Initial Hemostasis Research Articles

WITHDRAWN: Argon plasma coagulation therapy for acute non-variceal upper gastrointestinal bleeding.

Endoscopic treatment is recommended for initial hemostasis in non-variceal upper gastrointestinal bleeding. Many endoscopic hemostatic devices are used. Argon Plasma Coagulation (APC) is an alternative. This study reviews all available literature to access the efficacy of APC compared to other endoscopic therapies in the control of acute non-variceal upper GI hemorrhage. We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4 2003), MEDLINE 1966 to December 2003, EMBASE 1980 to December 2003, Web of Science for SCISEARCH (1980 to December 2003), BIOSIS (1985 to December 2003), and the National Research Register Issue 4 2003. We also handsearched abstracts from conference proceedings of the United European Gastroenterology Week and Digestive Disease Week. Randomized, controlled trials of APC compared with other endoscopic hemostasis interventions in the treatment of non-variceal upper gastrointestinal bleeding. Two reviewers assessed trial quality and independently extracted data. Two trials involving 121 people were included. There was no common intervention to pool. One trial compared APC to heat probe, another trial compared APC to injection sclerotherapy. There was no significant difference between groups in either of these trials. On the basis of the two randomised controlled trials identified in this review, there is no evidence to suggest that APC is superior to other endoscopic therapies. Further randomised controlled trials are needed.

Acrylate glue injection for acutely bleeding oesophageal varices: A prospective cohort study

Acrylate glue injection is seldom performed in patients with bleeding oesophageal varices. To assess efficacy and safety of acrylate glue injection in patients with bleeding oesophageal varices, as well as the impact of this technique on subsequent variceal ligation. Prospective study on 133 consecutive cirrhotic patients treated by intravariceal injection of undiluted N-butyl-2-cyanoacrylate into the bleeding varix. Outcome measures were initial haemostasis, recurrent bleeding, complications and mortality at 6 weeks. 52 patients were actively bleeding at endoscopy and 81 showed stigmata of recent haemorrhage. Initial haemostasis was achieved in 49/52 active bleeders (94.2% [95% CI 85.1-98.5]). Overall, early recurrent bleeding occurred in 7 patients (5.2% [95% CI 2.3-10.1]). No major procedure-related complication was recorded. At 6 weeks, death occurred in 11 patients, with an overall bleeding-related mortality of 8.2% [95% CI 5.8-15.3]. Mortality was higher in active (15.4% [95% CI 6.9-28.1]) than non-active bleeders (3.7% [95% CI 0.8-10.4], OR 4.7 [95% CI 1.05-28.7], p=0.02). Of those surviving the first bleeding episode, 112 patients subsequently underwent ligation. No technical difficulties were encountered in performing the banding procedure which was successfully completed in all cases. Emergency injection of acrylate glue is safe and effective for the treatment of acute bleeding oesophageal varices and does not hamper subsequent variceal ligation.

Comparison of ChitoFlex®, CELOX™, and QuikClot® in Control of Hemorrhage

Exsanguinating extremity wounds remain the primary source of battlefield mortality. Operating forces employ three agents in Iraq: HemCon® (HemCon Medical Technologies, Inc., Portland, OR), QuikClot® (Z-Medica Corporation, Wallingford, CT), and CELOX™ (SAM Medical, Tualatin, OR). Anecdotal reports suggest that these agents are less useful on small entrance, linear-tract injuries. ChitoFlex® (HemCon Medical Technologies, Inc., Portland, OR) has been introduced but is untested. To compare the equivalency of the ChitoFlex® dressing, QuikClot® ACS+™ dressing, CELOX™, and standard gauze in their effectiveness to control bleeding from non-cavitary groin wounds. Forty-eight swine were randomly assigned to one of four treatment groups: standard gauze dressing (SD), ChitoFlex® dressing (CF), QuikClot® ACS+™ dressing (QC), and CELOX™ dressing (CX). A groin injury with limited vessel access was created in each animal. Subjects were resuscitated with 500 mL of hetastarch. The primary endpoint was 180-min survival. Secondary endpoints included total blood loss in mL/kg, incidence of re-bleeding, survival times among the animals that did not survive for 180 min, failure to achieve initial hemostasis, incidence of recurrent bleeding, time to initial re-bleeding, amount of re-bleeding, and mass of residual hematoma. Survival occurred in 10 of 12 SD animals, 10 of 12 CF animals, 10 of 12 QC animals, and 9 of 12 CX animals. No statistically significant difference was found. In our study of limited-access extremity bleeding, ChitoFlex® performed equally well in mitigating blood loss and promoting survival. The ChitoFlex® dressing is an equally effective alternative to currently available hemostatic agents. However, no agents were superior to standard gauze in our model of limited access.

