High Risk Of Rebleeding Research Articles

Alcohol Abuse Increases Rebleeding Risk and Mortality in Patients with Non-variceal Upper Gastrointestinal Bleeding.

No current data are available on rebleeding and mortality risk in patients who use alcohol excessively and are admitted for non-variceal upper gastrointestinal bleeding (NVUGIB). This information could help in planning interventions and follow-up protocols for these patients. This study provides contemporary data on the long-term outcome after first-time NVUGIB in alcohol abusers (AAs) compared to non-abusers (NAs). Consecutive patients hospitalized for their first acute gastrointestinal bleeding from 2009 through 2011 were retrospectively recorded and categorized as AA or NA. Risk factors for one-year mortality and rebleeding were identified, and patients were further monitored for long-term mortality until 2015. Alcohol abuse was identified in 19.7% of patients with NVUGIB (n = 518). The one-year rebleeding rate was 16.7% in AAs versus 9.1% in NAs (P = 0.027). Alcohol abuse was associated with a twofold increase in rebleeding risk (P = 0.025); the risk especially increased 6 months after the initial bleeding. The study groups did not differ significantly in 30-day (6.0%) or one-year mortality rates (20.5%). However, there was a tendency for higher overall mortality in AAs than NAs after adjustment of comorbidities. AAs with NVUGIB are at high risk of rebleeding, and mortality is increased in AA patients. A close follow-up strategy and long-term proton pump inhibitor therapy are recommended for AA patients with peptic ulcer or esophagitis.

Endovascular Treatment of Dissecting Aneurysms of the Posterior Inferior Cerebellar Artery and Predictors of Outcome

Isolated dissecting aneurysms of the posterior inferior cerebellar artery (PICA) are rare lesions, which carry high risk of rebleeding and mortality. However, the existing literature concerning predictors of outcome after endovascular treatment is limited and controversial. Our present study retrospectively reviewed and analyzed the clinical outcome of endovascular treatment-ruptured PICA-dissecting aneurysms and explored the predictors of outcome. We retrospectively reviewed 17 consecutive patients with ruptured PICA dissecting aneurysms that underwent endovascular treatment from January 2003 to January 2014. Nine patients underwent selective coiling, whereas 7 patients underwent parent artery occlusion and 1 patient underwent stent-assisted coiling. Follow-up outcomes were evaluated using the modified Rankin Scale. The clinical outcomes of patients were categorized as favorable (modified Rankin Scale [mRS] score 0-1) or unfavorable (mRS score 2-6). Favorable outcomes (mRS score 0-1) were obtained in 13 of 17 patients. Post-treatment recurrence occurred in 1 patient with selective coiling in the 15-month follow-up, and the patient received stent-assisted coiling. The only patients with stent-assisted coiling developed PICA occlusion during follow-up. Aneurysm located in distal segment usually presented with intraventricular hemorrhage (P = .015). Hypertension, coexisting hydrocephalus, and time to operation (latter than 2 weeks) were associated with unfavorable outcome. Endovascular treatment of isolated dissecting aneurysm of PICA had excellent clinical outcomes, hypertension, coexisting hydrocephalus, and time to operation (latter than 2 weeks), which were associated with unfavorable outcome. Long-term follow-ups are necessary to provide stronger conclusions.

Therapies: Drugs, Scopes and Transjugular Intrahepatic Portosystemic Shunt - When and How?

Variceal bleeding is the most serious complication of portal hypertension. All cirrhotic patients should be screened endoscopically for varices which are present in about 30% of compensated and 60% of decompensated patients at diagnosis. In patients without varices, endoscopy surveillance should be continued every 2 years. Patients with high-risk varices (moderate or large in size, or with red color signs, or in Child-Pugh C patients) should be treated with a nonselective β-blocker to prevent bleeding (propranolol, nadolol or carvedilol). Endoscopic banding ligation is also effective for the prevention of first bleeding, and it is the first choice in patients with contraindications or intolerance to β-blockers. Acute variceal hemorrhage still has a high mortality rate (around 15%) and requires intensive care management and conservative blood transfusion policy. Treatment is based on the combined use of vasoactive drugs, endoscopic band ligation and prophylactic antibiotics. Failures are best managed by transjugular intrahepatic portosystemic shunt (TIPS). Balloon tamponade or specifically designed covered esophageal stents can be used as a bridge to definitive therapy in unstable patients. Early, preemptive TIPS might be the first choice in patients at high risk of failure (Child-Pugh B with active bleeding or Child-Pugh C up to 13 points). Patients surviving a variceal bleeding are at high risk of rebleeding. A combination of β-blockers and endoscopic band ligation is the most effective therapeutic approach. Preliminary data suggest that the addition of simvastatin increases survival in these patients.

