Gastroduodenal Ulcer Bleeding Research Articles

Outcomes Following Major Emergency Gastric Surgery: the Importance of Specialist Surgeons

Background: The increasing subspecialisation of general surgeons in their elective work may result in problems for the provision of expert care for emergency cases. There is very little evidence of the impact of subspecialism on outcomes following emergency major upper gastrointestinal surgery. This prospective study investigated whether elective subspecialism of general surgeon is associated with a difference in outcome following major emergency gastric surgery.Methods : Between February 1994 and June 2010, the data from all emergency major gastric procedures (defined as patients who underwent laparotomy within 12 hours of referral to the surgical service for bleeding gastroduodenal ulcer and/or undergoing major gastric resection) was prospectively recorded. The sub-specialty interest of operating surgeon was noted and related to post-operative outcomes.Results : Over the study period, a total of 63 major gastric procedures were performed of which 23 (37%) were performed by specialist upper gastrointestinal (UGI) consultants. Surgery performed by a specialist UGI surgeon was associated with a significantly lower surgical complication (4% vs. 28% of cases; p = 0.04) and in-patient mortality rate (22% vs. 50%; p = 0.03).Conclusions : Major emergency gastric surgery has significantly better clinical outcomes when performed by a specialist UGI surgeon. These results have important implications for provision of an emergency general surgical service.

Endoscopic injection of autologous blood versus diluted epinephrine for control of actively bleeding gastroduodenal ulcers: a randomized-controlled study.

A preliminary report showed that autologous blood is an effective and easily applicable technique that can control actively bleeding gastroduodenal ulcers. The aim of this study was to test whether an endoscopic injection of autologous blood is comparable to an endoscopic injection of diluted epinephrine in controlling bleeding from gastroduodenal ulcers. A total of 100 patients with actively bleeding gastroduodenal ulcers were assigned randomly to either an autologous blood injection (group A, n=50) or a diluted epinephrine injection (group B, n=50) along the edges of the ulcers. Groups were compared for rates of initial hemostasis, rebleeding, and complications. All patients initially achieved hemostasis (100%). Rebleeding occurred in four patients from group A (8%) and five patients from group B (10%). Two patients in group B developed cardiovascular complications (arrhythmia and ischemic heart attack), whereas none in group A developed complications. Autologous blood is effective, comparable to diluted epinephrine in achieving initial hemostasis from actively bleeding gastroduodenal ulcers, associated with an 8% rebleeding rate, and led to no complications.

Evaluating the effectiveness of endoscopic treatment of gastroduodenal bleeding in children

