Treatment Of Bleeding Peptic Ulcers Research Articles

Over-the-scope clip as first-line treatment of peptic ulcer bleeding: is it suitable for all?

Over-the-scope clip as first-line treatment of peptic ulcer bleeding: is it suitable for all?

Comparative analysis of early versus late feeding after an EGD-based intervention: meta-analysis

Background & AimsThe right time to re-start feeding after esophagogastroduodenoscopic (EGD interventions is not well established. However, impaired nutrition from prolonged fasting may lead to unfavorable clinical outcomes. Herein, we performed a systematic review and meta-analysis to study the impact of early feeding (within 24 hours) vs. late feeding (more than 24 hours) in patients undergoing acute therapeutic EGD interventions. MethodsMultiple databases, including Medline, Scopus, and Embase, were searched (in May 2022) using specific terms for studies evaluating the outcomes of early vs. late feeding after EGD interventions. Outcomes of interest were early rebleed (< 7 days), late rebleed (> 7 days), mortality rates, length of hospital stay, and rate of blood transfusion. Standard meta-analysis methods were employed using the random-effects model. I2% heterogeneity was used to assess the heterogeneity. The GRADE working group approach was used to assess the certainty of evidence. ResultsEight studies (813 patients) were included in the final analysis. The ‘Early feeding’ cohort included 411 patients, 31% females, with a mean age of 58 years, and the ‘late feeding’ cohort included 402 patients, 26.4% females, with a mean age of 57 years. Four studies (283 patients) evaluated patients with band ligation/sclerotherapy in acute variceal bleeding (224 patients), two studies (309 patients) with endoscopic treatment of peptic ulcer bleeding, and two studies in endoscopic mucosal dissection for gastric mucosal epithelial neoplasia. The pooled risk ratio (RR) of early rebleed in ‘early feeding’ vs. ‘late feeding’ was 1.6 (95% confidence interval (CI) [0.7-3.7; I2=0%, p=0.2]. Similarly, the RR of late rebleed was 0.9 [0.4-2.3; I2=0%, p= 0.9]. The pooled RR of total rebleed was 1.2 [0.7-2.2; I2=0%, p=0.3]. The pooled RR of mortality between the ‘early feeding’ and ‘late feeding’ groups was 0.6 [0.3-1.2; I2=0%, p=0.16]. The Pooled rate of standard difference of mean length of hospital stay was -1.184 (-1.5 - -0.81, I2 = 92%, p=0.00) between early and late feeding groups. The Pooled rate of mean difference in blood transfusion between early and late feeding groups was 0.1 [-0.4 - 0.41; I2= 77.6%, p=0.96]. ConclusionOur meta-analysis demonstrates early enteral feeding within 24 hours does not appear to have a higher risk of rebleeding and mortality than delayed enteral feeding in patients undergoing EGD therapeutic interventions. However, early feeding is associated with a shorter length of hospital stay compared to late feeding.

Medical therapy has similar hemostatic efficacy with endoscopic treatment for PUB patients with adherent clot (FIIb ulcers).

Currently, there is no clear consensus on whether medical treatment or endoscopic treatment should be used for peptic ulcer bleeding patients with adherent clot. The aim of this study is to investigate the hemostatic effects of medical treatment, single endoscopic treatment, and combination endoscopic treatment for peptic ulcer bleeding (PUB) patients with adherent clot. We retrospectively analyzed PUB patients with adherent clot who underwent endoscopic examination or treatment in our center from March 2014 to January 2023 and received intravenous administration of proton pump inhibitors. Patients were divided into medical treatment (MT) group, single endoscopic treatment (ST) group, and combined endoscopic treatment (CT) group. Subsequently, inverse probability of treatment weighting (IPTW) was performed to calculate the rebleeding rate. A total of 605 eligible patients were included in this study. After IPTW, the rebleeding rate in the MT group on days 3, 7, 14, and 30 were 13.3 (7.3), 14.2 (7.8), 14.5 (7.9), and 14.5 (7.9), respectively; the rebleeding rates in the ST group were 17.4 (5.1), 20.8 (6.1), 20.8 (6.1), and 20.8 (6.1), respectively; the rebleeding rates in the CT group were 0.4 (0.9), 1.7 (3.3), 2.3 (4.5), and 2.3 (4.5), respectively. Although the rebleeding rate in the medical treatment group was higher, there was no significant difference among the three groups on days 3, 7, 14, and 30 (P = 0.132, 0.442, 0.552, and 0.552). Medical therapy has similar hemostatic efficacy with endoscopic treatment for PUB patients with adherent clot (FIIb ulcers). However, for patients with more risk factors and access to well-equipped endoscopy centers, endoscopic treatment may be considered. The choice of treatment approach should be based on the individual conditions of the patient, as well as other factors such as medical resources available.