When Should a Patient with a Nonvariceal Upper Gastrointestinal Bleed Be Fed?

Nonvariceal upper gastrointestinal hemorrhage is a common cause for admission to the intensive care unit. Most patients are prohibited from oral or enteral feeding for 72 hours despite different risks for rebleeding. Fasting is believed to improve the ability to control intragastric pH, stabilize clots, and reduce the risk of rebleeding; however, studies have shown no difference in intragastric pH and complications in patients who received early feeding. Approximately 50% of patients are classified as low risk for rebleeding and can be safely fed immediately and discharged early, even on the same day as endoscopy. Only the patients with a high risk of rebleeding should be kept nil per os and be hospitalized for at least 72 hours after endoscopic treatment. Most high-risk lesions become low-risk lesions within 72 hours, and most rebleeding occurs within this time. Randomized controlled trials have demonstrated that early feeding does not have adverse consequences, however. More studies on the timing and type of nutrition in patients with high-risk stigmata are needed.

Predictive Factors for Rebleeding After Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating type of stroke associated with high morbidity and mortality. One of the most feared complications is an early rebleeding before aneurysm repair. Predictors for such an often fatal rebleeding are largely unknown. We therefore aimed to determine predictors for an early rebleeding after aSAH in relation with time after ictus. This observational prospective cohort study included all consecutive patients admitted with aSAH between January 1998 and December 2014 (n=1337) at our University Neurovascular Center. Clinical predictors for rebleeding ≤24 hours were identified using multivariable Cox regression analyses. Kaplan-Meier analyses were applied to evaluate the time of rebleeding ≤72 hours after aSAH. A modified Fisher grade of 3 to 4 was a predictor for an in-hospital rebleeding ≤24 hours after ictus (adjusted hazard ratio, 4.4; 95% confidence interval, 2.1-10.6; P<0.001). The numbers needed to treat to prevent 1 rebleeding ≤24 hours was calculated 15 (95% confidence interval, 10-25). Also, the initiation of external cerebrospinal fluid-drainage (adjusted hazard ratio, 1.9; 95% confidence interval, 1.4-2.5; P<0.001) was independently associated with a rebleeding ≤24 hours. Cumulative in-hospital rebleeding rates were 5.8% ≤24 hours, and 1.2% in the time frame 24-72 hours after ictus. In our opinion, timing of treatment of aSAH patients, especially those with an modified Fisher grade of 3 or 4 in a good clinical condition, should be reconsidered. These aSAH patients might be regarded a medical emergency, requiring aneurysm repair as soon as possible. In this respect, our findings should provoke the debate on timing of aneurysm repair, especially in patients considered to be at high risk for rebleeding.

Prevention of Rebleeding From Esophageal Varices in Patients With Cirrhosis Receiving Small-Diameter Stents Versus Hemodynamically Controlled Medical Therapy

Patients with cirrhosis and variceal hemorrhage have a high risk of rebleeding. We performed a prospective randomized trial to compare the prevention of rebleeding in patients given a small-diameter covered stent vs those given hepatic venous pressure gradient (HVPG)-based medical therapy prophylaxis. We performed an open-label study of patients with cirrhosis (92% Child class A or B, 70% alcoholic) treated at 10 medical centers in Germany. Patients were assigned randomly more than 5 days after variceal hemorrhage to groups given a small covered transjugular intrahepatic portosystemic stent-shunt (TIPS) (8 mm; n = 90), or medical reduction of portal pressure (propranolol and isosorbide-5-mononitrate; n = 95). HVPG was determined at the time patients were assigned to groups (baseline) and 2 weeks later. In the medical group, patients with an adequate reduction in HVPG (responders) remained on the drugs whereas nonresponders underwent only variceal band ligation. The study was closed 10 months after the last patient was assigned to a group. The primary end point was variceal rebleeding. Survival, safety (adverse events), and quality of life (based on the Short Form-36 health survey) were secondary outcome measures. A significantly smaller proportion of patients in the TIPS group had rebleeding within 2 years (7%) than in the medical group (26%) (P = .002). A slightly higher proportion of patients in the TIPS group experienced adverse events, including encephalopathy (18% vs 8% for medical treatment; P = .05). Rebleeding occurred in 6 of 23 patients (26%) receiving medical treatment before hemodynamic control was possible. Per-protocol analysis showed that rebleeding occurred in a smaller proportion of the 32 responders (18%) than in nonresponders who received variceal band ligation (31%) (P = .06). Fifteen patients from the medical group (16%) underwent TIPS placement during follow-up evaluation, mainly for refractory ascites. Survival time and quality of life did not differ between both randomized groups. Placement of a small-diameter, covered TIPS was straightforward and prevented variceal rebleeding in patients with Child A or B cirrhosis more effectively than drugs, which often required step-by-step therapy. However, TIPS did not increase survival time or quality of life and produced slightly more adverse events. Clinical Trial no: ISRCTN 16334693.