Introduction: One of the current problems of emergency abdominal child surgery are gastric (GU) and duodenal ulcer (DU). Thus, domestic and foreign researchers have noted that the prevalence of peptic ulcer disease in the pediatric population in recent years has nearly doubled. GU and duodenal ulcer occurs with frequency 1,6-2,7 cases per 1000 children and is 7-12 % of diseases of the gastrointestinal tract in children. Along with the growing incidence of this disease, there is a tendency of the number of complications increase.One of the major complications that pose a threat to a child's life is gastroduodenal bleeding. InUkraine, the rate for the last five years has increased by 14% and in the structure of hemorrhagic complications of diseases of the gastrointestinal tract up to 60 % .Despite the fact that endoscopic hemostasis is considered the "gold standard" treatment of gastroduodenal ulcer bleeding, their effectiveness in the primary use and application in cases of relapse in childhood actively discussed.Insufficient number of pediatric surgeons work on the effectiveness of the treatment of these complications with the use of modern minimally invasive technologies is largely determined by the relevance and purpose of the present study.Research objective. To analyze the efficacy of endoscopic treatment of bleeding and recurrence of gastric and duodenal ulcers in children.Material and research methods. Results of the treatment of 57children with acute bleeding from gastric and duodenal ulcers in age from 2 to 16 years who were treated in the surgical departments of pediatric surgery clinics Dnepropetrovsk State Medical Academy and Zaporozhye State Medical University were presented. 38 (67 %) were girls, 19 (33 %) - boys.All patients were admitted to the intensive care unit and undergone clinical, laboratory examinations, complex etiopathogenetic treatment (infusion, hemostatic, substitution, antisecretory therapy) and fibrogastroduodenoscopy (EGD) for diagnostic and therapeutic purposes. Activity of the bleeding was defined with scale by Forrest (Forrest-Rosch W., 1986) during endoscopy exam. Endoscopic electrocoagulation monoelektrod using fiberoptic gastroduodenoscopy «Olympus» UES 10 was done. Injection of 0.18% solution of adrenaline with endoscopic injection needle 5Ch in different volumes through the working channel of the endoscope and therapy in combination with electrocautery was done. Treatment effectiveness monitoring was based on clinical, laboratory data and endoscopic studies.Results of research. The study found that duodenal ulcer bleeding substantially prevailed and was found in 44 children, whereas bleeding from gastric ulcer were found in 13 patients. Thus at 52 (91 %) there was no history information of the diagnosed ulcer. Chronic abdominal pain with PUD previously was recorded only in 9% of cases.Bleeding duration up to 6 hours before admission was detected in 39% of children, between 6 and 24 hours – in 45% and more than 24 hours – in 16% of patients. During EGD macroscopic acute ulcers appearance was detected in the majority (86 %) of children, 32% of them in the last month had mentioned nonsteroidal anti-inflammatory drugs intake and 41% of patients noted aggressive and soft products intake. Ulcers size ranged approximately 5-7 mm. Contamination of Helicobacter pylori serological test according to the level of IgG antibodies was detected in 89.8% of children. Variations in the levels of pepsinogen and serum gastrin in 98 % of children do not cross the boundaries of age-reference values. The clinical picture was characterized by vomiting blood 15% of patients, vomiting "coffee grounds" was detected in 72 % of children, melena was observed in 61% of cases.Primary hemostasis using endoscopic electrocautery combinations and epinephrine injection solution was effective in 48 (84 %) children. 9 patients that undergone only electrocoagulation treatment on the 2nd day were diagnosed rebleeding, which required re-EGD using a combined endoscopic hemostasis. According to the results of clinical laboratory and endoscopic control full bleeding stop was observed during the first 2 days of children stay in hospital.Conclusions .1. Study improved predominance of duodenal ulcer bleeding in children.2. History of alcohol and/or nonsteroidal anti-inflammatory drugs intake increases the risk of acute gastric or duodenum ulcers complicated by bleeding.3. Use of surgery endoscopic hemostasis using combined coagulation- injection method on the background of the hemostatic and parenteral antisecretory therapy for primary and preventive stop ulcer bleeding ensures maximum efficiency of complex treatment in the practice.

158 Transarterial Angiographic Embolization vs. Surgery in Patients With Bleeding Peptic Ulcers Uncontrolled At Endoscopy; A Multicenter Randomized Trial

Background Further bleeding after endoscopic hemostasis to bleeding peptic ulcers is associated with an at least 3-fold increase in mortality. We sought to determine if preemptive angiographic embolization (AE) to high risk ulcers can reduce further bleeding and improves patients' outcome. Method Patients with bleeding gastro-duodenal ulcers that required endoscopic hemostasis were enrolled if they fulfilled one of the following criteria; Forrest I a bleeding, ulcer size hypotensive (systolic blood pressure < 90 mmHg) or hemoglobin ≤ 9g/dl. They were randomized to undergo angiographic embolization within 12 hours of endoscopy plus an intravenous infusion of high dose proton pump inhibitor (IV-PPI) or IV-PPI alone. Our primary endpoint was re-bleeding within 30 days of randomization. Results Between January 2010 to October 2013, 222 patients were randomized (AE 109, no AE 113). One and 3 patients were excluded after randomization. Baseline characteristics were similar between groups; mean age 65.3 vs. 67.7), in patient bleeding (19.2 vs. 18.6%), mean transfusion before randomization (2.53 vs. 2.6u),mean systolic BP (109 vs. 105mmHg). In the AE group, mean time to angiography was 4.2 (SD 3.3) hour. Of 109 randomized to AE, 16(14.7%) did not receive AE; 6 of 16 re-bled and 3 died (2 after surgery and 1 from major bleeding), 10 without further bleeding and one died. On an ITT analysis, further bleeding occurred in 8/109 (7.3%) and 12/113 (10.6%) of AE and no AE group respectively (P=0.39, OR, 95%CI=0.67; 0.26-1.70). On a PP analysis, further bleeding occurred in 4/ 91 (4.4%) patients in the AE group compared to 12/110 (10.9%) patients on iv-PPI alone (P=0.089; OR, 95%CI=2.66, 0.8-8.5). There was no 30 day mortality in the AE group (0/ 91 vs. 5/110, P=0.065). Hospitalization and blood transfusion were less in the AE group (6.9 vs. 8.7 days, P=0.2 and 1.2 vs. 1.9U, P=0.09 respectively). Reduction in re-bleeding after AE was seen mostly in patients with ulcers≥1.5cm in size (2/40 vs. 10/43, P=0.027) [Figure 1]. Conclusions Early angiographic embolization after endoscopic hemostasis to patients with gastro-duodenal ulcers ≥1.5cm in size reduces re-bleeding.

