Treatment Of Ulcer Bleeding Research Articles

X-RAY endovacular embolization in the treatment of ulcerate gastroduodenal bleeding

The use of targeted arterial embolization in the treatment of bleeding ulcers was accompanied by technical success in 97.6% of cases, clinical success in 95% of cases, bleeding recurrence occurred in 5% of patients, while repeated arterial embolization was used to eliminate it in 2.5% of cases. Delayed operations were performed in 8.3% of patients, mortality was 6.5%, which allows us to recommend transcatheter arterial embolization for the treatment of patients with ulcerative gastroduodenal bleeding.

Endovascular treatment of bleeding ulcer in a duodenal diverticulum fed by right hepatic artery

Endovascular treatment of bleeding ulcer in a duodenal diverticulum fed by right hepatic artery

Treatment of Bleeding Ulcer

Treatment of Bleeding Ulcer

Missed Opportunities in the Trial on Proton-Pump Inhibitor Therapy in Bleeding Peptic Ulcers

Letters20 October 2009Missed Opportunities in the Trial on Proton-Pump Inhibitor Therapy in Bleeding Peptic UlcersAlejandro Piscoya, MDAlejandro Piscoya, MDFrom Universidad Peruana de Ciencias Aplicadas, Lima, Peru.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-151-8-200910200-00022 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:I read with interest the article by Sung and colleagues (1). However, it's not news that PPI therapy is better than placebo in the treatment of ulcer bleeding. This was assessed more than a decade ago, and even some cost-effectiveness studies (2) support this conclusion. In addition, some studies (3–5) used low-dose PPI therapy and found no differences between high or low doses of PPI therapy.Is it ethical to continue to use placebo as a control when enough evidence exists that PPI therapy should be used in peptic ulcer bleeding? Perhaps the only new studies on ...

Acid-fundic selective vagotomy of the stomach without drainage in the treatment of duodenal ulcer: technique and results.

Abstract Out of 415 patients with duodenal ulcer under-going vagotomy in the past 6 years, 198 truncal vagotomies (T.V.) and 217 selective vagotomies (S.V.) were performed. Of the 217 S. V. s, 134 cases had a total selective vagotomy of the stomach (preserving the pyloroduodenal nervous peduncle), and in 83 cases a proximal selective vagotomy was performed (preserving also the antral branches of the two principal nerves of the gastric lesser curve or Latarjet nerves). The authors prefer the name ‘acid-fundic selective vagotomy (A.F.S.V.) of the stomach’ for the latter procedure. In 89 of the patients having S.V. no gastric drainage procedure was performed; in 27 of these a total S.V. had been performed and in 62 cases an A.F.S.V. In patients undergoing S.V. without gastric drainage the clinical results and gastric emptying were fairly good in the cases with a total S.V. (follow-up time, 12 months), and very good in the cases with an A.F.S.V. (follow-up time, 6 months). Basal acid output (B.A.O.) and maximal (pentagastrin-stimulated) acid output (M.A.O.) were evaluated in those patients undergoing A.F.S.V. before and 10 days after operation. B.A.O. was reduced by 80.5 per cent and M.A.O. by 68.5 per cent. An insulin test performed 3 months after operation was negative in 80 per cent of cases (complete vagotomy); in the other cases the vagotomy was adequate. Clinical results, although after only a short follow-up, suggest that the procedure can be considered as the treatment of choice in most patients with an uncomplicated duodenal ulcer (76 per cent in our series). Gastric drainage is required only in cases of stenosing duodenal ulcer with delayed gastric emptying. Pyloroplasty is also mandatory in the treatment of bleeding ulcer and of perforated ulcer (if the suture is stenosing).