Endoscopic Suturing for Ulcer Exclusion in Patients With Massively Bleeding Large Gastric Ulcer

Bleeding peptic ulcer is one of the most important causes for hospitalization worldwide. Though endoscopic hemostasis is the current standard of treatment for bleeding peptic ulcers, ulcer rebleeding remained a chief cause of mortality.1Chiu P.W. et al.Clin Gastroenterol Hepatol. 2009; 3: 311-316Abstract Full Text Full Text PDF Scopus (88) Google Scholar One of the important strategies to improve outcomes for bleeding peptic ulcers is to prevent rebleeding. Indeed, endoscopic features for ulcers with high risk of rebleeding include ulcers larger than 2 cm, actively bleeding and those located at posterior duodenal bulb or high lesser curvature.2Johnston J.H. et al.Gastroenterology. 1987; 92: 1101-1108Abstract Full Text PDF PubMed Scopus (111) Google Scholar With the use of high-dose intravenous proton pump inhibitors (PPI), those who developed rebleeding after PPI infusion were patients with significant perioperative risks, high proportion of comorbidities, as well as older age which rendered them high-risk surgical candidates.3Elmunzer B.J. et al.Am J Gastroenterol. 2008; 103: 2625-2632Crossref PubMed Scopus (119) Google Scholar A prototype endoscopic suturing device had been investigated for the safety and efficacy in achieving hemostasis among massively bleeding gastric ulcers.4Chiu P.W. et al.Dig Surg. 2009; 26: 243-248Crossref PubMed Scopus (16) Google Scholar This is an initial report on the clinical application of surgical ulcer exclusion using endoscopic suturing for large bleeding gastric ulcer. The Apollo Overstitch is an endoscopic suturing system which consists of a cap-based suturing system with a curved suture arm extending from one of the dual channels and the anchor exchange system extending from the same channel. The handle to control the suture plication system was mounted onto the shaft of a double-channel endoscope (Olympus 2T100 scope, Olympus Co Ltd, Hong Kong). The Overstitch system attached to the double-channel endoscope was introduced into the stomach through an overtube. The bleeding ulcer was first located with an ordinary single-channel endoscope. Endoscopic suturing begins with the needle first driving through the distal edge of the bleeding ulcer. After closing the curved needle driver, the detachable needle should be grasped by the anchor exchange and detached from the needle driver. After opening the needle driver, the endoscope with Overstitch should be moved away from the distal ulcer edge. The needle should be placed back in the needle driver by the anchor exchange. The needle should then be driven over the proximal edge of the ulcer and the procedure repeated until the 2 edges of the ulcer can be pulled together. The needle anchor should be dropped, while the anchor exchange is replaced by the cinching device which passes along the 2 ‘O’ polypropylene suture. After passage of the cinch to ulcer edge, the polypropylene suture should be tightened against the end of the cinch. The cinch is then closed to cut the stitch and release the plug to tighten the suture, and the ulcer should be excluded from an intragastric high acidity environment to stop current bleeding and prevent rebleeding. Three patients received endoscopic ulcer exclusion for a massively bleeding gastric ulcer. This video shows endoscopic suturing for ulcer exclusion in an actively bleeding gastric ulcer. The patient was a 78-year-old man who presented with passage of tarry stool for 3 days; upper endoscopy showing a 2 cm large gastric ulcer at angular incisura with visible vessel. There was active bleeding from visible vessel (Figure 1). The Overstitch device was introduced through an overtube. The first suture plication was performed over the superior edge of the ulcer. After exchange of the anchor, the second suture plication was performed over the inferior ulcer edge. This process was continued until a figure of eight suture was formed over the ulcer. The anchor was then dropped and the suture was tightened with the cinching device. The ulcer was excluded with adequate hemostasis (Figure 2). The patient had no clinical evidence of rebleeding, and a repeated endoscopy in 72 hours confirmed secure closure of the ulcer.Figure 2Ulcer exclusion achieved after tightening of overstitch.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Surgical exclusion of bleeding ulcer is a conventional treatment for prevention of further bleeding through suture closure of the ulcer and excluding it from intragastric acidity. This is the first technological report on clinical application of endoscopic surgical suturing for ulcer exclusion. The success of endoscopic ulcer exclusion will lead to improvement in primary endoscopic hemostasis, and theoretically excluding the ulcer from acid to prevent further bleeding. The ulcer exclusion shall be a better method to prevent rebleeding compared with adjunctive high-dose proton pump inhibitor infusion or prophylactic angiographic embolization. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI0NDRlMDkxM2NmMGRhNGUwNGJiZDFkODUyMjRjMjQxYyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjgxMzYwNDY3fQ.XXJzrp-6yqa5X_Fxu-t93ZJmJ4gGt5KEIICkg-xZWs2P9QUVTwPcWU5BIAoyY161WQqS9Xoq2xlMpMeFIa03TVHD9haMAQ-SBed6va3cMQtozXytNgaNMojGDSQwMA4hN2-dG7kGlLfGkDlU3dV9Oi0epZaZBfhQIxkNVWPYU76Fm68LSNLJ7_1G29qT5DlWZrSOHsW10o5dkts0yBD9W0Bc9PUUOiJX1P41J4-g2lAv77tNCIPyZNrVzhbQnAt1xIYBD1YAb1HHnXEHF1q2P_ISMMsqrfBJmW0OLGH8PblHrNNDwqnDn3pnyRIekdVxovny7vwoogxhrPzxLQT2mw Download .mp4 (43.03 MB) Help with .mp4 files Video 1

