Iatrogenic Ulcer Research Articles

Prediction of immediate bleeding after cold snare polypectomy: A prospective observational study.

The risk factors for immediate post-polypectomy bleeding (IPPB) after cold snare polypectomy (CSP) are not well-known. We sought to define such risk factors and develop a predictive risk-scoring model. This prospective observational study included 161 polyps (4-9 mm in diameter) that were removed via CSP from 118 patients during the period from June to September 2019 in 2 tertiary hospitals. IPPB was defined as post-polypectomy bleeding within 24 hours or grade 3 or 4 intraprocedural bleeding requiring endoscopic hemostasis. IPPB incidences according to grade were 13.0% (21/161) (grade 3) and 0% (grade 4). Univariate analysis showed that the polyp size and morphology, as well as iatrogenic ulcer size and shape, were significantly associated with IPPB. Multivariate analysis showed that polyp size [6-9 mm vs 4-5 mm, odds ratio (OR) 3.72, 95% confidence interval (CI) 1.28-10.79], polyp morphology (polypoid vs non-polypoid, OR: 3.93, 95% CI: 1.22-12.64), and iatrogenic ulcer size (≥10 vs ≤ 9 mm, OR: 3.12, 95% CI: 1.04-9.38) were significantly associated with IPPB. We created a four-marker risk-scoring model to predict IPPB after CSP; we summed the points assigned for the 4 factors. At a cutoff of 2, the sensitivity was 85.7% and the specificity was 65.0%; at a cutoff of 3, the sensitivity was 65% and the specificity was 90.0%. Polyp size and morphology, as well as iatrogenic ulcer size and shape, were associated with IPPB after CSP. The four-marker risk-scoring model appears to effectively predict IPPB after CSP (Clinical Research Information Service: KCT0004375).

Endoscopic Delivery of Polymers Reduces Delayed Bleeding after Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis.

New endoscopic approaches for the prevention of delayed bleeding (DB) after gastric endoscopic submucosal dissection (ESD) have been reported in recent years, and endoscopic delivery of biodegradable polymers for iatrogenic ulcer hemostasis and coverage has emerged as one of the most promising techniques for post-ESD management. However, the comparative efficacy of these techniques remains uncertain. We performed a systematic search of multiple databases up to May 2022 to identify studies reporting DB rates as outcomes in patients undergoing gastric ESD who were treated with subsequent endoscopic management, including endoscopic closure (clip-based methods and suturing), PGA sheet tissue shielding, and hemostatic powder/gel spray (including polymeric sealants and other adhesives). The risk ratios (RRs) of delayed bleeding in treatment groups and control groups were pooled, and the Bayesian framework was used to perform a network meta-analysis (NMA). Among these studies, 16 head-to-head comparisons that covered 2742 lesions were included in the NMA. Tissue shielding using PGA sheets significantly reduced the risk of DB by nearly two thirds in high-risk patients, while hemostatic spray systems, primarily polymer-based, reduced DB in low-risk patients nine-fold. Researchers should recognize the essential role of polymers in the management of ESD-induced ulcers, and develop and validate clinical application strategies for promising materials.

The Custom Total Contact Cast to Offload Foot Ulcers in the Presence of Biomechanical Deformities: A Case Report

Although offloading foot ulcers with a total contact cast (TCC) remains the cornerstone of managing these wounds, the TCC is underutilized. Patient intolerance and potential iatrogenic complications due to TCCs' general lack of customizability and the inability to address flexible biomechanical deformities that are not in the sagittal plane may be one of the reasons patients with foot ulcers do not receive this crucial component of care. To describe the use of a novel approach to the standard TCC technique that uses strategic padding to potentially increase patient compliance and comfort while decreasing the likelihood of iatrogenic ulceration, as well as to correct flexible frontal plane biomechanical deformities with casting tape that is pulled medial to lateral, or lateral to medial, to bring the plantar surface of the foot to neutral position. The custom total contact cast (C-TCC) was used in a 54-year-old woman who had diabetes, obesity, and a flexible cavovarus foot type with a recurring plantar fifth metatarsal base wound. Weekly debridement followed by silver dressings and C-TCC application were performed. The latter included strategic padding, 2 forms of plaster of paris with contouring, fiberglass, and medial-to-lateral positioning of the foot during application. This case study describes two (2) treatment episodes, with a focus on the second episode. At initial presentation, the ulcer took 5 weeks to heal. During the second treatment, a 48.7% reduction in wound volume was noted after 1 week. By the fourth week of treatment, a 98.7% wound volume reduction was achieved. By the ninth week, the ulcer epithelialized completely. At 1-month and 12-month follow-ups, the site remained fully epithelialized. No iatrogenic ulcerations, cast discomfort, or ambulatory dysfunction were reported by the patient. In this case, the C-TCC helped address flexible frontal plane deformities and facilitated healing. Randomized, controlled clinical studies to evaluate the safety and effectiveness of different TCC methods are needed to guide care and improve the utilization of optimal offloading methods for the management of plantar foot ulcers.

