Treatment Of Bleeding Peptic Ulcers Research Articles

Randomized Trial of N-Butyl-2-Cyanoacrylate Compared with Injection of Hypertonic Saline-Epinephrine in the Endoscopic Treatment of Bleeding Peptic Ulcers

Theoretically, the injection of cyanoacrylate may be effective for peptic ulcer bleeding, but randomized clinical trials are rare. The aim of this study was to compare the efficacy of N-butyl-2-cyanoacrylate (Histoacryl) and hypertonic saline-epinephrine (HSE) in the endoscopic treatment of major peptic ulcer hemorrhage. A total of 126 patients with major peptic ulcer hemorrhage and active bleeding or a nonbleeding visible vessel were randomly allocated to endoscopic injection with HSE (63 patients; group 1) or to injection with Histoacryl (63 patients; group 2). The two groups were well matched for age, sex, initial hemoglobin values, ulcer size and location, and bleeding stigmata. Initial hemostasis was achieved in 58 cases (92.1%) in group 1 and in 60 cases (95.2%) in group 2 (P=0.717). Rebleeding rates were 16 of 58 in group 1 and seven of 60 in group 2 (P=0.051). There were no significant differences regarding the rates of permanent hemostasis (51 of 63 in group 1 vs. 57 of 63 in group 2, P=0.203), emergency surgery (seven of 58 in group 1 vs. three of 60 in group 2, P=0.200), or hospital mortality due to bleeding (0 in group 1 and 0 in group 2). With regard to the rebleeding rate, there was a significant difference between group 1 and group 2 in the subgroup with active arterial bleeding (11 of 26 in group 1 and four of 29 in group 2, P=0.039) but not in the subgroup with a nonbleeding visible vessel (five of 32 in group 1 and three of 31 in group 2, P=0.708). There were no statistically significant differences in hemostatic results between the two treatment groups in the subgroups with gastric ulcers or duodenal ulcers. Although no complications followed HSE therapy, arterial embolization with infarction occurred in two patients in the Histoacryl group, of whom one died. Compared with HSE injection, Histoacryl injection showed no statistically significant differences in hemostatic results, except for decreasing the rebleeding rate in the patients with active arterial bleeding. However, the use of Histoacryl to control peptic ulcer bleeding should be reserved as a last resort before surgery, because of possible embolic complication.

Current status of endoscopic therapy for ulcer bleeding

This article provides an overview of the therapeutic endoscopic modalities available for the treatment of peptic ulcer bleeding. The benefits of endoscopic haemostasis have been fully demonstrated by three meta-analyses, which included most of the controlled trials published until 1992. In this review, an emphasis is placed on randomized, prospective comparative trials published during the past 20 years. Using an evidence-based medicine approach, the results of meta-analyses are translated into efficacy measures known as relative and absolute risk reductions, and number needed to treat. Single-modality treatments with injection agents such as epinephrine, sclerosants and thrombogenic substances, or with thermal therapies, are efficacious and comparable. Combination therapy involving injection and thermal techniques may offer an advantage over single-method therapy. The differences in the results between clinical trials and routine clinical practice, and among the various randomized studies, are probably related to operators' experience and variations in technique rather than to inconsistency of endoscopic haemostasis.

