Initial Endoscopic Hemostasis Research Articles

Predictive factors for intractability to endoscopic hemostasis in the treatment of bleeding gastroduodenal peptic ulcers in Japanese patients.

Background/AimsDespite improvements in endoscopic hemostasis and pharmacological therapies, upper gastrointestinal (UGI) ulcers repeatedly bleed in 10% to 20% of patients, and those without early endoscopic reintervention or definitive surgery might be at a high risk for mortality. This study aimed to identify the risk factors for intractability to initial endoscopic hemostasis.MethodsWe analyzed intractability among 428 patients who underwent emergency endoscopy for bleeding UGI ulcers within 24 hours of arrival at the hospital.ResultsDurable hemostasis was achieved in 354 patients by using initial endoscopic procedures. Sixty-nine patients with Forrest types Ia, Ib, IIa, and IIb at the second-look endoscopy were considered intractable to the initial endoscopic hemostasis. Multivariate analysis indicated that age ≥70 years (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.07 to 4.03), shock on admission (OR, 5.26; 95% CI, 2.43 to 11.6), hemoglobin <8.0 mg/dL (OR, 2.80; 95% CI, 1.39 to 5.91), serum albumin <3.3 g/dL (OR, 2.23; 95% CI, 1.07 to 4.89), exposed vessels with a diameter of ≥2 mm on the bottom of ulcers (OR, 4.38; 95% CI, 1.25 to 7.01), and Forrest type Ia and Ib (OR, 2.21; 95% CI, 1.33 to 3.00) predicted intractable endoscopic hemostasis.ConclusionsVarious factors contribute to intractable endoscopic hemostasis. Careful observation after endoscopic hemostasis is important for patients at a high risk for incomplete hemostasis.

Use of Needle Knife and Post-sphincterotomy Bleeding in Advanced Endoscopy Training

Background: The ACG/ASGE Quality in Endoscopy Taskforce recognizes that adverse events are inherent in the performance of ERCP and calls for continuous quality improvement in ERCP programs. Sphincterotomy, a part of the ERCP core curriculum for trainees, may be associated with bleeding complications. Aims: To study factors associated with post-sphincterotomy bleeding (PSB) during advanced endoscopy fellowship training. Methods: Retrospective case series at a tertiary academic center. Patients who underwent ERCP in the academic year 2011-2012 were identified. Cases complicated by PSB were included. Clinical and endoscopic variables were collected. Factors associated with bleeding were explored. Results: Three hundred fifty ERCP procedures were reviewed. Eleven PSB cases were identified. Demographics: 64% female; mean age 63; 73% inpatients. Clinical characteristics: jaundice was the most frequent indication (45%); coagulopathy was present in 27%; 55% were on antiplatelet and/or anticoagulant agents; 27% required ICU stay; rebleeding occurred in two patients (18%); mean number of packed red blood cell units transfused was two; mean hospital stay was 6 days. Technical characteristics: pre-cut needle knife sphincterotomy was performed in 45%; a trainee participated in 91% of PSB cases and in 100% of bleeding cases involving a needle knife; 73% of bleeding cases occurred in the first 6 months of the academic year; immediate bleeding occurred in 55%. Initial endoscopic hemostasis was successful in all cases, and involved epinephrine injection monotherapy in 4 of 11 patients (36%); epinephrine injection and heater probe therapy in four patients (36%); epinephrine injection and clip placement in one patient (9%); and triple combination therapy with epinephrine injection, heater probe, and clip placement in two patients (18%). One of two patients with rebleeding was treated with epinephrine injection and heater probe therapy, and the other patient with epinephrine injection, heater probe, and clip placement. Rescue IR intervention was required in one patient but failed. Hemostasis was achieved on third endoscopy with temporary biliary stent placement. Biliary cannulation and therapeutic ERCP intervention was successful in 100%. Conclusion: The performance of pre-cut needle knife sphincterotomy was a frequent technical factor in post-sphincterotomy bleeding during 1 year of advanced endoscopy training. This technique remains a high-risk procedure. The use of needle knife sphincterotomy by trainees warrants careful monitoring and the development of effective training methods to teach this technique.