Therapeutic Potential of a Self-Assembling Peptide Hydrogel to Treat Colonic Injuries Associated with Inflammatory Bowel Disease.

Background and AimsThe Self-assembling Peptide Hydrogel [SAPH, PuraMatrix], a fully synthetic peptide solution designed to replace collagen, has recently been used to promote mucosal regeneration in iatrogenic ulcers following endoscopic submucosal dissection. Herein, we evaluated its utility in ulcer repair using a rat model of topical trinitrobenzene sulphonic acid [TNBS]-induced colonic injuries.MethodsColonic injuries were generated in 7-week-old rats by injecting an ethanol solution [35%, 0.2 mL] containing 0.15 M TNBS into the colonic lumen. At 2 and 4 days post-injury, the rats were subjected to endoscopy, and SAPH [or vehicle] was topically applied to the ulcerative lesion. Time-of-flight secondary ion mass spectrometry [TOF-SIMS] was used to detect SAPH. Colonic expression of cytokines and wound healing-related factors were assessed using real-time polymerase chain reaction or immunohistochemistry.ResultsSAPH treatment significantly reduced ulcer length [p = 0.0014] and area [p = 0.045], while decreasing colonic weight [p = 0.0375] and histological score [p = 0.0005] 7 days after injury. SAPH treatment also decreased colonic expression of interleukin [IL]-1α [p = 0.0233] and IL-6[p = 0.0343] and increased that of claudin-1 [p = 0.0486] and villin [p = 0.0183], and β-catenin staining [p = 0.0237]. TOF-SIMS revealed lesional retention of SAPH on day 7 post-injury. Furthermore, SAPH significantly promoted healing in in vivo mechanical intestinal wound models.ConclusionsSAPH application effectively suppressed colonic injury, downregulated inflammatory cytokine expression, and upregulated wound healing-related factor expression in the rat model; thus, it may represent a promising therapeutic strategy for IBD-related colonic ulcers.

The effect of PPIs Alone, PPIs plus cytoprotective agent, and H2RA plus cytoprotective agent on ulcer healing after endoscopic submucosal dissection: A prospective randomized controlled trial

Background and Study AimsEndoscopic submucosal dissection (ESD) is the most effective treatment for early gastric cancer or gastric adenoma. However, ESD results in iatrogenic ulcers and postoperative bleeding from ulcers. This study aimed to evaluate the effect of using a proton pump inhibitor (PPI) alone, a PPI + rebamipide combination therapy, and an H2 receptor antagonist (H2RA) + rebamipide combination therapy on ulcer healing after ESD. Patients and MethodsA total of 204 patients who underwent ESD from April 2014 to July 2017 at Dong-A University Hospital were randomly assigned to the following groups: PPI-alone group, PPI + rebamipide combination therapy group, and H2RA + rebamipide combination therapy group. However, only 156 patients were studied since we excluded those who were lost to follow-up or had diseases other than early gastric cancer or gastric adenoma. Twenty-eight days after ESD, we evaluated the ulcer residual ratio, S stage rates, ulcer bleeding ratio, and gastric pH. ResultsThis study included 156 patients (PPI-alone group: 52 patients; PPI + rebamipide group: 52 patients; H2RA + rebamipide group: 52 patients). The ulcer residual ratios were 24.3 ± 14.2%, 17.0 ± 12.1%, and 21.0 ± 13.8% in the PPI alone, PPI + rebamipide, and H2RA + rebamipide groups, respectively (P = 0.048). ConclusionsPPI + rebamipide was more effective in reducing the ulcer residual ratio after ESD. There was no statistical difference in ulcer stage and delayed bleeding after ESD among the groups. These findings showed that PPI + rebamipide had limited benefits after ESD.

