Management Of Non-variceal Upper Gastrointestinal Bleeding Research Articles

Hemostatic Powders in Non-Variceal Upper Gastrointestinal Bleeding: The Open Questions.

Hemostatic powder (HP) is a relatively recent addition to the arsenal of hemostatic endoscopic procedures (HEPs) for gastrointestinal bleeding (GIB) due to benign and malignant lesions. Five types of HP are currently available: TC-325 (Hemospray™), EndoClot™, Ankaferd Blood Stopper®, and, more recently, UI-EWD (NexpowderTM) and CEGP-003 (CGBio™). HP acts as a mechanical barrier and/or promotes platelet activation and coagulation cascade. HP may be used in combination with or as rescue therapy in case of failure of conventional HEPs (CHEPs) and also as monotherapy in large, poorly accessible lesions with multiple bleeding sources. Although the literature on HP is abundant, randomized controlled trials are scant, and some questions remain open. While HP is highly effective in inducing immediate hemostasis in GIB, the rates of rebleeding reported in different studies are very variable, and conditions affecting the stability of hemostasis have not yet been fully elucidated. It is not established whether HP as monotherapy is appropriate in severe GIB, such as spurting peptic ulcers, or should be used only as rescue or adjunctive therapy. Finally, as it can be sprayed on large areas, HP could become the gold standard in malignancy-related GIB, which is often nonresponsive or not amenable to treatment with CHEPs as a result of multiple bleeding points and friable surfaces. This is a narrative review that provides an overview of currently available data and the open questions regarding the use of HP in the management of non-variceal upper GIB due to benign and malignant diseases.

Comparison of intermittent and continuous proton pump inhibitor infusions in patients with non-variceal upper gastrointestinal bleeding at King Abdulaziz University Hospital, Jeddah, Saudi Arabia: A retrospective study.

To compare the effectiveness of intermittent and continuous proton pump inhibitors (PPIs) infusion on the outcomes of patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). The study was a single-centred retrospective study in adult patients with active upper gastrointestinal bleeding who received intermittent or continuous PPI infusion at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, from January 2013 to October 2019. The outcomes assessed were rebleeding, length of hospital stays and mortality within 30 days of admission, and were compared between the treatment groups. A statistically significant p-value was set at 0.05. The study involved 97 patients with NVUGIB treated with intermittent (n=56) and continuous (n=41) PPI infusions, with mean (±SD) ages of 66.0±16.1 and 58.0±19.5 years, respectively. The baseline and clinical characteristics between the 2 treatment groups; age (p=0.116), gender (p=0.345) and comorbidities (p=0.401), were comparable. There were no significant differences in rebleeding rates within 30 days (5 [8.9%] versus 1 [2.4%], p=0.396), length of hospital stays (4 vs 5, p=0.067), and mortality rate (1 [1.7%] vs 3 [7.3%], p=0.308) between the 2 groups. The management of NVUGIB with intermittent and continuous PPI infusions demonstrated comparable outcomes in reducing rebleeding rate, length of hospital stays, and mortality rate among patients attending the university hospital in Saudi Arabia.

Management of non-variceal upper gastrointestinal bleeding: role of endoscopic ultrasound-guided treatments.

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common type of upper gastrointestinal emergency with high risk of life-threatening conditions. Nowadays some standard guidelines for the treatments of NVUGIB have been established based on endoscopic therapies, including injection of glues or sclerosing agents, coiling, band ligation, and thermal therapies. Nevertheless, some patients are refractory to standard endoscopic treatments. We have noticed that endoscopic ultrasound (EUS)–guided treatments have been performed by some endoscopists in certain conditions. This review aims to evaluate the role of EUS-guided treatments in the management of NVUGIB. We performed a MEDLINE/PubMed search, and relevant studies were extracted and examined. According to the existing literature, the most common lesions were Dieulafoy’s lesion, pancreatic pseudoaneurysms, and gastrointestinal stromal tumors. EUS-guided treatments mainly include injection, mechanical therapies, and combined therapies, and seem to be a promising technique in the management of NVUGIB, especially for refractory bleeding.

