Successful Initial Hemostasis Research Articles

Over-the-scope clip as first-line treatment of peptic ulcer bleeding: a multicenter randomized controlled trial (TOP Study).

First-line over-the-scope (OTS) clip treatment has shown higher efficacy than standard endoscopic therapy in acute nonvariceal upper gastrointestinal bleeding (NVUGIB) from different causes. We compared OTS clips with through-the-scope (TTS) clips as first-line mechanical treatment in the specific setting of peptic ulcer bleeding. We conducted an international, multicenter randomized controlled trial on consecutive patients with suspected NVUGIB. Patients with Forrest Ia-IIb gastroduodenal peptic ulcer were randomized 1:1 to OTS clip or TTS clip treatment. The primary outcome was the rate of 30-day rebleeding after successful initial hemostasis. Secondary outcomes included the rates of successful initial hemostasis and overall clinical success, defined as the composite of successful initial hemostasis and no evidence of 30-day rebleeding. 251 patients were screened and 112 patients were randomized to OTS (n = 61) or TTS (n = 51) clip treatment. The 30-day rebleeding rates were 1.6% (1/61) and 3.9% (2/51) in patients treated with OTS clips and TTS clips, respectively (Kaplan-Meier log-rank, P = 0.46). Successful initial hemostasis rates were 98.4% (60/61) in the OTS clip group and 78.4% (40/51) in the TTS clip group (P = 0.001). Overall clinical success rates were 96.7% (59/61) with OTS clips and 74.5% (38/51) with TTS clips (P = 0.001). Low rates of 30-day rebleeding were observed after first-line endoscopic treatment of acute peptic ulcer bleeding with either OTS or TTS clips. However, OTS clips showed higher efficacy than TTS clips in achieving successful initial hemostasis and overall clinical success.

Efficacy and safety of over-the-scope clips® com-pared to through-the-scope clips for initial bleeding control in non-variceal upper gastrointestinal bleeding: a multicenter randomized clinical trial

Introduction: Non-variceal upper gastrointestinal bleeding still poses a serious health problem due to high rebleeding rates, despite multiple treatment options. The relatively new over-the-scope clips® technique may be an effective alternative used in clinical practice and showed promising efficacy in predominantly observational studies. However, superiority over another mechanical technique as first-line therapy has not been established yet regarding initial hemostasis and recurring bleeding. Methods: The study will be a phase II, randomized, controlled, blinded, multicenter, parallel-group, superiority trial with a 1:1 allocation ratio. Adult patients with Ia-IIb Forrest classified ulcers will be randomized to either over-the-scope clips ® or through-the-scope clips. The primary outcome will be successful initial hemostasis and will be assessed by the endoscopist immediately after the procedure. Secondary outcomes will be rebleeding rate assessed by second-look endoscopy in case of substantial bleeding indicators, number of clips used, and mortality rate within 30 days. Further, the occurrence of adverse device effects will be assessed. Patient follow-up will occur periodically for a 3-month time frame. Discussion: By comparing two mechanical techniques for the treatment of common ulcers, our study will provide valuable grounds to deduce recommendations for first-line definite treatment and prevention of recurrent bleeding episodes. Trial registration: The trial will be registered at ClinicalTrials.gov (https://clinicaltrials.gov/). Keywords: upper gastrointestinal bleeding, hemostasis, bleeding control, OTSC, clinical trial

TC-325 hemostatic powder in the management of upper gastrointestinal malignant bleeding: a randomized controlled trial.