Epinephrine injection therapy versus a combination of epinephrine injection and endoscopic hemoclip in the treatment of bleeding ulcers

To assess the efficacy of hemoclip application in combination with epinephrine injection in the treatment of bleeding peptic ulcers and to compare the clinical outcomes between patients treated with such a combination therapy and those treated with epinephrine injection alone. A total of 293 patients (211 males, 82 females) underwent endoscopic therapy for bleeding peptic ulcers. Of these, 202 patients (152 males, 50 females) received epinephrine injection therapy while 91 patients (59 males, 32 females) received combination therapy. The choice of endoscopic therapy was made by the endoscopist. Hemostatic rates, rebleeding rates, need for emergency surgery and 30-d mortality were the outcome measures studied. Patients who received combination therapy were significantly older (mean age 66+/-16 years, range 24-90 years) and more suffered from chronic renal failure compared to those who received epinephrine injection therapy alone (mean age 61+/-17 years, range 21-89 years). Failure to achieve permanent hemostasis was 4% in the group who received epinephrine injection alone and 11% in the group who received combination therapy. When the differences in age and renal function between the two treatment groups were taken into account by multivariate analysis, the rates of initial hemostasis, rebleeding rates, need for surgery and 30-d mortality for both treatment options were not significantly different. Combination therapy of epinephrine injection with endoscopic hemoclip application is an effective method of achieving hemostasis in bleeding peptic ulcer diseases. However, superiority of combination therapy over epinephrine injection alone, could not be demonstrated.

Virtual Endoscopy Simulator: Can the Unexperienced Be Trained for Real Endoscopy?

Introduction: Virtual Endoscopy (GI-Mentor, Symbionix, Israel) is a new tool for preparation and skill training. The aim of the present study was to determine whether standardized virtual training can facilitate the first steps in clinical endoscopy. Methods: A total of 7 beginners (medical students) with no previous experience in GI endoscopy and 3 experts were included. All participants performed a psychomotoric skill test and a baseline test at the GI-Mentor including 2 therapeutic (treatment of ulcer bleeding) and 1 diagnostic (including tumor biopsies) EGD. The beginners were further trained (40 hours) and then re-evaluated. After finishing the virtual training the beginners performed a real EGD in patients. In both settings (live and virtual endoscopy) the parameters total time, time to reach the lower part of the duodenum, examined mucosal surface and efficiency were determined. Results: The beginners showed a significant improvement in Virtual Endoscopy after the training period (total time: 9 versus 4 minutes; time to reach second part of the duodenum: 3.39 versus 0.43 minutes; efficacy 64/96%). The results at the re-evaluation were comparable with the parameters of the experienced endoscopists and no significant differences were detected between the trained students and expert gastroenterologists. Furthermore, all beginners could finish the real endoscopy by themselves without significant help upon training with the Virtual Endoscopy Simulator. However, the endoscopic performance decreased compared to the Virtual training setting (total time 8 minutes; time to reach second part of the duodenum 3.25 minutes; efficacy 82%) probably due to differences between training situation and clinical setup. Discussion: Virtual training in GI Endoscopy is a valid tool for improving skill technique. The learning curve is rapid and after 40 hours training the performance of beginners and experienced endoscopists is comparable. Virtual endoscopy training prepares for live endoscopy and all beginners could perform their first endoscopic examination without significant help. However, due to disturbing factors in the clinical situation (patient and bowel movement; unfamiliar monitor noises) the live performance decreased, but is still better as compared to unexperienced endoscopists. Therefore, training with an endoscopy simulator might represent a new standard for gastroenterologists at the beginning of their endoscopic training in the near future.

Frontiers in Gastroenterology

There have been a number of exciting advancements and changes in the gastroenterology field over the last few years. A new mesalamine formulation, balsalazide disodium, is now available for the treatment of ulcerative colitis (UC). Balsalazide may be utilized as first line therapy for patients with UC, or patients who are intolerant to other mesalamine preparations. In the area of irritable bowel syndrome, alosetron was removed from the market after reports that it was associated with severe constipation and death, although a causal relationship could not be established. Published data examines the risk of certain medications and the development of reflux disease and esophageal adenocarcinoma. Also, new proton pump inhibitors (PPIs) are available, esomeprazole, as well as alternate methods of administration for others. The first intravenous PPI, pantoprazole, is available in the United States, although currently there is a paucity of data regarding its efficacy. Peptic ulcer disease is also discussed, including Helicobacter pylori resistance, nonsteroidal anti-inflammatory drugs, and the treatment of bleeding ulcers. With pegylated interferon, progress in the treatment of hepatitis C offers promise for many patients. This review will highlight many recent changes in gastroenterology an offer a perspective on how disease management has changed.