Reduced mortality for over-the-scope clips (OTSC) versus surgery for refractory peptic ulcer bleeding: a retrospective study

BackgroundSurgery or transcatheter arterial embolization or are both considered as standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over-The-Scope clips (OTSC) have shown superiority to standard endoscopic treatment but a comparison with surgery has not been performed, yet.Patients and methodsIn this retrospective, multicenter study, 103 patients treated with OTSC (n = 66) or surgery (n = 37) for refractory PUB in four tertiary care centers between 2009 and 2019 were analyzed. Primary endpoint was clinical success (successful hemostasis and no rebleeding within seven days). Secondary endpoints were adverse events, length of ICU-stay and in-hospital mortality. Univariable and multivariable regression models were performed to define predictive factors for allocation to surgical therapy and for mortality.ResultsAge, comorbidities, anticoagulation therapy, number of pretreatments, ulcer location, and Rockall-Score were similar in both groups. In the surgical group, there were significantly more patients in shock at rebleeding (78.1% vs. 43.9%; p = 0.002), larger ulcers (18.6 ± 7.4 mm vs. 23.0 ± 9.4 mm; p = 0.017) and more FIa bleedings (64.9% vs. 19.7%; p < 0.001) were detected. Clinical success was comparable (74.2% vs. 83.8%; p = 0.329). In the surgical group, length of ICU-stay (16.2 ± 18.0 days vs. 4.7 ± 6.6 days; p < 0.001), severe adverse events (70.3% vs. 4.5%; p < 0.001) and in-hospital mortality (35.1% vs. 9.1%; p = 0.003) were significantly higher. Multivariable analysis defined shock at rebleeding as the main predictor for allocation to surgical therapy (OR 4.063, 95%CI {1.496–11.033}, p = 0.006). Postsurgical adverse events were the main reason for the in-hospital mortality (OR 5.167, 95% CI {1.311–20.363}, p = 0.019).ConclusionIn this retrospective study, OTSC compared to surgical treatment showed comparable clinical success but was associated with shorter ICU-stay, less severe adverse events and lower in-hospital mortality.

S646 Endoscopic vs Conservative Treatment for Bleeding Peptic Ulcer With Adherent Clot: A Comprehensive Systematic Review and Meta-Analysis of Randomized Controlled Trials

S646 Endoscopic vs Conservative Treatment for Bleeding Peptic Ulcer With Adherent Clot: A Comprehensive Systematic Review and Meta-Analysis of Randomized Controlled Trials

Efficacy and safety of microporous polysaccharide hemostatic material in endoscopic treatment of peptic ulcer bleeding

Efficacy and safety of microporous polysaccharide hemostatic material in endoscopic treatment of peptic ulcer bleeding

Over-the-scope-clip (OTSC®) as a rescue treatment for gastrointestinal bleeding secondary to peptic ulcer disease.

over-the-scope-clips (OTSC®) have been proposed as a rescue treatment for bleeding peptic ulcers. However, their effectiveness has not been evaluated in Spain. this retrospective and single-center study (January 2018-December 2021) assessed the technical success, clinical success and safety of the device within 30 days. All patients with upper gastrointestinal bleeding due to a peptic ulcer and treated with the OTSC® clip (OVESCO) as a rescue therapy were included in the study. a total of eleven patients were included in the study, nine due to rebleeding and two due to persistent bleeding. Technical success was 81.9 % (9/11, confidence interval [CI] 95 %: 52-95 %). The per-protocol and intention-to-treat clinical success were 88.9 % (8/9, CI 95 %: 57-98 %) and 72.7 % (8/11, CI 95 %: 43-90 %), respectively. No device-related adverse effects were recorded. the OTSC® clip was an effective and safe rescue therapy for bleeding peptic ulcers.