158 Transarterial Angiographic Embolization vs. Surgery in Patients With Bleeding Peptic Ulcers Uncontrolled At Endoscopy; a Multicenter Randomized Trial

Background Further bleeding after endoscopic hemostasis to bleeding peptic ulcers is associated with an at least 3-fold increase in mortality. We sought to determine if preemptive angiographic embolization (AE) to high risk ulcers can reduce further bleeding and improves patients' outcome. Method Patients with bleeding gastro-duodenal ulcers that required endoscopic hemostasis were enrolled if they fulfilled one of the following criteria; Forrest I a bleeding, ulcer size hypotensive (systolic blood pressure < 90 mmHg) or hemoglobin ≤ 9g/dl. They were randomized to undergo angiographic embolization within 12 hours of endoscopy plus an intravenous infusion of high dose proton pump inhibitor (IV-PPI) or IV-PPI alone. Our primary endpoint was re-bleeding within 30 days of randomization. Results Between January 2010 to October 2013, 222 patients were randomized (AE 109, no AE 113). One and 3 patients were excluded after randomization. Baseline characteristics were similar between groups; mean age 65.3 vs. 67.7), in patient bleeding (19.2 vs. 18.6%), mean transfusion before randomization (2.53 vs. 2.6u),mean systolic BP (109 vs. 105mmHg). In the AE group, mean time to angiography was 4.2 (SD 3.3) hour. Of 109 randomized to AE, 16(14.7%) did not receive AE; 6 of 16 re-bled and 3 died (2 after surgery and 1 from major bleeding), 10 without further bleeding and one died. On an ITT analysis, further bleeding occurred in 8/109 (7.3%) and 12/113 (10.6%) of AE and no AE group respectively (P=0.39, OR, 95%CI=0.67; 0.26-1.70). On a PP analysis, further bleeding occurred in 4/ 91 (4.4%) patients in the AE group compared to 12/110 (10.9%) patients on iv-PPI alone (P=0.089; OR, 95%CI=2.66, 0.8-8.5). There was no 30 day mortality in the AE group (0/ 91 vs. 5/110, P=0.065). Hospitalization and blood transfusion were less in the AE group (6.9 vs. 8.7 days, P=0.2 and 1.2 vs. 1.9U, P=0.09 respectively). Reduction in re-bleeding after AE was seen mostly in patients with ulcers≥1.5cm in size (2/40 vs. 10/43, P=0.027) [Figure 1]. Conclusions Early angiographic embolization after endoscopic hemostasis to patients with gastro-duodenal ulcers ≥1.5cm in size reduces re-bleeding.

Response to “Transcatheter arterial embolization for gastroduodenal ulcer bleeding: the use of cyanoacrylate glue has gained acceptance”

Response to “Transcatheter arterial embolization for gastroduodenal ulcer bleeding: the use of cyanoacrylate glue has gained acceptance”

Transcatheter arterial embolization for gastroduodenal ulcer bleeding: the use of cyanoacrylate glue has gained acceptance

Transcatheter arterial embolization for gastroduodenal ulcer bleeding: the use of cyanoacrylate glue has gained acceptance

The Pitfall in Conservative Therapy for Working Patients with Brain Ischemia

A 59-year-old employed man was recommended to have surgical treatment for symptomatic left middle cerebral arterial stenosis. He refused surgical treatment for social reasons but was given conservative therapy for the prevention of the recurrence of cerebral infarction. Immediately after he retired, he had severe recurrent cerebral infarction with severe anemia and low blood pressure due to gastroduodenal ulcer bleeding. It was inferred from MRI findings that this recurrent cerebral infarction was related to a hemodynamic mechanism and mental stress due to the gastroduodenal ulcer. The influence of occupational mental stress has been reported to be a risk factor of gastroduodenal ulcer. The occupational situation of a patient should be an important factor in consideration of the prevention of cerebral apoplexy.