Mo1604 Recurrent Overt Obscure GI Bleed - Does Therapeutic Enteroscopy Change the Disease Course of Patients With Acquired Von Willebrand Factor (Vwf) Deficiency (Heyde's Syndrome)?

Mo1604 Recurrent Overt Obscure GI Bleed Does Therapeutic Enteroscopy Change the Disease Course of Patients With Acquired Von Willebrand Factor (Vwf) Deficiency (Heyde’s Syndrome)? Bhaumik Brahmbhatt*, Frank Lukens, Joseph L. Blackshear, Carlos R. Simons Linares, Paul T. Kroner, Abhishek Bhurwal, Mark E. Stark, Michael J. Bartel Gastroenterology, Mayo Clinic, Jacksonville, FL; Cardiology, Mayo Clinic, Jacksonville, FL Background: Patients with recurrent overt obscure GI bleed (OGIB) frequently undergo repetitive therapeutic enteroscopies. In this context, acquired vWF deficiency (Heyde’s syndrome) predisposes both AVM formation and hypocoagulability. Patients at risk for acquired vWF deficiency are those with underlying vascular pathology causing turbulent blood flow, especially aortic valve disease and hypertrophic obstructive cardiomyopathy (HOCM), which all result in destruction of vWF polymers. Aim: Investigate our outcome of patients who underwent therapeutic double balloon enteroscopy (DBE) for overt OGIB stratified by the presence or absence of acquired vWF deficiency or risk factors for acquired vWF deficiency. Methods: 1296 patients underwent 1747 double DBE between 2/2009 and 9/2013 at a single tertiary center. Of those, 243 patients underwent DBE for overt OGIB. Of which, 118 patients were tested for vWF polymers and/or underwent transthoracic echocardiogram (TTE). All patients with abnormal vWF level consistent with Heyde’s syndrome and/or very high likelihood for acquired vWF deficiency on TTE (Rmoderate aortic stenosis or regurgitation, Rmoderate mitral regurgitation, HOCM) are in cohort A. All other patients (normal vWF level and no high risk features on TTE) formed cohort B. The main outcome was the rate of recurrent OGIB. Results: 118 patients who met inclusion criteria (mean age 71.7years, SD 10, 44% female), underwent therapeutic DBE for overt OGIB. 8 patients had abnormal vWF level consistent with Heyde’s syndrome and 31 patients had normal vWF level. An additional 40 patients had TTE findings with very high likelihood for acquired vWF deficiency. No significant differences in age, gender, duration of bleed, transfusion requirement, number of transfusion, NSAID use, and anticoagulation were found between both cohorts. Also the DBE intubation depth (upper DBE 201cm vs 192cm; lower DBE 144cm vs 130cm), rate of total enteroscopy (70% vs 67%), DBE procedure time (118min vs 127min) and diagnostic yield (73% vs 73%) did not differ significantly between the cohorts. The findings on DBE did not differ significantly in both cohorts with the majority being AVMs. Median follow up was 180 days (range 1-2120 days, SEM 69). 39.5% of patients re-bled, 46% in cohort A and 38% in cohort B (NS). When considering only patients with a minimal follow up of 30 days, or stratifying by patients with only abnormal TTE or only abnormal vWF level, similar results were achieved. Conclusion: Patients with documented acquired vWF deficiency (Heyde’s syndrome) and patients with very high likelihood for acquired vWF deficiency based on TTE findings have a non-significant higher rebleeding risk following therapeutic DBE for overt OGIB. Based on our results, those patients should be considered for enteroscopy similarly to patients with normal vWF levels.

