Heater Probe Thermocoagulation Research Articles

Gastrointestinal: A rare cause of upper gastrointestinal bleeding: Epiphrenic esophageal diverticula

An 87-year-old man presented to the Emergency Department after a syncopal event at home associated with a 3-day history of melena. This was on a background of ischemic heart disease with previous coronary artery bypass graft and recent transesophageal echocardiogram cardioversion for atrial fibrillation 10-days prior. He was commenced on apixaban during this admission and re-commenced on aspirin by his general practitioner on review post discharge. On assessment, he was hemodynamically stable, with melena noted on digital rectal examination. His laboratory results revealed a hemoglobin of 68-g/L, urea of 22.8-mmol/L, and INR of 1.7. He was commenced on intravenous pantoprazole (proton pump inhibitor), transfused with two units of packed red blood cells, and underwent a gastroduodenoscopy the following day. Upper endoscopy revealed a 2–2.5-cm diameter esophageal diverticulum (Fig.-1) just above the gastroesophageal junction (GOJ) in the right posterior-lateral wall. There was no active bleeding, but there was evidence of recent bleeding with altered blood and mild mucosal erythema in the surrounding tissue. The remainder of the endoscopy also identified two further diverticula: one in the gastric fundus within a large hiatus hernia with evidence of some altered blood and a 3rd diverticulum noted in the second portion of the duodenum with no evidence of a recent bleed. No endoscopic therapy was required at the time for hemostatic control due to the absence of active bleeding or visible high-risk stigmata. We proceeded with a computed tomography of the chest and upper abdomen (Fig.-2) as well as a barium swallow that confirmed numerous diverticula involving the GOJ (22-×-6-mm), stomach, and duodenum. Upon further history, the patient did describe having intermittent dysphagia over many years. The patient's melena resolved, and he was discharged home off aspirin with continuation of an oral proton pump inhibitor. Esophageal diverticula have a reported annual incidence of 1:500-000 per year and epiphrenic esophageal diverticula (EED) that occur within 10-cm proximal to the GOJ account for about 15% of these. EED is a very rare cause of upper gastrointestinal bleeding. As far as we are aware, there have been only a handful of these cases published to date. Although EED are largely noted incidentally, some common symptoms of presentation include dysphagia, vomiting, chest pain, and heartburn. Assessment may also involve barium swallow and computed tomography of the chest, especially for pre-operative evaluation. There are no clear guidelines or consensus as to the best course of treatment. Therapeutic interventions that have been described in previous case reports include administration of adrenaline, heater probe thermocoagulation, and hemostasis clips. If endoscopic intervention is not successful, surgical options may include diverticulectomy, myotomy, and fundoplication. Although rare, this case demonstrates that EED could potentially cause significant upper gastrointestinal bleeding and should be considered as a differential in clinical practice.

Su1927 Gender Differences in GI Symptom Patterns Related to Clinically Significant Organic Diseases Are Detected in Japanese Patients