Acquired Hemophilia A: A Case Report

Case Report A 61-year-old African American male, with a past medical history of asthma and benign prostatic hypertrophy, presented from an outside hospital with complaints of hematuria and hematemesis. He had initially noted increased bruising two months prior to admission. He also had symptoms suggestive of a non-traumatic thigh hematoma the month prior. He developed hematuria one month prior to admission and underwent an outpatient cystoscopy one week prior to admission which was non-diagnostic. Cystoscopy was repeated on the day of admission localizing the hemorrhage to his right kidney with a biopsy specimen suggesting a low-grade papillary neoplasm. The patient subsequently developed hemetemesis. Emergent esophagogastroduodenoscopy (EGD) at the outside hospital revealed a Mallory-Weiss tear. Epinephrine was injected with initial hemostasis. EGD was repeated after transfer due to recurrent hematamesis and clips were placed to control the hemorrhage. The patient experienced continued hematuria requiring repeat cystoscopy with laser ablation, as well as biopsy of the right ureter and right mid-pole infundibulum. However, multiple repeated biopsies failed to confirm the presence of malignancy.

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.

Challenges and priorities for patients with immune thrombocytopenic purpura and their physicians

Immune thrombocytopenic purpura (ITP) is a disorder of too few platelets (termed thrombocytopenia), the smallest of the circulating blood cells. ITP is defined as isolated thrombocytopenia with no clinically apparent associated conditions or other causes of thrombocytopenia, such as congenital/hereditary thrombocytopenias, drug-induced thrombocytopenia, or autoimmune disorders such as systemic lupus erythematosus [1,2]. “Isolated” thrombocytopenia implies that the red blood cells and white blood cells are normal in number and appearance. The function of blood platelets is to provide initial hemostasis in response to vessel injury, creating a plug to prevent bleeding. Hemostasis is a term to describe prevention of bleeding. If blood vessel injury is small and superficial, the platelet plug is sufficient to stop bleeding. If the vessel injury is extensive, platelets can provide only an initial, temporary seal; permanent hemostasis of larger wounds requires plasma coagulation factors (such as antihemophilic factor and fibrinogen) to provide a strong fibrous matrix to strengthen the platelet plug [3]. Therefore the health problem of patients with ITP, and perhaps their only problem, is a risk for excessive bleeding. The normal platelet concentration in blood is 150,000–350,000 × 10 /L. Like many body functions, the normal number of platelets far exceeds the minimum requirement to provide effective hemostasis. A platelet count of 50,000 × 10 /L is sufficient to stop excessive bleeding following major trauma, surgery, or childbirth. A platelet count of 10,000–20,000× 10/L is sufficient to prevent spontaneous bleeding

