Initial Endoscopic Hemostasis Research Articles

Comparison of 2 Days versus 5 Days of Octreotide after Endoscopic Therapy in Preventing Early Esophageal Varices Rebleed: A Randomized Controlled Study

In esophageal varices bleeding, following the initial endoscopic hemostasis, it is recommended to administer vasoactive medications for a period of 2-5 days in order to avoid early rebleeding. Octreotide is the preferred vasoactive medication for treating variceal bleeding due to its favorable safety profile. This study aimed to assess the effectiveness of a 2-day octreotide infusion against a 5-day octreotide infusion following endoscopic intervention in avoiding early rebleeding of esophageal varices in individuals with cirrhosis. This study was a prospective, parallel, randomised controlled experiment conducted on a cohort of 184 subjects who were recruited from the endoscopy unit of the Tropical Medicine and Infectious Diseases Department at Tanta University Hospital in Egypt. The five days rate of rebleeding was 16.85% in the 2-days group against 15.91% in the 5- days group without significant difference (P= 0.865). In cirrhotic individuals with bleeding esophageal varices, a 2-day regimen of octreotide is equally efficacious as a 5-day regimen in avoiding rebleeding over a 5-day period, following successful control of bleeding with endoscopic intervention.

Development and validation of a model to predict rebleeding within three days after endoscopic hemostasis for high-risk peptic ulcer bleeding

BackgroundPeptic ulcer bleeding remains a typical medical emergency with significant morbidity and mortality. Peptic ulcer rebleeding often occurs within three days after emergent endoscopic hemostasis. Our study aims to develop a nomogram to predict rebleeding within three days after emergent endoscopic hemostasis for high-risk peptic ulcer bleeding.MethodsWe retrospectively reviewed the data of 386 patients with bleeding ulcers and high-risk stigmata who underwent emergent endoscopic hemostasis between March 2014 and October 2018. The least absolute shrinkage and selection operator method was used to identify predictors. The model was displayed as a nomogram. Internal validation was carried out using bootstrapping. The model was evaluated using the calibration plot, decision-curve analyses, and clinical impact curve.ResultsOverall, 386 patients meeting the inclusion criteria were enrolled, with 48 patients developed rebleeding within three days after initial endoscopic hemostasis. Predictors contained in the nomogram included albumin, prothrombin time, shock, haematemesis/melena and Forrest classification. The model showed good discrimination and good calibration with a C-index of 0.854 (C-index: 0.830 via bootstrapping validation). Decision-curve analyses and clinical impact curve also demonstrated that it was clinically valuable.ConclusionThis study presents a nomogram that incorporates clinical, laboratory, and endoscopic features, effectively predicting rebleeding within three days after emergent endoscopic hemostasis and identifying high-risk rebleeding patients with peptic ulcer bleeding.Trial registration This clinical trial has been registered in the ClinicalTrials.gov (ID: NCT04895904) approved by the International Committee of Medical Journal Editors (ICMJE).

Systematic Review and Meta-Analysis of Prophylactic Transarterial Embolization for High-Risk Bleeding Peptic Ulcer Disease

The present systematic review determined the role of transarterial embolization (TAE) as a prophylactic treatment in bleeding peptic ulcers after initial successful endoscopic hemostasis. PubMed and Ovid Medline databases were searched from inception until July 2019 for studies that included patients deemed high-risk based on Forrest Classification, Rockall score ≥ 5, or endoscopic evaluation in addition to those who underwent prophylactic TAE after initial successful endoscopic hemostasis. Meta-analysis was performed to compare patients who underwent endoscopic therapy (ET) and TAE with those who underwent ET alone. The primary outcomes measured included rates of rebleeding, reintervention, and 30-day mortality. Secondary outcome measures evaluated length of hospitalization, technical success rates, and complications associated with TAE. Of 916 publications, 5 were eligible for inclusion; 310 patients with high-risk peptic ulcer bleeding underwent prophylactic TAE, and 255 were compared against a control group of 580 patients that underwent standard treatment with ET alone. Patients who underwent ET with TAE had lower 30-day rebleeding rates (odds ratio [OR], 0.35; 95% confidence interval [CI] 0.15–0.85; P = .02; I2 = 50%). The ET with TAE group had a lower 30-day mortality rate (OR, 0.28; 95% CI, 0.10–0.83; P = .02; I2 = 58%). There was no difference in pooled reintervention rates (OR, 0.68; 95% CI, 0.43–1.08; P = .10; I2 = 0%) and length of hospitalization (mean difference, −0.32; 95% CI, −1.88 to 1.24; P = .69; I2 = 0%). Technical success rate of prophylactic TAE was 90.5% (95% CI, 83.09–97.98; I2 = 75.9%). Pooled proportion of overall complication rate was 0.18% (95% CI, 0.00–1.28; I2 = 0%). Prophylactic TAE has lower rebleeding and mortality with a good success rate and low complications. Prophylactic TAE after primary ET may be recommended for selected patients with high-risk bleeding ulcers; however, further studies should be performed to establish this as a routine tool in patients with bleeding peptic ulcer disease.