7138 Clinical usefulness of endoscopic argon plasma coagulation treatment on peptic ulcer bleeding.

Background:Argon plasma coagulation(APC) is a new method of contactfree electrocoagulation in which energy is transmitted to tissue through ionized argon gas. APC was effective and relatively safe in treating a wide range of G-I tract diseases. There are however few reports on the effect for endoscopic treatment of peptic ulcer bleeding. Aim:To evaluate the safety and efficacy of the use of APC on endoscopic treatment of peptic ulcer bleeding. Methods:In this trial, a total of 18 patients(M:F=11:7) with bleeding peptic ulcers(gastric ulcers: 12 patients, duodenal ulcers: 6 patients) received APC. According to Forrest classification, Ia was revealed in 8 patients, Ib in 6, II in 4. For APC we used the Soring/Quick born unit. We assessed the hemostatic rates, rebleeding rates, and complication rates retrospectively. Results: After APC, hemostatic rates were 63%(5/8) in Ia, 100%(6/6) in Ib, and 100%(4/4). The rate of rebleeding after initial hemostasis was 13.5% (2 of 15 patients). 3 patients were failed initial hemostasis after APC. 2 of 3 patients received injection sclerotherapy and 1 of 3 hemoclipping and all 3 patients were permanent hemostasis. No major complication was observed in APC. Conclusions: APC seems to be effective and relatively safe for the treatment of peptic ulcer bleeding. There was lower initial hemostasis rate in Ia (spurting type) than Ib or II. A longer follow-up period however,and comparative trials with other treatment modalities are necessary.

Endoscopic hemoclip treatment for bleeding peptic ulcer.

AIM:To evaluate the efficacy of endoscopic hemoclip in the treatment of bleeding peptic ulcer.METHODS:Totally, 40 patients with F1a and F1b hemorrhagic activity of peptic ulcers were enrolled in this uncontrolled prospective study for endoscopic hemoclip treatment.We used a newly developed rotatable clip-device for the application of hemoclip (MD850) to stop bleeding. Endoscopy was repeated if there was any sign or suspicion of rebleeding, and re-clipping was performed if necessary and feasible.RESULTS:Initial hemostatic rate by clipping was 95%, and rebleeding rate was only 8%.Ultimate hemostatic rates were 87%, 96%, and 93% in the F1a and F1b subgroups, and total cases, respectively.In patients with shock on admission, hemoclipping achieved ultimate hemostasis of 71% and 83% in F1a and F1b subgroups, respectively.Hemostasis reached 100% in patients without shock regar-dless of hemorrhagic activity being F1a or F1b. The average number of clips used per case was 3.0 (range 2-5). Spurting bleeders required more clips on average than did oozing bleeders (3.4 versus 2.8). We observed no obvious complications, no tissue injury, or impairment of ulcer healing related to hemoclipping.CONCLUSION: Endoscopic hemoclip placement is an effective and safe method. With the improvement of the clip and application device, the procedure has become easier and much more efficient. Endoscopic hemoclipping deserves further study in the treatment of bleeding peptic ulcers.

Injection techniques for nonvariceal hemorrhage

Endoscopic injection has been used worldwide as the first-line therapy for treatment of bleeding peptic ulcers. Actively bleeding ulcers and ulcers with nonbleeding visible vessels warrant this therapy. Epinephrine is still the most popular agent of choice and there is little evidence to justify combination treatment with other sclerosants. Fibrin glue injection is currently under intense investigation and may prove to facilitate ulcer healing. Injection can be combined with a thermocoagulation technique to secure ulcer hemostasis. Injection therapy can be repeated for recurrent bleeding and, in many cases, may avoid surgery.

Impact of Early Operation on the Mortality from Bleeding Peptic Ulcer – Ten Years’ Experience

In 1984, a risk-dependent combined endoscopic and operative approach for the treatment of bleeding peptic ulcer was developed. This treatment policy has as its major feature an early elective operation in patients with arterial bleeding and a visible vessel, providing that endoscopic control of the bleeding could be achieved. Using this concept in a prospective series resulted in a mortality of 5% compared to a mortality of 14% in a historical control group, where an operation was performed only on demand in case of recurrent bleeding. In 1986, the treatment policy was introduced into clinical routine circumstances at the University Hospital of Düsseldorf. In this paper the results of routine clinical application are presented. The treatment policy was followed in 47% of patients treated respectively primarily transferred to the surgical department. Mortality in arterial bleeding and visible vessel in the conservatively treated group was double the mortality in the early elective operated group (14 vs. 7%). The mortality in patients treated primarily in the department of internal medicine was double the mortality of patients treated at the surgical department (18 vs. 9%). The differences in mortality are mainly due to the procedure in the elderly patients. In patients aged 70 years or more, the mortality rate of patients treated in internal medicine was 31% compared to 16% in the surgery department. Younger patients do not seem to benefit from early elective operation. Our study clearly demonstrates the importance of avoiding late recurrent bleeding. Patients at high risk of this complication should therefore be identified as early as possible and early surgical intervention should be considered by agreed interdisciplinary and evaluated treatment concepts.