Iatrogenic skin ulceration following neurological assessment.

Iatrogenic skin ulceration following neurological assessment.

Rectal bleeding caused by iatrogenic ulceration after hemorrhoid ligation.

Rectal bleeding caused by iatrogenic ulceration after hemorrhoid ligation.

Comparison of efficacy of pharmacological therapies for gastric endoscopic submucosal dissection-induced ulcers: a systematic review and network meta-analysis

ABSTRACTObjectives: This study aimed to compare the efficacy of various anti-ulcer medications in preventing delayed bleeding and promoting ulcer healing after ESD.Methods: Asystematic search was conducted for articles up to August2019. The treatments of iatrogenic ulcer were analyzed by Bayesian network meta-analysis.Results: The analysis included 28 studies. Six treatments were compared. For the prevention of delayed bleeding, potassium-competitive acid blocker (P-CAB) alone was superior to proton-pump inhibitor (PPI) alone [RR = 1.02, 95%CI (1.00, 1.05)]. Treatments based on P-CAB tended to be better than the non-P-CAB groups [RR = 1.05, 95%CI (1.03, 1.07)]. Concerning the ulcer healing rate at 4 weeks, the combined treatment of PPI and mucoprotective agent (MP) was superior to PPI alone [RR = 1.81, 95%CI (1.19, 2.76)] and P-CAB alone [RR = 2.75, 95%CI (1.02, 7.44)]. At 8 weeks, PPI+MP and P-CAB+MP tend to be superior to than the other four groups. The healing effect of MP-based therapies was better than that of non-MP groups at 4 weeks [RR = 1.63, 95%CI (1.32, 2.01)] and 8 weeks [RR = 1.06, 95%CI (1.02, 1.11)].Conclusion: P-CAB may prevent delayed bleeding, but not significantly. MP agents have the potential to heal post-ESD ulcers.

Abordaje multidisciplinar en paciente con úlcera arterial de origen iatrogénico

Se define iatrogenia como una alteración negativa del estado de salud causada sin intención por la actuación de los profesionales sanitarios tras la administración de un tratamiento, y úlcera iatrogénica, como aquella lesión que cursa con pérdida de la integridad cutánea, provocada, entre otras causas, por diferentes dispositivos utilizados con fines diagnósticos o terapéuticos. Se presenta el caso de una mujer de 91 años, dependiente leve para las actividades de la vida diaria, sin deterioro cognitivo, que presenta úlcera iatrogénica en miembro inferior derecho. Tras caída casual, sufrió fractura bimaleolar de tobillo derecho; se realizó manipulación quirúrgica bajo sedación para reducción cerrada y tratamiento con yeso ortopédico. En la cuarta semana presentó cuadro febril que precisó ingreso hospitalario durante cuatro semanas, retirándose entonces la órtesis y objetivándose gran úlcera supramaleolar externa. Dada de alta y en seguimiento por Atención Primaria, presentó evolución tórpida de la úlcera y patología arterial asociada, por lo que se deriva de forma preferente a Cirugía Vascular, que indica ingreso para angioplastia y limpieza quirúrgica de lesiones. Tras alta hospitalaria, su enfermera comunitaria instauró un plan de cuidados destinado a unificar criterios y disminuir la variabilidad terapéutica, consiguiendo la epitelización de una lesión compleja en paciente frágil, pluripatológica y polimedicada en diez meses de tratamiento. Para la resolución del problema fue preciso un enfoque multidisciplinar e interdisciplinar, para proporcionar a la paciente una atención integral, programando la transición entre niveles y la comunicación entre los profesionales.

Helicobacter pylori Eradication in Patients with an Iatrogenic Ulcer after Endoscopic Resection and Peptic Ulcer

Helicobacter pylori Eradication in Patients with an Iatrogenic Ulcer after Endoscopic Resection and Peptic Ulcer

Continuous Infusion versus Intermittent Dosing with Pantoprazole for Gastric Endoscopic Submucosal Dissection.