Endoscopic management of postoperative anastomotic bleeding in patients with colorectal cancer.

Postoperative anastomotic bleeding is considered a rare but life-threatening complication. There is no standard treatment strategy for this emergency condition. The aim of this study was to report our experiences in the management of postoperative anastomotic bleeding in patients with colorectal cancer. We analyzed the general characteristics, treatments, and outcomes of patients with anastomotic bleeding after surgery for colorectal carcinoma at the Sixth Affiliated Hospital of Sun Yat-Sen University between July 2013 and September 2019 retrospectively. A univariate and multivariate analysis was performed to find protective factors for endoscopic hemostasis. Risk factors for anastomotic leakage after colonoscopy were also analyzed. A total of 9870 patients underwent surgeries for colorectal carcinoma between July 2013 and September 2019. Colonoscopies were performed in 78 cases with postoperative anastomotic bleeding. The effective rate of initial endoscopic hemostasis was 81% (63/78). In univariate and multivariate analysis, hemoclip therapy (odds ratio = 4.572; 95%CI 1.305-16.017; P = 0.017) and postoperative anastomotic bleeding within 5days (odds ratio = 3.639; 95%CI 1.045-12.675; P = 0.042) are protective factors for endoscopic hemostasis. Comorbidity was associated with an increased risk for anastomotic leakage. Colonoscopy seems to be an effective way to achieve hemostasis for patients with anastomotic bleeding after surgery for colorectal carcinoma. It may be more effective in the early postoperative period, and hemoclip appears to be the first choice to control postoperative anastomotic bleeding.

Embolization for gastrointestinal bleeding in patients with pancreatitis. Report of two cases and literature review

Gastrointestinal (GI) bleeding is rare but potentially fatal complication of pancreatitis. Early diagnosis and timely radiologic intervention are crucial for survival as when untreated the mortality of these patients is high. We present two patients, one with chronic pancreatitis and one with acute pancreatitis, both complicated with severe upper GI tract bleeding. Patients were successfully treated with transcatheter embolization after initial endoscopic hemostasis failed. The advances in endovascular devices and embolization materials and increased number of experienced interventional radiologists have increased the importance of angiographic embolization procedures as a safe minimally invasive therapeutic method of achieving successful hemostasis associated with the low incidence of complications. Due to its advantages over surgery, it should be considered treatment of choice in patients with upper GI bleeding refractory to endoscopy.

Effect of scheduled second-look endoscopy on peptic ulcer bleeding: a prospective randomized multicenter trial

