Therapy For Bleeding Peptic Ulcers Research Articles

Effective therapy for peptic ulcer bleeding with a diagnostic scope: Design and preliminary results of a randomized trial comparing 7 FR injection gold probe with 10 FR heater probe

Effective therapy for peptic ulcer bleeding with a diagnostic scope: Design and preliminary results of a randomized trial comparing 7 FR injection gold probe with 10 FR heater probe

The outcome of urgent surgery for major peptic ulcer haemorrhage following failed endoscopic therapy.

To review the outcome of patients who underwent emergency surgery for major peptic ulcer haemorrhage after failed endoscopic therapy. To address whether 'conservative' or 'aggressive' surgery is best. A retrospective analysis of emergency surgery for ulcer bleeding which could not be controlled by endoscopic therapy. The four admitting units in the Lothian region of Scotland. Sixty-seven patients who failed endoscopic therapy for bleeding peptic ulcer and underwent emergency surgery between December 1990 and December 1995. Simple underrunning or excision of ulcer alone was done in 31 patients whilst 36 had more radical surgery. Rebleeding and 30-day mortality rates. Rebleeding was significantly higher in patients treated by underrunning (7 versus 1, P < 0.013). There were fewer deaths in the radically treated group (5 versus 7, not significant). Patients undergoing surgical operation for severe peptic ulcer haemorrhage after failed endoscopic therapy may be best served by a relatively aggressive approach.

Endoscopic therapy for disorders of the stomach and duodenum

This review covers progress made over the past year in the area of endoscopic therapy for bleeding peptic ulcer and gastric varices, carcinoma of the stomach, and percutaneous endoscopic gastrostomy. There have been several major epidemiologic studies examining the incidence, mortality, and risk factors of acute upper gastrointestinal hemorrhage. With greater application of endoscopy as both diagnostic and therapeutic tools, attempts were made to develop prognostic models incorporating clinical characteristics and endoscopic findings that stratify patients into different risk categories. Active research continues in the area of endoscopic therapy for bleeding peptic ulcers and gastric varices.

Age-related mortality in patients treated endoscopically for bleeding peptic ulcer

Before the widespread use of endoscopic therapy, mortality from peptic ulcer hemorrhage was highest in elderly patients, and many deaths in this group were a consequence of postoperative complications. Endoscopic intervention greatly reduces the need for an emergency surgical operation, and consequently increasing age may no longer be a risk factor for death from bleeding ulcer. To examine this hypothesis, the outcome of 326 patients undergoing endoscopic therapy for bleeding peptic ulcer was related to age. One hundred two patients were less than 60 years of age (group I), 116 were 61 to 74 years of age (group II), and 108 were older than 75 years (group III). More group III patients were women ( p < .0001) and were receiving nonsteroidal anti-inflammatory drugs ( p < .0001). Associated concomitant diseases were significantly more common in group II and group III patients ( p < .001). Forty-nine (45%) group III patients bled from gastric ulcers. More of group II patients were receiving anticoagulant drugs ( p < .005). A previous history of peptic ulcer was most common in group I ( p < .005), and duodenal ulcer was usually the cause of bleeding in this group. The three groups were well matched in terms of endoscopic stigmata (active bleeding and nonbleeding vessel), admission hemoglobin concentration, the presence of shock, and total transfusion requirements. Endoscopic therapy (injection or heater probe) was possible in 95% of all patients. The need for surgical intervention tended to be lowest in group I (11%, 19%, and 18%), whereas hospital mortality (3%, 6%, and 5%) was very similar. In this large group of unselected patients with major peptic ulcer bleeding, age did not significantly influence response to endoscopic therapy or hospital mortality. (Gastrointest Endosc 1995;41:557-60.)

What Should be Done when Initial Endoscopic Therapy for Bleeding Peptic Ulcer Fails?

What Should be Done when Initial Endoscopic Therapy for Bleeding Peptic Ulcer Fails?

Value of second-look endoscopy after injection therapy for bleeding peptic ulcer: A prospective and randomized trial

A prospective and randomized trial involving 104 patients was performed to assess whether second-look endoscopy could improve the efficacy of injection therapy for bleeding ulcers. The inclusion criteria were the presence of active arterial bleeding or a non-bleeding visible vessel at emergency endoscopy. All the patients received emergency injection of 1:10,000 adrenaline and were subsequently randomized (52 patients in each group) according to whether or not they would receive a second elective endoscopy within the first 24 hours with repeated injection if a visible vessel was still identified. Both groups were well matched for clinical and endoscopic data. A tendency towards better results was noted in the group that received a second-look endoscopy; the two groups were compared in regard to further bleeding (21% versus 29%, 95% confidence interval of the difference = -24.3 to 8.5), need for emergency surgery (8% versus 15%, 95% confidence interval of the difference = -19.9 to 4.5), transfusion requirements (1.7 ± 1.9 versus 2.5 ± 2.5 units, 95% confidence interval of the difference = -1.6 to 0.07), length of hospital stay (9.3 ± 8.6 versus 11.8 ± 10.8 days, 95% confidence interval of the difference = -6.2 to 1.4), and mortality rate (2% versus 4%). Although these trends did not achieve statistical significance, a type II error cannot be ruled out. However, according to our results, several hundred patients would be required to demonstrate statistically these relatively small differences. In conclusion, our data suggest the possibility of a small benefit with second-look endoscopy, although the difference is unlikely to be very large; second-look endoscopy cannot be recommended routinely at present. (Gastrointest Endosc 1994;40:34-9.)