ENDOSCOPIC HEMOSTASIS WITH METALLIC HEMOCLIPS FOR IATROGENIC MALLORY‐WEISS TEAR CAUSED BY ENDOSCOPIC EXAMINATION

Applied endoscopic techniques including mucosal resection, sclerotherapy and endoscopic retrograde cholangiopancreatography (ERCP) have been advanced and iatrogenic complications including Mallory-Weiss tear (MWT) occasionally occur in daily endoscopic procedures. The present study aimed to examine the advantages of clipping for MWT complications that occur during endoscopic examination. Over 10 years, we experienced 47 patients with bleeding caused by MWT. Metallic hemoclips were applied for 38 patients for hemostasis. These patients were categorized into two groups: 18 patients in group A whose bleeding tear occurred during endoscopic examination in an iatrogenic condition, and 20 patients in group B visited the emergency unit due to other etiology of MWT. The background characteristics, including length of tears, were not different between the two groups. Initial hemostasis was 100% in groups A and B. Rebleeding was 0/18 (0%) in group A and 1/20 (5 %) in group B. Number of patients who received blood transfusion was significantly higher in group B (group A: 0/18, group B: 4/20). Hemoglobin level before hemostasis was 12.5 g/dL in group A which was not different to that in group B, 10.9 g/dL. Application of hemoclips was effective for bleeding MWT during endoscopic procedures, which warranted prophylactic application of hemoclips on MWT during endoscopic examination.

Evaluation of a Novel Reverse Thermosensitive Polymer for Use in Microvascular Surgery

Microvascular clamps have several potential shortcomings, including the risk of vessel injury. LeGoo, a novel reverse thermosensitive polymer (Pluromed Inc., Woburn, MA), is investigated as a substitute to vascular clamping in a microsurgical model and the technical details are described. Femoral vessels of Sprague Dawley rats were used to evaluate the usefulness of this polymer for performing end-to-end arterioarterial (AA), venovenous (VV), and end-to-side arteriovenous (AV) microvascular anastomoses. The ability to obtain and maintain hemostasis was assessed. Secondary endpoints, including polymer volume, concentration, temperature, infusion technique, ability to reinfuse, blood vessel stenting effect, polymer dissolution characteristics, and reestablishment of flow, were also noted. Initial hemostasis occurred in every case. Mean duration of efficacy (hemostasis) after initial injection was 17.8 minutes (4 minutes to 44.5 minutes) for AA anastomoses and 31.8 minutes (13 minutes to 46 minutes) for VV anastomoses. Mean volume of polymer initially injected was 0.11 mL (0.01 mL to 0.20 mL) and 0.07 mL (0.06 mL to 0.10 mL) for AA and AV arteries, respectively, and 0.14 mL (0.10 mL to 0.20 mL) and 0.20 mL (0.15 mL to 0.27 mL) for VV and AV veins. Use of LeGoo in veins was clearly superior to arterial use with regard to the technical aspects of injecting LeGoo and reestablishing hemostasis, as well as greater vessel stenting effect and less vessel retraction. This novel polymer showed promise for its ability to allow for hemostasis while performing microvascular anastomoses. Improvements were made with regard to injection techniques, appropriate volumes, ability to reliably determine gel plug dissolution, and final vessel patency. Preliminary results demonstrate that this polymer may be a viable substitute for microvascular clamps.

Bonne pratique et valeur diagnostique de la biologie : hémostase-hématologie

Inherited bleeding disorders are potentially causes of menorrhagia and must be investigated if no specific cause is identified. The reported prevalence of inherited bleeding disorders is high in women with menorrhagia compared to the general population. The most frequent disorders reported are von Willebrand's disease and Factor XI deficiency. Menorrhagia is, also, a frequent finding in women with congenital bleeding disorders. Morever, menorrhagia represents the major cause of iron-deficiency anemia among women of reproductive age. Primary evaluation for an underlying disorder of hemostasis in a woman wih menorrhagia is a focused history for familiy and personal history of bleeding symptoms and a complete blood cell count. This will rule out thrombocytopenic bleeding and also assesses for the degree, if any, of anemia. Those women with a positive screen and normal platelet count should be evaluated with laboratory investigation including prothrombin time, activated partial thromboplastin time, factor VIII, VWF ristocetin cofactor and antigen. If initial hemostasis testing above is normal, then further hemostasis testing can be considered, especially in terms of platelet aggregation, in a multidisciplinary clinic.