Prospective Assessment of the Rockall Risk Scoring System in Egyptian Patients with Upper Gastrointestinal Bleeding

Background: One of the major challenges in managing acute upper gastrointestinal bleeding involves the identification of patients who are at high risk of rebleeding and death; conversely, the identification of patients who are suitable for early discharge and outpatient endoscopy is also important for effective resource. The use of Rockall system has been shown to represent accurate and valid predictor of rebleeding and death. The aim of this prospective study was to evaluate validity of Rockall score for prediction of rebleeding and mortality in Egyptian patients with upper gastrointestinal bleeding. Patients and Methods: 50 patients presented with upper GI bleeding were subjected to detailed clinical, laboratory, sonographic and endoscopic examination together with Rockall score calculation. Results: According to the findings of upper GI endoscopy patients were further subdivided into two subgroups as follows: Group 1 (n = 32): Patients with portal hypertension manifested by variceal bleeding and/or portal hypertensive gastropathy; and Group 2 (n = 18): other causes of acute upper gastrointestinal bleeding (peptic ulcer disease, Mallory Weiss syndrome…). Clinical condition of the patients was assessed after 48 hours and mortality was recorded. Rockall score was the highest in mortality group, and higher in rebleeding group than stable group (P < 0.01). Rockall score was higher in Child C than Child B and Child A among hepatic patients (P < 0.01). The cutoff value of Rockall score = 3.5 was the best for prediction of rebleeding with sensitivity 100%, specificity 53%, while the cutoff value = 6.5 was the best for prediction of mortality with sensitivity 100% and 93.5% specificity. Conclusion: Rockall score is clinically useful in prediction of rebleeding and mortality in patients with upper gastrointestinal bleeding. It can accurately differentiate between patients with stable condition that could be discharged from hospital and those who require hospitalization and this could help to minimize hospital stay and cost.

EFFICACY OF ENDOSCOPIC INJECTION THERAPY WITH HSE 3% COMBINED WITH HIGH-DOSE PROTON PUMP INHIBITOR IN PEPTIC ULCER BLEEDING

Background: Peptic ulcer bleeding is one of the common medical emergencies with a high rate of mortality. Endoscopic hemostasis with HSE 3% injection is an effective treatment for patients with peptic ulcer bleeding, helps to save cost and avoid an unnecessary emergency surgery. Objective: To determine the success rate of endoscopic hemostatic with HSE 3% injection in patients with peptic ulcer bleeding. Patients and methods: A prospective, cross sectional study on 41 patients with peptic ulcer bleeding admitted in Can Tho Central General Hospital, from August 2012 to April 2013. All the patients underwent emergency endoscopy for hemostasis by injecting HSE 3% solution, and high- dose PPI use. Results: The rate of Forrest class IA, IB, IIA, IIB was 12.2%, 56.1%, 19.5% and 12.2%, respectively. The rate active bleeding group (Forrest class IA/IB) was 668.3%, while hemostatic group with high risk of rebleeding was 31.7%. The success rate was 92.7%, and the rebleeding rate was 7.3%. Conclusion: Endoscopic HSE 3% injection combined with high- dose PPI is an effective, relatively safe treatment for peptic ulcer bleeding. Key words: peptic ulcer bleeding, HSE, endoscopic hemostasis therapy.

Nonvariceal upper gastrointestinal bleeding.

Acute upper gastrointestinal bleeding is one of the most common medical emergencies. It is important to recognize potential etiologies of upper gastrointestinal bleeding and understand therapeutic modalities available in achieving hemostasis. This article summarizes guidelines in management of acute nonvariceal upper gastrointestinal bleeding and reviews recent advances in the field. Recent study showed that patients who received blood transfusion with threshold hemoglobin below 7 g/dl rather than below 9 g/dl had significantly lower mortality at 45 days. Endoscopic therapy should be performed on actively bleeding ulcers and ulcers with visible vessel or adherent clot. An over-the-scope clip is a novel device that can be used to achieve hemostasis. It may be a useful tool for achieving hemostasis for patients who failed endoscopic therapy with epinephrine injection, clip, or thermal therapy. Doppler ultrasound probe can evaluate arterial flow to the ulcer and identify ulcers that are at high risk of rebleeding. Upper gastrointestinal bleeding from peptic ulcer disease is not a new clinical problem. Yet, the approach to management continues to evolve with the accumulation of data and well designed studies on the subject.

