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Shin J, Cha B, Hong J, Kwon KS, Lee E, Maeng JH, Chung JW, Park DK, Kim YJ, Kwon KA, Kim JH, Seo KS, Hong SJ, Kim KO. Prevention of rebleeding after primary haemostasis using haemostatic powder in non-variceal upper gastrointestinal bleeding: a multicentre randomised controlled trial. Gut 2025:gutjnl-2024-332459. [PMID: 40360231 DOI: 10.1136/gutjnl-2024-332459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 05/01/2025] [Indexed: 05/15/2025]
Abstract
BACKGROUND Non-variceal upper gastrointestinal bleeding (NVUGIB) remains a major cause of morbidity and mortality. Rebleeding rates following endoscopic treatment can reach up to 25% within 72 hours in patients with high-risk lesions. OBJECTIVE To evaluate the efficacy of a haemostatic powder (Nexpowder) in reducing rebleeding rates after conventional endoscopic treatment in patients with NVUGIB. DESIGN This was a prospective, multicentre, randomised controlled trial involving patients with acute NVUGIB from high-risk lesions who achieved initial endoscopic haemostasis. Participants were randomised 1:1 to receive either the haemostatic powder or no further therapy (control group). The primary outcome was the rebleeding rate within 72 hours post-treatment. Secondary outcomes included the 30-day rebleeding rate and the safety profile. RESULTS A total of 341 patients (72.1% male; mean age 64.8 years) were included, with 173 in the powder group and 168 in the control group. Baseline characteristics were similar between groups. Ulcer bleeding was the predominant aetiology (n=317), with Forrest type I bleeding observed in two-thirds of cases. The 72-hour rebleeding rate was significantly lower in the powder group (2.9%, 95% CI 0.9 to 6.6%) compared with the control group (11.3%, 95% CI 6.9 to 17.1%; p =0.005). A significant reduction was also observed in the 30-day cumulative rebleeding rate (7.0% vs 18.8%), with similar findings in the ulcer subgroup for the 3-day rebleeding rate (3.0% vs 12.0%; p =0.004). No adverse events related to the powder application were reported. CONCLUSION The application of Nexpowder following endoscopic haemostasis significantly reduced both early (3 days) and late (30 days) rebleeding rates in patients with NVUGIB, particularly in cases of ulcer-related bleeding. TRIAL REGISTRATION NUMBER NCT04124588.
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Affiliation(s)
- Jongbeom Shin
- Department of Internal Medicine, Inha University Hospital, Inha University, Incheon, Korea (the Republic of)
| | - Boram Cha
- Department of Internal Medicine, Inha University Hospital, Inha University, Incheon, Korea (the Republic of)
| | - Jitaek Hong
- Department of Internal Medicine, Inha University Hospital, Inha University, Incheon, Korea (the Republic of)
| | - Kye Sook Kwon
- Department of Internal Medicine, Inha University Hospital, Inha University, Incheon, Korea (the Republic of)
| | - Eunhye Lee
- Utah-Inha DDS & Advanced Therapeutics Research Center, Incheon, Korea (the Republic of)
| | - Jin Hee Maeng
- Utah-Inha DDS & Advanced Therapeutics Research Center, Incheon, Korea (the Republic of)
| | - Jun-Won Chung
- Department of Internal Medicine, Gachon University College of Medicine, Gachon University Gil Medical Center, Incheon, Korea (the Republic of)
| | - Dong Kyun Park
- Department of Internal Medicine, Gachon University College of Medicine, Gachon University Gil Medical Center, Incheon, Korea (the Republic of)
| | - Yoon Jae Kim
- Department of Internal Medicine, Gachon University College of Medicine, Gachon University Gil Medical Center, Incheon, Korea (the Republic of)
| | - Kwang An Kwon
- Department of Internal Medicine, Gachon University College of Medicine, Gachon University Gil Medical Center, Incheon, Korea (the Republic of)
| | - Jung Ho Kim
- Department of Internal Medicine, Gachon University College of Medicine, Gachon University Gil Medical Center, Incheon, Korea (the Republic of)
| | - Kwang-Suk Seo
- Department of Dental Anesthesiology, School of Dentistry, Seoul National University, Seoul, Korea (the Republic of)
| | - Su Jin Hong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea (the Republic of)
| | - Kyoung Oh Kim
- Department of Internal Medicine, Gachon University College of Medicine, Gachon University Gil Medical Center, Incheon, Korea (the Republic of)
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Fujishiro M, Iguchi M, Ono S, Funasaka K, Sakata Y, Mikami T, Kataoka M, Shimaoka S, Michida T, Igarashi Y, Tanaka S. Guidelines for endoscopic management of nonvariceal upper gastrointestinal bleeding (second edition). Dig Endosc 2025; 37:447-469. [PMID: 40114631 DOI: 10.1111/den.15019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2024] [Accepted: 02/19/2025] [Indexed: 03/22/2025]
Abstract