Predictive Factors for Endoscopic Hemostasis in Patients with Upper Gastrointestinal Bleeding

Predictive Factors for Endoscopic Hemostasis in Patients with Upper Gastrointestinal Bleeding

Predictive factors for intractability to endoscopic hemostasis in the treatment of bleeding gastroduodenal peptic ulcers in Japanese patients.

Background/AimsDespite improvements in endoscopic hemostasis and pharmacological therapies, upper gastrointestinal (UGI) ulcers repeatedly bleed in 10% to 20% of patients, and those without early endoscopic reintervention or definitive surgery might be at a high risk for mortality. This study aimed to identify the risk factors for intractability to initial endoscopic hemostasis.MethodsWe analyzed intractability among 428 patients who underwent emergency endoscopy for bleeding UGI ulcers within 24 hours of arrival at the hospital.ResultsDurable hemostasis was achieved in 354 patients by using initial endoscopic procedures. Sixty-nine patients with Forrest types Ia, Ib, IIa, and IIb at the second-look endoscopy were considered intractable to the initial endoscopic hemostasis. Multivariate analysis indicated that age ≥70 years (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.07 to 4.03), shock on admission (OR, 5.26; 95% CI, 2.43 to 11.6), hemoglobin <8.0 mg/dL (OR, 2.80; 95% CI, 1.39 to 5.91), serum albumin <3.3 g/dL (OR, 2.23; 95% CI, 1.07 to 4.89), exposed vessels with a diameter of ≥2 mm on the bottom of ulcers (OR, 4.38; 95% CI, 1.25 to 7.01), and Forrest type Ia and Ib (OR, 2.21; 95% CI, 1.33 to 3.00) predicted intractable endoscopic hemostasis.ConclusionsVarious factors contribute to intractable endoscopic hemostasis. Careful observation after endoscopic hemostasis is important for patients at a high risk for incomplete hemostasis.

Platelet aggregation measurement for assessment of hemostasis failure mechanisms in patients with gastroduodenal ulcer bleeding

BackgroundThe purpose of this study was to identify factors associated with the risk of unsustainable hemostasis in patients with gastric and duodenal ulcer bleeding by in vitro assessment of platelet reactivity using artificial neural networks.MethodsPatients with gastroduodenal ulcers complicated by bleeding were studied. Platelet aggregation was measured using aggregometry with adenosine diphosphate 5 μM, epinephrine 2.5 μM, 5-hydroxytryptophan 10 μM, collagen 1 μM, and thrombin 0.06 NIH Unit/mL as agonists. Multiple logistic regression was used to evaluate the independent relationship between demographic, clinical, endoscopic, and laboratory data and in vitro assessment of platelet reactivity and local parameters of hemostasis in patients with ulcer bleeding.ResultsAnalysis of platelet aggregation in patients with gastroduodenal ulcer bleeding allowed the variability of platelet response to different agonists used in effective concentration which induces 50% platelet aggregation (EC50) to be established. The relationship between platelet aggregation and the spatial-temporal characteristics of ulcers complicated by bleeding was demonstrated. Adrenoreactivity of platelets was associated with time elapsed since the start of ulcer bleeding and degree of hemorrhage. The lowest platelet response to collagen and thrombin was detected in patients with active bleeding (P < 0.001) and unsustainable recent bleeding (P < 0.01). Decreased adenosine diphosphate-induced platelet aggregation in patients with ulcer bleeding was correlated with the platelet response to thrombin (r = 0.714, P < 0.001) and collagen (r = 0.584, P < 0.01).ConclusionEstimation of platelet reactivity in vitro indicates the key mechanisms of failure of hemostasis in patients with ulcer bleeding. In addition to gender, an important determinant of unsustainable hemostasis was a decreased platelet response to thrombin and adenosine diphosphate.