Background and study aims Upper gastrointestinal bleeding (UGIB) from malignancy is associated with high rebleeding and mortality rates. Recently, TC-325 powder has shown promising results in the treatment of UGIB, including malignant bleeding. The aim of this study was to compare the efficacy of TC-325 versus best clinical management. Patients and methods From August 2016 to February 2020, all patients with evidence of UGIB from malignancy were randomized to receive TC-325 therapy or control group, in which endoscopic treatment was not mandatory. Exclusion criteria were hemoglobin drop without overt bleeding and UGIB from non-tumor origin. The primary outcome was 30-day mortality. Secondary outcomes were 30-day rebleeding, blood transfusion and length of hospital stay. Results Sixty-two patients were randomized, three were excluded and 59 were included in the final analysis (TC-325 group = 28; control = 31). Groups were similar at baseline. Active bleeding was observed in 22 patients in the TC-325 group and 19 in the control group ( P = 0.15). Successful initial hemostasis with TC-325 was achieved in all cases. Additional therapy (radiotherapy, surgery or arterial embolization) was equally performed in both groups (42.9 % vs 58.1 %; P = 0.243). There were no differences in 30-day mortality (28.6 % vs. 19.4 %, P = 0.406) or 30-day rebleeding rates (32.1 % vs. 19.4 %, P = 0.26). Logistic regression identified no significant predictors of rebleeding. Age, Eastern Cooperative Oncology Group (ECOG) score 3 to 4 and AIMS65 score > 1 predicted greater mortality. Conclusions TC-325 was effective in achieving immediate hemostasis in malignant gastrointestinal bleeding but did not reduce 30-day mortality, 30-day rebleeding, blood transfusion or length of hospital stay. Age, ECOG 3–4, and AIMS65 > 1 were predictive factors of mortality.

Peri-Ulcerative Mucosal Inflammation Appearance is an Independent Risk Factor for 30-Day Rebleeding in Patients with Gastric Ulcer Bleeding: A Multicenter Retrospective Study.

AimThe aim of this study was to identify clinical endoscopic indicators related to peri-ulcerative mucosal inflammation and to analyze whether the degree of peri-ulcerative mucosal inflammation appearance is an independent risk factor for gastric ulcer rebleeding.MethodsWe conducted a retrospective study that included patients with gastric ulcer bleeding who were hospitalized at three medical centers in China from January 1, 2016 to December 31, 2019. Ulcer rebleeding that occurred within 30 days of successful initial hemostasis was analyzed to determine whether this event was related to the degree of peri-ulcerative mucosal inflammation appearance or other mucosal inflammation-related factors.ResultsWe enrolled 1111 patients and determined that GBS-Rebleeding-ROC (P<0.001), age (P=0.01), use of NSAIDs (P=0.001), bile reflux (P<0.001), and Helicobacter pylori (P<0.001) are all risk factors for peri-ulcerative mucosal inflammation appearance. Through multivariate analysis, we determined that severe peri-ulcerative mucosal inflammation appearance (P=0.002) was an independent risk factor for ulcer rebleeding within 30 days. Finally, we developed a risk assessment model using factors associated with mucosal inflammation that may be useful for early prediction of rebleeding.ConclusionThe risk factors for peri-ulcerative mucosal inflammation appearance were identified. Severe peri-ulcerative mucosal inflammation appearance is an independent risk factor for ulcer rebleeding.

Endoscopic thermocoagulation hemostasis for acute non-varicose upper gastrointestinal hemorrhage: a randomized controlled study.

This study evaluated the application of the bipolar electrocoagulation catheter via a peripheral-to-central (3 + 1) technique, relative to directly pressing only at the center of the bleeding site (direct-stroke), to effect endoscopic hemostasis of acute non-varicose gastrointestinal bleeding (ANVUGIB). Patients (n = 148) with endoscopically diagnosed ANVUGIB were randomly apportioned to receive treatment by 3 + 1 (n = 78) or direct-stroke (n = 70) application of the bipolar electrocoagulation catheter. The 3 + 1 strategy required pressing at3 narrowly restricted sites equidistant peripheral and center to the site of bleeding. The rates of initial success, hemostasis time, and number of compressions were compared according to intention-to-treat (ITT) or per protocol (PP). The ITT (PP) rate of initial hemostatic success in patients receiving the 3 + 1 catheter was 91.02% (95.9%); and for the direct-stroke group was 71.42% (76.9%). For Forrest IIa lesions specifically, these rates were respectively 91.70% (97.1%) and 63.9% (67.6%). The ITT (PP) hemostasis times of the 3 + 1 and direct-stroke groups were 10.96 ± 3.28 (10.65 ± 2.90) and 14.27 ± 6.58 (14.12 ± 6.67) min; and the number of compressions numbered 5.73 ± 1.98 (5.42 ± 1.46) and 6.47 ± 2.82 (6.16 ± 2.47). During thermocoagulation treatment of ANVUGIB via bipolar electrocoagulation catheter, the 3 + 1 strategy showed a significantly higher rate of successful initial hemostasis relative to the direct-stroke technique, and shorter hemostasis time, with no increase in total procedural steps.

Outcomes of patients treated with Sengstaken-Blakemore tube for uncontrolled variceal hemorrhage.