The Japan Gastroenterological Endoscopy Society has prepared Guidelines for Endoscopic Practice in Nonvariceal Upper Gastrointestinal Bleeding as part of the initiative to develop evidence-based endoscopic practice guidelines. Hemorrhagic gastroduodenal (peptic) ulcers are the primary cause of nonvariceal upper gastrointestinal bleeding. With the advent of a super-aged society, the cases caused by Helicobacter pylori are on the decline, whereas those caused by drugs (e.g. aspirin) have been increasing. Endoscopic hemostasis is currently the first-line treatment for nonvariceal upper gastrointestinal bleeding, and various methods have been devised for this purpose. It is recommended to stabilize the vital signs of the patient before and after endoscopic hemostasis with appropriate management based on an assessment of the severity of illness, in addition to the administration of acid secretion inhibitors. These guidelines describe the evaluation and initial treatment of nonvariceal upper gastrointestinal bleeding, as well as the selection of endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding and its management after endoscopic hemostasis. This is achieved by classifying nonvariceal upper gastrointestinal bleeding into two main categories, namely, peptic ulcer and other types of gastrointestinal bleeding. We prepared statements for any available literature with supporting evidence, including the levels of evidence and recommendations. New evidence has been pooled since the publication of the first edition in this area; however, the levels of evidence and recommendations mostly remain low.
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Affiliation(s)
| | | | - Satoshi Ono
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kohei Funasaka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Tatsuya Mikami
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | - Tomoki Michida
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Shinji Tanaka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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Seong G, Cha B, Shin J, Kong SM, Hong JT, Kwon KS. UI-EWD hemostatic powder in the management of refractory lower gastrointestinal bleeding: a multicenter study. Scand J Gastroenterol 2024; 59:1172-1177. [PMID: 39264069 DOI: 10.1080/00365521.2024.2403120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 09/01/2024] [Accepted: 09/05/2024] [Indexed: 09/13/2024]
Abstract
INTRODUCTION Lower gastrointestinal bleeding (LGIB) is a common cause of emergency hospitalization and may require readmission for re-bleeding. A novel adhesive endoscopic hemostatic powder (UI-EWD/NexpowderTM, Nextbiomedical, Incheon, South Korea) has been developed and recently utilized for LGIB hemostasis. The aim of the current study was to assess the efficacy and safety of UI-EWD as a rescue therapy for the treatment of refractory LGIB. METHODS In this study, a total of 59 consecutive patients with LGIB who experienced initial hemostasis failure with conventional endoscopic therapy were enrolled into this multicenter single-arm study. These patients subsequently underwent UI-EWD application for the refractory LGIB hemostasis. We evaluated the success rate of hemostasis, re-bleeding rate within 30 d, and adverse events related to UI-EWD. RESULTS UI-EWD was successfully administered to the bleeding sites in all enrolled refractory bleeding patients. Hemostasis was achieved in the entirety of the 59 patients (100%). The cumulative re-bleeding rate within 30 d was 8.5% (5/59). There were no UI-EWD-related adverse events, such as perforation nor embolism. CONCLUSION Based on our results, the utilization of UI-EWD demonstrated a remarkable success rate in achieving hemostasis for refractory LGIB, while also exhibiting promising outcomes in reducing the re-bleeding rate within a 30-day period. Particularly, UI-EWD exhibits a favorable safety profile across all segments of the colon in cases of refractory LGIB.
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Affiliation(s)
- Gyeol Seong
- Digestive Disease Center, Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, South Korea
| | - Boram Cha
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, South Korea
| | - Jongbeom Shin
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, South Korea
| | - Sung Min Kong
- Division of Gastroenterology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine
| | - Ji Taek Hong
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, South Korea
| | - Kye Sook Kwon
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, South Korea
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Voiosu A, State M, Drăgan V, Văduva S, Bălănescu P, Mateescu RB, Voiosu T. Systematic review of self-assembling peptides as topical agents for treatment and prevention of gastrointestinal bleeding. Clin Endosc 2024; 57:454-465. [PMID: 38919060 PMCID: PMC11294863 DOI: 10.5946/ce.2023.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/28/2023] [Accepted: 09/30/2023] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND/AIMS Gastrointestinal bleeding is a significant and potentially lethal event. We aimed to review the efficiency and safety of self-assembling peptides for the treatment and prevention of gastrointestinal tract bleeding. METHODS We conducted a systematic search for studies describing the endoscopic use of self-assembling peptides for treatment or prevention of bleeding in the gastrointestinal tract in a parallel, independent fashion. The primary outcomes were rates of successful initial hemostasis, delayed bleeding, and rebleeding. The secondary outcomes were adverse events and ease and volume of gel used. RESULTS Seventeen studies were analyzed. Overall success rate of self-assembling peptides in gastrointestinal bleeding was 87.7% (38%-100%), regardless of etiology or associated treatments. Rebleeding rate ranged from 0% to 16.2%, with a mean of 4.7%, and overall delayed bleeding rate was 5% (range, 0%-15.9%). Only three adverse events were reported in a pooled number of 815 patients. The volume of gel used varied (0.43 to 3.7 mL) according to indication and type of bleeding. CONCLUSIONS The limited available data on the use of self-assembling peptides in gastrointestinal endoscopy suggest a high efficiency and good safety profile.