Injection Therapy for Bleeding Peptic Ulcers

In the treatment of bleeding peptic ulcers, the concept of dual therapy combining a second modality to epinephrine injection is theoretically appealing. The addition of a sclerosant has not been shown to be beneficial. Early evidence suggests that adding contact thermocoagulation of a thrombogenic agent improves patient outcome.

Randomised trial of single and repeated fibrin glue compared with injection of polidocanol in treatment of bleeding peptic ulcer

Although injection treatments for ulcer haemostasis seem to be effective, recurrent bleeding remains a serious problem. Large randomised clinical trials are required to show differences between treatment modalities for gastrointestinal bleeding. The aim of this study was to compare the safety and efficacy of repeated endoscopic injection of fibrin glue (FG) with that of single endoscopic injection of polidocanol in the prevention of recurrent bleeding. 854 patients with active gastroduodenal bleeding (spurting, oozing), or ulcers with a visible non-bleeding vessel, were randomly assigned one of three endoscopic treatments: single application of polidocanol 1%, single application of FG, or daily repeated application of FG until the visible vessel had disappeared. All patients were pretreated with local injection of epinephrine (1/10,000), and had daily repeat endoscopies until the vessel observed at initial endoscopy was no longer visible. Recurrent bleeding rates among the 790 patients in whom the rates could be assessed were 58 (22.8%) of 254 in the polidocranol group, 51 (19.2%) of 266 in the FG-single group, and 41 (15.2%) of 270 in the FG-repeated group. The difference between FG-repeated treatment and polidocanol was significant (p = 0.036). Treatment failed, making other treatments (including surgery) necessary, in 34 (13.0%) of 261 in the polidocanol group, 34 (12.4%) of 274 in the FG-single group, and 21 (7.7%) of 274 in the FG-repeated group. The difference between FG-repeated treatment and polidocanol was significant (p = 0.046). The 30-day-mortality rates were low in all three treatment groups (polidocanol 4.7%; FG-single treatment 5.3%, FG-repeated treatment 4.3%). The safety profiles of the three treatment strategies were similar. Repeated injection with FG glue is significantly more effective than injection with polidocanol 1% in the treatment of bleeding from gastroduodenal ulcers.

The comparision of hemostatic efficacy of endoscopic hemoclip, hypertonic saline epinephrine injection and combined method in treatment for bleeding peptic ulcer

The comparision of hemostatic efficacy of endoscopic hemoclip, hypertonic saline epinephrine injection and combined method in treatment for bleeding peptic ulcer

Endoscopic injection for bleeding peptic ulcer: A comparison of adrenaline alone with adrenaline plus human thrombin

BACKGROUND & AIMS: Endoscopic injection therapy improves outcome in bleeding peptic ulcer, but the optimum regimen is unknown. The aim of this study was to compare the efficacy of endoscopic therapy with dilute adrenaline alone vs. adrenaline plus human thrombin in the treatment of patients with major peptic ulcer hemorrhage. METHODS: One hundred forty patients with significant peptic ulcer hemorrhage and active arterial bleeding or a nonbleeding visible vessel were randomized to endoscopic injection with 1:100,000 adrenaline (70 patients; group 1) or to adrenaline plus 600-1000 IU of human thrombin (70 patients; group 2). The two groups were well matched for age, shock, hemoglobin concentration, comorbid disease, endoscopic findings, and consumption of nonsteroidal anti-inflammatory drugs. RESULTS: Fourteen patients from group 1 (20%) and 3 patients from group 2 (4.5%) rebled (P < 0.005). Seven patients from group 1 (10%) but no patients from group 2 died within 30 days of admission (P < 0.013). Patients from group 1 were administered a total of 297 units of blood compared with 219 units in group 2 (P < 0.041). CONCLUSIONS: Endoscopic injection using adrenaline plus human thrombin is superior to injection with dilute adrenaline alone and may represent the best treatment for bleeding peptic ulcers. (Gastroenterology 1996 Sep;111(3):623-8)