This study aimed to investigate the effectiveness of scheduled second-look endoscopy (EGD) with endoscopic hemostasis on peptic ulcer rebleeding and to identify the risk factors related to the need for second-look EGD. We prospectively randomized patients who had endoscopically confirmed bleeding peptic ulcer with stigmata of active bleeding, visible vessel, or adherent clot into 2 groups between August 2010 and January 2013. Hemoclip application or thermal coagulation and/or epinephrine injection were allowed for initial endoscopic therapy. The same dosage of proton pump inhibitor was injected intravenously. The study group received scheduled second-look EGD 24 to 36 hours after the initial hemostasis, and further therapy was applied if endoscopic stigmata persisted, as above. Those patients who developed rebleeding underwent operation or radiologic intervention despite the additional endoscopic therapy. Outcome measures included rebleeding, amount of transfusion, duration of hospitalization, and mortality. After initial endoscopic hemostasis, 319 eligible patients were randomized into 2 groups. Sixteen(10.1%) and 9 (5.6%) patients developed rebleeding (P= .132), respectively. There was also no difference in surgical intervention (0, 0% vs 1, .6%, P >.999) or radiologic intervention (3, 1.9% vs 2, 1.2%, P= .683), median duration of hospitalization (6.0 vs 5.0 days, P= .151), amount of transfusion (2.4±1.7 vs 2.2 ± 1.6 units, P= .276), and mortality (2, 1.3% vs 2, 1.2%, P > .999) between the 2 groups. Multivariate analysis showed that grades 3 to 4 of endoscopists' estimation to success of initial hemostasis, history of nonsteroidal anti-inflammatory drug (NSAID) use, and larger amounts of blood transfusions (≥4units of red blood cells) were the independent risk factors of rebleeding. A single EGD with endoscopic hemostasis is not inferior to scheduled second-look endoscopyin terms of reduction in rebleeding rate of peptic ulcer bleeding. Repeat endoscopy would be helpful in the patients with unsatisfactory initial endoscopic hemostasis, use of NSAIDs, and larger amounts of transfused blood. (Clinical trial registration number: KCT0000565; 4-2010-0348.).

Gastrointestinal Bleeding Due to Gastrointestinal Tract Malignancy: Natural History, Management, and Outcomes

Gastrointestinal (GI) tumor bleeding can vary from occult bleeding to massive hemorrhage and can be the presenting sign of malignancy. Our primary aims were to: (1) characterize the natural history, treatment, and outcomes in patients with GI tumor bleeding and (2) compare and contrast bleeding in upper GI (UGI)/small bowel (SB) and lower GI malignancies. Patients with endoscopically confirmed tumor bleeding were identified through search of consecutive electronic medical records: Bleeding was determined by the presence of melena, hematochezia, hematemesis, or fecal occult blood. Comprehensive clinical and management data were abstracted. A total of 354 patients with GI tumors were identified: 71 had tumor bleeding (42 UGI/SB and 29 colonic). GI bleeding was the initial presenting symptom of malignancy in 55/71 (77%) of patients; 26/71 patients had widely metastatic disease at presentation. Further, 15 of 26 patients with metastatic disease presented with GI bleeding. Visible bleeding was present in 14/42 (33%) and 4/29 (14%) of UGI/SB and colonic tumors, respectively. Endoscopic hemostasis was attempted in 10 patients, and although initial control was successful in all, bleeding recurred in all of these patients. The most common endoscopic lesion was clean-based tumor ulceration. Overall mortality at 1year was 57% for esophageal/gastric, 14% for SB, and 33% for colonic tumors. When patients with GI malignancy present with GI bleeding, it is often the index symptom. Initial endoscopic hemostasis is often successful, but rebleeding is typical. Esophageal and gastric tumors carry the poorest prognosis, with a high 1-year mortality rate.

Gastrointestinal Bleeding Due to Gastrointestinal Tract Malignancy - Natural History, Management, and Outcomes

