992-2005 at St. Willehad Hospital, Germany. The Forrest classification was used to designate ulcer bleeding: Ia--ulcer with active bleeding, spurting vessel, Ib--oozing ulcer, II--ulcer with visible vessel, clot, or flat spot. Of the 266 patients, Ia--26 patients (9.7%), Ib--129 (48.5%), and II-- 111(42.8%). The stomach was involved in 38% and duodenum 62%. The degree of ulcer bleeding based on site: Ia--stomach (10), duodenum (16). Ib--stomach (55), duodenum (63), gastroenteric anastomosis (5), esophagus (6). For II, stomach (45), duodenum (60), gastroenteric anastomosis (4), PEG site (2). Results: Definitive initial hemostasis achieved in 231 patients (86%). Hemostasis achieved in 249 (93.3%) after second endoscopic intervention. The rate of rebleeding after fibrin adhesion therapy: total 29 patients (10.9%) with Ia--11 patients (42.3%), Ib--16 patients (12.4%), II--2 (1.8%). Surgical intervention was required in 11 patients (4.1%), with Ia -- 8(30.7%), Ib-- 3 (2.3%). Total case fatality rate: 10 patients (3.7%), with Ia--3 (11.5%), Ib--6 (4.7%), II--1 (.9%). Of the 11 patients who had an operation, 4 died. Autopsies on 2 showed cause of death being pulmonary embolism and the other with multiorgan failure. Of the 255 who required no surgerical intervention, 6 died. Autopsies on 4 revealed causes of death: pulmonary embolism (1), coronary occlusion (1), overlooked bleeding ulcer (1), small intestine bleed (1). Conclusion: This study on the use of fibrin adhesion therapy for the treatment of acute gastroduodenal ulcer bleeds reveals good results. Fibrin adhesion is indicated particularly for type Ib and II bleeds. More studies are required regarding its use as a supplement to other therapeutic modalities.

Size of the peptic ulcer in Helicobacter pylori-positive patients: association with the clinical and histological characteristics

Objective. Based on a large trial of Helicobacter pylori-positive peptic ulcer patients, we studied whether the size of the ulcer, along with other clinical and histological characteristics, has any effect on healing. We also studied the clinical and endoscopic characteristics associated with size of the peptic ulcer. Material and methods. A total of 333 consecutive patients with H. pylori infection and peptic ulcer were enrolled (mean age 54.8±12.7 years). Location of the ulcer was recorded by gastroscopy and the presence of H. pylori was assured by rapid urease test, histology and by serum H. pylori IgG and IgA antibody measurement. The diameter of the ulcer was measured by placing the opened biopsy forceps (7 mm) beside it. Biopsy specimens were examined in accordance with the Sydney system. Results. Mean size of the peptic ulcer was 13.2±8.3 in corpus, 11.3±5.3 in antrum, 13.8±7.8 in angulus, 9.5±5.3 in prepylorus and 9.2±4.7 mm in duodenum (duodenal versus gastric type; p<0.05). Average size of the ulcers was 9.4±5.3 mm in patients with Forrest III type and 11.5±6.8 in other types (p<0.05). Patients who were ≥50 years of age, currently smoking, or who had corpus-predominant chronic gastritis or atrophic gastritis, had larger ulcers than others. Size of index ulcers, successful eradication of H. pylori and the presence of atrophic gastritis were independent factors for healing. The odds ratio was 11.5 (95% CI 3.3–40.5; p<0.01) for eradication of H. pylori, 3.5 (95% CI 1.1–11.2; p<0.05) for size of the index ulcer (≤10 mm versus >10 mm) and 3.4 (95% CI 1.2–9.8; p<0.05) for atrophic gastritis versus no atrophy. Conclusions. Size of the peptic ulcer, successful H. pylori eradication and atrophic gastritis were independent factors for the healing of peptic ulcers. A number of clinical and endoscopic variables (age, current smoking, corpus-predominant gastritis, Forrest classification) were associated with size of the peptic ulcer in H. pylori-positive patients.