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Affiliation(s)
- Andrei Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Monica State
- Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Victor Drăgan
- Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Sergiu Văduva
- Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Paul Bălănescu
- Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Radu Bogdan Mateescu
- Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Theodor Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Mujadzic H, Noorani S, Riddle PJ, Wang Y, Metts G, Yacu T, Abougergi MS. Ulcer Bleeding in the United States: Epidemiology, Treatment Success, and Resource Utilization. Dig Dis Sci 2024; 69:1963-1971. [PMID: 38446313 DOI: 10.1007/s10620-024-08322-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 10/09/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND AND GOALS Peptic ulcer disease is the most frequent cause of upper gastrointestinal bleeding. We sought to establish the epidemiology and hemostasis success rate of the different treatment modalities in this setting. METHODS Retrospective cohort study using the National Inpatient Sample. Non-elective adult admissions with a principal diagnosis of ulcer bleeding were included. The primary outcome was endoscopic, radiologic and surgical hemostasis success rate. Secondary outcomes were patients' demographics, in-hospital mortality and resource utilization. On subgroup analysis, gastric and duodenal ulcers were studied separately. Confounders were adjusted for using multivariate regression analysis. RESULTS A total of 136,425 admissions (55% gastric and 45% duodenal ulcers) were included. The mean patient age was 67 years. The majority of patients were males, Caucasians, of lower income and high comorbidity burden. The endoscopic, radiological and surgical therapy and hemostasis success rates were 33.6, 1.4, 0.1, and 95.1%, 89.1 and 66.7%, respectively. The in-hospital mortality rate was 1.9% overall, but 2.4% after successful and 11.1% after failed endoscopic hemostasis, respectively. Duodenal ulcers were associated with lower adjusted odds of successful endoscopic hemostasis, but higher odds of early and multiple endoscopies, endoscopic therapy, overall and successful radiological therapy, in-hospital mortality, longer length of stay and higher total hospitalization charges and costs. CONCLUSIONS The ulcer bleeding endoscopic hemostasis success rate is 95.1%. Rescue therapy is associated with lower hemostasis success and more than a ten-fold increase in mortality rate. Duodenal ulcers are associated with worse treatment outcomes and higher resource utilization compared with gastric ulcers.
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Affiliation(s)
- Hata Mujadzic
- Department of Internal Medicine, Prisma Health Midlands, Columbia, SC, USA
- University of South Carolina School of Medicine, Columbia, SC, USA
| | - Shayan Noorani
- Department of Internal Medicine, Prisma Health Midlands, Columbia, SC, USA
- University of South Carolina School of Medicine, Columbia, SC, USA
| | - Philip J Riddle
- Department of Internal Medicine, Prisma Health Midlands, Columbia, SC, USA
- University of South Carolina School of Medicine, Columbia, SC, USA
| | - Yichen Wang
- Mercy Internal Medicine Service, Trinity Health of New England, Springfield, MA, USA
| | - Gracelyn Metts
- Department of Health Sciences, Clemson University, Clemson, SC, USA
| | - Tania Yacu
- Department of Health Sciences, Clemson University, Clemson, SC, USA
| | - Marwan S Abougergi
- Catalyst Medical Consulting, Huntingdon Valley, PA, USA.
- Division of Gastroenterology, Department of Internal Medicine, INOVA Fairfax Hospital, INOVA Health, 3300 Gallows Road, Falls Church, VA, 22042, USA.