Background/AimsThe aim of this study was to investigate the mortality, bleeding control rate, and their associated predictors in patients treated with Sengstaken-Blakemore (SB) tube for uncontrolled variceal hemorrhage associated with hemodynamic instability or failure of endoscopic treatment.MethodsThe clinical data of 66 consecutive patients with uncontrolled variceal hemorrhage treated with SB tube at Gyeongsang National University Hospital from October 2010 to October 2015 were retrospectively analyzed.ResultsThe overall success rate of initial hemostasis with SB tube was 75.8%, and the independent factors associated with hemostasis were non-intubated state before SB tube (odds ratio, 8.50; p = 0.007) and Child-Pugh score < 11 (odds ratio, 15.65; p = 0.022). Rebleeding rate after successful initial hemostasis with SB tube was 22.0%, and esophageal rupture occurred in 6.1%. Mortality within 30 days was 42.4%, and the related independent factors with mortality were failure of initial hemostasis with SB tube (hazard ratio, 6.24; p < 0.001) and endotracheal intubation before SB tube (hazard ratio, 2.81; p = 0.018).ConclusionsSince the era of endoscopic band ligation, SB tube might be a beneficial option as a temporary salvage treatment for uncontrolled variceal hemorrhage. However, rescue therapy had a high incidence of fatal complication and rebleeding.

Management of pseudoaneurysms of the internal carotid artery in postirradiated nasopharyngeal carcinoma patients

Massive epistaxis due to ruptured pseudoaneurysm of the internal carotid artery (ICA) is an often fatal complication of radiation treatment for patients with nasopharyngeal carcinoma. We review the clinical characteristics and predictors of survival in patients suffering from this serious complication after radiotherapy. Retrospective case series. Clinical records and radiological investigations of postirradiated NPC patients with ICA pseudoaneurysm diagnosed with digital subtraction angiography in Queen Mary Hospital from January 2003 to December 2012 were reviewed. Risk factors analyzed for survival included gender, size of initial tumor, history of second course of radiotherapy, history of previous maxillary swing nasopharyngectomy, presence of persistent disease, successful initial hemostasis, successful airway control, and endovascular treatment. Twenty-six were included in the analysis. Twenty-three patients underwent endovascular treatment, and 20 (87%) had successful control of the bleeding. Eighteen (69%) patients survived. Univariate analysis showed that successful temporary control of bleeding and airway control were associated with survival. Prompt bleeding control and airway management is necessary to improve survival. Endovascular treatment is a good definitive treatment option with a high success rate.

Self-expandable metal stents as definitive treatment for esophageal variceal bleeding

The use of self-expandable metal stents (SEMS) has occasionally been described for the treatment of uncontrollable esophageal variceal bleeding (EVB) as a bridge to an alternative treatment option (i. e. transjugular intrahepatic portosystemic shunt [TIPS]). It is currently not known whether SEMS placement is appropriate for more than temporary hemostasis. This case series report describes five patients in whom EVB could not be controlled with variceal band ligation and who were not suitable to undergo a TIPS procedure at the time of bleeding. SEMS were placed in these patients with the intent of definitive treatment. Successful initial hemostasis was achieved in all five patients, and sustained hemostasis occurred in four. Stents were removed from two patients after > 14 days and remained in situ until death in three other patients (range 6 - 214 days). No complications related to this longer duration were observed. In one case, TIPS could be performed at a later stage. SEMS could be a definitive treatment for uncontrollable esophageal bleeding in patients with a limited life expectancy or those unsuitable for TIPS at the time of bleeding.

Etiology, endoscopic management and mortality of upper gastrointestinal bleeding in patients with cancer.