Non-variceal upper gastrointestinal bleeding

Severe upper gastrointestinal bleeding remains a common medical emergency. In the last two decades endoscopy has become the cornerstone of diagnosis, risk stratification and treatment of peptic ulcer bleeding. Clinical assessment and endoscopic recognition of the stigmata of recent haemorrhage can allow the identification of patients with a high risk of rebleeding. Patients with active bleeding at the time of endoscopy and with non-bleeding visible vessels should receive endoscopic treatment. Studies comparing different treatment modalities are mostly single centre studies with relatively small groups of patients and therefore lack statistical power. Furthermore most of those trials were heterogeneous because of differences in the end points, differences in the risk factors for rebleeding and differences in the levels of experience of the endoscopists in both recognition and treatment of bleeding ulcers. Recently different treatment modalities have been studied. The injection of clot-inducing factors, a combination of injection and thermal therapies, repeat endoscopies and the use of mechanical devices such as clips and ligatures are promising new techniques. However, there are, at present, no convincing data to suggest that any one of these treatment modalities is superior when looking at the overall group of patients with bleeding peptic ulcer. Larger randomized controlled trials must focus on tailoring therapies and using the optimal therapy for different subgroups of patients.

Medical Therapy for Bleeding Peptic Ulcer

The majority of patients with upper gastrointestinal bleeding due topeptic ulcers stop bleeding spontaneously. The remainder of patients who have persistentor recurrent bleeding will require surgical or endoscopic intervention. Medicaltherapy provides an attractive alternative to these two treatment options. The adventof H2 antagonists in the mid 1970s revolutionized the treatment of peptic ulcer diseaseas it provided good ulcer healing with a treatment course of 6-8 weeks. A more potentacid suppressing class of drugs: the proton-pump inhibitors (PPl's) were introduced inthe late 1980s and provided even better and faster ulcer healing. It was natural that theacid suppressing drugs were also used for the treatment of ulcer bleeding. IntravenousH2 antagonist and more recently intravenous PPI's have routinely been prescribed inmany hospitals as soon as a bleeding patient is admitted. Critical evaluation of theliterature shows, however, that H2 antagonists are no more effective than placebo instopping ulcer bleeding. The PPI's, on the other hand, have been shown in severalclinical studies to have a beneficial effect. The action of acid suppression in stoppingulcer bleeding is believed to be due to its effect in the stabilization of an ulcer clot byproviding a high pH milieu and to commence the process of ulcer healing.