A COST-EFFECTIVE APPROACH TO THE PATIENT WITH PEPTIC ULCER BLEEDING

The average hospital cost to manage patients hospitalized at Virginia Mason Hospital who bleed from a peptic ulcer is approximately $5000 per patient in our series of 30 patients. Because there are 150,000 admissions per year in the United States for peptic ulcer bleeding, the total hospital cost can be estimated to be $750 million. The actual cost may be higher because our 30 patients had minimal complications and were discharged on average in less than 4 days. The majority of hospital cost is incurred by the intensive care unit or the hospital nursing floor. There is a close to linear relation between the length of stay and the total hospital cost. Upper gastrointestinal endoscopy is a major advance in the treatment of peptic ulcer bleeding. It can provide significant cost savings by identifying some patients with bleeding peptic ulcers who have clean bases on endoscopy who are then eligible for prompt discharge from the hospital. In addition, endoscopic thermal therapy (with multipolar electrocautery or heater probe) and injection therapy cost less than $50 in incremental cost and can reduce further bleeding by 43%, reduce the need for urgent surgery by 63%, and reduce the mortality rate by 60%. Some patients still require urgent surgical intervention, which is substantially more costly than endoscopic hemostasis but is highly effective. Preliminary studies show promise in predicting further bleeding, with clinical scoring systems such as the Baylor Bleeding Score and with the use of Doppler ultrasonography. Better prediction of further bleeding should guide the choice of durable hemostasis early in the hospitalization. Additional studies should clarify the role of NSAID avoidance and H. pylori eradication in the long-term prevention of recurrent peptic ulcer bleeding.

A prospective randomized trial of heater probe thermocoagulation versus injection therapy in peptic ulcer hemorrhage

Background: A prospective, randomized study was performed to compare the hemostatic effect of injection therapy and heater probe thermocoagulation in the treatment of peptic ulcer bleeding.Methods: This study includes 104 patients with upper gastrointestinal bleeding in whom endoscopy revealed a gastric or duodenal ulcer with nonbleeding or bleeding vessel (n = 66), oozing hemorrhage (n = 21), or adherent red clot (n = 17). Patients with other stigmata or clean ulcers were excluded. Patients were randomly assigned during endoscopy to receive injection therapy (adrenaline and polidocanol) (n = 51) or heater probe thermocoagulation (10F probe, at setting of 30 J (n = 53). Therapy was considered successful if there was no further hemorrhage or only minor rebleeding that was controlled with a second endoscopic procedure. Patients with major rebleeding or failure of retreatment underwent emergency surgery.Results: There were no significant differences in effectiveness between injection therapy and thermocoagulation in any of the assessed parameters: the percentage of patients with major recurrent hemorrhage (4% vs 6%) or minor rebleeding (16% vs 17%), need for emergency surgery (two patients from each group), transfusion requirement (0.45 ± 0.9 units vs 0.51 ± 1.1 units), the mean number of hospitalization days (7.1 ± 4.2 vs 6.9 ± 4.9), and mortality (one patient from each group died).Conclusion: Injection therapy and heater probe have similar efficacies in the treatment of bleeding peptic ulcers. (Gastrointest Endosc 1996;43:117-20.)

A review on treatment of bleeding peptic ulcer: a collaborative task of gastroenterologist and surgeon.