Over-the-scope clip versus transcatheter arterial embolization for refractory peptic ulcer bleeding-Apropensity score matched analysis.

BackgroundTranscatheter arterial embolization (TAE) or surgery are standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over‐the‐scope clips (OTSC) have shown superiority to standard endoscopic treatment.ObjectiveTo compare OTSC treatment to TAE in refractory peptic ulcer bleeding.Patients and MethodsIn this retrospective, multicenter study, 128 patients treated with OTSC (n = 66) or TAE (n = 62) for refractory PUB between 2009 and 2019 in four academic centers were analyzed. Primary endpoint was clinical success (hemostasis + no rebleeding within 7 days). Secondary endpoints were adverse events, length of ICU stay, and mortality. Propensity score matching was performed to adjust for differences in baseline characteristics.ResultsPatients characteristics were similar in both groups but ulcers in the TAE group were larger, more often located in the duodenal bulb (85.5% vs. 65.2%; p = 0.014), and that the proportion of Forrest Ia bleedings was higher (38.7% vs. 19.7%; p = 0.018). Clinical success was comparable in both groups (74.2% vs. 59.7%; p = 0.092). Stay on the intensive care unit (ICU) was significantly longer in the TAE group (mean 8.0 vs. 4.7 days; p = 0.002). Serious adverse events after re‐therapy (12.9% vs. 1.5%; p = 0.042) and in‐hospital mortality were significantly higher in the TAE group (9.1 vs. 22.6%, OR 2.92 [95% CI 1.04–8.16]; p = 0.05). After propensity score matching, the differences found regarding ICU stay (4.9± 5.9 and 9.2 ± 11.2; p = 0.009) and in‐hospital mortality (5% vs. 22.5%; OR 5.52 [95% CI: 1.11–27.43]; p = 0.048) stayed significant.ConclusionsOTSC treatment for refractory PUB was superior to TAE in terms of ICU stay and in‐hospital mortality.

Peptic Ulcer Bleeding: Update on Standards from International Guidelines

We review the latest advances in management of peptic ulcer bleeding and the updates from international guidelines. A low Glasgow Blatchford score of ≤ 1 can safely identify low-risk patients to manage in out-patient settings. Except patients with persistent haemodynamic instability, early endoscopy within 24 h appears safe when compared with earlier intervention. Over-the-scope-clips (OTSC) show promising result as first-line and second-line endoscopic haemostaic therapy, while haemostatic spray can be considered as a stop-gap treatment. After endoscopic intervention, high-dose oral proton-pump-inhibitor (PPI) is an alternative to intravenous use in selected cases. Retrospective data shows new-generation P2Y12 inhibitors (prasugrel and ticagrelor) have higher risk of bleeding when compared with clopidogrel. Vonoprazan, a potassium-competitive acid blocker and a potent acid suppressor, shows encouraging initial results in management of gastrointestinal bleeding. Endoscopic therapy remains the mainstay of treatment of peptic ulcer bleeding and future research will clarify the role of new endoscopic treatment modalities such as OTSC. Good peri-endoscopic treatment remains crucial, and more data is needed to guide management in patients on new generation anti-platelet drugs and direct oral anti-coagulants.

Correlation of Treatment of Peptic Ulcer Bleeding by Argon Plasma Coagulation (APC) via Contact Heat Probe Method (heater probe) with Epinephrine Injection.