Hemodynamics and Blood Coagulation System in Patients Operated Following Ulcer Disease Hemorrhagia

Objective: to evaluate the clinical efficacy of hypoxen and nutrients used in the combination therapy of patients operated for bleeding gastroduodenal ulcer. Subjects and methods. Seventy-four patients were examined and treated. All the patients were divided into 3 groups: 1) standard therapy + hypoxen in a daily dose of 1 g for a week; 2) standard therapy + hypox-en and nutrients; 3) standard therapy only. Hypoxen and nutrients were administered on postoperative day 1 via an enter-al feeding tube. Systemic hemodynamic and hemostatic parameters were determined using MICAR-RHEO hardware-software rheographic unit APG2-01 analyzer, respectively. Results. It was established that the hyper- and eukinetic hemodynamic types were predominant before surgery and the eukinetic type was prevalent in the early postoperative period. Hypoxen and nutrients were observed to positively affect central hemodynamic parameters, such as blood pressure, cardiac output, circulating blood volume, and heart rate. Hypercoagulation changes (shorter blood clotting time in a study group and elevated serum fibrinogen levels in a comparison group) on postoperative day 10 suggest that the hemostatic parameters should be monitored and corrected as soon as possible. Key words: ulcer disease, hypoxen, nutritional support, blood circulation, hemostatic system.

Su1927 Gender Differences in GI Symptom Patterns Related to Clinically Significant Organic Diseases Are Detected in Japanese Patients

[Introduction] Endoscopic therapy has been demonstrated to be effective in achieving hemostasis for bleeding peptic ulcers. Thermal coagulation is one of the most commonly used methods with a high success rate. Recently, endoscopic submucosal dissection for early gastric carcinoma was developed and hemostasis with soft coagulation using hemostatic forceps was introduced. We applied endoscopic hemostasis with soft coagulation to gastroduodenal ulcer bleeding and reported that initial and final hemostatic rates were 95% and 100%, respectively. The aim of this study was to compare the hemostatic effects of soft coagulation with those of heater probe thermocoagulation for peptic ulcer bleeding. [Methods] Patients who visited our hospital with hematemesis or melena and required life-saving endoscopic treatment were recruited. Inclusion criteria in this study were that they presented with an actively bleeding ulcer, a nonbleeding visible vessel, or an adherent clot. Patients were excluded if they were unwilling to give written informed consent or had bleeding gastric malignancy. Patients were randomized to receive endoscopic hemostasis with soft coagulation (Group S) or heater probe thermocoagulation (Group H). In Group S, endoscopic hemostasis with soft coagulation was performed using a monopolar hemostatic forceps (FD410LR, Olympus) and an electrosurgical unit (ICC-200, ERBE) at 70W. In Group H, a heater probe unit (HPU-20, Olympus) was used and pulses of 20 to 30 J were given. When the allocated treatment failed to achieve hemostasis, the other method was applied. If hemostasis was not obtained using thesemethods, intervention radiology or surgical treatment was applied. Initial hemostasis was declared when hemostasis was obtained by the single allocated method and second-look endoscopy revealed no bleeding from ulcers. The primary endpoint was the initial hemostasis rate and secondary endpoints were the rebleeding rate, complications and the procedure time. [Results] Between May 2010 and February 2012, a total of 111 patients (89 gastric ulcers and 22 duodenal ulcers) were enrolled. There were no significant differences in the background characteristics between Groups S and H. Initial hemostasis was achieved in 54 patients (96%) in Group S and 37 patients (67%) in Group H (p , 0.0001). Rebleeding occurred in 4 patients in Group H and none in Group S. Of these patients, urgent surgery was performed in one patient. Perforation occurred in two patients in Group H, which were managed conservatively. The duration of endoscopic therapy was shorter in Group S than in Group H, although not significantly (P = 0.10). [Conclusions] For patients with gastroduodenal ulcer bleeding, soft coagulation using a monopolar hemostatic forceps provides an advantage in achieving hemostasis compared with heater probe thermocoagulation.