Linear Accelerator Stereotactic Radiosurgery in the Management of Intracranial Arteriovenous Malformations: Long-Term Outcome

Background: Arteriovenous malformation (AVM) is one of the cerebrovascular diseases that bear a high risk of hemorrhage. The treatment modalities include microsurgical resection, endovascular embolization, stereotactic radiosurgery, or combinations that vary widely. Several large series have been reported, while data from Asian populations were few. The aim of this study was to examine the efficacy of linear accelerator stereotactic radiosurgery (LINAC SRS) for the treatment of intracranial AVMs, to evaluate the hemorrhage rate and to analyze associated factors. Methods: One hundred and sixteen patients with AVM were treated with LINAC SRS in a single institute between September 1994 and May 2005 and were retrospectively evaluated. The demographics of patients, clinical characteristics of AVM, the treatment modalities, and the parameters of the LINAC SRS were analyzed. Delayed toxicity and hemorrhage rate after treatment were also evaluated. The AVM obliteration and bleed rates were calculated using the Kaplan-Meier method and Cox regression analyses. Results: The efficacy rate with total obliteration after treatment was 81.9% (95 of 116 patients). The median interval to achieve total obliteration was 49 months. Microsurgical resection combined with SRS for residual AVMs achieved better obliteration rates compared to SRS alone (statistically significant, p = 0.001), while no significant difference was found between the embolization group and the group with no prior treatment (p = 0.895). The Spetzler-Martin grade of AVM is a relative factor of obliteration, higher grades resulting in a worse outcome (p = 0.009). Obliteration was significantly influenced by AVM volume in univariate analysis (p = 0.034), and volume <5 cm³ contributed to improved obliteration (p = 0.01). There was no statistically significant difference in the hemorrhagic rate and the complication rate between ruptured and unruptured AVMs, while the unruptured group had a higher obliteration rate (p = 0.024). The annual hemorrhage rate after LINAC SRS treatment was 1.9%. The bleeding rate was 3.3% in the first year after radiosurgery, 2.1% in the second year, 1.9% between the second and fifth year, and 1.5% between the fifth and tenth year. Patients with hemorrhagic events before radiosurgery appeared to have a higher rebleeding risk during the latency period. Twenty-three patients (19.8%) had late adverse effects with regard to posttreatment radiological follow-up, but only 1 (0.8%) had newly developed neurological deficits. Conclusion: LINAC SRS achieved a high obliteration rate and reduced the risk of hemorrhage effectively in ruptured and unruptured intracranial AVMs. Prior microsurgical resection provided better outcome, while embolization showed no benefit. Adverse effects after treatment are acceptable and require long-term follow-up.

Application of endovascular coiling and subsequent Onyx 34 embolization in anterior communicating artery aneurysms with adjacent hematoma

ObjectiveSmall anterior communicating artery aneurysms with recurrent bleeding and adjacent hematoma may have a high risk of post-operative rebleeding. This clinical study summarizes our preliminary experience with this subset of aneurysms, which were treated with endovascular coiling and subsequent Onyx 34 embolization. MethodsWe retrospectively reviewed the data of 9 patients suffering from small anterior communicating artery aneurysms treated with the combination of coils and Onyx. The clinical characteristics, angiographic outcomes, and follow-up results are reviewed. ResultsEndovascular coiling and Onyx embolization were successfully accomplished in all 9 cases. The Raymond scale ratings of the treatments are all class I with the parent arteries kept patent. One patient died of severe brain edema on the 5th post-operative day. The modified Rankin scale (mRS) score for the other 8 patients at follow-ups (6m to 26m, 15.8m on average) was 0 in 5 cases, 1 in 2 cases, and 3 in 1 case. Seven of 8 patients (87.5%) underwent angiographic follow-up that demonstrated persistent durable occlusion with no recanalization. ConclusionsEndovascular coiling and subsequent Onyx 34 embolization may be effective in treating anterior communicating artery aneurysms with adjacent hematoma. Further studies with larger sample size and adequate follow-up are required to verify its safety and efficacy as well as to evaluate the long-term outcome.

Mo1092 C-Reactive Protein as a Predictive Marker for Rebleeding in the Patients With Acute Non-Variceal Upper Gastrointestinal Bleeding