BACKGROUND This clinical investigation aimed to compare the efficacy of treatment of peptic ulcer hemorrhage by argon plasma coagulation (APC) via contact heat probe method (heater probe) along with epinephrine injection. METHODS 100 patients who underwent endoscopic treatment, were randomly divided into two groups consisting of 50 patients each. In the first group, an intervention was performed using foot pedal and 2.3 mm and 3.2 mm argon probes placed in a 2 to 8 mm distance of delivery place leading to plasma coagulation, sufficient necrosis and hemostasis. In the second group, wound press contact probe was used for wound healing with 15 watts of heat for about 25 degrees, causing coagulation and hemostasis. To evaluate and compare the ulcer treatment in both groups, the patient progress results were monitored for a period of one month from the day of discharge. Statistical analyses of data were performed using SPSS software version 22 along with Chi-square test and T-test. RESULTS No significant difference observed in two groups in term of age, sex and clinical symptoms, but patients treated with APC method had higher hemoglobin levels (p < 0.001). The duration of intervention and abdominal bloating in APC group was significantly higher with two cases of re-admission. In HP group, 3 cases (6.3%) had treatment failure and an average transfused blood was significantly higher in the HP group (p < 0.001). CONCLUSION Endoscopy treatment duration was significantly lower in patients treated with the HP method due to separate washing route. HP method seems to be more appropriate for treatment of cases with abdominal bloating, distal gastric lesion and HP bulbs.

Systematic review and meta-analysis: monopolar hemostatic forceps with soft coagulation in the treatment of peptic ulcer bleeding.

Monopolar hemostatic forceps with soft coagulation (MHFSC) have been compared with hemoclips, heater probe, and argon plasma coagulation (APC) for the treatment of peptic ulcer bleeding. In this systematic review and meta-analysis, we compared MHFSC with other modalities in the treatment of peptic ulcer bleeding. We reviewed MEDLINE, Embase, Scopus, Cochrane, Web of Science, and Scopus from inception to 7 January 2019 to identify studies comparing MHFSC with other modalities for peptic ulcer bleeding. The primary outcome of interest was achievement of initial hemostasis. Secondary outcomes were rebleeding, adverse events, procedure time, and length of hospital stay. Data were analyzed using a random effects model and summarized as pooled odds ratio (OR) with 95% confidence interval (CI). Heterogeneity was assessed by I statistic. We included five randomized controlled trials and one observational study comprising 693 patients with endoscopically confirmed actively bleeding ulcers (spurting or oozing) or nonbleeding visible vessel. MHFSC was superior to other modalities in achieving initial hemostasis (OR 0.25; 95% CI 0.08-0.81; I = 67%) and prevention of rebleeding (OR 0.28; 95% CI 0.09-0.86; I = 46%). Rates of adverse events were similar between MHFSC and other modalities. Procedure times were shorter with MHFSC (mean difference -4.15 min; 95% CI -4.83 to -3.47; I= 59%). Length of hospital stay was also shorter with MHFSC. MHFSC appears to be more effective than other modalities for achievement of initial hemostasis and reduction of rebleeding among patients with peptic ulcer bleeding.

Comparison of monopolar hemostatic forceps with soft coagulation versus hemoclip for peptic ulcer bleeding: a randomized trial (with video)

Although various methods are used in the treatment of peptic ulcer bleeding, there is not a standard recommended approach. The choice depends on multiple factors such as location of the ulcer, clinical experience of the endoscopist, and local facilities of the clinic. We aimed to compare the efficacy of monopolar hemostatic forceps soft coagulation (MHFSC) and hemoclips (HCs) in the treatment of peptic ulcer-related upper GI bleeding. The study group included patients who had GI bleeding due to Forrest 1a, 1b, and 2a gastric or duodenal ulcers within 1 year. Patients with bleeding diathesis, history of gastrectomy, pregnancy, or younger than age 18 years were excluded. The remaining were randomized to MHFSC and HC treatment groups and compared in terms of clinical and endoscopic features, initial hemostasis success rates, recurrent bleeding rates within the first 7 days, time to achieve hemostasis, length of hospitalization stay, and adverse events. One hundred twelve patients were randomized to MHFSC (n= 56) and HC (n= 56) groups. There was no statistically significant difference between the groups with respect to demographic features, medications, underlying chronic diseases, location, and Forrest classification of the ulcers. The initial hemostasis success rate was 98.2% (55/56) in the MHFSC group and 80.4% (45/56) in the HC group (P= .004). Recurrent bleeding was detected in 2 patients in the MHFSC group (3.6%) and 8 patients in the HC group (17.7%; P= .04). The duration of endoscopic procedures (302 ± 87.8 vs 568 ± 140.4 seconds) and the length of hospital stay (3.50 ± 1.03 vs 4.37 ± 1.86 days) were significantly shorter in the MHFSC group. There were no adverse events in either group. MHFSC is more effective in achieving initial hemostasis compared with HCs in the treatment of peptic ulcer bleeding and provides a shorter procedure time and a lower recurrent bleeding rate.