Guidelines for Nonvariceal Upper Gastrointestinal Bleeding.

Nonvariceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB requires hospitalization and is associated with significant morbidity and mortality. Although European and Asian-Pacific guidelines have been published, there have been no previous guidelines regarding management of NVUGIB in Korea. Korea has a high prevalence of Helicobacter pylori infections, and patients have easy accessibility to endoscopy. Therefore, we believe that guidelines regarding management of NVUGIB in Korea are essential. The Korean Society of Gastroenterology reviewed the recent evidence and recommends practical management guidelines on NVUGIB in Korea.

Guidelines for Non-variceal Upper Gastrointestinal Bleeding

Non-variceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB is an important cause for visiting the hospital and is associated with significant morbidity and mortality. Although European and Asian-Pacific guidelines have been published, there has been no previous guidelines regarding management of NVUGIB in Korea. Korea is a country with a high prevalence of Helicobacter pylori infection and patients have easy accessibility to receive endoscopy. Therefore, we believe that guidelines regarding management of NVUGIB are mandatory. The Korean Society of Gastroenterology reviewed recent evidence and recommends practical management guidelines on NVUGIB in Korea.

Endoscopic Ultrasound-Guided Treatments for Non-Variceal Upper GI Bleeding: A Review of the Literature.

Endoscopic injection of glues, clotting factors, or sclerosing agents is a well-known therapy for the treatment of non-variceal upper gastrointestinal bleeding (NVUGIB), but less is known about endoscopic ultrasound (EUS)-guided treatments. In this setting, literature data are scarce, and no randomized controlled trials are available. We performed a review of the existing literature in order to evaluate the role of EUS-guided therapies in the management of NVUGIB. The most common treated lesions were Dieulafoy’s lesions, pancreatic pseudoaneurysms, and gastrointestinal stromal tumors (GISTs). Mostly, the treatments were performed as a salvage option after failure of conventional endoscopic hemostatic attempts, showing good efficacy and a good safety profile, also documented by Doppler monitoring of treated lesions. EUS-guided therapies may be an effective option in the treatment of refractory NVUGIB, thus avoiding radiological or surgical management. Nevertheless, available literature still lacks robust data.

Simulation training for the endoscopic management of upper gastrointestinal bleeding: a nationwide survey of rural surgeons' needs and preferences analysis.

Published needs analyses of rural surgeons have identified a need for training in the endoscopic management of non-variceal upper gastrointestinal bleeding (NVUGIB). The study aim was to survey rural surgeons regarding their requirements and preferences for a simulation model on which they could rehearse the endoscopic management of NVUGIB. Rural surgeons were contacted via the American College of Surgery Advisory Council listserv and invited to complete an online survey. A total of 66 responses were received, representing all 4 US regional divisions. Seventy-seven percent of respondents perform > 100 endoscopy cases per year. A majority have no experience with simulation models (77%), citing cost, time, and access to training courses as the three most limiting factors. Thirty-three percent lacked confidence in managing UGIBs, and 73% were interested in receiving additional training. Preference analysis revealed that respondents preferred a portable simulation model (81%) that costs between $500 and $1000 (46%), and requires 1-2weeks of training (34%). Verbal feedback from an expert was viewed as the most helpful type of feedback (61%). Rural surgeons frequently perform flexible endoscopy in their practice and are interested in further training for the endoscopic management of NVUGIB. These results will be used to develop a simulation platform for training in the endoscopic management of NVUGIB that meets rural surgeons' needs.

Clinical outcomes of non-variceal upper gastrointestinal bleeding and its relation to aspirin and anticoagulants.