The source and outcomes of upper gastrointestinal bleeding (UGIB) in oncologic patients are poorly investigated. The study aimed to investigate these issues in a tertiary academic referral center specialized in cancer treatment. This was a retrospective study including all patients with cancer referred to endoscopy due to UGIB in 2010. UGIB was confirmed in 147 (of 324 patients) referred to endoscopy for a suspected episode of GI bleeding. Tumor was the most common cause of bleeding (N = 35, 23.8%), followed by varices (N = 30, 19.7%), peptic ulcer (N = 29, 16.3%) and gastroduodenal erosions (N = 16, 10.9%). Among the 32 patients with cancer of the upper GI tract, the main causes of bleeding were cancer (N = 27, 84.4%) and peptic ulcer (N = 5, 6.3%). Forty-one patients (27.9%) presented with bleeding from the primary tumor or from a metastatic lesion, and seven received endoscopic therapy, with successful initial hemostasis in six (85.7%). Rebleeding and mortality rates were not different between endoscopically treated (N = 7) and non-treated (N = 34) patients (28.6% vs. 14.7%, p = 0.342; 43.9% vs. 44.1%, p = 0.677). Median survival was 20 days, and the overall 30-day mortality rate was 44.9%. There was no predictive factor of mortality or rebleeding. Tumor bleeding is the most common cause of UGIB in cancer patients. UGIB in cancer patients correlates with a high mortality rate regardless of the bleeding source. Current endoscopic treatments may not be effective in preventing rebleeding or improving survival.

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.

CURRENT MANAGEMENTS AND OUTCOMES OF PEPTIC AND ARTIFICIAL ULCER BLEEDING IN JAPAN

The recent trend of gastroduodenal ulcer bleeding in Japan has not been elucidated in detail and the data for a new categorized type, artificial ulcer bleeding, is completely lacking. The purpose of this paper is to elucidate current managements and outcomes of peptic and artificial ulcer bleeding in Japan. A retrospective multicenter study of consecutive case series was carried out during one year at nine departments of high-volume hospitals in Japan. The study included 325 consecutive patients (239 with peptic ulcers and 86 with artificial ulcers) with bleeding nonmalignant gastroduodenal ulcers that were revealed by emergency endoscopy between January 2008 and December 2008. Hemostasis was carried out mainly using endoscopic treatments. Rates of successful initial hemostasis, rebleeding, transfer to surgery, and death were recorded according to peptic and artificial ulcer bleeding. Additionally, preferred endoscopic methods, concomitant use of antisecretory drugs, and timing of second-look endoscopy were also measured. A total of 227 (99.1%) of 229 peptic ulcer patients with endoscopic treatment and all (100%) 84 artificial ulcer patients underwent successful tentative hemostasis. Rebleeding occurred in 23 peptic ulcer patients (10.1%) and 10 artificial ulcer patients (11.9%). One peptic ulcer patient and two artificial ulcer patients had final surgical rescue due to rebleeding. No death was observed. Monotherapy was predominant (around 65% of cases) in both types of ulcers. The coagulation forceps method was more frequently applied in artificial ulcers (P < 0.05). A per oral proton pump inhibitor was more frequently used in artificial ulcers (P < 0.05), although an intravenous proton pump inhibitor was used in the majority of patients in both types of ulcers. The frequency of second-look endoscopy in peptic ulcers (88%) was significantly higher than that in artificial ulcers (71%) (P < 0.05). There seemed to be no rule as to the timing of second-look endoscopy, although it was most frequently performed on the day after hemostasis. The recent outcomes of endoscopic treatment for nonmalignant gastroduodenal bleeding in Japan were excellent in both peptic and artificial ulcers with similar efficacies. Although they were minor findings, some differences in applied endoscopic methods, concomitant use of antisecretory drugs, and presence of second-look endoscopy were observed.

Extrahepatic portal venous obstruction: Is the knife irrelevant?