3367 A prospective evaluation of 10 easie team-training workshops on endoscopic hemostasis.

Introduction:The Erlangen Active Simulator for Interventional Endoscopy (EASIE®) is a new close to life training model permitting for the first time the creation of artierial spurting ulcer bleedings, varices and polyps in a specially prepared pig stomach. Overall about 25 different interventional techniques in the upper GI-tract and hepatobiliary system can be trained. Methods:10 systematically structured EASIE team-training courses (21.3.98-8.5.99) on endoscopic hemostasis were evaluated prospectively by the participants according to a questionnaire at the end of one day training. The courses were designed as a team-training for groups of 3 doctors and 3 nurses per simulator. 207 of 283 participants (73.1%) filled in the questionnaire (133 doctors, 65 nurses). As training models 4x EASIE®, 3x miniEASIE®, 3x compactEASIE® were used all equipped with the same, specially prepared pig esophago-gastro-duodenal organ package. For the training of ulcer hemostasis, vessels, polyps and submucosal varices were created. Perfusion was achieved by a roller-pump with the addition of an on demand bypass regulating the pressure of the blood surrogate. Workshop structure: 30 min. theoretical introduction on treatment of ulcer bleeding, 2 hours practical training of injection techniques (epinephrine, fibrin glue) and hemoclip application, 30 min. theoretical introduction of variceal therapy, 2 hours practical training of sclerotherapy (including cyanoacrylat) and banding techniques. Results: Most trainees rated themselves as advanced (39%) or experienced (35%) endoscopists. 19% were endoscopic novices, 7% no statement. Previous experience in endoscopic hemostasis was distributed as follows: No experience 19%, <1 year 9%, 1- 3 years 22%, 3-6 years 21%, >6 years 20%, 9% no statement. Nearly all trainees assessed the training as excellent or good (83% excellent (++), 14% good (+), 0% unsatisfactory(-), 3% no statement Φ). Single techniques were evaluated as follows: Injection therapy:73% (++), 18% (+), 0% (-), 9% Φ; Clip application:83% (++), 9% (+), 1% (-), 7% Φ; Sclerotherapy:60% (++), 18%(+), 1%(-), 21%Φ; Multiband ligation: 77%(++), 17% (+), 0% (-),. 6% Φ; Closeness to realitywas assessed as good, specifically: 72% (++), 22% (+), 0% (-), 6% Φ. Conclusion: EASIE team-training endoscopic hemostasis has a high acceptance by the trainees. A prospective comparison between conventional endoscopic education and practical education in interventional endoscopy using EASIE will be done soon. Introduction:The Erlangen Active Simulator for Interventional Endoscopy (EASIE®) is a new close to life training model permitting for the first time the creation of artierial spurting ulcer bleedings, varices and polyps in a specially prepared pig stomach. Overall about 25 different interventional techniques in the upper GI-tract and hepatobiliary system can be trained. Methods:10 systematically structured EASIE team-training courses (21.3.98-8.5.99) on endoscopic hemostasis were evaluated prospectively by the participants according to a questionnaire at the end of one day training. The courses were designed as a team-training for groups of 3 doctors and 3 nurses per simulator. 207 of 283 participants (73.1%) filled in the questionnaire (133 doctors, 65 nurses). As training models 4x EASIE®, 3x miniEASIE®, 3x compactEASIE® were used all equipped with the same, specially prepared pig esophago-gastro-duodenal organ package. For the training of ulcer hemostasis, vessels, polyps and submucosal varices were created. Perfusion was achieved by a roller-pump with the addition of an on demand bypass regulating the pressure of the blood surrogate. Workshop structure: 30 min. theoretical introduction on treatment of ulcer bleeding, 2 hours practical training of injection techniques (epinephrine, fibrin glue) and hemoclip application, 30 min. theoretical introduction of variceal therapy, 2 hours practical training of sclerotherapy (including cyanoacrylat) and banding techniques. Results: Most trainees rated themselves as advanced (39%) or experienced (35%) endoscopists. 19% were endoscopic novices, 7% no statement. Previous experience in endoscopic hemostasis was distributed as follows: No experience 19%, <1 year 9%, 1- 3 years 22%, 3-6 years 21%, >6 years 20%, 9% no statement. Nearly all trainees assessed the training as excellent or good (83% excellent (++), 14% good (+), 0% unsatisfactory(-), 3% no statement Φ). Single techniques were evaluated as follows: Injection therapy:73% (++), 18% (+), 0% (-), 9% Φ; Clip application:83% (++), 9% (+), 1% (-), 7% Φ; Sclerotherapy:60% (++), 18%(+), 1%(-), 21%Φ; Multiband ligation: 77%(++), 17% (+), 0% (-),. 6% Φ; Closeness to realitywas assessed as good, specifically: 72% (++), 22% (+), 0% (-), 6% Φ. Conclusion: EASIE team-training endoscopic hemostasis has a high acceptance by the trainees. A prospective comparison between conventional endoscopic education and practical education in interventional endoscopy using EASIE will be done soon.