Background and Aims: Acute non-variceal upper GI bleeding (NUGIB) is an important clinical issue with high mortality rate. Rebleeding occurs in 10% to 25% of acute NUGIB patients irrespective of the treatment methods. Identification of patients at high risk of rebleeding is important to decide the appropriate treatment plan. C-reactive protein (CRP) has been reported as a prognostic indicator in various disorders. We were to investigate whether the initial CRP level can provide prognostic information for the risk of rebleeding in acute NUGIB patients. Patients and Methods: Between May 2011 and August 2013, 453 patients with acute NUGIB were investigated. The initial CRP level in the whole blood was evaluated in all patients. Rebleeding was checked for 30days after initial treatment. The clinical characteristics, endoscopic features, and CRP level were compared between the patients with and without rebleeding. Dichotomization of CRP level was performed with receiver operating characteristic (ROC) curve for the rebleeding. Results: The incidence of 30-day rebleeding was 15,9% (n = 72). The ROC curve area of CRP level in rebleeding was 0.69 (95% confidence interval, 0.618-0.760; p<0.001). Univariate analysis showed that old age (≥60 years), underlying comorbidities, hematochezia, shock (systolic blood pressure <100 mmHg), low hemoglobin level (<10 g/dL), high CRP level (≥0.5 mg/dL) and the presence of blood in the stomach were associated with the high risk of rebleeding. Multivariate logistic regression analysis indicated that initial CRP level of ≥0.5 mg/dL (p<0.01; OR, 3.6) was an independent factor for rebleeding after adjusting for initial hemoglobin level, shock, and the presence of blood in the stomach. Conclusions: CRP can be a useful predictive indicator for the risk of rebleeding in the patients with acute NUGIB.

Mo1096 Portable Inhaled Methoxyflurane for Colonoscopy in Patients With Morbid Obesity and/or Obstructive Sleep Apnoea Is Feasible and More Cost Effective Than Anaesthesia Assisted Approach

Background and Aims: Acute non-variceal upper GI bleeding (NUGIB) is an important clinical issue with high mortality rate. Rebleeding occurs in 10% to 25% of acute NUGIB patients irrespective of the treatment methods. Identification of patients at high risk of rebleeding is important to decide the appropriate treatment plan. C-reactive protein (CRP) has been reported as a prognostic indicator in various disorders. We were to investigate whether the initial CRP level can provide prognostic information for the risk of rebleeding in acute NUGIB patients. Patients and Methods: Between May 2011 and August 2013, 453 patients with acute NUGIB were investigated. The initial CRP level in the whole blood was evaluated in all patients. Rebleeding was checked for 30days after initial treatment. The clinical characteristics, endoscopic features, and CRP level were compared between the patients with and without rebleeding. Dichotomization of CRP level was performed with receiver operating characteristic (ROC) curve for the rebleeding. Results: The incidence of 30-day rebleeding was 15,9% (n = 72). The ROC curve area of CRP level in rebleeding was 0.69 (95% confidence interval, 0.618-0.760; p<0.001). Univariate analysis showed that old age (≥60 years), underlying comorbidities, hematochezia, shock (systolic blood pressure <100 mmHg), low hemoglobin level (<10 g/dL), high CRP level (≥0.5 mg/dL) and the presence of blood in the stomach were associated with the high risk of rebleeding. Multivariate logistic regression analysis indicated that initial CRP level of ≥0.5 mg/dL (p<0.01; OR, 3.6) was an independent factor for rebleeding after adjusting for initial hemoglobin level, shock, and the presence of blood in the stomach. Conclusions: CRP can be a useful predictive indicator for the risk of rebleeding in the patients with acute NUGIB.

Mo1095 Which Is the Most Clinically Useful Risk-Scoring System in Predicting Needs of Intervention and Clinical Outcomes of Upper Gastrointestinal Bleeding?

Background and Aims: Acute non-variceal upper GI bleeding (NUGIB) is an important clinical issue with high mortality rate. Rebleeding occurs in 10% to 25% of acute NUGIB patients irrespective of the treatment methods. Identification of patients at high risk of rebleeding is important to decide the appropriate treatment plan. C-reactive protein (CRP) has been reported as a prognostic indicator in various disorders. We were to investigate whether the initial CRP level can provide prognostic information for the risk of rebleeding in acute NUGIB patients. Patients and Methods: Between May 2011 and August 2013, 453 patients with acute NUGIB were investigated. The initial CRP level in the whole blood was evaluated in all patients. Rebleeding was checked for 30days after initial treatment. The clinical characteristics, endoscopic features, and CRP level were compared between the patients with and without rebleeding. Dichotomization of CRP level was performed with receiver operating characteristic (ROC) curve for the rebleeding. Results: The incidence of 30-day rebleeding was 15,9% (n = 72). The ROC curve area of CRP level in rebleeding was 0.69 (95% confidence interval, 0.618-0.760; p<0.001). Univariate analysis showed that old age (≥60 years), underlying comorbidities, hematochezia, shock (systolic blood pressure <100 mmHg), low hemoglobin level (<10 g/dL), high CRP level (≥0.5 mg/dL) and the presence of blood in the stomach were associated with the high risk of rebleeding. Multivariate logistic regression analysis indicated that initial CRP level of ≥0.5 mg/dL (p<0.01; OR, 3.6) was an independent factor for rebleeding after adjusting for initial hemoglobin level, shock, and the presence of blood in the stomach. Conclusions: CRP can be a useful predictive indicator for the risk of rebleeding in the patients with acute NUGIB.