Background/AimsProton pump inhibitors are widely used to prevent gastric endoscopic submucosal dissection (ESD)-related bleeding, but no standard administration regimens have been established. We aimed to prospectively compare the effects of continuous infusion and intermittent dosing with pantoprazole on preventing gastric ESD-related bleeding. Additionally, we analyzed the risk factors for bleeding.MethodsFrom April 2012 to May 2013, patients with a gastric epithelial neoplasm scheduled for ESD in the Pusan National University Hospital were randomly assigned to one of two groups according to the pantoprazole administration regimen (continuous infusion or intermittent dosing). The primary outcomes measured were intra- and postprocedural bleeding events.ResultsThe final analysis included 401 patients. The rate of significant intraprocedural bleeding was 25.4% in the C group and 24.0% in the I group, with no significant difference (p=0.419). In addition, there was no significant difference in the postprocedural bleeding rate between the C and I groups (11.7% vs 10.2%, p=0.374). Multivariate analysis showed that intraprocedural bleeding was associated with the proximal tumor location, the presence of fibrosis, and the size of the resected specimen, whereas postprocedural bleeding was associated with the size of the resected specimen and the procedure/coagulation time.ConclusionsIntermittent dosing with pantoprazole is sufficient and cost-effective for the prevention of gastric ESD-related bleeding. Operators should consider tumor characteristics when planning ESD to minimize the risk of intraprocedural bleeding, and patients with large iatrogenic ulcers should be carefully monitored for postprocedural bleeding.

Comparative efficacy of various anti-ulcer medications after gastric endoscopic submucosal dissection: a systematic review and network meta-analysis.

The comparative efficacy of various anti-ulcer medications after gastric endoscopic submucosal dissection (ESD) has not been fully evaluated. Recently, vonoprazan, a novel potassium-competitive acid blocker, has also been used in ulcer treatment after ESD. We searched for all relevant randomized controlled trials examining the efficacy of anti-ulcer medications after gastric ESD, published through October 2017. Healing of iatrogenic ulcers was investigated at 4-8weeks after ESD. A network meta-analysis was performed to calculate the network estimates. Twenty-one studies with 2005 patients were included. Concerning the comparative efficacy for ulcer healing at 4weeks after ESD, no network inconsistency was identified (Cochran's Q-test, df = 10, P = 0.13; I2 = 34%). A combination therapy of proton-pump inhibitor (PPI) and muco-protective agent was superior to PPI alone [risk ratio (RR) (95% confidence interval, CI) 1.69 (1.20-2.39)]. The combination therapy of PPI and muco-protective agents tended to be superior to vonoprazan [RR (95% CI) 1.98 (0.99-3.94)]. There was no difference of ulcer healing effect between PPI and vonoprazan [RR (95% CI) PPI vs. vonoprazan, 1.17 (0.64-2.12)]. Concerning the ulcer healing rate at 8weeks after ESD, however, vonoprazan was superior to PPI [RR (95% CI) 1.27 (1.03-1.56)]. Additionally, vonoprazan tended to be superior to the combination therapy of PPI and muco-protective agent [RR (95% CI) 1.20 (0.96-1.51)]. A combination therapy of PPI and muco-protective agent was superior to PPI alone for ulcer healing at 4weeks after ESD. In the ulcer healing effect at 8weeks after ESD, vonoprazan was superior to PPI.

Sa1962 THE HEMOSTATIC EFFECT OF MUSSEL-INSPIRED CATECHOL ADHESIVE SHEET AFTER MUCOSECTOMY INDUCED ULCER: PORCINE EXPERIMENT