The majority of patients presenting with acute upper gastrointestinal haemorrhage bleed from peptic diseases erosive gastritis and duodenal or gastric ulcers. Early gastroscopy is essential in order to reach a diagnosis, assess the prognosis, and institute appropriate therapy. In a meta-analysis it was shown that H2-antagonists significantly reduced mortality. However, two large, prospective and placebo-controlled studies with famotidine and omeprazole failed to show reduction of rebleeding or death. The value of endoscopic haemostatic therapy in patients with high-risk peptic ulcers (active bleeding and non-bleeding visible vessel) has been firmly established with 75% decrease in rebleeding and operation rate, and a 40% reduction in mortality. Risk factors for an adverse outcome are: elderly patients, concomitant diseases and large ulcers in the posterior duodenal bulb or on the lesser curvature. The mortality for emergency surgery in upper GI bleeding is still 10-50%. The mortality of elective operations is less than 2%. Some studies have reduced mortality by avoiding emergency surgery through early elective surgery in high-risk patients.

The role of acid in upper gastrointestinal haemorrhage due to ulcer and stress-related mucosal damage.

A peptic ulcer is a lesion in which acid and pepsin are essential components of pathogenesis. Regardless of the type of patient or the setting in which the ulcer presents, the basic pathogenetic scheme is the same. The primary event is disruption of mucosal integrity. In the presence of acid and pepsin, such disruption of integrity leads to an ulcer. While rarely sufficient by itself to cause ulceration, the presence of acid is a necessary cofactor. The causes of disruption of mucosal integrity include nonsteroidal anti-inflammatory drugs (NSAIDs), Helicobacter pylori and critical illness. With the latter, tissue ischaemia may be the primary event, leading to back-diffusion of H+ ions through increased membrane permeability. Impaired mucosal buffering then leads to intramural acidosis and cell death. Risk factors for bleeding peptic ulcer in the intensive care unit (ICU) include severe trauma, sepsis, respiratory failure, and coagulopathy. Potential roles for decreasing gastric acidity in the treatment of bleeding peptic ulcer include cessation of active bleeding, prevention of rebleeding in hospital and primary prevention of bleeding. Most published studies dealing with the first two situations suggest no benefit with antisecretory therapy. However, the optimal pH for clot and platelet function may be > or = 7.0. Can such pH levels be maintained with antisecretory agents such as the proton pump inhibitors? Are the published trials adequate to demonstrate any benefit from antisecretory agents? Primary prevention of bleeding ulcer in the outpatient setting includes avoidance of NSAIDs, use of antisecretory agents and eradication of H. pylori.(ABSTRACT TRUNCATED AT 250 WORDS)

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

Laser Photocoagulation Versus Ethanol Injection Therapy after Preinjection with Epinephrine in the Treatment of Bleeding Peptic Ulcers

Abstract: A prospective, randomized trial was performed to compare the efficacy of Nd: YAG laser photocoagulation (LP) and absolute ethanol injection therapy (AEIT) in the treatment of peptic ulcer bleeding. Of 396 patients who underwent endoscopy for acute gastrointestinal hemorrhage over a 18‐month period, 185 were found to have peptic ulcers. The patients who had an ulcer with active bleeding (n = 25) or with a nonbleeding visible vessel (n = 35) were randomized to receive either LP (n = 29) or AEIT (n = 31). The two treatment groups were comparable in terms of age, severity of bleeding, site of ulcer, and endoscopic stigmata of recent hemorrhage. There were no significant differences between the LP and AEIT groups in terms of their transfusion requirements after treatment (0.6 ±1.0 vs. 0.5±0.9 unit), rate of initial hemostatic failure or rebleeding (13.8 vs. 9. 7%), emergency surgery (0 vs. O%), median hospital stay (6 us. 8 days), and mortality (0 us. 6.5%). All of the seven patients who rebled received a second session of endoscopic therapy with the other modality and bleeding was controlled. The cause of death in the two expired patients was not related to bleeding. We concluded that LP and AEIT are equally effective in the treatment of peptic ulcer bleeding but AEIT may be preferred over LP because of its simplicity and lower cost.