Risk factors influencing the outcome of peptic ulcer bleeding in end stage renal diseases after initial endoscopic haemostasis

Background and Aims: Patients suffering from peptic ulcer (PU) bleeding who have end-stage renal disease (ESRD) may encounter more adverse outcomes. The primary objective is to investigate the risk factors that influence the outcomes of ESRD and chronic kidney disease (CKD) patients with PU bleeding after successful initial endoscopic haemostasis. Methods: A total of 540 patients with PU bleeding after initial endoscopic haemostasis in a tertiary hospital were investigated retrospectively. They were sorted into three groups after randomised age-matched adjustment: ESRD group (n = 90), CKD group (n = 90) and control group (n = 360). Main outcome measurements were rebleeding, requirement for blood transfusion and surgery, length of hospital stay and mortality. Results: The rebleeding rates were 43% for the ESRD group vs. 21% for the CKD group vs. 12% for the control group (overall p = < 0.001). Multivariate analysis showed the predictors of rebleeding were ESRD, time to endoscope, and non-high-dose proton-pump inhibitors (PPI) users. The risk factors for bleeding-related mortality were presence of moderate degree of CKD and ESRD group, time to endoscope, and Rockall score. All-cause mortality was related to presence of moderate degree of CKD and ESRD group, platelet count, time to endoscope, Rockall score and length of hospital stay. Conclusions: ESRD patients who suffered from PU bleeding were at risk of excessive rebleeding and mortality with frequent occurrence of delayed rebleeding. This study suggests that early endoscopy for initial haemostasis and high-dose intravenous PPI are associated with the reduction of rebleeding risk especially in patients with high Rockall scores.

Gastrointestinal bleeding associated with antithrombotic therapy in the elderly in Japan.

We summarize data of patients with gastrointestinal bleeding (GIB) and discuss the relationship between antithrombotic drug use and age in patients with GIB. One-hundred and twenty patients with GIB were divided into two groups according to age (=75 years old and <75 years old). The causes and clinical outcome of each group were compared. Forty-two patients received antithrombotic therapy. The main antithrombotic drugs were low dose aspirin (38 patients), ticlopidine (5 patients) and warfarin (3 patients). Compared with younger GIB patients, elderly patients had more coexisting illness and antithrombotic drugs. In patients taking antithrombotic drugs, upper GIB is more frequent than those not taking antithrombotic drugs (p<0.05) and antithrombotic drugs were the risk for GIB from erosive lesions of the esophagus or stomach. In the lower gastrointestinal tract, there was no difference of incidence related to antithrombotic use. The initial endoscopic hemostasis was performed in 14 patients. Eight varices patients received endoscopic vanding and 6 of 43 gastroduodenal ulcer patients had mechanical clip hemostasis. From our findings, antithrombotic drugs were considered to be a risk for GIB. It might be important to prevent or minimize GIB in elderly patients prescribed antithrombotic drugs.

The efficacy of transcatheter arterial embolization as the first‐choice treatment after failure of endoscopic hemostasis and endoscopic treatment resistance factors

The aim of this retrospective study was to evaluate the efficacy of transcatheter arterial embolization (TAE) as the first-choice treatment in patients with bleeding peptic ulcer after the failure of endoscopic hemostasis. An additional objective was to clarify endoscopic treatment resistance factors. Between April 2004 and December 2010, 554 patients were admitted to Kasugai Municipal Hospital for necessary endoscopic hemostasis for bleeding gastric ulcer or duodenal ulcer. In the patients for whom endoscopic hemostasis failed, TAE was attempted. If TAE failed, the patients underwent surgery. The backgrounds of the patients in whom endoscopic treatment was successful and in whom it failed were compared. TAE was attempted in 15 patients (2.7%). In 12 (80.0%) of 15 patients, embolization with coils was successful. In one patient (6.7%), embolization was ineffective. This patient underwent emergent salvage surgery. In two (13.3%) of 15 patients, no extravasation was observed during arteriography. These patients were cured with medication. In two patients, ulcer perforation was observed during endoscopy after rebleeding. These patients underwent surgery. In total, 3 (0.5%) of 554 patients underwent surgery. No recurrent bleeding was observed after TAE. Hemoglobin level <8 g/dL at presentation (P = 0.02), Rockall score ≥7 at presentation (P = 0.002), and Forrest class Ia/Ib at initial endoscopic hemostasis (P < 0.001) were found to be independent significant endoscopic treatment resistance factors. TAE is a safe and effective first-choice treatment for patients in whom endoscopic hemostasis has failed.

