Treatment Of Acute Upper Gastrointestinal Bleeding Research Articles

Tranexamic acid in upper gastrointestinal bleed in patients with cirrhosis: A randomized controlled trial.

Patients with Child-Turcotte-Pugh class B and C cirrhosis with upper gastrointestinal bleeding (UGIB) have systemic as well as localized (in the mucosa of the esophagus and stomach) fibrinolysis. The aim of this study was to evaluate the efficacy and safety of tranexamic acid in the treatment of acute UGIB in patients with cirrhosis. A total of 600 patients with advanced liver cirrhosis (Child-Turcotte-Pugh class B or C) presenting with UGIB were randomly allocated to either the tranexamic acid (n=300) or the placebo group (n=300). The primary outcome measure was the proportion of patients developing 5-day treatment failure. Failure to control bleeding by day 5 was seen in 19/300 (6.3%) patients in the tranexamic acid group and 40/300 (13.3%) patients in the placebo group ( p =0.006). Esophageal endoscopic variceal ligation (EVL) site as a source of failure to control bleeding by day 5 among patients undergoing first-time esophageal EVL (excluding patients with a previous post-EVL ulcer as a source of bleed) was seen in 11/222 (4.9%) patients in the tranexamic acid group and 27/225 (1212.0%) patients in the placebo group ( p =0.005). However, 5-day and 6-week mortality was similar in the tranexamic acid and placebo groups. Tranexamic acid significantly reduces the failure to control bleeding by day 5 and failure to prevent rebleeding after day 5 to 6 weeks in patients with advanced liver cirrhosis (Child-Turcotte-Pugh class B or C) presenting with UGIB, by preventing bleeding from the EVL site.

Long-Term Outcomes following Acute Upper Gastrointestinal Bleeding Remain Poor: A Single-Center Comparison over Two Distinct Time Periods within the Last 15 Years in Finland

Introduction: Acute upper gastrointestinal bleeding (AUGIB) is a common and life-threatening condition. This study aimed to compare the causes and long-term outcomes of AUGIB over two distinct periods in the last 15 years. Methods: This population-based study included consecutive patients who underwent emergency upper endoscopy for visible bleeding in 2006 and 2016. Our primary focus was on long-term mortality up to 5 years after the endoscopy, although short-term mortality was also reported. Results: A total of 832 patients (median age 67 [12–96] years, 37% female) were included, with peptic ulcer disease (48%), esophagitis (20%), and variceal bleeding (15%) being the most common diagnoses. The incidence of AUGIB increased with age, reaching 8.31 cases per 1,000 person-years among those aged 80 years or older. Mortality rates at 30 days, 90 days, 1 year, and 5 years were 13%, 16%, 27%, and 47%, respectively. The standardized mortality ratio was high in all age groups, with particularly elevated rates observed among younger patients compared to the standard population. Variceal bleeding, liver cirrhosis, and chronic alcohol abuse were associated with the highest mortality. Only two short-term deaths were attributed to failed hemostasis. The primary causes of death were malignancies, liver failure, and cardiac failure. No improvement in outcomes was observed between the two time periods. Conclusion: Although the treatment of AUGIB may be relatively straightforward, the outcomes following treatment remain poor. High mortality can be attributed to the presence of coexisting conditions and patients’ lifestyle.

PTH-010 Uk training in therapeutic endoscopy – are we achieving the basics? results of the bsg national training survey

Introduction Colonoscopic polypectomy and endoscopic treatment of acute upper gastrointestinal bleeding (AUGIB) are key skills for the majority of consultant gastroenterologists. Competence in polypectomy is assessed by direct observation of polypectomy skills (DOPyS) with 4 competent level 2 (>1 cm) polypectomies required for full colonoscopy certification. Measures for defining competence in endoscopic treatment of AUGIB are in development. There is evidence of slow rates of progression to achieve basic endoscopic skills amongst gastroenterology trainees due to other service and training pressures. 1 Method The BSG national training survey was open to all UK gastroenterology trainees from June–August 2014. Data on exposure to polypectomy and endoscopic treatment of AUGIB was analysed as well as trainees desire to train in advanced endoscopic techniques. Results 32.6% (263/806) of UK trainees completed the survey. 68% of ST6 (year 4) trainees and 38% of final year trainees have performed senior trainees ) wish to formally train in endoscopic mucosal resection (EMR), with corresponding figures of 40% for ERCP, 29% for EUS, and 33% for enteroscopy. 28% of senior trainees report having the opportunity to perform endoscopy in a patient with AUGIB either monthly or less often (less than once per month/never). >95% of senior trainees feel they will be competent to perform variceal and non-variceal AUGIB endoscopic treatment as a newly qualified consultant. 91% feel they will be competent to place a Sengstaken-Blakemore tube if required. Conclusion Exposure to level 2 polypectomy amongst senior gastroenterology trainees is limited, which may explain slow rates of progression to full colonoscopy certification. 1 Over a quarter of senior trainees have limited opportunity to perform endoscopy in cases of AUGIB. Virtually all trainees feel they will be competent in the endoscopic management of AUGIB as a new consultant, but the documented lack of exposure for some trainees suggests this may not be the case. Despite slow progression to basic endoscopy competencies, large numbers of trainees wish to train in advanced endoscopic techniques. These results suggest the need for focused training lists to develop key therapeutic endoscopic skills such as removal of level 2 polyps, and systems to guarantee dedicated supervised exposure to AUGIB cases. Disclosure of interest None Declared. Reference Neale JR, Basford PJ. General medical training in gastroenterology: views from specialist trainees on the challenges of dual accreditation. Clin Med. 2015;15(1):35–9

Management of acute nonvariceal upper gastrointestinal bleeding: Current policies and future perspectives

Acute upper gastrointestinal bleeding (UGIB) is a gastroenterological emergency with a mortality of 6%-13%. The vast majority of these bleeds are due to peptic ulcers. Nonsteroidal anti-inflammatory drugs and Helicobacter pylori are the main risk factors for peptic ulcer disease. Endoscopy has become the mainstay for diagnosis and treatment of acute UGIB, and is recommended within 24 h of presentation. Proton pump inhibitor (PPI) administration before endoscopy can downstage the bleeding lesion and reduce the need for endoscopic therapy, but has no effect on rebleeding, mortality and need for surgery. Endoscopic therapy should be undertaken for ulcers with high-risk stigmata, to reduce the risk of rebleeding. This can be done with a variety of modalities. High-dose PPI administration after endoscopy can prevent rebleeding and reduce the need for further intervention and mortality, particularly in patients with high-risk stigmata.

Gastric Hemostasis by Laser Phototherapy in Man

LASER energy has previously been shown to control bleeding from superficial gastric erosions in the dog. In the initial report by Goodale et al, 1 carbon dioxide laser energy was transmitted through a rigid, hollow endoscope. Subsequently, Nath et al 2 described a flexible fiberoptic delivery system through which argon laser energy could be transmitted. In 1975, Dwyer et al 3 reported the successful use of such a system to treat hemorrhage from superficial gastric erosions in dogs. This communication describes the use of argon ion laser phototherapy for the treatment of acute upper-gastrointestinal bleeding in man. Materials and Methods An argon ion retinal photocoagulator with a flexible fiberoptic delivery system was attached to the outside of an endoscope as previously reported. 3 The tip of the fiberoptic cable was covered by a protective cap, and the cap was equipped with two channels, one for water to wash the quartz