A study on long term outcomes following variceal eradication in patients with extrahepatic portal venous obstruction (EHPVO) was clearly needed. In this issue of the Journal, Thomas et al. present the results of long-term follow up of a cohort of patients treated with endoscopic variceal sclerotherapy (EST). Of the 223 patients treated between 1985 and 1994, they had follow up data available for 198 patients. On a retrospective analysis of these data, 34 (17.2%) patients had rebleeding after initial variceal eradication, 39 (19.7%) had reappearance of esophageal varices and 19 (9.5%) had de novo appearance of fundal varices. The mean duration from the time of eradication of varices to rebleeding was 5.4 (range 1 to 16) years. Based on these results, the authors suggest that endoscopic variceal eradication is an effective treatment modality for bleeding esophageal varices in patients with EHPVO. This study, though retrospective, is quite thorough. 1 It clarifies several questions, while throwing up some new ones. First, the authors base their premise on a cohort of patients in whom they had achieved successful initial hemostasis and long term variceal eradication. A large majority (87%) of their patients presented with active variceal bleeding. However, we remain unsure of the outcome in patients in whom initial EST failed to achieve hemostasis. In 10%–15% of patients, endoscopic treatment may not achieve initial control of bleeding. 2,3 This subset of patients is important since their exclusion may mislead us into believing that EST is successful in all patients with variceal bleeding due to EHPVO. Secondly, 12 patients were lost to follow up from the initial cohort of 223 patients; did these patients die or undergo some other form of treatment elsewhere? No doubt the long term results are important, but without these initial data, establishing the overall efficacy of EST in this group of patients would be incomplete. In the broader clinical perspective, the treatment options available for patients with EHPVO must include surgery. Evidence in the Western literature indicates that if shunt surgery has a role in treatment of portal hypertension, it is in patients with non-cirrhotic portal hypertension, and especially those with EHPVO. 4,5 From India too, excellent long term results of proximal lieno-renal shunt (PLRS) have been reported in such patients. Of 160 children who underwent PLRS with splenectomy at our institution, the overall mortality was 1.9% (elective: 1/140 [0.7%]; emergency 2/20 [10%]), rebleeding rate was 11% and actuarial survival at 15 years by life-table analysis was 95%. 6,7 None of these patients developed encephalopathy. The procedure cured hypersplenism in all the patients who had this. Only one patient developed meningococcal meningitis, which recovered following treatment. Similarly, a study from Chandigarh that included 104 patients with non-cirrhotic portal hypertension who had undergone side-to-side lieno-renal shunt showed a shunt patency rate of 87%, a rebleeding rate of 10%, and no occurrence of encephalopathy after a mean follow up of 54 months. 8 Thus, surgery is a one-time treatment procedure with durable, long term efficacy in preventing variceal rebleeding. Long term studies (15–40 years) from the West have repeatedly shown that shunt surgery with or without splenectomy (proximal lieno-renal, side-to-side splenorenal, distal splenorenal or mesocaval) for EHPVO in children and adults, is associated with shunt patency rates between 90% and 95%, rebleeding rates of 5%–10%, no encephalopathy and 15-year actual survival rates of 95%. 5,9–11 These studies have found portosystemic shunts to be consistently effective for bleeding esophagogastric varices due to EHPVO.

Transcatheter arterial embolization for hemorrhage caused by injury of the hepatic artery

Background: The aims of the study were to compare (i) the effects of transcatheter arterial embolization on initial hemostasis and the control of rebleeding in the treatment of hemorrhage due to hepatic artery injury; and (ii) the outcomes of embolization by different locations. Methods: Subjects were 32 patients with suspected hepatic artery injury who were transferred to Chi-Mei Foundation Medical Center for hepatic angiography and embolization. The causes of arterial injury included liver trauma (n = 15) and iatrogenic injury (n = 17). The sites of embolization were classified into four groups: group 1 (n = 8) was classified as ‘combined outlet, target and inlet control’ with embolization of the vascular lesion (target) and hepatic artery distal (outlet) and proximal (inlet) to the vascular lesion simultaneously; group 2 (n = 11) as ‘combined target and inlet control’; group 3 (n = 8) as ‘combined outlet and inlet control’; group 4 (n = 5) as ‘inlet control’ only. Results: Successful initial hemostasis was achieved in 30 of the 32 patients (93.8%), with two failures, both of which were caused by liver injury and occurred in subjects in group 4. Rebleeding was seen in three patients who had successful initial hemostasis: two of them in group 4 (66.7%) and one in group 1 (12.5%). All rebleedings were successfully managed by repeat embolization. Abscess formation was found in two group 1 patients, and both were successfully managed by percutaneous drainage. Conclusions: Transcatheter arterial embolization is an effective method for hemostasis in hepatic artery hemorrhage for both patients with liver trauma and patients with iatrogenic injuries to the hepatic artery. Based on this experience, embolization of the vascular lesion and/or the arterial lumen distal to the vascular lesion combined with inlet control is recommended for preventing recurrent hemorrhage, but studies with larger sample sizes will be required to validate this conclusion.