Efficacy and safety of terlipressin in cirrhotic patients with variceal bleeding or hepatorenal syndrome

Terlipressin is an analog of the natural hormone arginine-vasopressin. It is used in the treatment of patients with cirrhosis and bleeding esophageal varices (BEV) and in patients with hepatorenal syndrome (HRS): two of the most dramatic and feared complications of cirrhosis. Terlipressin exerts its main pharmacological effect through stimulation of vasopressin-1 receptors. These receptors are located in vascular smooth muscle and mediate vasoconstriction. In patients with cirrhosis and portal hypertension, treatment with terlipressin increases mean arterial pressure and decreases portal flow and pressure within minutes of administration. Furthermore, in patients with ascites terlipressin improves glomerular filtration and excretion of sodium. Terlipressin decreases failure of initial hemostasis by 34%, decreases mortality by 34%, and is considered a first-line treatment for BEV, when available. Terlipressin in combination with albumin reverses type 1 HRS in 33%-60% of cases and is the only treatment with proven efficacy in randomized trials. The safety profile is favorable when considering the clinical efficacy and the high mortality of these clinical entities. Adverse events are mostly cardiovascular and related to vasoconstriction. Mortality and withdrawal of terlipressin due to adverse events occurs in less than 1% of cases. Mild adverse events related to terlipressin treatment occur in 10%-20% of patients. The benefit, however, of terlipressin on long-term survival in HRS remains to be determined. At present, treatment with terlipressin and albumin is considered the most efficient therapy and should therefore be recommended for the treatment of type 1 HRS-1.

Somatostatin analogues for acute bleeding oesophageal varices

Somatostatin and its derivatives are sometimes used for emergency treatment of bleeding oesophageal varices in patients with cirrhosis of the liver. To study whether somatostatin or its analogues improve survival or reduce the need for blood transfusions in patients with bleeding oesophageal varices. PubMed and The Cochrane Library were searched (November 2007). Reference lists of publications, contacts with authors. All randomised trials comparing somatostatin or analogues with placebo or no treatment in patients suspected of acute or recent bleeding from oesophageal varices. The outcome measures extracted were: mortality, blood transfusions, use of balloon tamponade, initial haemostasis and rebleeding. Intention-to-treat analyses including all randomised patients were conducted if possible; a random-effects analysis was preferred if there was significant heterogeneity between the trials (P < 0.10). The trials were divided in two groups: trials with a low risk of bias, which had concealed allocation of patients and were double-blind, and other trials. We included 21 trials (2588 patients). The drugs did not reduce mortality significantly (relative risk 0.97, 95% confidence interval (CI) 0.75 to 1.25, for the trials with a low risk of bias, and 0.80, 95% CI 0.63 to 1.01, for the other trials). Units of blood transfused were 0.7 (0.2 to 1.1) less with drugs in the trials with a low risk of bias and 1.5 (0.9 to 2.0) less in the other trials. Number of patients failing initial haemostasis was reduced, relative risk 0.68 (0.54 to 0.87). Number of patients with rebleeding was not significantly reduced for the trials with a low risk of bias, relative risk 0.84 (0.52 to 1.37) while it was substantially reduced in the other trials, relative risk 0.36 (0.19 to 0.68). Use of balloon tamponade was rarely reported. The need for blood transfusions corresponded to one half unit of blood saved per patient. It is doubtful whether this effect is worthwhile. The findings do not suggest a need for further placebo-controlled trials of the type reviewed here. A large placebo controlled trial enrolling thousands of patients is needed if one wishes to rule out the possibility that a worthwhile effect on mortality might have been overlooked.

Abdominal Insufflation Decreases Blood Loss without Worsening the Inflammatory Response: Implications for Prehospital Control of Internal Bleeding