BACKGROUND: Non-variceal upper gastrointestinal bleeding (NVUGIB) is a life-threatening emergency that requires an urgent management. Antiplatelet (e.g., aspirin) and anticoagulant drugs are widely chronically used in various cardiac and coronary artery diseases. These drugs increase the risk of NVUGIB as they may cause ulceration of the upper gastrointestinal (GI) mucosa directly or may cause bleeding or rebleeding. The management of NVUGIB is complicated as the risk between GI bleeding episodes and cardiovascular attacks needs to be well managed.
 AIM: The aim of this study is to determine the impact of antiplatelets (aspirin) and anticoagulants use on the morbidity, mortality, and clinical outcomes in patients presented with non-variceal GI bleeding.
 PATIENTS AND METHODS: A total of 105 patients presented with melena and/or hematemesis and diagnosed by upper GI endoscopy were enrolled in a prospective cohort study. Patients were sub-grouped according to their use of antiplatelets, anticoagulants, or none (controls). Patients were excluded if they had portal hypertension or nonsteroidal anti-inflammatory drugs (NSAIDs) use and divided into five groups: Group I – patients who had not taken anticoagulants and antiplatelet; Group II – patients on heparin, warfarin, and LMWH only; Group III – patients on aspirin only; Group IV – patients on clopidogrel and ticlopidine with or without aspirin; and Group V – patients on combined anticoagulants and antiplatelet. All patients were subjected to clinical, laboratory (complete blood count, liver function tests, renal function tests, prothrombin time, and partial thromboplastin time), and endoscopic investigations. Clinical details were reported including admission, blood transfusion, rebleeding, and mortality.
 RESULTS: Full medical history revealed that 43 patients were diabetic, 45 patients were cardiac, and 67 patients were hypertensive. Regarding the history of analgesic drug intake, 38 patients used NSAIDs and 29 of them used non-selective NSAIDs and 8 patients used selective NSAIDs. There were non-significant differences among the studied groups with NVUGIB regarding sex, hematemesis only presentation, melena only presentation, liver function tests, and endoscopic findings. On the other hand, there were statistically significant differences between the studied groups with NVGIB regarding increasing age, NSAIDs use whatever selective or non-selective, decrease level of HB, WBCs, serum albumin, bleeding profile, kidney function tests, clinical presentation in the form of hematemesis and melena, need for blood transfusion, history of associated diseases, especially being cardiac patients, rebleeding after 6 and 12 months, and mortality.
 CONCLUSION: Aspirin intake may be associated with less favorable clinical outcomes in patients with NVUGIB, while combined anticoagulants and antiplatelets seem to be associated with the worse outcomes.

Efficacy of Hemospray in non-variceal upper gastrointestinal bleeding: a systematic review with meta-analysis.

BackgroundRecently, amongst other hemostatic modalities, Hemospray (TC-325) has emerged as an effective method for managing patients with non-variceal upper gastrointestinal bleeding (GIB). We conducted this systematic review and meta-analysis to assess the efficacy of Hemospray in patients with non-variceal upper GIB.MethodsOur primary outcomes were clinical and technical success; secondary outcomes were aggregate rebleeding, early rebleeding, delayed rebleeding, refractory bleeding, mortality, and treatment failure. A meta-analysis of proportions was conducted for all reported primary and secondary outcomes. A relative risk meta-analysis was conducted for studies reporting direct comparisons between Hemospray and other hemostatic measures.ResultsA total of 20 studies with 1280 patients were included in the final analysis. Technical success of Hemospray was seen in 97% of cases (95% confidence interval [CI] 94-98%, I2=52.89%) and a significant trend towards increasing technical success was seen during publication years 2011-2019. Clinical success of Hemospray was seen in 91% of cases (95%CI 88-94%, I2=47.72%), compared to 87% (95%CI 75-94%, I2=0.00%) for other hemostatic measures. The secondary outcomes of aggregate rebleeding, early rebleeding, delayed rebleeding, refractory rebleeding, mortality and treatment failure following the use of Hemospray were seen in 27%, 20%, 9%, 8%, 8%, and 31% of cases, respectively.ConclusionHemospray is safe, effective and non-inferior to traditional hemostatic measures for the management of non-variceal upper GIB, and can thus be used as an alternative option.

Nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline.