Su1923 A Prospective, Randomized Trial of Soft Coagulation Versus Heater Probe Thermocoagulation for Peptic Ulcer Bleeding

[Introduction] Endoscopic therapy has been demonstrated to be effective in achieving hemostasis for bleeding peptic ulcers. Thermal coagulation is one of the most commonly used methods with a high success rate. Recently, endoscopic submucosal dissection for early gastric carcinoma was developed and hemostasis with soft coagulation using hemostatic forceps was introduced. We applied endoscopic hemostasis with soft coagulation to gastroduodenal ulcer bleeding and reported that initial and final hemostatic rates were 95% and 100%, respectively. The aim of this study was to compare the hemostatic effects of soft coagulation with those of heater probe thermocoagulation for peptic ulcer bleeding. [Methods] Patients who visited our hospital with hematemesis or melena and required life-saving endoscopic treatment were recruited. Inclusion criteria in this study were that they presented with an actively bleeding ulcer, a nonbleeding visible vessel, or an adherent clot. Patients were excluded if they were unwilling to give written informed consent or had bleeding gastric malignancy. Patients were randomized to receive endoscopic hemostasis with soft coagulation (Group S) or heater probe thermocoagulation (Group H). In Group S, endoscopic hemostasis with soft coagulation was performed using a monopolar hemostatic forceps (FD410LR, Olympus) and an electrosurgical unit (ICC-200, ERBE) at 70W. In Group H, a heater probe unit (HPU-20, Olympus) was used and pulses of 20 to 30 J were given. When the allocated treatment failed to achieve hemostasis, the other method was applied. If hemostasis was not obtained using thesemethods, intervention radiology or surgical treatment was applied. Initial hemostasis was declared when hemostasis was obtained by the single allocated method and second-look endoscopy revealed no bleeding from ulcers. The primary endpoint was the initial hemostasis rate and secondary endpoints were the rebleeding rate, complications and the procedure time. [Results] Between May 2010 and February 2012, a total of 111 patients (89 gastric ulcers and 22 duodenal ulcers) were enrolled. There were no significant differences in the background characteristics between Groups S and H. Initial hemostasis was achieved in 54 patients (96%) in Group S and 37 patients (67%) in Group H (p , 0.0001). Rebleeding occurred in 4 patients in Group H and none in Group S. Of these patients, urgent surgery was performed in one patient. Perforation occurred in two patients in Group H, which were managed conservatively. The duration of endoscopic therapy was shorter in Group S than in Group H, although not significantly (P = 0.10). [Conclusions] For patients with gastroduodenal ulcer bleeding, soft coagulation using a monopolar hemostatic forceps provides an advantage in achieving hemostasis compared with heater probe thermocoagulation.

Su1925 Characteristics of Gastric Polyps in African Americans and Hispanics

[Introduction] Endoscopic therapy has been demonstrated to be effective in achieving hemostasis for bleeding peptic ulcers. Thermal coagulation is one of the most commonly used methods with a high success rate. Recently, endoscopic submucosal dissection for early gastric carcinoma was developed and hemostasis with soft coagulation using hemostatic forceps was introduced. We applied endoscopic hemostasis with soft coagulation to gastroduodenal ulcer bleeding and reported that initial and final hemostatic rates were 95% and 100%, respectively. The aim of this study was to compare the hemostatic effects of soft coagulation with those of heater probe thermocoagulation for peptic ulcer bleeding. [Methods] Patients who visited our hospital with hematemesis or melena and required life-saving endoscopic treatment were recruited. Inclusion criteria in this study were that they presented with an actively bleeding ulcer, a nonbleeding visible vessel, or an adherent clot. Patients were excluded if they were unwilling to give written informed consent or had bleeding gastric malignancy. Patients were randomized to receive endoscopic hemostasis with soft coagulation (Group S) or heater probe thermocoagulation (Group H). In Group S, endoscopic hemostasis with soft coagulation was performed using a monopolar hemostatic forceps (FD410LR, Olympus) and an electrosurgical unit (ICC-200, ERBE) at 70W. In Group H, a heater probe unit (HPU-20, Olympus) was used and pulses of 20 to 30 J were given. When the allocated treatment failed to achieve hemostasis, the other method was applied. If hemostasis was not obtained using thesemethods, intervention radiology or surgical treatment was applied. Initial hemostasis was declared when hemostasis was obtained by the single allocated method and second-look endoscopy revealed no bleeding from ulcers. The primary endpoint was the initial hemostasis rate and secondary endpoints were the rebleeding rate, complications and the procedure time. [Results] Between May 2010 and February 2012, a total of 111 patients (89 gastric ulcers and 22 duodenal ulcers) were enrolled. There were no significant differences in the background characteristics between Groups S and H. Initial hemostasis was achieved in 54 patients (96%) in Group S and 37 patients (67%) in Group H (p , 0.0001). Rebleeding occurred in 4 patients in Group H and none in Group S. Of these patients, urgent surgery was performed in one patient. Perforation occurred in two patients in Group H, which were managed conservatively. The duration of endoscopic therapy was shorter in Group S than in Group H, although not significantly (P = 0.10). [Conclusions] For patients with gastroduodenal ulcer bleeding, soft coagulation using a monopolar hemostatic forceps provides an advantage in achieving hemostasis compared with heater probe thermocoagulation.