Introduction: Gastrointestinal (GI) malignancy remains highly prevalent despite advances in screening and treatment strategies. Bleeding as a direct result of GI malignancy can vary in presentation from occult to massive hemorrhage and can be the initial presenting sign of malignancy. Literature to date is limited on this subject, particularly bleeding associated with lower GI malignancy.Figure 1Methods: Patients were identified through search of consecutive electronic medical records of patients who had endoscopy to evaluate GI bleeding and found to have pathologically confirmed GI malignancy. Bleeding was determined by the presence of melena, hematochezia, hematemesis, or by fecal occult blood testing. Comprehensive clinical and management data were abstracted. Results: 71 patients with GI tumor bleeding were identified (42 upper GI and small bowel and 29 colonic tumors), including 24 women with an average age of 60 years. The most common histology was adenocarcinoma. Symptoms at presentation were multiple, but GI bleeding (Table 1) was the initial presenting symptom in 71% of patients with upper GI (UGI)/small bowel (SB) bleeding and in 86% with lower GI (LGI) bleeding. 33% of UGI/SB tumors and 41% of colonic tumors were metastatic at presentation. The Charlson Comorbidity Index was high in both groups (7.14 vs. 6.34). Active bleeding was noted in 48% and 14% of UGI/SB and colonic tumors, respectively. The most common endoscopic lesion in both groups was a clean based ulceration within the tumor mass. 17% and 10% of patients with UGI/SB and colonic tumors underwent endoscopic intervention, successful in achieving initial hemostasis in all cases. Rebleeding after the initial bleeding episode occurred in 36% of UGI/small bowel patients and 21% with colonic tumors (including 7% of patients within the first 72 hours). UGI/SB malignancies were most often managed with chemotherapy and radiation (48% and 31%), and 24% of patients underwent surgery. Colonic tumors were most often managed surgically (59%). Overall mortality at 1 year was 58% for UGI, 14% for SB, and 17% for colonic tumors. Conclusion: When GI bleeding was the presenting of symptom of GI malignancy, over one-third of patients had metastatic disease and 1-year survival, particularly in patients with UGI tumors, is poor. Although initial endoscopic hemostasis for bleeding lesions is often successful, long term management of GI malignancy is difficult, likely due to comorbid conditions and the advanced nature of the underlying malignancy.

Risk factors influencing the outcome of peptic ulcer bleeding in chronic kidney disease after initial endoscopic hemostasis: A nationwide cohort study.

Patients with chronic kidney disease (CKD) who had peptic ulcer bleeding (PUB) may have more adverse outcomes. This population-based cohort study aimed to identify risk factors that may influence the outcomes of patients with CKD and PUB after initial endoscopic hemostasis. Data from 1997 to 2008 were extracted from the National Health Insurance Research Database in Taiwan. We included a cohort dataset of 1 million randomly selected individuals and a dataset of patients with CKD who were alive in 2008. A total of 18,646 patients with PUB were screened, and 1229 patients admitted for PUB after endoscopic hemostasis were recruited. The subjects were divided into non-CKD (n = 1045) and CKD groups (n = 184). We analyzed the risks of peptic ulcer rebleeding, sepsis events, and mortality among in-hospital patients, and after discharge. Results showed that the rebleeding rates associated with repeat endoscopic therapy (11.96% vs 6.32%, P = 0.0062), death rates (8.7%, vs 2.3%, P < 0.0001), hospitalization cost (US$ 5595±7200 vs US$2408 ± 4703, P < 0.0001), and length of hospital stay (19.6 ± 18.3 vs 11.2 ± 13.1, P < 0.0001) in the CKD group were higher than those in the non-CKD group. The death rate in the CKD group was also higher than that in the non-CKD group after discharge. The independent risk factor for rebleeding during hospitalization was age (odds ratio [OR], 1.02; P = 0.0063), whereas risk factors for death were CKD (OR, 2.37; P = 0.0222), shock (OR, 2.99; P = 0.0098), and endotracheal intubation (OR, 5.31; P < 0.0001). The hazard ratio of rebleeding risk for aspirin users after discharge over a 10-year follow-up period was 0.68 (95% confidence interval [CI]: 0.45–0.95, P = 0.0223). On the other hand, old age (P < 0.0001), CKD (P = 0.0090), diabetes (P = 0.0470), and congestive heart failure (P = 0.0013) were the independent risk factors for death after discharge. In-hospital patients with CKD and PUB after endoscopic therapy had higher recurrent bleeding, infection, and mortality rates, and the need for second endoscopic therapy. Age was the independent risk factor for recurrent bleeding during hospitalization. After being discharged with a 10-year follow-up period, nonaspirin user was a significant factor for recurrent bleeding.

Endoscopic ultrasound-assisted gastrointestinal hemostasis: an evolving technique.