In order to address the status of gastrointestinal (GI) endoscopy in Africa, a European Society of Gastrointestinal Endoscopy (ESGE) International Affairs Working Group (IAWG) was established with participation from the World Endoscopy Organization (WEO) 1 . A previous survey conducted by the IAWG on the main indications of GI endoscopy in African countries showed nonvariceal upper GI hemorrhage (NVUGIH) to be among the top three indications 1 . This indication may reflect the very high prevalence of Helicobacter pylori infection, which is well known to be associated with gastroduodenal peptic ulcers and their complications, such as bleeding. In addition, the increased use of aspirin as prevention and treatment of cardiovascular disease, and the increase in life expectancy, may also, at least in part, account for the NVUGIH indication 2 3 4 . The management of NVUGIH requires a multi-step approach, involving endoscopic factors such as emergency endoscopy with different hemostatic devices, and clinical factors such as hospitalization, blood transfusion, and drugs. Such an approach is clearly sensitive to organizational, medical, pharmaceutical, and technological resources. However, the lack of structural endoscopic and clinical health resources in some underserved African areas is likely to affect the clinical outcome of patients with NVUGIH. In this regard, the previous IAWG survey revealed several critical needs in training, education, and technology that may represent a barrier to adequate NVUGIH management 1 . Most of the respondents from the African countries participating in the IAWG survey reported a lack of national guidelines for GI endoscopy; however, there was interest in the international guidelines, pending adaptation to reflect the endoscopic resources available in their regions. For this reason, the IAWG decided to apply the cascade methodology to adapt ESGE guidelines to resource-sensitive settings in partnership with African experts 1 . Cascade guidelines are resource oriented and provide hierarchical recommendations based on the resources available to the medical care provider 5 6 . In detail, four levels of resource availability – basic, limited, enhanced, and maximal levels – are identified, with most of the interest being in the basic and limited levels. We aimed to standardize the management of NVUGIH in low-resources setting. Here, we report the cascade adaptation of the ESGE guideline on the diagnosis and management of NVUGIH 7 .

Management of Upper Gastrointestinal Bleeding by an Internist

Nonvariceal upper gastrointestinal bleeding (UGIB) carries high morbidity and mortality, which can be lowered by timely evaluation and management. This article presents a comprehensive literature review and current guidelines for the management of nonvariceal UGIB by an internist. Pre-endoscopic management includes optimal resuscitation, and making a decision about holding the anticoagulation and antiplatelet therapy versus continuation due to risk of thrombosis. Proton pump inhibitors (PPIs) are beneficial for both ulcer and nonulcer diseases as they reduce the risk of re-bleeding by clot stabilization. Endoscopy should only be performed after hemodynamic stability has been achieved and should not be delayed by more than 24 hours. Resumption of anticoagulation and antiplatelet therapy is based on endoscopic findings and thromboembolic risk. The patient should be discharged on PPIs and should be followed up by a primary care physician.

What Does Lesion Blood Flow Tell Us About Risk Stratification and Successful Management of Non-variceal UGI Bleeding?

There has been a decline in mortality associated with upper gastrointestinal (UGI) hemorrhage as the use of urgent endoscopy has increased. This review will examine endoscopic risk stratification of non-variceal UGI bleeding (e.g., ulcers, Dieulafoy lesions, and Mallory-Weiss tears), including the use of the Doppler endoscopic probe (DEP). Prospective studies evaluating the use of DEP in non-variceal UGI hemorrhage showed that lesions with high-risk stigmata of recent hemorrhage (SRH) have a higher rate of a positive DEP signal compared to those with intermediate-risk SRH. Additionally, lesions with a persistently positive DEP signal after endoscopic hemostasis were seen with high-risk SRH and had a higher 30-day rebleeding rate. Residual arterial blood flow underneath ulcers is a significant risk factor for rebleeding. However, if more endoscopic treatment is applied, clinical outcomes for patients with severe non-variceal UGI hemorrhage are improved, as documented by a recent CURE Hemostasis randomized controlled trial (RCT).