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Wasserman RD, Abel W, Monkemuller K, Yeaton P, Kesar V, Kesar V. Non-variceal Upper Gastrointestinal Bleeding and Its Endoscopic Management. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2024; 35:599-608. [PMID: 39150279 PMCID: PMC11363156 DOI: 10.5152/tjg.2024.23507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/17/2024] [Indexed: 08/17/2024]
Abstract
Upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality. Clinical symptoms that patients may present with include: hematemesis, coffee-ground emesis, melena, and hematochezia. Clinical signs can range from tachycardia to shock. The anatomical landmark that differentiates upper gastrointestinal (GI) bleeds from lower bleeds is the ligament of Treitz. The first steps of treating a patient who presents with signs of UGIB are resuscitation with appropriate fluids and blood products as necessary. The consideration of endoscopy and the urgency at which it should be performed is also vital during initial resuscitation. Endoscopic therapy should ideally be performed within 24 hours of presentation after initial stabilization with crystalloids and blood products. Intravenous proton pump inhibitors are the mainstay in the initial management of upper GI bleeding from a non-variceal etiology, and they should be administered in the acute setting to decrease the probability of high-risk stigmata seen during endoscopy. Pro-kinetic agents can be given 30 minutes to an hour before endoscopy and may aid in the diagnosis of UGIB. There are 3 broad categories of endoscopic management for UGIB: injection, thermal, and mechanical. Each endoscopic method can be used alone or in combination with others; however, the injection technique with epinephrine should always be used in conjunction with another method to increase the success of achieving hemostasis. In this review article, we will review the steps of triage and initial resuscitation in UGIB, causes of UGIB and their respective management, several endoscopic techniques and their effectiveness, and prognosis with a primary focus limited to non-variceal bleeding.
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Affiliation(s)
- Reid D. Wasserman
- Department of Internal Medicine, Institute of Carilion Clinic, Riverside Circle, Roanoke, Virginia, United States
| | - William Abel
- Department of Internal Medicine, Institute of Carilion Clinic, Riverside Circle, Roanoke, Virginia, United States
| | - Klaus Monkemuller
- Department of Gastroenterology, Institute of Carilion Clinic, Riverside Circle, Roanoke, Virginia, United States
| | - Paul Yeaton
- Department of Gastroenterology, Institute of Carilion Clinic, Riverside Circle, Roanoke, Virginia, United States
| | - Vivek Kesar
- Department of Gastroenterology, Institute of Carilion Clinic, Riverside Circle, Roanoke, Virginia, United States
| | - Varun Kesar
- Department of Gastroenterology, Institute of Carilion Clinic, Riverside Circle, Roanoke, Virginia, United States
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Ahmed K, Abdallah M, Abbas D, Jaber F, Abdalla AO, Mohamed M, McDonald N, Hanson BJ, Bilal M. Analysis of Reported Adverse Events Related to Hemospray: An FDA MAUDE Database Study. J Clin Gastroenterol 2024; 58:402-406. [PMID: 37267458 DOI: 10.1097/mcg.0000000000001859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/31/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Topical hemostatic powder is a mineral powder that forms an adherent barrier and coagulates active bleeding in the gastrointestinal (GI) tract. Hemospray is the first hemostatic powder approved by the Food and Drug Administration (FDA) in the United States. Hemospray has been increasingly used to manage GI bleeding. However, data on the adverse events of hemostatic powders are lacking. Therefore, we aim to report and analyze adverse events associated with Hemospray using the FDA's "Manufacturer and User Facility Device Experience" database. METHODS We analyzed the postmarketing surveillance data from the FDA's Manufacturer and User Facility Device Experience database for Hemospray, initially known as TC-325, from June 2018 through April 2022. Results of the search were classified into device-related technical issues, patient-related adverse events and health care staff-related adverse events. RESULTS Five hundred two medical device reporting claims were identified from June 2018 through April 2022. Seven duplicate claims were identified, and some claims included more than one event type. Therefore, there were 558 device-related problems, 28 patient-related adverse events, and 2 adverse events in health care staff members. The most common device-related problems were activation failure or failure to fire (n = 385, 70.0%) and obstruction of carbon dioxide flow (n = 121, 21.7). The most common patient-related adverse events included tissue injury or bleeding (n = 21) and perforation (n = 5). CONCLUSION Although Hemospray is a valuable tool in the armamentarium for endoscopists in managing GI bleeding, endoscopists must be mindful of deice-related problems and potential patient-related adverse events.