Tu1695 Risk Factors Influencing the Outcome of Peptic Ulcer Bleeding in End Stage Renal Diseases After Initial Endoscopic Hemostasis

Tu1695 Risk Factors Influencing the Outcome of Peptic Ulcer Bleeding in End Stage Renal Diseases After Initial Endoscopic Hemostasis

Intravenous non-high-dose pantoprazole is equally effective as high-dose pantoprazole in preventing rebleeding among low risk patients with a bleeding peptic ulcer after initial endoscopic hemostasis

BackgroundMany studies have shown that high-dose proton-pumps inhibitors (PPI) do not further reduce the rate of rebleeding compared to non-high-dose PPIs but we do not know whether intravenous non-high-dose PPIs reduce rebleeding rates among patients at low risk (Rockall score < 6) or among those at high risk, both compared to high-dose PPIs. This retrospective case-controlled study aimed to identify the subgroups of these patients that might benefit from treatment with non-high-dose PPIs.MethodsSubjects who received high dose and non-high-dose pantoprazole for confirmed acute PU bleeding at a tertiary referral hospital were enrolled (n = 413). They were divided into sustained hemostasis (n = 324) and rebleeding groups (n = 89). The greedy method was applied to allow treatment-control random matching (1:1). Patients were randomly selected from the non-high-dose and high-dose PPI groups who had a high risk peptic ulcer bleeding (n = 104 in each group), and these were then subdivided to two subgroups (Rockall score ≥ 6 vs. < 6, n = 77 vs. 27).ResultsAn initial low hemoglobin level, serum creatinine level, and Rockall score were independent factors associated with rebleeding. After case-control matching, the significant variables between the non-high-dose and high-dose PPI groups for a Rockall score ≥ 6 were the rebleeding rate, and the amount of blood transfused. Case-controlled matching for the subgroup with a Rockall score < 6 showed that the rebleeding rate was similar for both groups (11.1% in each group).ConclusionIntravenous non-high-dose pantoprazole is equally effective as high-dose pantoprazole when treating low risk patients with a Rockall sore were < 6 who have bleeding ulcers and high-risk stigmata after endoscopic hemostasis.

RETROSPECTIVE MULTICENTER STUDY CONCERNING ELECTROCAUTERY FORCEPS WITH SOFT COAGULATION FOR NONMALIGNANT GASTRODUODENAL ULCER BLEEDING IN JAPAN

Electrocautery forceps with soft coagulation are actively used for treatment of bleeding and nonbleeding visible vessels during endoscopic submucosal dissection, but the usefulness of gastroduodenal ulcer bleeding has not been elucidated so far. The purpose of this paper is to elucidate the outcomes of electrocautery forceps with soft coagulation for peptic and artificial gastroduodenal ulcer bleeding. A retrospective multicenter study of consecutive case series during one year involved nine departments of high-volume hospitals in Japan. The study included 128 consecutive patients (62 with peptic ulcers and 66 with artificial ulcers) with bleeding nonmalignant gastroduodenal ulcers that were revealed using emergency endoscopy between January 2008 and December 2008. Hemostasis was carried out using electrocautery forceps with soft coagulation. Rates of successful initial hemostasis, rebleeding, transfer to surgery, and death according to peptic and artificial ulcer bleeding were recorded. Successful initial endoscopic hemostasis was obtained in 61 peptic ulcer patients (98.4%) and 66 artificial ulcer patients (100%). Rebleeding was observed in seven peptic ulcer patients (11.5%) and five artificial ulcer patients (7.6%). Rates of successful management with endoscopic methods alone were 96.8% (60/62) and 100% (66/66) in peptic ulcer patients and artificial ulcer patients, respectively. There were no severe complications or deaths related to the management of gastroduodenal ulcer bleeding. The novel endoscopic method using electrocautery forceps with soft coagulation for gastroduodenal ulcer bleeding seems to provide safety and efficacy that is comparable with that of endoscopic hemostasis with other established hemostatic techniques.