Gastrointestinal bleeding can range from grossly visible blood in stool or vomitus to microscopic bleed. However, any kind of bleeding can lead to potential life-threatening consequences. A small proportion of patients with gastrointestinal bleeding remain refractory to initial endoscopic hemostasis. While some are successfully managed by repeat endoscopic intervention, a few fail to respond or are not amenable to endoscopic hemostasis. As of now, the next level of intervention is passed on to either surgeons or interventional radiologists. There is new evidence suggesting the increased utility of endoscopic ultrasound (EUS) in diagnosis and treatment of culprit vascular lesions across the gut. In addition, EUS-assisted technique has also been used in the primary prevention of bleeding from gastroesophageal varices. In this review article, we have summarized case series and reports describing the use of EUS-assisted hemostasis. Indications, techniques, complications and success rates reported are discussed. While most of the authors describe their experience with primary and secondary treatment of gastric varices, treatment of other gastrointestinal lesions with EUS assisted hemostatic techniques is also discussed.

Mo1371 Risk Factors Influencing the Outcome of Peptic Ulcer Bleeding in Chronic Kidney Disease After Initial Endoscopic Hemostasis - A Nationwide Cohort Study

Mo1371 Risk Factors Influencing the Outcome of Peptic Ulcer Bleeding in Chronic Kidney Disease After Initial Endoscopic Hemostasis - A Nationwide Cohort Study

EUS Guided Coiling for Bleeding Duodenal Collateral Vessel

65 year old male, a chronic smoker and alcoholic and a diagnosed case of chronic calcific pancreatitis since 2014, presented with recurrent abdominal pain, loss of weight and loss of appetite. CT SCAN of abdomen showed 3.4 x 3.6 cm mass in the head of pancreaas with biliary and pancreatic ductal dilation. It also showed calcification of pancreatic parenchyma. EUS guided FNA was suggestive of neuroendocrine tumor of pancreas. Prominant collaterals were seen adjacent to the mass. He presented a week later with massive upper GI bleed from the 2nd part of duodenum. Initial endoscopic hemostasis was achieved with hemoclips. However, as he rebled within 48hrs, EUS was done which showed active bleeding from the collateral seen near the mass. EUS guided coil (4 mm size, Three in number) were placed into the collateral. Complete thrombosis of the collateral was noted. Hemostasis was achieved. Patient remained stable and was discharged after 3 days.

Predictors of re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy bleeding.

To predict the re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy (ES) bleeding. Over a 15-year period, data from 161 patients with delayed post-ES bleeding were retrospectively collected from a single medical center. To identify risk factors for re-bleeding after initial successful endoscopic hemostasis, parameters before, during and after the procedure of endoscopic retrograde cholangiopancreatography were analyzed. These included age, gender, blood biochemistry, co-morbidities, endoscopic diagnosis, presence of peri-ampullary diverticulum, occurrence of immediate post-ES bleeding, use of needle knife precut sphincterotomy, severity of delayed bleeding, endoscopic features on delayed bleeding, and type of endoscopic therapy. A total of 35 patients (21.7%) had re-bleeding after initial successful endoscopic hemostasis for delayed post-ES bleeding. Univariate analysis revealed that malignant biliary stricture, serum bilirubin level of greater than 10 mg/dL, initial bleeding severity, and bleeding diathesis were significant predictors of re-bleeding. By multivariate analysis, serum bilirubin level of greater than 10 mg/dL and initial bleeding severity remained significant predictors. Re-bleeding was controlled by endoscopic therapy in a single (n = 23) or multiple (range, 2-7; n = 6) sessions in 29 of the 35 patients (82.9%). Four patients required transarterial embolization and one went for surgery. These five patients had severe bleeding when delayed post-ES bleeding occurred. One patient with decompensated liver cirrhosis died from re-bleeding. Re-bleeding occurs in approximately one-fifth of patients after initial successful endoscopic hemostasis for delayed post-ES bleeding. Severity of initial bleeding and serum bilirubin level of greater than 10 mg/dL are predictors of re-bleeding.

Prophylactic Transcatheter Arterial Embolization After Successful Endoscopic Hemostasis in the Management of Bleeding Duodenal Ulcer.