PWE-032 Hemospray for acute upper gastrointestinal bleeding – a single centre experience

Introduction Upper gastrointestinal bleeding (UGIB) is the commonest medical emergency managed by the Gastroenterologists. Despite of familiarisation with a variety of medical and endoscopic strategies to treat underlying aetiologies, rebleeding and mortality rates remain high. A novel agent, known commercially as Hemospray, has recently been licensed for use in non-variceal upper gastrointestinal bleeding (NVUGIB). Method The aim of this study was to assess the effectiveness of Hemospray therapy, either as primary endotherapy, or as part of salvage endotherapy in NVUGIB, when conventional measures to achieve haemostasis were deemed insufficient. All patients treated with Hemospray at University Hospital Birmingham, since its introduction to the Unit in 2013, were retrospectively identified using the Unisoft endoscopy database. Data on the indications for Hemospray use, and application in conjunction with other therapeutic modalities were collected. Outcomes including mortality, primary haemostasis and re bleeding rates were analysed. Results Hemospray was applied in 48 patients with NVUGIB (median age 63 years, 70% male). Four patients had Hemospray used on more than one occasion. Causes of bleeding included peptic ulcer disease 29/48 patients (60.5%), other non variceal upper GI pathology 13/48 (27%) and post variceal banding oesophageal ulcers 6/48 (12.5%). Hemospray was used as primary endotherapy in 42/48 patients (87.5%), achieving initial haemostasis in 40/42 cases (95%). 6/48 patients (12.5%) received Hemospray as salvage therapy following a rebleed after treatment with standard primary therapy. Rebleeding within 7 days occurred in 4/42 patients (9.5%); two of them received Hemospray as monotherapy. 30-day mortality in this patient cohort was 9/48 (19%). There were no documented complications of Hemospray therapy. Conclusion Hemospray is a safe and effective endoscopic therapy in achieving initial haemostasis, both as primary and salvage therapy, and either as monotherapy or in combination with other endoscopic modalities in a wide variety of upper GI pathologies, including post variceal banding oesophageal ulcers. We have found this to be a useful adjunct in the management of NVUGIB when conventional techniques have failed. However, further studies are needed to define its cost-effectiveness in the acute hospital setting. Disclosure of interest None Declared.

Sa1883 Antithrombotic vs. Ulcer Effects in Non-Variceal Bleeding in Users of Antithrombotic Drugs

Introduction The use of antithrombotic drugs (ATDs) remains a considerable challenge in the aetiology and management of non-variceal upper gastrointestinal bleeding (NVUGIB). In the upper gastrointestinal tract, ATD use may result in bleeding by mucosal damage (ulcer effect) or through its basic antithrombotic effect. The clinical significance of these effects is unclear. In this controlled analysis, we AIMED to clarify the significance of the antithrombotic effect as compared with the ulcer effect in patients with NVUGIB using ATDs. Methods We previously found that ATD users tended to be older and to have higher comorbidity and different endoscopy findings. To overcome these confounding factors, we compared 202 patients with NVUGIB using ATDs (ATD Group) with 202 patients with NVUGIB but not using ATDs (Controls), having matched both groups in a pairwise manner for age, Charlson comorbidity score and a composite endoscopic score covering the oesophagus, stomach, and duodenum. Antithrombotic drugs included low-dose aspirin, clopidogrel, dipyridamole, warfarin, and heparin. Patients using NSAIDs were excluded. Characteristics of the groups were compared using the Wilcoxon signed rank test and McNemar’s test. Continuous variables are reported as median (IQR). Results The characteristics of the two matched study groups are shown in Table 1. Conclusion After matching for age, comorbidity, and composite endoscopy score, patients with NVUGIB and using ATDs had significantly lower haemoglobin level, higher Blatchford risk score, and were 1.5 times more likely to be transfused. These effects are most likely to be due to the antithrombotic activity of ATDs rather than ulcers alone, and they need to be considered in the management of NVUGIB. Disclosure of Interest A. Taha Consultant for: Almiral Pharma UK, Vifor Pharma UK, Horizon Pharma USA, C. McCloskey: None Declared, T. Craigen: None Declared, W. Angerson: None Declared.