Gastrointestinal bleeding is the common problem in daily clinical practice. InnoSEAL Plus® is a sheet-type hemostat that is made of a mussel-inspired catecholic adhesive material. It can stop a variety of bleedings in a coagulopathy independent manner. The aim of this study was to evaluate hemostatic efficacy of the catechol-adhesive sheet on gastric ulcer bleeding on porcine model. In a total of 15 pigs, iatrogenic ulcer bleedings were made using endoscopic mucosal resection method. Five minutes before intervention the pigs were given full weight-adjusted heparin. Four ulcer bleedings (Forrest Ib) were made per 1 pig, and one of them was not treated as a negative control (NC) group. The other ulcers were treated with gauze compression (GC), argon plasma coagulation (APC), and InnoSEAL Plus® respectively. Initial hemostasis and recurrent bleeding were recorded. Initial hemostasis achivement at 2 minutes after the treatment was 14 of 15 (93.3%) with InnoSEAL Plus group while 1 of 15 (6.7%) of NC group, 2 of 15 (13.3%) of GC group, and 13 of 15 (86.7%) of the APC group. There was no recurrent bleeding in InnoSEAL Plus® group. Recurrent bleedings were occurred in NC group (n=2), GC group (n=1), and APC group (n=2) on day 1. One in APC group also showed recurrent bleeding on day 5. InnoSEAL Plus® has hemostatic efficacy to stop Forrest I b bleeding in pigs receiving anticoagulant therapy. This could be new endoscopic treatment for GI bleedings.

Helicobacter pylori Eradication in Patients with an Iatrogenic Ulcer after Endoscopic Resection and Peptic Ulcer

<i>Helicobacter pylori</i> Eradication in Patients with an Iatrogenic Ulcer after Endoscopic Resection and Peptic Ulcer

Difference inHelicobacter pyloriEradication between Patients with Iatrogenic Ulcer after Endoscopic Resection and Patients with Peptic Ulcer

Difference in<i>Helicobacter pylori</i>Eradication between Patients with Iatrogenic Ulcer after Endoscopic Resection and Patients with Peptic Ulcer

Comparison on Intragastric pH and Therapeutic Effectiveness According to Routes of Administration of PPI in Peptic Ulcer: A Prospective, Randomized, Controlled Trial

Introduction: Intravenous proton pump inhibitor (PPI) therapy has been used for patients with acute peptic ulcer at bleeding risk. If sublingual or oral PPI is equipotent to reach and sustain intragastric pH > 6 against intravenous PPI, these can be favoured for convenience and cost-effectiveness as the management of active peptic ulcer. Methods: Patients with iatrogenic ulcers after endoscopic procedures, such as endoscopic mucosal resection or submucosal dissection had been enrolled consecutively from October 2012 to January 2014. Then they had intragastric pH probes positioned and pH of 24-hour period measured. A total of 65 patients were randomly assigned to three groups according to routes of administration of PPI; Sublingual lansoprazole, oral lansoprazole, and intravenous pantoprazole. Results: There was no difference in the basal characteristics of these three groups. All groups had no significant difference in the mean time to reach intragastric pH > 6. The mean proportion of time pH > 6 (%) for sublingual PPI group was greater than intravenous and oral PPI group but not statistically significantly so (89.9±13.5 vs. 73.7±29.2 vs. 73.0±33.4; P=0.112). The median pH of sublingual group was meaningfully higher than intravenous group (7.51±0.50 vs. 6.67±1.04; P=0.022). All these groups had similar outcomes in the bleeding, perforation, and hospital stay. Conclusion: The therapeutic effectiveness of sublingual or oral PPI is not inferior to intravenous PPI. Sublingual or oral PPI may be able to substitute intravenous PPI in the treatment of acute peptic ulcer at bleeding risk. Furthermore, the sublingual administration has a good potential for better outcomes in view of maintaining the higher intragastric pH successfully.

Early Attempts to Eradicate Helicobacter pylori after Endoscopic Resection of Gastric Neoplasm Significantly Improve Eradication Success Rates.

PurposeAfter endoscopic resection (ER) of gastric tumors, eradication of Helicobacter pylori (H. pylori) infection is advised to reduce metachronous recurrence. Optimal timing of such therapy (yet to be established) was investigated herein, examining early active and late scarring stages of post-ER iatrogenic ulcers.Materials and MethodsAnalysis included 514 patients who received proton-pump inhibitor (PPI)-based triple therapy for H. pylori eradication after ER for gastric neoplasms between January 2008 and June 2015. Clinicopathologic characteristics, particularly the timing of triple therapy, were used to compare eradication rates, assigning patients to early- (≤2 weeks), intermediate- (2–8 weeks), and late-phase (≥8 weeks) treatment groups.ResultsH. pylori eradication rates differed significantly by timing of triple therapy after ER (early, 90.0%; intermediate, 76.2%, late, 72.4%; p <.001). However, eradication success rates were not significantly affected by age, smoking, alcohol consumption, preexisting comorbidity, method of ER, size and location of iatrogenic ulcer, and duration of therapeutic regimen. Early initiation of H. pylori eradication was also identified as a significant independent predictor of eradication success in multivariate analysis (Odds ratio = 3.67, 95% CI 2.18–6.16; p <.001).ConclusionIn patients undergoing ER of gastric tumors, early post-ER attempts at eradication of H. pylori offer the best chance of eradication success.