M1429: Predictors of Recurrent Bleeding After Initial Endoscopic Hemostasis With Epinephrine Injection Monotherapy in High Risk Ulcer Patients

M1429: Predictors of Recurrent Bleeding After Initial Endoscopic Hemostasis With Epinephrine Injection Monotherapy in High Risk Ulcer Patients

Upper gastrointestinal bleeding from the surgeon’s view

Upper Gastrointestinal bleeding (GIB) represents about 90% of the total number of haemorrhages for the entire gastrointestinal tract. Its mortality rate approaches 10%, even in specialized Centers. The commonest causes of admissions are benign (60%). Neoplasms account for a percentage of 15%, while other diseases represent the remaining 25%. The main risk factors for bleeding include: elderly, shock on admission, renal or hepatic failure and diffuse cancer, endoscopic findings (active, diffuse bleeding from peptic ulcer, non-bleeding visible vessel, large varices). Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper GIB lesions. Endoscopic therapy reduces the risk of rebleeding, the need for blood transfusions, the requirement for surgery, and patient morbidity. However, in cases of endoscopic haemostasis failure or continuous haemorrhage or recurrence of bleeding despite the initial successful endoscopic haemostasis, an emergency surgical operation will be necessary aimed at the ligation of the bleeding vessel and the haemodynamic stabilization of the patient; in duodenal ulcer either subtotal gastrectomy or vagotomy and pyloroplasty (with a greater chance of recurrence of bleeding), while in gastric ulcer either gastrectomy or vagotomy and draining operation. In Mallory-Weiss syndrome, bleeding episodes are self-limited in 80–90 % of cases and the need for surgery is very rare. In Dieulafoy’s Lesion treatment is endoscopic or surgical, while in gastric antral vascular ectasia, the preferred endoscopic therapy is argon plasma cogulation. Laparoscopic tholoplasty is the operation of first choice for hiatus hernias. Common hepatic artery aneurysms are treated with ligation or excision without arterial repair, as opposed to proper hepatic artery aneurysms that require arterial repair with graft interference. Finally, in regard to esophageal variceal bleeding as a consequence of portal hypertension, new methods of treatment have emerged due to the evolution of endoscopes and interventional actinology, apart from porto-systemic shunts. The essence, however, is to identify those patients who can be managed by such decompressive operations and reserve liver transplantation for those who cannot be managed with any lesser therapy.

Treating delayed endoscopic sphincterotomy-induced bleeding: Epinephrine injection with or without thermotherapy

To compare the hemostatic efficacy between epinephrine injection alone and epinephrine injection combined with thermotherapy for delayed post-endoscopic sphincterotomy (ES) bleeding. Cases with delayed post-ES bleeding undergoing epinephrine injection alone (epinephrine injection group, n = 26) or epinephrine combined with thermotherapy (combination therapy group, n = 33) in our institution between 1999 and 2007 were retrospectively investigated. The main outcome measurements were: initial endoscopic hemostasis, re-bleeding, complications, requirement of angiographic embolization or surgery, requirement for blood transfusion, and mortality. The initial hemostatic efficacy was 96.2% for epinephrine injection alone and 100% for combination therapy (P = 0.44). There were four patients with re-bleeding in each group (16.0% vs 12.1%, P = 0.72). There was only one complication of pancreatitis from the combination therapy group. Three patients (11.5%) in the epinephrine injection group and one patient (3%) in the combination therapy group required angiographic embolization or surgery (P = 0.31). The total number of blood transfusions was not significantly different between the two groups (3.5 +/- 4.6 U vs 3.5 +/- 4.5 U, P = 0.94). There was no bleeding-related death in either group. Epinephrine injection alone is as effective as epinephrine injection combined with thermotherapy for the management of delayed post-ES bleeding.

Prediction of recurrent bleeding after endoscopic haemostasis in non-variceal upper gastrointestinal haemorrhage.

Endoscopic haemostasis by injection of adrenaline was attempted in 135 consecutive patients with active upper gastrointestinal bleeding. Initial haemostasis was obtained in 127 patients following injection of 5-15 ml 1:10,000 adrenaline; eight patients in whom haemostasis was not achieved underwent immediate laparotomy. There was further haemorrhage in 25 patients, which was successfully treated by further injection of adrenaline in ten. Fifteen patients had major rebleeding requiring emergency surgery. Stepwise logistic regression analysis identified three factors that, taken together, were highly predictive of the need for surgery: pulse rate on admission, the position of the ulcer and whether the patient was obese. A scoring system was derived from the logistic analysis equation that was found to predict correctly the need for emergency surgery in 84 per cent of patients. In patients with a high probability of rebleeding surgery should be considered after initial endoscopic haemostasis and stabilization. In the majority of patients endoscopic treatment alone is sufficient for permanent haemostasis.