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Affiliation(s)
- Khalid Ahmed
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA
| | - Mohamed Abdallah
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota
| | - Daniyal Abbas
- Department of Internal Medicine, East Carolina University, Greenville, NC
| | - Fouad Jaber
- Department of Medicine, University of Missouri-Kansas City, Kansas City, MO
| | - Abubaker O Abdalla
- Division of Gastroenterology and Hepatology, Emory University, Atlanta, GA
| | - Mouhand Mohamed
- Brown University, Warren Alpert Medical School, Providence, RI
| | - Nicholas McDonald
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota
| | - Brian J Hanson
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota
- Division of Gastroenterology and Hepatology, Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN
| | - Mohammad Bilal
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota
- Division of Gastroenterology and Hepatology, Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN
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Vakil N. Endoscopic Diagnosis, Grading, and Treatment of Bleeding Peptic Ulcer Disease. Gastrointest Endosc Clin N Am 2024; 34:217-229. [PMID: 38395480 DOI: 10.1016/j.giec.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Peptic ulcer bleeding is a major cause for hospital admissions and has a significant mortality. Endoscopic interventions reduce the risk of rebleeding in high-risk patients and several options are available including injection therapies, thermal therapies, mechanical clips, hemostatic sprays, and endoscopic suturing. Proton-pump inhibitors and Helicobacter pylori treatment are important adjuncts to endoscopic therapy. Endoscopic therapy is indicated in Forrest 1a, 1b, and 2a lesions. Patients with Forrest 2b lesions may do well with proton-pump inhibitor therapy alone but can also be managed by removal of the clot and targeting endoscopic therapy to the underlying lesion.
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Affiliation(s)
- Nimish Vakil
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Kozarek RA. DDS Perspective: If Gastroenterology Were a Dog, Would Endoscopy Be Its Tail? Has Therapeutic GI Endoscopy Learned to Wag the Dog? Dig Dis Sci 2023; 68:4297-4300. [PMID: 37798571 DOI: 10.1007/s10620-023-08115-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 09/14/2023] [Indexed: 10/07/2023]
Affiliation(s)
- Richard A Kozarek
- Emeritus Executive Director, Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98101, USA.
- Clinical Investigator, Center for Interventional Immunology, Benaroya Research Institute, 1201 Ninth Ave, Seattle, WA, 98101, USA.
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Su DS, Li CK, Gao C, Qi XS. Hemostatic powder for acute upper gastrointestinal bleeding: Recent research advances. Shijie Huaren Xiaohua Zazhi 2023; 31:249-255. [DOI: 10.11569/wcjd.v31.i7.249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
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Novak I, Bass LM. Gastrointestinal Bleeding in Children: Current Management, Controversies, and Advances. Gastrointest Endosc Clin N Am 2023; 33:401-421. [PMID: 36948753 DOI: 10.1016/j.giec.2022.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Upper gastrointestinal bleeding (UGIB) in children has many causes, with its prevalence varying by age. Often presenting as hematemesis or melena, the initial treatment is stabilization of the patient, including protection of the airway, fluid resuscitation, and a transfusion hemoglobin threshold of 7 g/L. Endoscopy should be performed with the goal of using combinations of therapies to treat a bleeding lesion, generally involving epinephrine injection along with either cautery, hemoclips, or hemospray. This review discusses the diagnosis and treatment of variceal and non-variceal gastrointestinal bleeding in children with a focus on current advances in the treatment of severe UGIB.
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Affiliation(s)
- Inna Novak
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Avenue, Bronx, NY 10467, USA.
| | - Lee M Bass
- Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Avenue, Chicago, IL 60611, USA
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Kanno T, Arata Y, Hatayama Y, Koike T, Masamune A. Novel simulator of endoscopic hemostasis with actual endoscope and devices. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2023; 8:56-59. [PMID: 36820256 PMCID: PMC9938294 DOI: 10.1016/j.vgie.2022.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Video 1Demonstration of novel simulator of endoscopic hemostasis.
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Affiliation(s)
- Takeshi Kanno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yutaro Arata
- Graduate Medical Education center, Tohoku University Hospital, Sendai, Japan
| | - Yutaka Hatayama
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Hu J, Jiang M, Liu H, Zhou H, Wang Y. Application of endoscopic purse-string sutures in high-risk peptic ulcer hemorrhage: preliminary experience of 38 cases. Scand J Gastroenterol 2023; 58:216-221. [PMID: 36039564 DOI: 10.1080/00365521.2022.2116291] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study is a prospective study to explore the therapeutic effect of endoscopic purse-string sutures in high-risk peptic ulcer hemorrhage. PATIENTS AND METHODS We prospectively collected and analyzed data from July 2018 to December 2020 from patients in Jinshan hospital, Fudan University, who underwent emergency endoscopy for acute severe high-risk non-variceal upper gastrointestinal hemorrhage (NVUGIB) and were treated with endoscopic purse-string sutures. RESULTS We included 38 patients whose median age was 64 years (interquartile range: 57.2 - 71.2 years). All patients were high risk gastric ulcer larger than 1 cm, including Forrest Ia (n = 4, 10.5%), Forrest Ib (n = 13, 34.2%) and Forrest IIa (n = 21, 55.3%). All patients were treated with endoscopic purse-string sutures. The clinical success rate reached 89.5%. Three patients suffered from rebleeding within seven days, and were treated with surgery or arterial embolization, respectively, all of which successfully stopped bleeding. One patient died of myocardial infarction. All other patients were followed up for 30 days without bleeding. CONCLUSIONS We conclude that endoscopic purse-string sutures seem to be safe and effective in the treatment of patients at high risk of ulcer bleeding.