Epidemiological Clinical Features and Evolution of Gastroduodenal Ulcer Bleeding in a Tertiary Care Hospital in Spain, during the Last Seven Years

Background. Gastroduodenal ulcer bleeding is a common medical emergency. The aim of this study was to analyze the characteristics of bleeding episodes and to identify changes in the clinical trends over seven years. Methods. Retrospective observational clinical study on a cohort of 272 consecutive adult patients with peptic ulcer bleeding, during the 2006–2012 period. Results. Mean annual admission rate was 12.8 per 100.000 inhabitants. Men were predominant (71%), with a mean age of 66.6 years. Comorbidities were present in 131 cases (48.2%) and 156 patients (57.4%) had received ulcerogenic drugs. Duodenal ulcer was the commonest location (61%). Endoscopic therapy was necessary in 183 cases (67.3%) and rebleeding occurred in 30 patients (11%). Overall mortality rate was 5.5%, with a significant association with the presence of comorbidities (P < 0.01). There were no differences in trends of annual hospitalization, clinical features at presentation, and outcomes during this 7-years period. Conclusions. Annual hospitalization rates and prognosis of peptic ulcer bleeding have remained unchanged in the study period. This may be due to the fact that the effect of improved approach on this condition is probably counteracted by risk factors such as older age, severe comorbidities, and ulcerogenic drugs consumption, which have also remained stable over recent years.

Pantoprazole before Endoscopy in Patients with Gastroduodenal Ulcer Bleeding: Does the duration of Infusion and Ulcer Location Influence the Effects?

The aim of this study was to investigate the effect of preemptive pantoprazole infusion on early endoscopic findings in patients with acute ulcer bleeding. Records of 333 patients admitted with acute ulcer bleeding were analyzed. Ulcer bleeders were given either 80 mg bolus of pantoprazole followed by continuous infusion of 8 mg per hour or saline infusion until endoscopy. In 93 patients saline infusion whereas in 240 patients bolus plus infusion of pantoprazole was administrated with mean (±SD) durations of 5.45 ± 12.9 hours and 6.9 ± 13.2 hours, respectively (P = 0.29). Actively bleeding ulcers were detected in 46/240 (19.2%) of cases in the pantoprazole group as compared with 23/93 (24.7%) in the saline infusion group (P = 0.26). Different durations of pantoprazole infusion (0–4 hours, >4 hours, and >6 hours) had no significant effect on endoscopic and clinical outcome parameters in duodenal ulcer bleeders. Gastric ulcer bleeders on pantoprazole infusion longer than 4 and 6 hours before endoscopy had actively bleeding ulcers in 4.3% and 5% compared to the 19.5% active bleeding rate in the saline group (P = 0.02 and P = 0.04). Preemptive infusion of high-dose pantoprazole longer than 4 hours before endoscopy decreased the ratio of active bleeding only in gastric but not in duodenal ulcer patients.

Major Adverse Upper Gastrointestinal Events in Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Coronary Intervention and Dual Antiplatelet Therapy

The aim of this study was to investigate the incidence of composite short-term and long-term major adverse upper gastrointestinal (UGI) events (MAUGIEs; defined as gastric ulcer, duodenal ulcer, gastroduodenal ulcer, or UGI bleeding) in patients with acute ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention and routinely received dual-antiplatelet therapy. From May 2002 to September 2010, a total of 1,368 consecutive patients who experienced ST-segment elevation myocardial infarction and underwent primary percutaneous coronary intervention were prospectively enrolled in the study. The incidence of in-hospital UGI bleeding complications and composite MAUGIEs was 8.9% and 9.9%, respectively. The in-hospital mortality rate was significantly higher in patients with in-hospital MAUGIEs than in those without (p <0.001). Multivariate analysis showed that age, advanced Killip score (≥3), and respiratory failure were the strongest independent predictors of in-hospital composite MAUGIEs (all p <0.003). The cumulative composite of MAUGIEs after uneventful discharge in patients without adverse UGI events who continuously received dual-antiplatelet therapy for 3 to 12 months, followed by aspirin therapy, was 10.4% during long-term (mean 4.0 years) follow-up. In conclusion, the results of this study show a remarkably high incidence of composite short-term and long-term MAUGIEs in patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention and received routine dual-antiplatelet therapy. Age, advanced Killip score, and respiratory failure were significantly and independently predictive of in-hospital composite MAUGIEs.