Over-the-Scope Clips Are More Effective Than Standard Endoscopic Therapy for Patients With Recurrent Bleeding of Peptic Ulcers

Endoscopic hemostasis is effective in treatment of bleeding peptic ulcers. However, rebleeding is difficult to treat and associated with substantial morbidity and mortality. We performed a prospective randomized trial to determine whether over-the-scope clips (OTSCs) are more effective than standard treatment of severe recurrent upper gastrointestinal bleeding. We performed our study at 9 academic referral centers (in Germany, Switzerland, and Hong Kong) from March 2013 through September 2016. Adult patients with recurrent peptic ulcer bleeding following initially successful hemostasis (66 patients in the intent-to-treat analysis) were randomly assigned to groups (1:1) that underwent hemostasis with either OTSC or standard therapy. Standard therapy was defined as hemostasis with through-the-scope clips (TTSC, n= 31) or thermal therapy plus injection with diluted adrenaline (n= 2). The primary endpoint was further bleeding (a composite endpoint of a persistent bleeding despite endoscopic therapy according to the protocol or recurrent bleeding within 7 days after successful hemostasis). Patients with further bleeding were allowed to cross over to OTSC therapy. Main secondary endpoints were mortality, necessity of surgical or angiographic salvage therapy, duration of stay in the hospital or intensive care, number of blood units transfused, and complications associated with endoscopic therapy. Persistent bleeding after per-protocol hemostasis was observed in 14 patients (42.4%) in the standard therapy group and 2 patients (6.0%) in the OTSC group (P= .001). Recurrent bleeding within 7 days occurred in 5 patients (16.1%) in the standard therapy group vs 3 patients (9.1%) in the OTSC group (P= .468). Further bleeding occurred in 19 patients (57.6%) in the standard therapy group and in 5 patients (15.2%) in the OTSC group (absolute difference 42.4%; 95% confidence interval 21.6-63.2; P= .001) Within 30 days of follow-up, 1 patient in the standard therapy group (3.0%) and 1 patient in the OTSC group (3.0%) required surgical therapy (P= .999). Within 30 days of the procedure, 2 patients died in the standard therapy group (6.3%) and 4 patients died in the OTSC group (12.1%) (P= .672). There were no significant differences in the other secondary endpoints. In prospective randomized trial, we found endoscopic treatment with OTSCs to be superior to standard therapy with TTSCs for patients with recurrent peptic ulcer bleeding. STING Study, Clinicaltrials.gov no: NCT1836900.

Transcatheter Arterial Embolization for Bleeding Peptic Ulcers: A Multicenter Study.

To investigate the outcomes of transcatheter arterial embolization (TAE) for the treatment of peptic ulcer bleeding (PUB). This is a retrospective, multicenter study, which investigated all patients who underwent TAE for the treatment of severe upper gastrointestinal hemorrhage from peptic ulcers in five European centers, between January 1, 2012 and May 1, 2017. All patients had undergone failed endoscopic hemostasis. Forty-four patients (male; mean age 74.0 ± 11.1years, range 49-94), with bleeding from duodenum (36/44; 81.8%) or gastric ulcer (8/44; 18.2%) were followed up to 3.5years (range 2-1354days). In 42/44 cases, bleeding was confirmed by pre-procedural CT angiography. In 50% of the cases, coils were deployed, while in the remaining glue, microparticles, gel foam and combinations of the above were used. The study's outcome measures were 30-day survival technical success (occlusion of feeding vessel and/or no extravasation at completion DSA), overall survival, bleeding relapse and complication rates. The technical success was 100%. The 30-day survival rate was 79.5% (35/44 cases). No patients died due to ongoing or recurrent hemorrhage. Re-bleeding occurred in 2/44 cases (4.5%) and was successfully managed with repeat TAE (one) or surgery (one). The rate of major complications was 4.5% (2/44; one acute pancreatitis and one partial pancreatic ischemia), successfully managed conservatively. According to Kaplan-Meier analysis survival was 71.9% at 3.5years. TAE for the treatment of PUB was technically successful in all cases and resulted in high clinical success rate. Minimal re-bleeding rates further highlight the utility of TAE as the second line treatment of choice, after failed endoscopy.