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Affiliation(s)
- Jingxian Hu
- Department of Gastroenterology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Miao Jiang
- Department of Gastroenterology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Hongyan Liu
- Department of Gastroenterology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Hao Zhou
- Department of Gastroenterology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Yajie Wang
- Department of Gastroenterology, Jinshan Hospital, Fudan University, Shanghai, China
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14
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Perekhodov SN, Karpun NA, Snitsar AV, Zelenin DA, Varfalomeev SI, Martyntsov AA, Matkov IV, Pankratov AA. [Endovascular embolization for prevention of recurrent bleeding from the upper gastrointestinal tract]. Khirurgiia (Mosk) 2023:30-38. [PMID: 36583491 DOI: 10.17116/hirurgia202301130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate the results of preventive endovascular hemostasis in patients with high risk of recurrent bleeding from the upper gastrointestinal tract. MATERIAL AND METHODS We analyzed treatment outcomes in 158 patients with ulcerative gastroduodenal bleeding and high risk of recurrence (≥17 scores), Forrest 1-2 A/B and mortality (SAPS II score ≥30). Endovascular embolization of the left gastric or gastroduodenal artery was performed to prevent recurrent bleeding. RESULTS Endovascular hemostasis was technically successful in 94.4% of cases (153 patients). Embolization could not be performed due to technical reasons in 5 patients. One patient developed retroperitoneal hematoma as a complication after transcatheter angiography and embolization that required surgical intervention. Recurrent bleeding after technically successful embolization occurred in 11 (7%) patients. The PVA microemboli and spirals were used for embolization of the left gastric and gastroduodenal arteries, respectively. Additional PVA microemboli were also used in gastroduodenal artery in some cases. Twenty-six (16.5%) patients died. CONCLUSION Endovascular hemostasis in patients with severe comorbidities (SAPS II score ≥30) and high risk of recurrent bleeding (≥17 scores) reduced the incidence of recurrent bleeding to 6.96% and mortality to 17%.
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Affiliation(s)
- S N Perekhodov
- Demikhov Moscow City Clinical Hospital, Moscow, Russian Federation
| | - N A Karpun
- Demikhov Moscow City Clinical Hospital, Moscow, Russian Federation
| | - A V Snitsar
- Demikhov Moscow City Clinical Hospital, Moscow, Russian Federation
| | - D A Zelenin
- Demikhov Moscow City Clinical Hospital, Moscow, Russian Federation
| | - S I Varfalomeev
- Demikhov Moscow City Clinical Hospital, Moscow, Russian Federation
| | - A A Martyntsov
- Demikhov Moscow City Clinical Hospital, Moscow, Russian Federation
| | - I V Matkov
- Demikhov Moscow City Clinical Hospital, Moscow, Russian Federation
| | - A A Pankratov
- Demikhov Moscow City Clinical Hospital, Moscow, Russian Federation
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15
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Galloro G, Zullo A, Luglio G, Chini A, Telesca DA, Maione R, Pollastro M, De Palma GD, Manta R. Endoscopic clipping in non-variceal upper gastrointestinal bleeding treatment. Clin Endosc 2022; 55:339-346. [PMID: 35534934 PMCID: PMC9178136 DOI: 10.5946/ce.2021.249] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 11/20/2022] Open
Abstract
Since the earliest reports, advanced clipping systems have been developed, and it is possible to choose among many models with different structural and technical features. The main drawback of through-the-scope clips is their small size, which allows the compression of limited amounts of tissue needed for large-size vessel treatment. Therefore, the over-the-scope clip system was realized, allowing a larger and stronger mechanical compression of large tissue areas, with excellent results in achieving a definitive hemostasis in difficult cases. Many studies have analyzed the indications and efficacy of two-pronged endoclips and have shown good results for initial and permanent hemostasis. The aim of this review was to provide updated information on indications, positioning techniques, and results of clip application for endoscopic treatment of upper gastrointestinal non-variceal bleeding lesions.