[Introduction] Endoscopic therapy has been demonstrated to be effective in achieving hemostasis for bleeding peptic ulcers. Thermal coagulation is one of the most commonly used methods with a high success rate. Recently, endoscopic submucosal dissection for early gastric carcinoma was developed and hemostasis with soft coagulation using hemostatic forceps was introduced. We applied endoscopic hemostasis with soft coagulation to gastroduodenal ulcer bleeding and reported that initial and final hemostatic rates were 95% and 100%, respectively. The aim of this study was to compare the hemostatic effects of soft coagulation with those of heater probe thermocoagulation for peptic ulcer bleeding. [Methods] Patients who visited our hospital with hematemesis or melena and required life-saving endoscopic treatment were recruited. Inclusion criteria in this study were that they presented with an actively bleeding ulcer, a nonbleeding visible vessel, or an adherent clot. Patients were excluded if they were unwilling to give written informed consent or had bleeding gastric malignancy. Patients were randomized to receive endoscopic hemostasis with soft coagulation (Group S) or heater probe thermocoagulation (Group H). In Group S, endoscopic hemostasis with soft coagulation was performed using a monopolar hemostatic forceps (FD410LR, Olympus) and an electrosurgical unit (ICC-200, ERBE) at 70W. In Group H, a heater probe unit (HPU-20, Olympus) was used and pulses of 20 to 30 J were given. When the allocated treatment failed to achieve hemostasis, the other method was applied. If hemostasis was not obtained using thesemethods, intervention radiology or surgical treatment was applied. Initial hemostasis was declared when hemostasis was obtained by the single allocated method and second-look endoscopy revealed no bleeding from ulcers. The primary endpoint was the initial hemostasis rate and secondary endpoints were the rebleeding rate, complications and the procedure time. [Results] Between May 2010 and February 2012, a total of 111 patients (89 gastric ulcers and 22 duodenal ulcers) were enrolled. There were no significant differences in the background characteristics between Groups S and H. Initial hemostasis was achieved in 54 patients (96%) in Group S and 37 patients (67%) in Group H (p , 0.0001). Rebleeding occurred in 4 patients in Group H and none in Group S. Of these patients, urgent surgery was performed in one patient. Perforation occurred in two patients in Group H, which were managed conservatively. The duration of endoscopic therapy was shorter in Group S than in Group H, although not significantly (P = 0.10). [Conclusions] For patients with gastroduodenal ulcer bleeding, soft coagulation using a monopolar hemostatic forceps provides an advantage in achieving hemostasis compared with heater probe thermocoagulation.

Su1923 A Prospective, Randomized Trial of Soft Coagulation Versus Heater Probe Thermocoagulation for Peptic Ulcer Bleeding

[Introduction] Endoscopic therapy has been demonstrated to be effective in achieving hemostasis for bleeding peptic ulcers. Thermal coagulation is one of the most commonly used methods with a high success rate. Recently, endoscopic submucosal dissection for early gastric carcinoma was developed and hemostasis with soft coagulation using hemostatic forceps was introduced. We applied endoscopic hemostasis with soft coagulation to gastroduodenal ulcer bleeding and reported that initial and final hemostatic rates were 95% and 100%, respectively. The aim of this study was to compare the hemostatic effects of soft coagulation with those of heater probe thermocoagulation for peptic ulcer bleeding. [Methods] Patients who visited our hospital with hematemesis or melena and required life-saving endoscopic treatment were recruited. Inclusion criteria in this study were that they presented with an actively bleeding ulcer, a nonbleeding visible vessel, or an adherent clot. Patients were excluded if they were unwilling to give written informed consent or had bleeding gastric malignancy. Patients were randomized to receive endoscopic hemostasis with soft coagulation (Group S) or heater probe thermocoagulation (Group H). In Group S, endoscopic hemostasis with soft coagulation was performed using a monopolar hemostatic forceps (FD410LR, Olympus) and an electrosurgical unit (ICC-200, ERBE) at 70W. In Group H, a heater probe unit (HPU-20, Olympus) was used and pulses of 20 to 30 J were given. When the allocated treatment failed to achieve hemostasis, the other method was applied. If hemostasis was not obtained using thesemethods, intervention radiology or surgical treatment was applied. Initial hemostasis was declared when hemostasis was obtained by the single allocated method and second-look endoscopy revealed no bleeding from ulcers. The primary endpoint was the initial hemostasis rate and secondary endpoints were the rebleeding rate, complications and the procedure time. [Results] Between May 2010 and February 2012, a total of 111 patients (89 gastric ulcers and 22 duodenal ulcers) were enrolled. There were no significant differences in the background characteristics between Groups S and H. Initial hemostasis was achieved in 54 patients (96%) in Group S and 37 patients (67%) in Group H (p , 0.0001). Rebleeding occurred in 4 patients in Group H and none in Group S. Of these patients, urgent surgery was performed in one patient. Perforation occurred in two patients in Group H, which were managed conservatively. The duration of endoscopic therapy was shorter in Group S than in Group H, although not significantly (P = 0.10). [Conclusions] For patients with gastroduodenal ulcer bleeding, soft coagulation using a monopolar hemostatic forceps provides an advantage in achieving hemostasis compared with heater probe thermocoagulation.