EFFICACY OF INITIAL AND PERMANENT HEMOSTASIS OF THE ENDOSCOPIC HEMOCLIP METHOD COMBINED WITH HIGH-DOSE INFUSION OF PROTON PUMP INHIBITOR IN PATIENTS WITH PEPTIC ULER BLEEDING

Background: Peptic ulcer bleeding is one of the common medical emergencies. The hemostatic efficacy of endoscopic therapeutic modalities has been reported in many studies and frequently has been found to exceed 90%. Four groups of modalities are used in the endoscopic management of bleeding peptic ulcers: thermal probe methods, injection sclerotherapy, local spray methods, and mechanical hemostatic therapy. The endoscopic hemoclip method is a safe and effective hemostatic therapy for managing bleeding peptic ulcers. Objective: To determine the success rate of hemoclip in endoscopic hemostasis. Patients and methods: Clinical intervention study on 36 patients with peptic ulcer bleeding admitted in Can Tho Central General Hospital from May 2012 to November 2014. All the patients underwent emergency endoscopy for hemostasis by hemoclip and high-dose PPI use. Results: The success rate of initial hemostasis was 97.2%, and permanent hemostasis was 91.7%. The rates of rebleeding, surgery, mortality were 11.1%, 5.6%, 2.8%, respectively. Conclusion: Endoscopic hemostasis therapy by clipping combined with high- dose PPI is an effective, relatively safe treatment for peptic ulcer bleeding. Key words: Peptic ulcer bleeding, hemoclip, endoscopic hemostasis therapy

Endoscopic Collagen Spray A Novel Method Which can be Used as an Adjunct to Conventional Hemostatic Techniques in Peptic Ulcer Bleeding

Aim: To study endoscopic collagen spray as a hemostatic agent in peptic ulcer bleeding not controlled by conventional therapy. Methods: In this prospective study, endoscopic collagen spray, VGM’s Haemoseal spray has been used in the treatment of peptic ulcer bleeding, as a single agent or in combination with other agents. Haemoseal Spray Kit consists of air pump, Haemoseal probe, a 7.5 Fr spray catheter, 230 cm in length and a pre-loaded collagen cartridge that contains 5 grams of powder. A maximum of 2 grams is applied depending on the area to be covered. Results: Eighteen consecutive patients, who presented with peptic ulcer bleeding were included. There were sixteen patients with duodenal ulcer and two patients with gastric ulcer. The hemorrhagic ulcers were Forrest classification category Ib in sixteen patients and Ia in two patients. After spraying collagen, the bleeding stopped within seconds in all the patients. Repeat endoscopy after 48 hours showed no rebleeding. One patient had an arterial spurt from duodenal ulcer. Collagen spray was used initially as there was poor visibility. After 24 hours, repeat endoscopy revealed visible vessel with no bleeding. Hemoclipping could be achieved. There were no side effects experienced by the patients. Conclusion: Collagen spray is a safe and effective endoscopic hemostatic agent in treatment of peptic ulcer bleeding not controlled by conventional therapy.

Endoscopic Hemostatic Treatment of Peptic Ulcer Bleeding

Endoscopic Hemostatic Treatment of Peptic Ulcer Bleeding

Pharmacological Treatment for Peptic Ulcer Bleeding

Pharmacological Treatment for Peptic Ulcer Bleeding

Efficacy of pantoprazole and omeprazole in treatment of peptic ulcer bleeding

Efficacy of pantoprazole and omeprazole in treatment of peptic ulcer bleeding

115 Hemospray Versus the Combined Conventional Technique for Endoscopic Treatment of Bleeding Peptic Ulcers: A Pilot Randomized Controlled Study

115 Hemospray Versus the Combined Conventional Technique for Endoscopic Treatment of Bleeding Peptic Ulcers: A Pilot Randomized Controlled Study