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Affiliation(s)
- Giuseppe Galloro
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
| | - Angelo Zullo
- Gastroenterology and Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Roma, Italy
| | - Gaetano Luglio
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
| | - Alessia Chini
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
| | | | - Rosa Maione
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
| | - Matteo Pollastro
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
| | - Giovanni Domenico De Palma
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
| | - Raffaele Manta
- Gastroenterology and Digestive Endoscopy Unit, General Hospital, Perugia, Italy
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16
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Zhu W, Chen L, Zhang J, Wang P. Effects of high-dose versus low-dose proton pump inhibitors for treatment of gastrointestinal ulcer bleeding: a meta-analysis of randomized controlled trials. J Int Med Res 2022; 50:3000605211067396. [PMID: 35414289 PMCID: PMC9014724 DOI: 10.1177/03000605211067396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background We performed a meta-analysis to compare the effects of high-dose (80 mg/day) versus low-dose (40 mg/day) proton pump inhibitors (PPIs) on gastrointestinal ulcer bleeding. Methods We retrieved studies of randomized controlled trials of PPIs administered according to different schedules for the treatment of gastrointestinal ulcer bleeding from Medline, Embase, Web of Science, Clinical Trials, and the Cochrane Database in April 2020. Results Nine randomized controlled trials including 2329 patients were included in this meta-analysis. There were no significant differences in the incidences of re-bleeding, operation intervention, postoperative mortality, and length of hospital stay between the low-dose and high-dose groups. However, the blood transfusion volume was significantly higher in the high-dose group. Conclusion Compared with low-does PPIs, high-dose PPIs had no effect on the incidence of re-bleeding, operation intervention, or postoperative mortality, and did not reduce hospital stay in patients treated with endoscopic hemostasis for gastrointestinal bleeding.
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Affiliation(s)
- Wei Zhu
- Department of Gastrointestinal Vascular Pediatric Surgery, Dongfeng General Hospital of National Medicine, Hubei University of Medicine, Shiyan, Hubei, P.R. China
| | - Liang Chen
- Department of Gastrointestinal Surgery, Affiliated Huadu Hospital of Southern Medical University (People's Hospital of Huadu District), Guangzhou, Guangdong, P.R. China
| | - Jian Zhang
- Department of Gastrointestinal Surgery, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, P.R. China
| | - Pei Wang
- Department of Gastrointestinal Surgery, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, P.R. China
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17
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Kate V, Sureshkumar S, Gurushankari B, Kalayarasan R. Acute Upper Non-variceal and Lower Gastrointestinal Bleeding. J Gastrointest Surg 2022; 26:932-949. [PMID: 35083723 DOI: 10.1007/s11605-022-05258-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/17/2022] [Indexed: 01/31/2023]
Abstract
Acute gastrointestinal (GI) bleeding is a common surgical emergency requiring hospital admission and associated with high morbidity and mortality. Appropriate decision-making is essential to make a prompt diagnosis, accurate risk assessment, and proper resuscitation of patients with gastrointestinal bleeding. Despite multiple randomized trials and meta-analyses, there is still controversy on various management issues like appropriate risk stratification, the timing of endoscopy, choosing an appropriate endoscopic, and radiological intervention in these groups of patients. As the usage of nonsteroidal anti-inflammatory drugs, antiplatelet, and antithrombotic agents is common in patients with gastrointestinal bleeding, the physician is challenged with proper management of these drugs. The present review summarizes the current strategies for risk stratification, localization of bleeding source, endoscopic and radiological intervention in patients with acute nonvariceal upper GI, middle GI, and lower GI bleeding.
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Affiliation(s)
- Vikram Kate
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India.
| | - Sathasivam Sureshkumar
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Balakrishnan Gurushankari
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Raja Kalayarasan
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
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18
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Gao DJ, Wang SP, Fu XH, Yin L, Ye X, Yang XW, Zhang YJ, Hu B. Urgent Endoscopy Improves Hemostasis in Patients With Upper Gastrointestinal Bleeding Following Biliary-pancreatic Surgery: A Retrospective Analysis. Surg Laparosc Endosc Percutan Tech 2021; 32:228-235. [PMID: 34966156 DOI: 10.1097/sle.0000000000001027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 11/04/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) is a lethal complication of biliary-pancreatic surgery (BPS). The role of endoscopic intervention has not been fully defined in such a critical condition. The aim of this study was to assess the efficacy and safety of endoscopic hemostasis in a retrospective cohort. MATERIALS AND METHODS Consecutive patients with acute UGIB after BPS who received interventional endoscopy between January 2007 and August 2020 were included in this study. The clinical characteristics were collected and analyzed to screen for predictive factors significantly associated with successful hemostasis. RESULTS Among 37,772 patients who underwent BPS, 26 patients (0.069%) developed acute UGIB. The sites and causes of hemorrhage were as follows: gastroenteric anastomoe (n=17), gastric stump (n=2), jejunal anastomose (n=1), duodenal bulb ulcer (n=2), pancreatojejunal anastomosis hemorrhage (n=1), cholangiojejunal anastomose (n=1), gastroenteric anastomose and gastric stump hemorrhage (n=1), and Dieulafoy lesion (n=1). Successful endoscopic hemostasis was achieved in 19 (73.1%) of the 26 UGIB patients. In the 7 patients who failed endotherapy, 1 patient received a successful radiologic intervention, 6 patients underwent reoperation and achieved hemostasis in 4, and the other 2 patients died after reoperation. Logistic regression analysis showed that presentation-to-endoscopy time (≤12 h) was the only independent predictive factor associated with successful endoscopic hemostasis. CONCLUSIONS Endoscopic hemostasis is relatively safe and effective in controlling UIGB after BPS. Prompt intervention (≤12 h) could improve the success rate of endoscopic hemostasis.