Outcome of endoscopic injection therapy for bleeding peptic ulcer in relation to the timing of the procedure

Objective: To determine whether the timing of therapeutic endoscopic injection affects prognosis in major peptic ulcer bleeding. Design: Single operator, prospective study of high-risk patients treated by injection therapy, during routine working hours or out of hours. Outcome was further related to the timing of endoscopy. Setting: Four acute admitting units in the Lothian region, UK: Edinburgh Royal Infirmary, Western General Hospital, Eastern General Hospital and St John's Hospital, Livingston. Patients: The study included 114 patients undergoing attempted emergency endoscopic injection treatment for bleeding peptic ulcer between November 1991 and September 1992

Endoscopic hemostasis. An effective therapy for bleeding peptic ulcers

We performed a meta-analysis of 25 randomized control trials that compared endoscopic hemostasis with standard therapy for bleeding peptic ulcer. For recurrent or continued bleeding, the mean rate in control patients was 0.39, and the pooled rate difference, or reduction due to therapy, was 0.27 +/- 0.15 (95% confidence interval) (69% relative reduction). For emergency surgery, the mean rate in control patients was 0.26, and the pooled rate difference was 0.16 +/- 0.05 (62% relative reduction). Most important, for overall mortality, the mean rate in control patients was 0.10, and the pooled rate difference was 0.03 +/- 0.02 (30% relative reduction). The effects were greatest in patients with spurting or visible blood vessels and equivocal when the ulcer showed only signs of recent bleeding. We conclude that endoscopic hemostasis is clearly effective but that data were insufficient for direct comparisons between modalities. Randomized control trials to compare the different modes of endoscopic therapy should continue.

Randomized Comparison of Nd YAG Laser, Heater Probe, and No Endoscopic Therapy for Bleeding Peptic Ulcers

Of 550 patients admitted with acute upper gastrointestinal hemorrhage, 143 with peptic ulcers containing stigmata of recent hemorrhage accessible to endoscopic therapy were included in a randomized comparison of neodymium yttrium aluminum garnet laser, heater probe, and no endoscopic therapy. The rebleeding rate in laser-treated patients (20%) was significantly less than in controls (42%; p less than 0.05), but in heater probe-treated patients (28%) it was not significantly different from either of the other two groups. The mortality rate in the laser group (2%) was not significantly different from either the heater probe (10%) or the control (9%) group. This trial has confirmed the efficacy of the Nd YAG laser but not that of the heater probe in the prevention of rebleeding from recently bleeding peptic ulcers.

Nature of the Bleeding Vessel in Recurrently Bleeding Gastric Ulcers

An unselected consecutive series of 826 patients admitted for acute upper gastrointestinal bleeding underwent urgent endoscopy. Peptic ulcers were found in 402 (49%). Of the 329 ulcer craters that could be fully examined, visible vessels were identified in 156 (47%), other stigmata of recent hemorrhage in 66, and no stigmata of recent hemorrhage in 107. One hundred twenty-nine patients with stigmata of recent hemorrhage (93 of whom had visible vessels) randomly allocated to no endoscopic treatment were observed for evidence of further bleeding. Fifty-four of the 93 patients (58%) with visible vessels rebled, compared with 2 of 36 (6%) with other stigmata of recent hemorrhage. No patient without stigmata of recent hemorrhage rebled. Twenty-seven patients in whom a visible vessel in a gastric ulcer was identified at endoscopy underwent urgent partial gastrectomy because of recurrent bleeding. The vessel identified at endoscopy was found in 26 of 27 resection specimens (96%). The arterial vessel wall protruded above the surface of the ulcer crater in 10 specimens, and clot in continuity with a breach in the vessel wall protruded in a further 10 specimens. Postoperative angiography, when technically possible, showed that the breached artery ran across the base of the ulcer in all of these specimens. Pathological changes were common in the bleeding artery and included arteritis in 24 of 29 (83%) eroded arteries found in these specimens, with aneurysmal dilatation in 14 of 27 (52%) bleeding points that could be fully examined. The ulcer had penetrated to serosa in 13 specimens (45%). The bleeding artery had a mean external diameter of 0.7 mm with a range of 0.1-1.8 mm. This study provides new information about the nature of the bleeding vessel in gastric ulcers, and some of this information is relevant in planning studies of endoscopic therapy for bleeding peptic ulcers. It validates the endoscopic identification of a visible vessel, and confirms that such identification has a high predictive value for the development of recurrent hemorrhage.