The aim of this study was to demonstrate the new strategy of prophylactic transcatheter arterial embolization (TAE) of the gastroduodenal artery after endoscopic hemostasis of bleeding duodenal ulcers. TAE is a well-established method for the treatment of recurrent or refractory ulcer bleeding resistant to endoscopic intervention, which increasingly replaces surgical procedures. A new approach for improving outcome and reducing rebleeding episodes is the supplemental and prophylactic TAE after successful endoscopic hemostasis. This retrospective study included all patients (n=117) treated from 2008 to 2012 for duodenal ulcer bleeding. After initial endoscopic hemostasis, patients were assessed regarding their individual rebleeding risk. Patients with a low rebleeding risk (n=47) were conservatively treated, patients with a high risk for rebleeding (n=55) had prophylactic TAE of the gastroduodenal artery, and patients with endoscopically refractory ulcer bleeding received immediate TAE. The technical success of prophylactic TAE was 98% and the clinical success was 87% of cases. Rebleeding occurred in 11% of patients with prophylactic TAE and was successfully treated with repeated TAE or endoscopy. The major complication rate was 4%. Surgery was necessary in only 1 prophylactic TAE patient (0.9%) during the whole study period. Mortality associated with ulcer bleeding was 4% in patients with prophylactic TAE. Prophylactic TAE in patients with duodenal ulcers at high risk for rebleeding was feasible, effective at preventing the need for surgery, and had low major complication rates. Given these promising outcomes, prophylactic TAE should be further evaluated as a preventative therapy in high-risk patients.

Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Main Recommendations MR1. ESGE recommends immediate assessment of hemodynamic status in patients who present with acute upper gastrointestinal hemorrhage (UGIH), with prompt intravascular volume replacement initially using crystalloid fluids if hemodynamic instability exists (strong recommendation, moderate quality evidence). MR2. ESGE recommends a restrictive red blood cell transfusion strategy that aims for a target hemoglobin between 7 g/dL and 9 g/dL. A higher target hemoglobin should be considered in patients with significant co-morbidity (e. g., ischemic cardiovascular disease) (strong recommendation, moderate quality evidence). MR3. ESGE recommends the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Outpatients determined to be at very low risk, based upon a GBS score of 0 – 1, do not require early endoscopy nor hospital admission. Discharged patients should be informed of the risk of recurrent bleeding and be advised to maintain contact with the discharging hospital (strong recommendation, moderate quality evidence). MR4. ESGE recommends initiating high dose intravenous proton pump inhibitors (PPI), intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour), in patients presenting with acute UGIH awaiting upper endoscopy. However, PPI infusion should not delay the performance of early endoscopy (strong recommendation, high quality evidence). MR5. ESGE does not recommend the routine use of nasogastric or orogastric aspiration/lavage in patients presenting with acute UGIH (strong recommendation, moderate quality evidence). MR6. ESGE recommends intravenous erythromycin (single dose, 250 mg given 30 – 120 minutes prior to upper gastrointestinal [GI] endoscopy) in patients with clinically severe or ongoing active UGIH. In selected patients, pre-endoscopic infusion of erythromycin significantly improves endoscopic visualization, reduces the need for second-look endoscopy, decreases the number of units of blood transfused, and reduces duration of hospital stay (strong recommendation, high quality evidence). MR7. Following hemodynamic resuscitation, ESGE recommends early (≤ 24 hours) upper GI endoscopy. Very early ( MR8. ESGE recommends that peptic ulcers with spurting or oozing bleeding (Forrest classification Ia and Ib, respectively) or with a nonbleeding visible vessel (Forrest classification IIa) receive endoscopic hemostasis because these lesions are at high risk for persistent bleeding or rebleeding (strong recommendation, high quality evidence). MR9. ESGE recommends that peptic ulcers with an adherent clot (Forrest classification IIb) be considered for endoscopic clot removal. Once the clot is removed, any identified underlying active bleeding (Forrest classification Ia or Ib) or nonbleeding visible vessel (Forrest classification IIa) should receive endoscopic hemostasis (weak recommendation, moderate quality evidence). MR10. In patients with peptic ulcers having a flat pigmented spot (Forrest classification IIc) or clean base (Forrest classification III), ESGE does not recommend endoscopic hemostasis as these stigmata present a low risk of recurrent bleeding. In selected clinical settings, these patients may be discharged to home on standard PPI therapy, e. g., oral PPI once-daily (strong recommendation, moderate quality evidence). MR11. ESGE recommends that epinephrine injection therapy not be used as endoscopic monotherapy. If used, it should be combined with a second endoscopic hemostasis modality (strong recommendation, high quality evidence). MR12. ESGE recommends PPI therapy for patients who receive endoscopic hemostasis and for patients with adherent clot not receiving endoscopic hemostasis. PPI therapy should be high dose and administered as an intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour) for 72 hours post endoscopy (strong recommendation, high quality evidence). MR13. ESGE does not recommend routine second-look endoscopy as part of the management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). However, in patients with clinical evidence of rebleeding following successful initial endoscopic hemostasis, ESGE recommends repeat upper endoscopy with hemostasis if indicated. In the case of failure of this second attempt at hemostasis, transcatheter angiographic embolization (TAE) or surgery should be considered (strong recommendation, high quality evidence). MR14. In patients with NVUGIH secondary to peptic ulcer, ESGE recommends investigating for the presence of Helicobacter pylori in the acute setting with initiation of appropriate antibiotic therapy when H. pylori is detected. Re-testing for H. pylori should be performed in those patients with a negative test in the acute setting. Documentation of successful H. pylori eradication is recommended (strong recommendation, high quality evidence). MR15. In patients receiving low dose aspirin for secondary cardiovascular prophylaxis who develop peptic ulcer bleeding, ESGE recommends aspirin be resumed immediately following index endoscopy if the risk of rebleeding is low (e. g., FIIc, FIII). In patients with high risk peptic ulcer (FIa, FIb, FIIa, FIIb), early reintroduction of aspirin by day 3 after index endoscopy is recommended, provided that adequate hemostasis has been established (strong recommendation, moderate quality evidence).