Endovascular management of nonvariceal upper gastrointestinal hemorrhage

Upper gastrointestinal bleeding (UGIB) remains a frequent presentation in the emergency department. There are several causes of UGIB, which can be generally classified into variceal and nonvariceal bleeding. Although most cases of nonvariceal UGIB spontaneously resolve or respond to medical management and/or endoscopic treatment, transcatheter arterial embolization (TAE) remains an important available tool in the emergency evaluation and management of nonvariceal UGIB. In this article, we will discuss the current strategies for rendering a specific diagnosis of nonvariceal UGIB, and we will focus on the various TAE techniques for its management. We will also provide an algorithm for the diagnostic work-up of these patients. The majority of patients with nonvariceal UGIB that is refractory to endoscopic treatment is successfully treated with minimally invasive TAE and can avoid undergoing surgery.

Effect of Physician Specialty and Call Back Endoscopy Teams in Non-Variceal Upper Gastrointestinal Bleeding: A Comparison between Two Health Regions

Purpose: Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common medical emergency and a frequent cause for admission to Canadian hospitals. There is significant morbidity and mortality associated with these admissions. In certain Canadian health regions, many NVUGIB are admitted to general surgical wards and many do not have call back endoscopy teams. The effect of these factors on mortality and re-bleeding is unknown. Methods: We examined two similar health regions which differed in the management of NVUGIB. The Saskatoon Health Region (SHR) has no formal call back endoscopy team and 40% of NVUGIB patients were admitted to a general surgery ward. In contrast, the Regina Qu'Appelle Health Region (RQHR) has a formal call back team and 80% of patients are admitted to a GI ward. ICD-10 codes were used to identify patients with a primary or secondary diagnosis of NVUGIB admitted to the SHR or RQHR between January 2008 and February 2010. The primary outcomes of interest were mortality and 30-day re-bleeding rates. Primary outcomes were also stratified by health region, endoscopist specialty, and weekend admission. Descriptive statistics using mean, medians and ranges were used to describe demographic and patient variables. Group comparisons of proportions and means were performed using Chi-square analysis and Student's t-test. Results: The mortality rate across both health regions for NVUGIB was 12.4% with 15.8% experiencing rebleeding and 3.6% readmitted within thirty days due to re-bleeding. There was no significant mortality difference between health regions (14.7% vs. 10.1% p=0.1), but there was a significant increase in rebleeding (23.1% vs. 8.5% p=<0.001; CI 0.17-0.30) and readmission (6.9% vs. 0.6% p=0.002; CI 0.03-0.11) in the SHR. This was unchanged when adjusted for age and comorbidities by logistic regression with an odds ratio of 3.11 (p=0.001; CI 1.6-5.9). Mortality and rebleeding rates were similar independent of endoscopist specialty. Readmission rates were higher across both health regions if admitted to a general surgeon versus gastroenterologist (7.5% vs. 1.9% p=0.01; CI 0.89-0.99). There was no significant weekend effect. Early endoscopy (<24 hrs) was significantly more frequent within the RQHR (84.7% vs. 65.0%; p<0.001; CI 1.13-1.36) and if the attending physician was a gastroenterologist (80.5% vs. 65.1% p=0.009; CI 1.13-1.36). Conclusion: Mortality rates across both health regions were higher than the national average, but not statistically different between the two. The presence of gastroenterologists admitting a larger proportion of NVUGIB and formal call back teams was associated with decreased rebleeding rates, readmission rates, and increased rates of early endoscopy.

Nonvariceal Upper Gastrointestinal Bleeding

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is an important condition facing gastroenterologists. The focus of this article is the management of NVUGIB, with a particular emphasis on the endoscopic modalities and techniques that are most effective for various bleeding etiologies. Attention also is given to medical management, risk assessment, and issues pertaining to the timing of endoscopy and need for scheduled second-look endoscopy.