Predictors of Hemostatic Failure After Hemoclip Treatment for Active Peptic Ulcer Bleeding

Predictors of Hemostatic Failure After Hemoclip Treatment for Active Peptic Ulcer Bleeding Tae Hyeon Kim, Mi Ryeong Sim, Joo Jin Yeom, Suck Chei Choi, Yong Ho Nah Active bleeding and non-bleeding visible vessel in patients with bleeding peptic ulcer is associated with a high risk of rebleeding. The aim of our study was to define risk factors associated with failure of endoscopic hemostasis and rebleeding in patients with active peptic ulcer bleeding. Method: Ninety-six patients (56 men and 40 women; 58.8 G 15 years) with active peptic ulcer bleeding (spurting, oozing, non-bleeding visible vessel) treated in Wonkwang Medical Center from January 2002 to July 2004 were retrospectively analyzed. They were classified to endoscopic hemoclip (N Z 61) and epinephrine injection plus hemoclip (N Z 35). The clinical outcomes were compared both therapeutic modalities and the factors associated with rebleeding were analyzed. Results: Initial hemostasis was achieved in 79 patients (82.2%), 5 patients needed operations (5.2%), and 4 deaths occurred (4.1%). Recurrent bleeding, the duration of hospital stay, blood transfusion requirements, complication rate, and mortality rate were not statistically different between hemoclip alone and combination group. Univariate analysis showed that rebleeding was significantly related to the presence of shock on admission (p Z 0.04), ulcer size of more than 2 cm (p Z 0.03), hemoglobin level of less than 8 g/dL (p Z 0.001) in all patients. In a multivariate analysis, hemoglobin level of less than 8 g/dL was only positive predictor (OR 6.721, 95% CI 1.617w27.931, p Z 0.009). Conclusion: This results suggest that the combination method does not provide substantial advantage over use of the hemoclip method alone in the hemostatic management of active peptic ulcers bleeding. The presence of shock, low hemoglobin on admission, and ulcer size of more than 2 cm may be useful to predict rebleeding after initial endoscopic hemostasis in patients with active peptic ulcer bleeding. Abstracts

The Prediction of Peptic Ulcer Rebleeding After Therapeutic Scheduled Second Endoscopy - Clinical or Endoscopic Factors?

Aim Recurrent bleeding carries a significant impact in patients with bleeding peptic ulcers. From our published randomised controlled trial, we have demonstrated that by repeating a second endoscopy with appropriate therapy within 16-24 hours after endoscopic hemostasis, we could reduce the rate of recurrent bleeding from 13.8% to 5%. In this study, we would like to identify possible factors that predict the development of recurrent bleeding in patients after receiving a scheduled second endoscopy. Methods 249 patients presented to the United Christian Hospital, Hong Kong from 8.1999 to 12. 2002 with acute bleeding peptic ulcers. All these patients received a scheduled second endoscopy after initial successful endoscopic hemostasis. The data, which included clinical, endoscopic and outcome measures were collected and subjected to statistical analysis. Results There were 146 patients with bleeding duodenal ulcers (58.6%), 101 patients with gastric ulcers (40.6%) and 2 patients with anastomotic ulcers (0.8%). 17 patients developed recurrent bleeding (6.8%), 7 of them were treated by another successful endoscopic therapy, while the remaining 10 patients required surgical intervention. The overall mortality rate was 2.8 %. Mortality rate in the recurrent bleeding group was 17.6%, compared with 1.7% in the non-rebleeding group (p=0.008). Multiple logistic regression on the possible prediction factors found that endoscopic findings of persistent stigmata of active bleeding, vessel or clots on scheduled second endoscopy (Odd ratio 6.58, 95% CI 2.23-19.4), ulcer with size > 1.0cm (Odd ratio 5.62, 95% CI 1.90-16.6), and Hb on admission less than 8 g/dl (Odd ratio 3.91, 95% CI 1.39-11.0) are associated with a significant risk of recurrent bleeding after scheduled second endoscopy. Conclusions Recurrent bleeding after scheduled second endoscopy carries a high mortality. Endoscopic factors, including the endoscopic classification of bleeding peptic ulcers on scheduled second endoscopy and ulcer size, and clinical factors like low Hb on admission are important predictors for recurrent ulcer bleeding. Those high risk patients perhaps will benefit from early surgery.