Abdominal insufflation (AI) by carbon dioxide has been shown to decrease the rate of bleeding in different swine models of abdominal organ injuries. With development of appropriate tools, AI could be used to control bleeding temporarily in the prehospital setting. Concerns have been raised about the inflammatory response to AI, which could damage organs at a later stage despite initial hemostasis. We hypothesized that AI controls bleeding without inducing an unfavorable inflammatory response. An experimental splenic injury was caused in 28 Yorkshire pigs, which were randomized to: 1) standard resuscitation (n = 14) with crystalloids to a mean arterial pressure of 60 mm Hg, or 2) standard resuscitation and AI (n = 14) to an abdominal pressure of 20 cmH2O. The experiment lasted for 30 minutes, and intra-abdominal blood loss was measured. Blood serum interleukin 1beta (IL-1beta), transforming growth factor beta1, and lung tissue heat shock protein 70 gene expression were measured at 0, 15, and 30 minutes, as markers of the inflammatory response. All animals survived to the end of the experiment. Total blood loss was significantly less in the AI group compared with the other standard resuscitation animals (733 +/- 76 vs 1094 +/- 153 mL, P = 0.049). The pH at the end of the experiment was significantly lower in the AI group (7.28 +/- 0.02 vs 7.44 +/- 0.05, P < 0.01) but there was no difference in lactate levels (1.5 +/- 0.4 vs 1.7 +/- 0.3, P = 0.7). Similarly, there was no difference in IL-1beta, transforming growth factor beta1, or lung tissue heat shock protein 70 gene expression between the two groups at any time point, although there was a trend towards lower IL-1beta levels in the AI group. Our conclusion is that AI reduces blood loss from splenic injury without a measurable effect on the early inflammatory response in a clinically relevant animal model.

Treatment of Acute Ulcer Bleeding in the Upper Gastrointestinal Tract with Fibrin Adhesion

Introduction: Various endoscopic therapies such as cauterization, epinephrine injection, and clip deployment are used to treat patients with gastroduodenal ulcer hemorrhage. Fibrin adhesion with its biologic properties is another potential modality. The aim of this study is to examine its efficacy in the management of acute ulcer bleeds of the UGI tract. Methods: 266 patients underwent endoscopic fibrin adhesion therapy during the period 1992-2005 at St. Willehad Hospital, Germany. The Forrest classification was used to designate ulcer bleeding: Ia--ulcer with active bleeding, spurting vessel, Ib--oozing ulcer, II--ulcer with visible vessel, clot, or flat spot. Of the 266 patients, Ia--26 patients (9.7%), Ib--129 (48.5%), and II-- 111(42.8%). The stomach was involved in 38% and duodenum 62%. The degree of ulcer bleeding based on site: Ia--stomach (10), duodenum (16). Ib--stomach (55), duodenum (63), gastroenteric anastomosis (5), esophagus (6). For II, stomach (45), duodenum (60), gastroenteric anastomosis (4), PEG site (2). Results: Definitive initial hemostasis achieved in 231 patients (86%). Hemostasis achieved in 249 (93.3%) after second endoscopic intervention. The rate of rebleeding after fibrin adhesion therapy: total 29 patients (10.9%) with Ia--11 patients (42.3%), Ib--16 patients (12.4%), II--2 (1.8%). Surgical intervention was required in 11 patients (4.1%), with Ia -- 8(30.7%), Ib-- 3 (2.3%). Total case fatality rate: 10 patients (3.7%), with Ia--3 (11.5%), Ib--6 (4.7%), II--1 (.9%). Of the 11 patients who had an operation, 4 died. Autopsies on 2 showed cause of death being pulmonary embolism and the other with multiorgan failure. Of the 255 who required no surgerical intervention, 6 died. Autopsies on 4 revealed causes of death: pulmonary embolism (1), coronary occlusion (1), overlooked bleeding ulcer (1), small intestine bleed (1). Conclusion: This study on the use of fibrin adhesion therapy for the treatment of acute gastroduodenal ulcer bleeds reveals good results. Fibrin adhesion is indicated particularly for type Ib and II bleeds. More studies are required regarding its use as a supplement to other therapeutic modalities.

Depth of Hemoclip Attachment, Tissue Injury, & Fibrosis After Hemostasis of Bleeding Acute Canine Gastric Ulcers in a Randomized Controlled Study

Thermal probes (e.g. Multipolar probe-MPEC) have been used for about 3 decades to effectively seal vessels in bleeding non-variceal UGI lesions. However, thermal hemostasis can enlarge ulcers & cause complications especially with bleeding acute ulcers (AU). Now different hemoclips (HC) are marketed for endoscopic treatment (Rx) but their tissue injury patterns & depth of attachment have not been reported. Whether HC's accelerate or delay ulcer healing vs. MPEC is unknown. Purposes: In a randomized controlled study (RCS) of HC's & MPEC: 1) to compare initial hemostasis & HC closure of AU's & retention rates of HC's.