Su1925 Characteristics of Gastric Polyps in African Americans and Hispanics

[Introduction] Endoscopic therapy has been demonstrated to be effective in achieving hemostasis for bleeding peptic ulcers. Thermal coagulation is one of the most commonly used methods with a high success rate. Recently, endoscopic submucosal dissection for early gastric carcinoma was developed and hemostasis with soft coagulation using hemostatic forceps was introduced. We applied endoscopic hemostasis with soft coagulation to gastroduodenal ulcer bleeding and reported that initial and final hemostatic rates were 95% and 100%, respectively. The aim of this study was to compare the hemostatic effects of soft coagulation with those of heater probe thermocoagulation for peptic ulcer bleeding. [Methods] Patients who visited our hospital with hematemesis or melena and required life-saving endoscopic treatment were recruited. Inclusion criteria in this study were that they presented with an actively bleeding ulcer, a nonbleeding visible vessel, or an adherent clot. Patients were excluded if they were unwilling to give written informed consent or had bleeding gastric malignancy. Patients were randomized to receive endoscopic hemostasis with soft coagulation (Group S) or heater probe thermocoagulation (Group H). In Group S, endoscopic hemostasis with soft coagulation was performed using a monopolar hemostatic forceps (FD410LR, Olympus) and an electrosurgical unit (ICC-200, ERBE) at 70W. In Group H, a heater probe unit (HPU-20, Olympus) was used and pulses of 20 to 30 J were given. When the allocated treatment failed to achieve hemostasis, the other method was applied. If hemostasis was not obtained using thesemethods, intervention radiology or surgical treatment was applied. Initial hemostasis was declared when hemostasis was obtained by the single allocated method and second-look endoscopy revealed no bleeding from ulcers. The primary endpoint was the initial hemostasis rate and secondary endpoints were the rebleeding rate, complications and the procedure time. [Results] Between May 2010 and February 2012, a total of 111 patients (89 gastric ulcers and 22 duodenal ulcers) were enrolled. There were no significant differences in the background characteristics between Groups S and H. Initial hemostasis was achieved in 54 patients (96%) in Group S and 37 patients (67%) in Group H (p , 0.0001). Rebleeding occurred in 4 patients in Group H and none in Group S. Of these patients, urgent surgery was performed in one patient. Perforation occurred in two patients in Group H, which were managed conservatively. The duration of endoscopic therapy was shorter in Group S than in Group H, although not significantly (P = 0.10). [Conclusions] For patients with gastroduodenal ulcer bleeding, soft coagulation using a monopolar hemostatic forceps provides an advantage in achieving hemostasis compared with heater probe thermocoagulation.

Randomised clinical trial: high‐dose vs. standard‐dose proton pump inhibitors for the prevention of recurrent haemorrhage after combined endoscopic haemostasis of bleeding peptic ulcers

The optimal dosage of intravenous proton pump inhibitors (PPIs) for the prevention of peptic ulcer rebleeding remains unclear. To compare the rebleeding rate of high-dose and standard-dose PPI use after endoscopic haemostasis. A total of 201 patients with bleeding ulcers undergoing endoscopic treatment with epinephrine injection and heater probe thermocoagulation were randomised to receive a high-dose regimen (80 mg bolus, followed by pantoprazole 8 mg/h infusion, n = 100) or a standard-dose regimen (pantoprazole 40 mg bolus daily, n = 101). After 72 h, all patients were given 40 mg pantoprazole daily orally for 27 days. There were no statistical differences in mean units of blood transfused, length of hospitalisation ≦5 days, surgical or radiological interventions and mortality within 30 days between two groups. Bleeding recurred within 30 days in six patients [6.2%, 95% confidence interval (CI) 1.3-11.1%] in the high-dose group, as compared to five patients (5.2%, 95% CI 0.6-9.7%) in the standard-dose group (P = 0.77). The stepwise Cox regression analysis showed end-stage renal disease, haematemesis, chronic obstructive pulmonary disease (hazard ratio: 37.15, 10.07, 9.12, 95% CI: 6.76-204.14, 2.07-49.01, 1.66-50.00 respectively) were independent risk factors for rebleeding and Helicobacter pylori infection was associated with lower risk of rebleeding (hazard ratio: 0.20, 95% CI: 0.04-0.94). Following combined endoscopic haemostasis of bleeding ulcers, co-morbidities, haematemesis and H. pylori Status, but not PPI dosage, are associated with rebleeding (http://www.Clinical Trials.gov.ID: NCT00709046).