THE EFFECT OF SCHEDULED REPEAT ENDOSCOPY ON PEPTIC ULCER REBLEEDING—A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL

Aim: Recurrent bleeding after initial haemostasis in peptic ulcer haemorrhage is an important factor that directly related to increased mortality. Conflicting reports have been published concerning the effectiveness of scheduled repeat endoscopy on ulcer rebleeding. We investigate the use of scheduled repeat endoscopy with subsequent further therapy in peptic ulcer bleeding.Method: From August 1999 to January 2001, we prospectively randomized patients who had endoscopically confirmed bleeding peptic ulcer with stigmata of acute bleeding, visible vessel or adherent clot into two groups. Endoscopic therapy was standardized to be adrenaline injection and heater probe application. One group received scheduled second endoscopy 16–24 hours after initial endoscopic haemostasis (Group A), and further therapy applied if endoscopic stigmata persist as above. The other group received close observations (Group B). Those patients in the two groups that develop rebleeding will receive operation if further endoscopic therapy failed. The outcome measures include ulcer re‐bleeding, transfusion, length of stay, and mortality.Results: After initial endoscopic haemostasis, 196 patients were randomized to two groups. 2 patients were excluded after randomization as pathology confirmed carcinoma of stomach. The results were analyzed by using either Chi square or student t tests. Conclusion:A scheduled repeat endoscopy with appropriate therapy 16 to 24 hours after initial endoscopic haemostasis reduce the amount of peptic ulcer rebleeding siginificantly.

Surgical therapy for peptic ulcer and nonvariceal bleeding.

Wider use of endoscopic hemostasis in upper gastrointestinal bleeding (UGIB) has reduced significantly the need for operation. Nevertheless, surgery still plays a pivotal role. Failure to control bleeding endoscopically should not delay surgery when necessary, and a close cooperation between endoscopists and surgeons is essential. Initial endoscopy stops the bleeding in approximately 94% of patients and helps to identify those patients with a high or low risk of rebleeding. High-risk patients should be examined for rebleeding by clinical and endoscopic assessment within at least the first 2-3 days. Large ulcers are the most likely to rebleed, and in elderly patients with severe comorbidity showing little or no healing tendency, they benefit from repeated fibrin glue treatment. In cases of rebleeding despite initial endoscopic hemostasis and conservative treatment, another attempt to stop the hemorrhage endoscopically is justified in most patients. A subgroup of patients who are old, suffering from hypotension due to rebleeding, with large ulcers and several other illnesses should undergo surgery immediately because endoscopic intervention often fails, and these patients deteriorate quickly. The surgical procedure should be limited to safe hemostasis.

Ulcers and nonvariceal bleeding.

Although peptic ulcer continues to be the commonest cause of acute upper gastrointestinal bleeding, obscure haemorrhage from the Dieulafoy malformation and haemobilia must be considered, and may be amenable to endoscopic therapy. The patients who are at the highest risk of rebleeding and death are elderly, in shock at presentation, and have major stigmata of recent haemorrhage (SRH). The endoscopist must identify SRH, and identification may be made easier by washing the area with hydrogen peroxide. The natural history of SRH has been defined. There is wide interobserver variation in the interpretation of SRH, and there is probably therefore little value in the endoscopist describing subtle appearances. Although the value of endoscopic haemostatic therapy is established, it has still not been taken up by all institutions. Endoscopic injection of fibrin glue into the bleeding ulcer is a logical and relatively easy approach, and a systematic histological study of resected ulcers has shown that this does not adversely affect the ulcer healing process. Thermal therapies such as argon plasma coagulation and the heater probe have comparable efficacy. Although a combination of injection and thermal treatments may be logical, there are only trends suggesting that this is better than monotherapy. Nevertheless, the gold probe continues to be used in clinical practice. Experiments in an animal model of gastric bleeding suggest that the gold probe is effective, and that the version with a wide-gauge needle is best. Haemoclips may stop acute upper gastrointestinal bleeding from a range of sources. Patients who rebleed after initial endoscopic haemostasis have a tenfold increase in the risk of death. An important study from Hong Kong suggests that repeat endoscopic treatment after rebleeding has comparable morbidity and mortality to a policy of urgent surgery without endoscopic repeat intervention.