Comparison of hemostatic forceps with soft coagulation versus argon plasma coagulation for bleeding peptic ulcer--a randomized trial.

Endoscopic high-frequency soft coagulation is used to manage visible bleeding or nonbleeding vessels during endoscopic submucosal dissection. The aim of the present study was to compare the efficacy of hemostasis by soft coagulation (using hemostatic forceps) with argon plasma coagulation (APC), in a prospective randomized trial. From January 2013 to June 2014, 276 patients were randomly assigned into two groups: epinephrine injection plus APC (the APC group); or epinephrine injection plus soft coagulation using hemostatic forceps (the HFSC group). As the primary outcome we compared recurrent bleeding rates within 30 days after initial hemostasis in a noninferiority design. After exclusion, 75 patients in the APC group and 76 in the HFSC group were finally evaluated. In the APC group 72 patients (96 %) were successfully treated with the assigned treatment alone vs. 73 (96 %) in the HFSC group. Initial endoscopic hemostasis using a single or combined modality was achieved in all patients. Recurrent bleeding within 30 days was experienced by five patients (6.7 %) and seven patients (9.2 %) in the AFC and HFSC groups, respectively (P = 0.563), and within 7 days by three patients (4.0 %) and five patients (6.6 %), respectively (P = 0.719). We found no significant difference in the rates of adverse events (1.3 % vs. 2.6 %) or mortality (2.7 % vs. 2.6 %) between the groups. The efficacy and safety of soft coagulation using endoscopic hemostatic forceps is not inferior to APC when used to treat patients with bleeding peptic ulcers. Clinicaltrials.gov NCT02020603.

Transcatheter arterial embolization for endoscopically unmanageable non-variceal upper gastrointestinal bleeding