Risk factors of delayed ulcer healing after gastric endoscopic submucosal dissection.

Although post-endoscopic submucosal dissection (ESD) iatrogenic ulcer is known to heal faster than peptic ulcer, some iatrogenic ulcers show delayed healing. The aim of this study was to clarify risk factors of delayed ulcer healing after gastric ESD. We retrospectively reviewed medical records of all patients who had ESD for gastric neoplasms (866 adenomas and 814 early gastric cancers) between January 2005 and February 2011. Of 1680 subjects, 95 had delayed ulcer healing in 3-month follow-up. Multivariate analysis showed that diabetes (OR 1.743; 95% CI 1.017-2.989, p = 0.043), coagulation abnormality (OR 3.195; 95% CI 1.535-6.650, p = 0.002), specimen size greater than 4 cm (OR 2.999; 95% CI 1.603-5.611, p = 0.001), and electrocoagulation (OR 7.149; 95% CI 1.738-29.411, p = 0.006) were revealed to be independent risk factors of delayed ulcer healing. Meanwhile, persistent Helicobacter pylori infection was not related to the delayed ulcer healing. Large iatrogenic ulcer by ESD with massive hemostasis, especially in patients with diabetes mellitus or coagulation abnormalities, tends to take more than 3 months to heal. For such cases, initial dosage increment of PPI or addition of other anti-ulcer agents after ESD may be beneficial.

Sa1573 Bio-Sheet Graft Therapy for Iatrogenic Gastric Ulcer After Endoscopic Submucosal Dissection: an Animal Feasibility Study

The various bio-sheet grafts have been tried to improve the iatrogenic ulcer and prevent complications after endoscopic submucosal dissection (ESD). However, the effect of bio-sheet on the healing process of ulcer has not been investigated. The aim of this study is to evaluate the effect of the bio-sheet graft on the ulcer healing process and the feasibility of it as the endoscopic treatment modality for the iatrogenic ulcer after ESD.

Comparison of the efficacy of 4- and 8-week lansoprazole treatment for ESD-induced gastric ulcers: a randomized, prospective, controlled study

Although endoscopic submucosal dissection (ESD) is widely used to treat gastric neoplasms, there is no consensus for the optimal treatment for ESD-induced ulcers. We compared efficacy between 4 and 8 weeks of lansoprazole treatment for iatrogenic gastric ulcers that developed after ESD. Eighty-four patients who were diagnosed with gastric adenoma or early gastric cancer were enrolled and randomly assigned to treatment with lansoprazole (30 mg/day) for 4 or 8 weeks. Eight weeks after ESD, we conducted follow-up endoscopy to compare ulcer stage and ulcer reduction ratio (dividing the ulcer dimension at 8 weeks by the initial ulcer dimension) between the two groups. From the 84 patients, 69 patients were included in the final analysis, with 34 in the 4-week group and 35 in the 8-week group. Eight weeks after ESD, there were no significant difference observed between the two groups in terms of the ulcer stage (68 % in the scar stage in the 4-week group vs. 69 % in the 8-week group, P = 0.93) or the ulcer reduction ratio (0.0081 ± 0.015 in the 4-week group vs. 0.0037 ± 0.008 in the 8-week group, P = 0.15). Also, in the subgroup analysis among the patients with large ulcers (>30 mm), those parameters were not different. For ESD-induced gastric ulcers, treatment with lansoprazole for 4 weeks was as effective as treatment for 8 weeks. Considering cost-effectiveness, proton pump inhibitor therapy for 4 weeks may be sufficient for ESD-induced gastric ulcers.