4704 Risk factors for early rebleeding after initial endoscopic hemostasis in patients with bleeding peptic ulcers.

Background & Aims: Rebleeding after initial endoscopic hemostasis in patients with ulcer hemorrhage was been reported in 20-30%. Identification of patients who are at high risk for rebleeding would be expected to improve the outcome of endoscopic hemostasis. The purpose of this study was to evaluate the risk factors for early rebleeding after initial hemostasis in the view of clinical and endoscopic characteristics. Materials & Methods:We reviewed 99 patients who presented with bleeding peptic ulcers and were treated with endoscopic hemostasis including hypertonic saline injection, electrocautery and clipping. We compared the clinical variables (age, blood transfusioin, comorbid illness, initial systolic BP and pulse rate, hemoglobin), endoscopic characteristics of ulcer (size, number, and location of ulcer, clots on the base, bleeding stigmata, size and color of exposed vessle) and Baylor Bleeding Score between the patients who had early rebleeding (n=22) and who had no early rebleeding (n=77) within 5 days. All data were compared with Pearson's chisquare test in both groups, and multivariate analysis was tested with logistic regression and expressed as odds ratio in 95% confidence interval. Results: The stasistically significant correlates with early rebleeding after hemostasis were number of comorbid illness (≥2) (p=0.031), volume of transfusion (≥5 units) (p=0.001), size of ulcer (>1 cm) (p=0.024), multiple ulcers (p=0.017), presence of blood clots on ulcer base (p=0.008), stigmata (active bleeding and visible vessles) (p=0.005), size of vessle (>1 mm) (p=0.001) and pearl-colored vessle rather than black-colored (p=0.001). In multivariate analysis, volume of transfusion (5.4;1.94-14.97), ulcer size (4.53;0.98-20.94), multiple ulcers (3.17;1.16-8.17) and size of exposed vessle (16.73;5.23-53.49) were significant risk factors. There was no correlation between Baylor Bleeding Score and rebleeding in our study. Old age(>60 years), smoking, NSAIDs use, initial systolic BP, initial hemoglobin, location of ulcer and H. pylori infection were not stastistically significant factors adversely affecting rebleeding. Conclusions: The risk factors for early rebleeding after hemostasis in bleeding peptic ulcer can be predicted by clinical variables and endoscopic findings. Early evaluation of risk factors such as transfusion over 5 units, large-sized ulcer, multiple ulcers and size of exposed vessle over 1 mm in initial hemostasis can improve the outcome of hemostasis.

Preventing ulcer rebleeding: the role of second-look endoscopy.

Whether a second-look endoscopy after initial endoscopic hemostasis is of value is controversial. Routine surveillance endoscopy on the next day and treatment of any remaining stigmata may provide marginal benefit, but existing studies are not large enough to demonstrate significant differences. Endoscopic retreatment when patients develop rebleeding may allow emergency surgery to be avoided if successful but may endanger life if further bleeding occurs. Early data indicate that surgery can be avoided in about 75% of patients by retreatment without an increase in mortality.

Endoscopic Treatment of Major Bleeding From Advanced Gastroduodenal Malignant Lesions

To summarize the results of endoscopic therapy for acute hemorrhage from gastroduodenal malignant lesions. The 3-year experience (1989 through 1991) of a specialized gastrointestinal (GI) bleeding team in the endoscopic treatment of acute upper GI bleeding from gastroduodenal malignant tumors was retrospectively reviewed. Of 1,083 consecutive patients with acute major upper GI hemorrhage, 21 (1.9%) were found to have advanced tumors of the stomach and duodenum, 15 of whom received endoscopic therapy. In this study group of 15 patients, the tumors were gastric in 11 and duodenal in 4. Endoscopic treatment consisted of injection of epinephrine, heater probe coagulation, neodymium:yttrium-aluminum-garnet laser coagulation, or injection of sodium tetradecyl sulfate. Initial endoscopic hemostasis was achieved in 10 of the 15 patients (67%); however, bleeding recurred in 8 of 10 (80%), and all 5 in whom endoscopic hemostasis was not achieved continued to bleed. Mean transfusion requirements for the 30 days before and the 30 days after the first endoscopic treatment were 7.6 and 6.4 units of packed erythrocytes, respectively (P > 0.10). Five major procedure-related complications occurred, two of which were fatal. The median duration of survival after the first endoscopic treatment was 39 days (range, 1 to 1,414). In patients with major bleeding from advanced gastroduodenal malignant lesions, endoscopic therapy seems to provide limited benefit.