Randomized Comparison of a Novel Hemostatic Clip (Resolution Clip™) to Combined Epinephrine Injection and Heater Probe (HP) Thermocoagulation in Endoscopic Control of Peptic Ulcer Bleeding (PUB)

Randomized Comparison of a Novel Hemostatic Clip (Resolution Clip™) to Combined Epinephrine Injection and Heater Probe (HP) Thermocoagulation in Endoscopic Control of Peptic Ulcer Bleeding (PUB)

Intravenous proton pump inhibitors: requiem for endoscopic therapy?

Intravenous proton pump inhibitors: requiem for endoscopic therapy?

Endoscopic haemoclip versus heater probe thermocoagulation plus hypertonic saline–epinephrine injection for peptic ulcer bleeding

Background. Treating patients of bleeding peptic ulcers with heater probe thermocoagulation and haemoclip is considered to be safe and very effective. Yet, there is no report comparing the haemostatic effects of endoscopic haemoclip versus heater probe thermocoagulation plus hypertonic saline–epinephrine injection in these patients. Aim. To compare the clinical outcomes of both therapeutic modalities in patients with peptic ulcer bleeding. Methods. A total of 93 patients with active bleeding or non-bleeding visible vessels were randomised to receive either endoscopic haemoclip ( n=46) or heater probe thermocoagulation plus hypertonic saline–epinephrine injection ( n=47). Five patients from the haemoclip group were excluded because of the inability to place the haemoclip. Results. Initial haemostasis was achieved in 39 patients (95.1%) of the haemoclip group and 47 patients (100%) of the heater probe group ( P>0.1). Rebleeding occurred in four patients (10.3%) of the haemoclip group and three patients (6.4%) of the heater probe group ( P>0.1). The volume of blood transfused after entry into the study, duration of hospital stay, number of patients requiring urgent surgery and the mortality rates were not statistically different between the two groups. Conclusions. If the haemoclip can be applied properly, the clinical outcomes of the haemoclip group would be similar to those of the heater probe group in patients with peptic ulcer bleeding. However, if the bleeders are located at the difficult-to-approach sites, heater probe plus hypertonic saline injection is the first choice therapy.

Endoscopic hemostasis of a bleeding marginal ulcer: hemoclipping or dual therapy with epinephrine injection and heater probe thermocoagulation.

Endoscopic hemoclipping and dual therapy with epinephrine injection and heater probe thermocoagulation have been proven effective in the hemostasis of bleeding peptic ulcers. However, the hemostatic efficacy has not been investigated in bleeding marginal ulcers. The aim of this study is to investigate the hemostatic efficacy of endoscopic hemoclipping and dual therapy with epinephrine injection and heater probe thermocoagulation in bleeding marginal ulcers. From November 1997 to July 2000, 50 patients with active marginal ulcer bleeding underwent either hemoclipping (20 patients) or dual therapy (30 patients) for hemostasis. The demographic data, clinicopathological characteristics, endoscopic findings, initial hemostatic rates, rebleeding rates, amount of blood transfusion, the need of surgery, and mortality rates were collected and analyzed. Marginal ulcers were located at the anastomotic site (64%), saddle portion (22%), efferent loop (10%), or at the afferent loop (4%). The bleeding stigmata were classified into spurting artery (32%), oozing vessel (38%), visible vessel (20%), and blood clot adhesion (10%). The overall therapeutic results in 50 patients were initial hemostasis (100%), rebleeding rate (22%), need for surgery (4%), and hospital mortality rate (4%). There was no significant difference in demographic data and clinicopathological characteristics between the two modes of treatments, whereas recurrent bleeding developed in 5% in the hemoclipping group and 33% in the dual therapy group. No complication related to the procedure occurred in either mode of therapy. The hospital mortality rates were 0 and 6.7%, respectively. Endoscopy is effective in achieving initial hemostasis from bleeding marginal ulcers. However, the rebleeding rate remains high and repeated endoscopy may be needed to arrest the hemorrhage.