COMPARISON OF ADJUVANT THERAPIES BY AN H2‐RECEPTOR ANTAGONIST AND A PROTON PUMP INHIBITOR AFTER ENDOSCOPIC TREATMENT IN HEMOSTATIC MANAGEMENT OF BLEEDING GASTRODUODENAL ULCERS

Upper gastrointestinal bleeding is often associated with a higher risk of serious blood loss. Both H2-receptor antagonists and proton pump inhibitors are commonly given intravenously for endoscopic hemostatic therapies. We compared the effects of a H2-receptor antagonist (famotidine) and a proton pump inhibitor (omeprazole) injected during the early phase (the first 3 days) on cessation of bleeding and prevention of its recurrence in patients who underwent endoscopic therapy for gastroduodenal ulcer bleeding. Consecutive patients who were hospitalized at our clinic with bleeding gastroduodenal ulcers and underwent endoscopic therapy were randomly assigned to receive injections of famotidine, omeprazole, or both. Injection of acid suppressants was switched on the fourth day to the oral administration of omeprazole continued for 8 weeks. Over a 25-month period, 116 patients were enrolled. The overall success rate for endoscopic hemostasis was 115/116 (99.1%). The success rate of hemostasis and prevention of recurrent ulcer bleeding by type of acid suppressant following endoscopic hemostasis was 39/40 (97.5%) for Group 1 (3-day omeprazole administration), 35/37 (94.6%) for Group 2 (3-day famotidine administration), and 38/39 (97.4%) for Group 3 (1-day famotidine and then 2-day omeprazole administration), yielding an overall rate of 112/116 (96.6%). No significant difference in the hemostatic effect was observed among the groups. There were also no differences in the duration of hospital days and the number of fasting days between the three groups. Famotidine and omeprazole injected during the early phase of a bleeding ulcer may have similar effects to an adjuvant therapy for preventing rebleeding from endoscopically treated upper gastrointestinal bleeding in Japanese patients.

RETROSPECTIVE MULTICENTER STUDY CONCERNING ELECTROCAUTERY FORCEPS WITH SOFT COAGULATION FOR NONMALIGNANT GASTRODUODENAL ULCER BLEEDING IN JAPAN

Electrocautery forceps with soft coagulation are actively used for treatment of bleeding and nonbleeding visible vessels during endoscopic submucosal dissection, but the usefulness of gastroduodenal ulcer bleeding has not been elucidated so far. The purpose of this paper is to elucidate the outcomes of electrocautery forceps with soft coagulation for peptic and artificial gastroduodenal ulcer bleeding. A retrospective multicenter study of consecutive case series during one year involved nine departments of high-volume hospitals in Japan. The study included 128 consecutive patients (62 with peptic ulcers and 66 with artificial ulcers) with bleeding nonmalignant gastroduodenal ulcers that were revealed using emergency endoscopy between January 2008 and December 2008. Hemostasis was carried out using electrocautery forceps with soft coagulation. Rates of successful initial hemostasis, rebleeding, transfer to surgery, and death according to peptic and artificial ulcer bleeding were recorded. Successful initial endoscopic hemostasis was obtained in 61 peptic ulcer patients (98.4%) and 66 artificial ulcer patients (100%). Rebleeding was observed in seven peptic ulcer patients (11.5%) and five artificial ulcer patients (7.6%). Rates of successful management with endoscopic methods alone were 96.8% (60/62) and 100% (66/66) in peptic ulcer patients and artificial ulcer patients, respectively. There were no severe complications or deaths related to the management of gastroduodenal ulcer bleeding. The novel endoscopic method using electrocautery forceps with soft coagulation for gastroduodenal ulcer bleeding seems to provide safety and efficacy that is comparable with that of endoscopic hemostasis with other established hemostatic techniques.