Transcatheter arterial embolization for hemorrhage caused by injury of the hepatic artery

The aims of the study were to compare (i) the effects of transcatheter arterial embolization on initial hemostasis and the control of rebleeding in the treatment of hemorrhage due to hepatic artery injury; and (ii) the outcomes of embolization by different locations. Subjects were 32 patients with suspected hepatic artery injury who were transferred to Chi-Mei Foundation Medical Center for hepatic angiography and embolization. The causes of arterial injury included liver trauma (n = 15) and iatrogenic injury (n = 17). The sites of embolization were classified into four groups: group 1 (n = 8) was classified as 'combined outlet, target and inlet control' with embolization of the vascular lesion (target) and hepatic artery distal (outlet) and proximal (inlet) to the vascular lesion simultaneously; group 2 (n = 11) as 'combined target and inlet control'; group 3 (n = 8) as 'combined outlet and inlet control'; group 4 (n = 5) as 'inlet control' only. Successful initial hemostasis was achieved in 30 of the 32 patients (93.8%), with two failures, both of which were caused by liver injury and occurred in subjects in group 4. Rebleeding was seen in three patients who had successful initial hemostasis: two of them in group 4 (66.7%) and one in group 1 (12.5%). All rebleedings were successfully managed by repeat embolization. Abscess formation was found in two group 1 patients, and both were successfully managed by percutaneous drainage. Transcatheter arterial embolization is an effective method for hemostasis in hepatic artery hemorrhage for both patients with liver trauma and patients with iatrogenic injuries to the hepatic artery. Based on this experience, embolization of the vascular lesion and/or the arterial lumen distal to the vascular lesion combined with inlet control is recommended for preventing recurrent hemorrhage, but studies with larger sample sizes will be required to validate this conclusion.

Routine second look endoscopy: ineffective, costly and potentially misleading.

Despite the best medical and endoscopic efforts, some patients with nonvariceal upper gastrointestinal bleeding suffer recurrences. Because high risk stigmata (visible vessels, active bleeders and adherent clots) often persist despite apparently successful initial hemostasis and have a variable natural history, it would seem reasonable to at least consider a routine second look endoscopy. However, a review of the literature revealed six randomized trials that, in aggregate, do not support such a strategy. In fact, a second look does not appear to be effective and is associated with an increased number of procedures, treatment sessions and possibly retreatment-related complications. In addition, the cointerventions in these trials are already out of date and the potential absolute risk reductions are low when a second look is used with intravenous proton pump inhibitors and/or the application of endoscopic hemoclips or combination endoscopic therapy. Finally, the Forrest classification may provide dangerously misleading estimates of prognosis because it is being used out of context. This review critically analyzes routine second look endoscopy.

New and Alternative Hemostatic Techniques

In upper gastrointestinal bleeding, endoscopic management does reduce rates of rebleeding, surgery, and mortality. In active bleeding, however, early recurrence still occurs in around 20% despite successful initial hemostasis. Several new techniques or modifications of endoscopic hemostatic methods have been invented to improve the results. They include ligating devices, biological injection agents, argon plasma coagulation, and hemoclips. Hemoclips and injection therapy using fibrin glue do not cause relevant tissue damage and appear to have better results in terms of lower rebleeding rates. Fibrin glue seems to be effective only if injected repeatedly. Due to limited experience, no final conclusion can be made at this stage. Further clinical investigation is warranted.

Endoscopic Injection of Absolute Ethanol Achieves Ultimate Hemostasis in Bleeding Caused by Peptic Ulcers

Abstract: This study was performed to assess the efficacy of endoscopic injection therapy with absolute ethanol to prevent emergency surgery and recurrent bleeding in patients with peptic ulcers. We compared two different treatment protocols of peptic ulcers with active bleeding or with visible vessels on the ulcer bed. In group I (1981–1984, control group), 45 patients underwent emergency endoscopy with spraying 0.1% epinephrine and thrombin, but no other endoscopic hemostatic procedure. In group II (1989–1992, experimental group), we performed endoscopic injection therapy with absolute ethanol for peptic ulcers in 46 patients. The background characteristics of the patients were not different in the two groups. The rate of successful initial hemostasis tended to be greater in the ethanol injection group compared with the control group without significance. The ultimate hemostatic rate in the ethanol injection group was markedly and significantly greater compared to the control group (P&lt;0.05). Ultimate hemostasis by ethanol injection was performed effectively in peptic ulcers with spurting and oozing hemorrhage and in the non‐bleeding peptic ulcers with visible vessels at the initial endoscopy (P&lt;0.05 for each). These results indicate that ethanol injection therapy by endoscopy achieves ultimate hemostasis and prevents emergency surgery due to hemorrhage from peptic ulcers. (Dig Endoc 1994; 6 : 34–38)