A prospective, randomized trial of endoscopic hemoclip versus heater probe thermocoagulation for peptic ulcer bleeding

OBJECTIVES: Endoscopic heater probe thermocoagulation and hemoclip are considered to be safe and very effective in the treatment of bleeding peptic ulcer. So far, there are only few reports concerning hemostasis with endoscopic hemoclip. The aims of this study were to compare the hemostatic effects of both therapeutic modalities in patients with peptic ulcer bleeding. METHODS: A total of 80 patients with active bleeding or nonbleeding visible vessels were randomized to receive endoscopic hemoclip (n = 40) or heater probe thermocoagulation (n = 40). RESULTS: Initial hemostasis was achieved in 34 patients (85%) in the hemoclip group and 40 patients (100%) in the heater probe group ( p = 0.01277). Rebleeding occurred in three patients (8.8%) in the hemoclip group and two patients (5%) in the heater probe group ( p > 0.1). Among patients with difficult-to-approach bleeding, we obtained a better hemostatic rate in the heater probe group (nine of 11 patients vs three of 10, p = 0.02417). The volume of blood transfused after entry into the study, duration of hospital stay, number of patients requiring urgent surgery, and the mortality rate were not statistically significantly different between the two groups. CONCLUSIONS: For patients with peptic ulcer bleeding, heater probe thermocoagulation offers an advantage in achieving hemostasis than hemoclip. In difficult-to-approach bleeders, heater probe is a more suitable therapeutic modality.

Effect of endoscopic treatment of gastric antral vascular extasia associated with chronic liver disease

Background: Gastric antral vascular ectasia (GAVE), as a cause of upper gastrointestinal bleeding, has been treated surgically, endoscopically and pharmacologically for the past 20 years. Methods: We analyzed the clinical effect of endoscopic treatment for 12 cases of GAVE diagnosed at Osaka National Hospital between January 1993 and October 1998. Results: Eight of the 12 cases were treated endoscopically due to marked anemia and histories of gastrointestinal bleeding. All had chronic liver disease (CLD). Mean age was 69 years on diagnosis. Male to female ratio was 1 : 1. Gastric antral vascular ectasia was a cause of 3.9% of bleeding associated with CLD. The modes of endoscopic treatment of the eight cases were laser photocoagulation (1), electrocautery (3), and heater probe thermocoagulation (4). The initial treatment required an average of 5.1 sessions over a period of 43 days. Initial hemostasis was successful in all cases. Treatments for recurrent bleeding were necessary in six cases within 9.2 months, and endoscopic coagulation was again effective in two cases. Corticosteroids were effective in two of three cases resistant to endoscopic therapy. Mean follow‐up period after initial treatment was 2.8 years. The mean total number of therapeutic endoscopy sessions was 9.6. Conclusion: Endoscopic treatments and/or corticosteroids have yielded sufficient results in the hemorrhage of GAVE. Factors affecting the recurrence of GAVE need to be analyzed in CLD patients.