STUDY THE EFFICACY OF HEMOCLIP IN ENDOSCOPIC HEMOSTASIS COMBINED WITH HIGH-DOSE INFUSION OF PROTON-PUMP INHIBITOR IN PATIENTS WITH PEPTIC ULCER BLEEDING

Background: Peptic ulcer bleeding is one of the common emergency cases in gastroenterology, the mortality rate is high. The study of the effecacy of hemoclip in endoscopic hemostasis therapy that helps to give an effective method for treatment peptic ulcer bleeding, to save cost for patients, to avoid a surgery that is serious for these patients. Objective:(i) To determine the prevalence of peptic ulcer bleeding with high risk of rebleeding (FIA, FIB and FIIA) according to Forrest classification; (ii) To determine effecacy of hemoclip in endoscopic hemostasis in patients with peptic ulcer bleeding. Patients and methods:A cross sectional study on 22 patients with peptic ulcer bleeding in Can Tho Center General Hospital during May 2012 to October 2013. Results:The rate of active bleeding group (Forrest type IA and IB) and visible vessel group (Forrest type FIIA) were 50% and 50%. Hemostatic rate by clipping was 95.5%, and the rebleeding rate was only 9.1%; the rate of emergent surgery and mortality were 4.5% and 4.5%. Conclusion:Endoscopic hemoclip treatment for bleeding due to peptic ulcer is an effective and safe method. The percentage of success was high 95.5%. The rebleeding rate was low, only 9.1%. The number of patients haved been operated and the dead rate were low, only 4.5%. Key words: Peptic ulcer bleeding, hemoclip, endoscopic hemostasis therapy

Consensus on control of risky nonvariceal upper gastrointestinal bleeding in Taiwan with National Health Insurance.

Background and Aims. To compose upper gastrointestinal bleeding (UGIB) consensus from a nationwide scale to improve the control of UGIB, especially for the high-risk comorbidity group. Methods. The steering committee defined the consensus scope to cover preendoscopy, endoscopy, postendoscopy, and overview from Taiwan National Health Insurance Research Database (NHIRD) assessments for UGIB. The expert group comprised thirty-two Taiwan experts of UGIB to conduct the consensus conference by a modified Delphi process through two separate iterations to modify the draft statements and to vote anonymously to reach consensus with an agreement ≥80% for each statement and to set the recommendation grade. Results. The consensus included 17 statements to highlight that patients with comorbidities, including liver cirrhosis, end-stage renal disease, probable chronic obstructive pulmonary disease, and diabetes, are at high risk of peptic ulcer bleeding and rebleeding. Special considerations are recommended for such risky patients, including raising hematocrit to 30% in uremia or acute myocardial infarction, aggressive acid secretory control in high Rockall scores, monitoring delayed rebleeding in uremia or cirrhosis, considering cycloxygenase-2 inhibitors plus PPI for pain control, and early resumption of antiplatelets plus PPI in coronary artery disease or stroke. Conclusions. The consensus comprises recommendations to improve care of UGIB, especially for high-risk comorbidities.

Coincidental vascular anomalies at the foramen magnum: Dural arteriovenous fistula and high flow aneurysm on perimedullary fistula

We report the case of a 59-year-old woman admitted for a sudden headache due to a subarachnoid haemorrhage. On CT scan, the clots predominated into the posterior fossa without high-density in the sylvian or interhemispheric fissures. The vertebral angiography revealed a dural arteriovenous fistula at the foramen magnum associated to an aneurysm of the cervical anterior spinal artery. Due to the high rebleeding risk of a dural shunt, we proposed curative treatment using microsurgical interruption of the intradural draining vein. On the postoperative angiography at 15-day follow-up, the 2 malformations were corrected and the outcome at 6 months was excellent. Based on the literature, we assess this exceptional association and suggest its possible management.

Acute management of stroke – II: haemorrhagic stroke

Haemorrhagic strokes are relatively less common compared to ischaemic strokes, with the vast majority of haemorrhages being intracerebral as opposed to subarachnoid. The definitive diagnosis of a haemorrhagic stroke is based on non-contrast CT imaging of the brain. Acute care should focus on prompt identification of the cause, minimizing the risk of haemorrhage expansion by controlling blood pressure and correcting any underlying coagulopathy, and obliterating vascular lesions with a high risk of rebleeding. Patients should be closely monitored, and emergent surgery should be considered in those patients who display signs of clinical deterioration, especially in the presence of posterior fossa haemorrhages. Future directions include refining the use of bedside neuro-monitoring and neuro-imaging techniques as well as developing novel approaches to minimize the complications of haemorrhagic stroke.