Objective. Transcatheter arterial embolization (TAE) is a therapeutic option for endoscopically unmanageable upper gastrointestinal (GI) bleeding. We aimed to assess the efficacy and clinical outcomes of TAE for acute non-variceal upper GI bleeding and to identify predictors of recurrent bleeding within 30 days. Materials and methods. Visceral angiography was performed in 66 patients (42 men, 24 women; mean age, 60.3 ± 12.7 years) who experienced acute non-variceal upper GI bleeding that failed to be controlled by endoscopy during a 7-year period. Clinical information was reviewed retrospectively. Outcomes included technical success rates, complications, and 30-day rebleeding and mortality rates. Results. TAE was feasible in 59 patients. The technical success rate was 98%. Rebleeding within 30 days was observed in 47% after an initial TAE and was managed with re-embolization in 8, by endoscopic intervention in 5, by surgery in 2, and by conservative care in 12 patients. The 30-day overall mortality rate was 42.4%. In the case of initial endoscopic hemostasis failure (n = 34), 31 patients underwent angiographic embolization, which was successful in 30 patients (96.8%). Rebleeding occurred in 15 patients (50%), mainly because of malignancy. Two factors were independent predictors of rebleeding within 30 days by multivariate analysis: coagulopathy (odds ratio [OR] = 4.37; 95% confidence interval [CI]: 1.25–15.29; p = 0.021) and embolization in ≥2 territories (OR = 4.93; 95% CI: 1.43–17.04; p = 0.012). Catheterization-related complications included hepatic artery dissection and splenic embolization. Conclusion. TAE controlled acute non-variceal upper GI bleeding effectively. TAE may be considered when endoscopic therapy is unavailable or unsuccessful. Correction of coagulopathy before TAE is recommended.

Predictive Factors for Endoscopic Hemostasis in Patients with Upper Gastrointestinal Bleeding

Predictive Factors for Endoscopic Hemostasis in Patients with Upper Gastrointestinal Bleeding

Rebleeding after initial endoscopic hemostasis in peptic ulcer disease.

Endoscopic hemostasis is the first-line treatment for upper gastrointestinal bleeding (UGIB). Although several factors are known to be risk factors for rebleeding, little is known about the use of antithrombotics. We tried to verify whether the use of antithrombotics affects rebleeding rate after a successful endoscopic hemostasis for peptic ulcer disease (PUD). UGIB patients who underwent successful endoscopic hemostasis were included. Rebleeding was diagnosed when the previously treated lesion bled again within 30 days of the initial episode. Of 522 UGIB patients with PUD, rebleeding occurred in 93 patients (17.8%). The rate of rebleeding was higher with aspirin medication (P=0.006) and after a long endoscopic hemostasis (P<0.001). Of all significant variables, procedure time longer than 13.5 min was related to the rate of rebleeding (OR, 2.899; 95% CI, 1.768-4.754; P<0.001) on the logistic regression analysis. The rate of rebleeding after endoscopic hemostasis for PUD is higher in the patients after a long endoscopic hemostasis. Endoscopic hemostasis longer than 13.5 min is related to rebleeding after a successful endoscopic hemostasis for PUD.

Outcome of holiday and nonholiday admission patients with acute peptic ulcer bleeding: a real-world report from southern Taiwan.

Background. Recent findings suggest that patients admitted on the weekend with peptic ulcer bleeding might be at increased risk of adverse outcomes. However, other reports found that there was no “holiday effect.” The purpose of this study was to determine if these findings hold true for a real-life Taiwanese medical gastroenterology practice. Materials and Methods. We reviewed the medical files of hospital admissions for patients with peptic ulcer bleeding who received initial endoscopic hemostasis between January 2009 and March 2011. A total of 744 patients were enrolled (nonholiday group, n = 615; holiday group, n = 129) after applying strict exclusion criteria. Holidays were defined as weekends and national holidays in Taiwan. Results. Our results showed that there was no significant difference in baseline characteristics between the two groups. We also observed that, compared to the nonholiday group, patients in the holiday group received earlier endoscopy treatment (12.20 hours versus 16.68 hours, P = 0.005), needed less transfused blood (4.8 units versus 6.6 units, P = 0.02), shifted from intravenous to oral proton-pump inhibitors (PPIs) more quickly (5.3 days versus 6.9 days, P = 0.05), and had shorter hospital stays (13.05 days versus 17.36 days, P = 0.005). In the holiday and nonholiday groups, the rebleeding rates were 17.8% and 23.41% (P = 0.167), the mortality rates were 11.63% versus 13.66% (P = 0.537), and surgery was required in 2.11% versus 4.66% (P = 0.093), respectively. Conclusions. Patients who presented with peptic ulcer bleeding on holidays did not experience delayed endoscopy or increased adverse outcomes. In fact, patients who received endoscopic hemostasis on the holiday had shorter waiting times, needed less transfused blood, switched to oral PPIs quicker, and experienced shorter hospital stays.