Techniques for endoluminal intestinal tract surgery

SummaryEndoluminal surgery may be defined as procedures performed in a hollow organ using typical surgical techniques, such as dissection, suturing and stapling. By their nature, these procedures must be performed under endoscopic control. Applications of endoluminal surgery to the gastrointestinal tract should ideally be performed via natural orifices. Gastric endoluminal procedures, such as tissue resection by means of strip biopsy or polypectomy, are becoming increasingly common, especially in Japan. The laparoscopic transgastric approach has also been described recently. Endoluminal rectal surgery using retractors started many centuries ago. Complex surgical techniques under endoscopic vision can be performed by transanal endoscopic microsurgery (TEM). Today TEM is widely accepted, but not in every country. With the current impact of new technology, numerous potential endoluminal applications can be foreseen. Ongoing projects in endoluminal surgery include the treatment of bleeding ulcers of the gastrointestinal tract, antireflux techniques for gastro-oesophageal reflux disease (GERD) and the full-thickness resection of early gastrointestinal lesions. Compared with laparoscopic surgery, endoluminal surgery is a further important step in reducing the invasiveness of procedures. In combination with future endoscopic screening programmes for early tumours of the gastrointestinal tract, a revolution in the surgical treatment of these diseases can be foreseen.

Bleeding peptic ulcer.

Peptic ulcer is the most common cause of acute hemorrhage in the upper gastrointestinal tract, accounting for about 50 percent of cases114. There are approximately 150,000 hospitalizations per year in the United States for evaluation and treatment of bleeding ulcers (based on 1985 estimates and excluding federal hospitals)15. Although hospitalization and surgery for uncomplicated ulcers have decreased in the United States and Europe over the past 20 to 30 years, the number of hospital admissions for hemorrhage associated with ulcers has remained relatively unchanged1517. It is noteworthy that the incidence of bleeding ulcers appears to . . .

Bleeding peptic ulcers.

Peptic ulcer is the most common cause of acute hemorrhage in the upper gastrointestinal tract, accounting for about 50 percent of cases1–14. There are approximately 150,000 hospitalizations per year in the United States for evaluation and treatment of bleeding ulcers (based on 1985 estimates and excluding federal hospitals)15. Although hospitalization and surgery for uncomplicated ulcers have decreased in the United States and Europe over the past 20 to 30 years, the number of hospital admissions for hemorrhage associated with ulcers has remained relatively unchanged15–17. It is noteworthy that the incidence of bleeding ulcers appears to . . .

Clinical Development Programme for Omeprazole

Omeprazole has been shown to provide more rapid symptom relief and to heal ulcers more quickly and reliably than H2-receptor antagonists in duodenal ulcer, gastric ulcer and reflux oesophagitis. In addition, omeprazole is well tolerated and has a good safety profile. Among the areas for clinical development with omeprazole are the maintenance treatment of duodenal ulcer, treatment of non-steroidal anti-inflammatory drugs (NSAID)-induced gastro-duodenal lesions, maintenance treatment of reflux oesophagitis and the treatment of bleeding ulcer. Two studies of patients with duodenal ulcer have shown that maintenance treatment with omeprazole, 10 mg once daily, was as effective as, or superior to, treatment with omeprazole, 20 mg given on Friday, Saturday and Sunday only, and markedly superior to placebo. In patients with gastric ulcer which developed during treatment with NSAIDs omeprazole, 20 mg once daily, resulted in a higher healing rate than ranitidine, 150 mg b.i.d., both at 4 and at 8 weeks. Reflux oesophagitis is often a persistent condition requiring continuous maintenance treatment. In a recent multicentre trial, a substantially higher proportion of patients remained in remission with omeprazole, 20 mg once daily, than with ranitidine, 150 mg b.i.d. Studies comparing omeprazole and ranitidine (administered intravenously) in patients with bleeding peptic ulcers have also demonstrated the superiority of omeprazole with regard to the control of bleeding and the avoidance of surgery. Further studies are currently underway in this and other related areas.