Endoscopic injection for haemostasis in the gastrointestinal tract

Haemostasis by endoscopic injection was attempted in 169 patients with acute gastrointestinal haemorrhage between 1976 and 1982. Despite various caused initial haemostasis in the upper and lower digestive tract was achieved in 95%. Recurrences were seen in 10%. Definitive haemostasis thus was 85%. Best results were obtained in Mallory-Weiss syndrome, angiodysplasia and post-polypectomy haemorrhage. The success rate for gastroduodenal ulcers was around 75 to 80%. Until now no complications have been observed. Apart from effectiveness, the injection method has the advantage of simplicity and little technical needs over other procedures.

Clinical Features and Treatment Outcomes of Upper Gastrointestinal Bleeding in Patients with Cirrhosis

With recent progress in treatment modalities, mortality from upper gastrointestinal (UGI) bleeding has decreased appreciably. The aim of this study was to establish how UGI bleeds are managed in Korean patients with cirrhosis and to evaluate treatment outcomes. A total of 479 episodes of acute UGI bleeding in 464 patients with cirrhosis were included during a six-month period at nine tertiary medical centers. Treatment outcomes were assessed by failure to control bleeding, rebleeding and mortality. The source of bleeding was esophagogastric varices in 77.7% of patients, nonvariceal lesions in 15.9%, and undefined in 6.5%. For control of bleeding, endoscopic and pharmacologic treatments were used in 74.7% and 81.9% of patients, respectively. Variceal ligation was a major technique for endoscopic treatment (90%), and terlipressin and somatostatin were the main pharmacologic agents used (96.4%). Initial hemostasis was achieved in 86.8% of cases, but rebleeding occurred in 3.8% and 16.8% of cases within five days and six weeks of hemorrhage, respectively. Five-day and six-week mortality were 11.3% and 25.9%, respectively. Survival of patients with variceal bleeding seems to be remarkably improved than previous reports, which may suggest the advances in hemostatic methods for control of variceal hemorrhage.

Clinical Experiences with Recombinant Activated Factor VII for Managing Uncontrolled Hemorrhage in Non-Hemophilic Patients

Objective Recombinant activated factor VII (rFVIIa) is a novel hemostatic agent originally developed to treat hemophilia patients who had developed inhibitors with bleeding. Its role in treating uncontrolled bleeding in patients without pre-existing coagulation abnormalities has not been well established. We herein report our experiences with its use in non-hemophilic patients. Patients and Methods Four patients, aged 33 to 94 years, with different underlying diseases were treated with rFVIIa for uncontrolled, life-threatening hemorrhage. rFVIIa was initially administered by intravenous bolus injection at 80–100 mg/kg. Doses were adjusted according to clinical response. Results Clinical response with significant hemostasis was evident in three patients after initial treatment. One patient was unresponsive to rFVIIa treatment and died of uncontrolled bleeding. Of those who achieved initial hemostasis, two died of their underlying diseases. One had recurrent bleeding controlled by subsequent multiple doses of rFVIIa, but she died of acute myocardial infarction, a thromboembolic complication that probably arose from the use of rFVIIa. Conclusion Our results suggest that rFVIIa could play a role in the management of bleeding other than congenital coagulation disorder. However, clinical hemostatic effects that do not translate into a survival benefit require further study, especially with regard to appropriate timing for clinical use. Its potential risk, especially that of thromboembolism when treating bleeding in elderly patients, warrants further investigation.