Controlled trial of endoscopic injection treatment for bleeding from peptic ulcers with visible vessels

Controlled trials have shown that bleeding peptic ulcers can be successfully treated by endoscopy and injection of adrenaline, with or without sclerosant. However, these trials have been done in major research centres, and endoscopic treatment of upper gastrointestinal bleeding has not yet become routine in general hospitals. We have done a prospective, randomised, controlled trial of injection treatment for bleeding peptic ulcers in a district general hospital. Between April, 1989, and June, 1991, all patients with acute upper gastrointestinal bleeding (n = 555) underwent endoscopy by an experienced endoscopist within 24 h of admission. 98 patients were found to have an ulcer with a visible vessel, of whom 93 were randomised to injection (n=48) or standard treatment alone (n=45). Injection treatment consisted of 1-2 ml of 1 in 10 000 adrenaline injected at four to six sites around the ulcer. Adrenaline and 5% ethanolamine oleate (1-2 ml) were then injected directly into the vessel. The medical team managing the patient was unaware of the endoscopic treatment given. The two groups were similar for age, initial haemoglobin concentration, shock, and ulcer site. Rebleeding (injected 8 [16·7%] vs control 21 [46·7%], p=0·011) was significantly reduced in treated patients. The treated group also had lower mortality (4 [8·3%] vs 9 [20%]), requirement for surgery (4 [8·3%] vs 8 [17·8%]), and mean blood-transfusion requirement (5 vs 7·5 units). Endoscopic injection treatment in our patients significantly reduced rebleeding rate and may have other benefits. This cheap and widely applicable treatment can be used routinely in the management of patients with bleeding peptic ulcers who are at high risk of rebleeding.

Randomized comparison of endoscopic microwave coagulation and endoscopic sclerosis in the treatment of bleeding peptic ulcers

We conducted a prospective randomized trial to evaluate the effectiveness and safety of endoscopic microwave coagulation in comparison to endoscopic sclerosis in the treatment of peptic ulcer bleeding. Over 15 months 127 ulcer-bleeding patients with an actively bleeding vessel (N = 21), a non-bleeding vessel (N = 53), oozing hemorrhage (N = 25), or an adherent clot (N = 28) in the ulcer base were randomly assigned during endoscopy to receive treatment with endoscopic sclerosis or with microwave coagulation. There were no significant differences in effectiveness between endoscopic sclerosis and microwave coagulation in any of the assessed parameters: the percentage of patients with major recurrent hemorrhage (5 vs. 12), the percentage who needed emergency surgery (5 vs. 9), the mean (+/- SD) transfusion requirements (0.32 +/- 0.89 vs. 0.78 +/- 1.65), the mean number of hospital days (10.3 +/- 3.5 vs. 10.7 +/- 4.1), and the number of deaths due to bleeding (0 vs. 2) were similar in both groups. No case of perforation occurred in either group. The data suggest that microwave coagulation is as effective and safe as endoscopic sclerosis in the treatment of bleeding peptic ulcers.

Medical treatment of bleeding peptic ulcer: old drugs, new regimens.

Medical treatment of bleeding peptic ulcer: old drugs, new regimens.

Nd: YAG Laser for Treatment of: Bleeding Ulcers: Techniques and Results of Randomized Prospective Trials

Studies using Nd:YAG laser have generated a new sense of optimism that endoscopic hemostasis can improve the outcome of patients with bleeding peptic ulcer. The results of most of the 12 randomized controlled trials of Nd:YAG versus no endoscopic therapy have shown significant improvement in outcomes. Metaanalysis of laser trials shows statistically highly significant improvement for all major endpoints including rebleeding rate, requirement for urgent surgery, as well as mortality. Although Nd:YAG laser is more expensive than alternative endoscopic treatments for bleeding peptic ulcer such as bipolar, heat probe, and injection treatment, there is a larger body of clinical trial, controlled trial, and comparative trials evidence supporting its efficacy and safety than is currently available for any other known treatment of peptic ulcer bleeding.