A prospective randomized trial of heater probe thermocoagulation versus injection therapy in peptic ulcer hemorrhage

Background: A prospective, randomized study was performed to compare the hemostatic effect of injection therapy and heater probe thermocoagulation in the treatment of peptic ulcer bleeding.Methods: This study includes 104 patients with upper gastrointestinal bleeding in whom endoscopy revealed a gastric or duodenal ulcer with nonbleeding or bleeding vessel (n = 66), oozing hemorrhage (n = 21), or adherent red clot (n = 17). Patients with other stigmata or clean ulcers were excluded. Patients were randomly assigned during endoscopy to receive injection therapy (adrenaline and polidocanol) (n = 51) or heater probe thermocoagulation (10F probe, at setting of 30 J (n = 53). Therapy was considered successful if there was no further hemorrhage or only minor rebleeding that was controlled with a second endoscopic procedure. Patients with major rebleeding or failure of retreatment underwent emergency surgery.Results: There were no significant differences in effectiveness between injection therapy and thermocoagulation in any of the assessed parameters: the percentage of patients with major recurrent hemorrhage (4% vs 6%) or minor rebleeding (16% vs 17%), need for emergency surgery (two patients from each group), transfusion requirement (0.45 ± 0.9 units vs 0.51 ± 1.1 units), the mean number of hospitalization days (7.1 ± 4.2 vs 6.9 ± 4.9), and mortality (one patient from each group died).Conclusion: Injection therapy and heater probe have similar efficacies in the treatment of bleeding peptic ulcers. (Gastrointest Endosc 1996;43:117-20.)

Active, bleeding marginal ulcer of Billroth II gastric resection: a clinical experience of 18 patients.

From July 1988 to April 1993, 18 patients with active, marginal ulcer bleeding were investigated for their clinical presentation, endoscopic findings, and successful rate of therapeutic endoscopy. Through endoscopic survey, data on the ulcer number, ulcer location, and prevalence rate of each major stigmata of recent hemorrhage were obtained. Therapeutic methods used include heater probe thermocoagulation and local injection with diluted epinephrine (0.01%) or 95% alcohol through the endoscope. All patients were male with a mean age of 65.3 years. Tarry stool passage (15/18; 83.3%) was the most common clinical presentation. Fifteen patients (15/18; 83.3%) had single marginal ulcer. Ulcerations were located in the jejunal site (12/18; 66.6%) and gastro-jejunal anastomosis (5/18; 27.7%). There were two patients with spurting artery, six with nonbleeding visible vessel, two with blood clot adhesion, four with oozing, three with visible vessel-associated oozing and three, with blood clot adhesion accompanying oozing. The rate of therapeutic endoscopy to successfully stop bleeding or prevent rebleeding was 94.4% (17/18). Sixteen cases (16/17) received one session of endoscopic therapy, and one patient (1/17) accepted two sessions. One patient with multiple underlying diseases died of persistent bleeding after three sessions of therapy. No complication was found to be related to the endoscopic procedure. Marginal ulcer bleeding exhibits the same endoscopic findings as peptic ulcer hemorrhage. Most marginal ulcers are single and located at the saddle area of the jejunal site. Endoscopy can be useful in diagnosing marginal ulcer, and it is safe and effective in managing active marginal ulcer bleeding.

Esophageal Visible Vessel as a Cause of Massive Upper Gastrointestinal Hemorrhage

Besides peptic ulcers, erosions, esophageal varices, tumors and non-variceal esophageal lesions, vascular abnormalities lead to an upper gastrointestinal hemorrhage in 1-5% of cases. Among 581 emergency esophagogastro-duodenoscopies for acute gastrointestinal bleeding performed in our institution between 1987 and 1989, an esophageal visible vessel was found to be the source of massive hemorrhage in five patients. All patients were males with ages ranging from 37 to 84 years. Esophageal visible vessel was localized in one patient in the middle third and in four patients in the distal portion of the esophagus. Using the Forrest classification, endoscopy revealed an oozing hemorrhage (Ib) in two patients and a protruding vessel (IIa) in three patients. Definitive hemostasis could be achieved in all patients by local injection of adrenaline combined with heater probe thermocoagulation. In some patients with recurrent upper gastrointestinal bleeding, visible esophageal vessel is a rare source of bleeding that has not yet been described.