Review of the Methods to Prevent Femoral Arteriotomy Complications and Contrast Nephropathy in Patients Undergoing Cardiac Catheterization

There are different care and treatment approaches to prevent femoral arteriotomy complications and contrast nephropathy in patients undergoing cardiac catheterization. The purpose of our study was to identify approaches widely used in Turkey to prevent femoral arteriotomy complications and contrast nephropathy in patients undergoing cardiac catheterization. The study was a descriptive study. A questionnaire was mailed to 36 university medical faculty hospitals that have active interventional cardiology units. Twenty-nine universities (80.5%) responded. In general in Turkey, only manual pressure is used to achieve initial hemostasis at the femoral insertion site, with a pressure dressing and sandbag added to maintain hemostasis. Arterial closure devices are rarely used. In general, after the procedure, patients are required to lie flat with, at most, a 15- to 30-degree elevation during bed rest. To prevent contrast nephropathy in patients at risk, intravenous saline solutions are started before the procedure and continued afterward. In other patients, only oral fluid replacement is used. Traditional approaches in the management of femoral artery insertion site continue, and practices used in the prevention of contrast nephropathy are similar to current practices.

Endoscopic hemostasis by using the TriClip for peptic ulcer hemorrhage: a pilot study

The feasibility, efficacy, and safety of the TriClip in the management of peptic ulcer hemorrhage in human beings are scarcely reported in the literature. A pilot study was conducted to assess the feasibility, efficacy, and safety of the TriClip endoscopic clipping device in the control of peptic ulcer hemorrhage. Prospective evaluation. Regional government hospital. From July 2004 to January 2005, patients older than 16 years and with Forrest type I and IIa peptic ulcer hemorrhages were included in the study. TriClips were used for initial hemostasis. Salvage procedures, including adrenalin injection, heat probe application, argon plasma coagulation, or surgery will be carried out appropriately if TriClip failed to control bleeding alone. An endoscopy was repeated 24 hours later for the security of the TriClip and for any endoscopic evidence of recurrent bleeding. A follow-up endoscopy was performed 8 weeks later to assess ulcer healing. Procedure time, successful hemostatic rate, number of clips used, ulcer recurrent bleeding rate, complications, and ulcer healing rate were measured. No comparative arm; pilot study only. A total of 27 cases (11 women, 16 men) were included in the study, with a median age of 70 years (range 18-88 years). There were 19 cases of duodenal ulcer and 8 cases of gastric ulcer, with median size of 8 mm (range 2-20 mm). The rate of successful hemostasis in the first endoscopy by TriClips alone was 81.5% (22/27), with a median procedure time of 10 minutes (range 3-30 minutes). In the second endoscopy, the endoscopic recurrent bleeding rate was 14.8% (4/27) and the TriClips were found dislodged in 11 patients (40.7%). The permanent hemostasis rate was 67% (18/27). The overall failure rate was 33% (9/27). Three patients required blood transfusion before the first endoscopy. There was no morbidity or mortality observed in all cases. All ulcers healed after 8 weeks. The use of the TriClip is feasible in the initial control of peptic ulcer hemorrhage. However, we could not detect any obvious advantages in arresting bleeding vessels by using this new clipping device.

Aspectos clínicos y tratamiento endoscópico de la hemorragia digestiva por lesión de Dieulafoy

the aim of the study was to assess the incidence, clinical presentation, location, and response to endoscopic therapy of gastrointestinal bleeding from Dieulafoy's lesion. ALL consecutive episodes of gastrointestinal bleeding due to Dieulafoy's lesion seen between 2000 and 2006 were retrospectively reviewed. All main clinical and endoscopic data were collected: type and effectiveness of endoscopic therapy, rebleeding, complications, and mortality during hospitalization. WE found 41 patients, 26 males and 15 females, median age of 71.19 years. Dieulafoy's lesion accounted for 1.55% of all gastrointestinal bleeding episodes during the study period. The incidence of Dieulafoy's lesion was 2.2 cases/100.000 inhabitants/year. Active bleeding at endoscopy was present in 85.36%, and comorbidity in 92.68%. The stomach was the most frequent location (60.97%), followed by duodenum (29.26%). Endoscopic therapy achieved initial hemostasis in all cases. Three patients (7.31%) initially treated with epinephrine injection showed rebleeding and properly responded to a second session of endoscopic therapy. No surgery was needed. The mortality rate during hospitalization was 4.87%. Dieulafoy's lesion is an uncommon, but potentially severe cause of gastrointestinal bleeding. It may be found in any location within the gastrointestinal tract. Endoscopic therapy is effective and safe. Injected epinephrine alone is associated with a higher risk of rebleeding.