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Affiliation(s)
| | | | - Xiao-Hui Fu
- Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P.R. China
| | - Lei Yin
- Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P.R. China
| | | | - Xin-Wei Yang
- Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P.R. China
| | - Yong-Jie Zhang
- Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P.R. China
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19
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McDonald MJ. Acute Gastrointestinal Bleeding – Locating the Source and Correcting the Disorder. PHYSICIAN ASSISTANT CLINICS 2021. [DOI: 10.1016/j.cpha.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abe H, Kamimura K, Arao Y, Kohisa J, Terai S. Advances in the Treatment of Gastrointestinal Bleeding: Safety and Efficiency of Transnasal Endoscopy. MEDICINES (BASEL, SWITZERLAND) 2021; 8:53. [PMID: 34564095 PMCID: PMC8471608 DOI: 10.3390/medicines8090053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/02/2021] [Accepted: 09/10/2021] [Indexed: 11/16/2022]
Abstract
Acute upper gastrointestinal bleeding (UGIB) is a common disorder and a gastroenterological emergency. With the development of new techniques and devices, the survivability after gastrointestinal bleeding is improving. However, at the same time, we are facing the difficulty of severely complicated cases with various diseases. For example, while endoscopic examination with a normal diameter endoscope is essential for the diagnosis and treatment of UGIB, there are several cases in which it cannot be used. In these cases, transnasal endoscopy (TNE) may be a viable treatment option. This report reviews current hemostatic devices for endoscopic treatment and the safety and efficiency of using TNE in complicated cases. The latter will be demonstrated in a case report where TNE was employed in a patient with severe esophageal stenosis. This review summarizes the advances made in the devices used and will provide further ideas for the physician in terms of combining these devices and TNE.
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Affiliation(s)
- Hiroyuki Abe
- Division of Gastroenterology and Hepatology, Sado General Hospital, 161 Chigusa, Sado 952-1209, Japan;
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachido-ri, Chuo-ku, Niigata 950-2181, Japan; (Y.A.); (J.K.); (S.T.)
| | - Kenya Kamimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachido-ri, Chuo-ku, Niigata 950-2181, Japan; (Y.A.); (J.K.); (S.T.)
- Department of General Medicine, Niigata University School of Medicine, 1-757 Asahimachido-ri, Chuo-ku, Niigata 951-8510, Japan
| | - Yoshihisa Arao
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachido-ri, Chuo-ku, Niigata 950-2181, Japan; (Y.A.); (J.K.); (S.T.)
| | - Junji Kohisa
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachido-ri, Chuo-ku, Niigata 950-2181, Japan; (Y.A.); (J.K.); (S.T.)
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachido-ri, Chuo-ku, Niigata 950-2181, Japan; (Y.A.); (J.K.); (S.T.)
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21
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Experience with the use of a hemostatic powder in 152 patients undergoing urgent endoscopy for gastrointestinal bleeding. Clin Res Hepatol Gastroenterol 2021; 45:101558. [PMID: 33168481 DOI: 10.1016/j.clinre.2020.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/02/2020] [Accepted: 10/12/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND STUDY AIMS In the recent years, topical hemostatic powders have been used for the management of upper gastrointestinal bleeding. The aim of this study was to report on the use of an hemostatic powder (Hemospray®), outside regular hours, by on-call endoscopists during urgent endoscopic procedures. MATERIAL AND METHODS In this retrospective multicenter cohort study, consecutive patients having undergone an urgent endoscopy with the use of Hemospray® from November 2015 to December 2018 in the Paris and suburbs area were included. We collected clinical, biological and endoscopic variables. The outcomes such as the recurrence, repeat endoscopy and hemostatic treatment need, complications and survival were also collected. RESULTS A total of 152 patients (mean 65 years old, 70.4% male) were included. Amongst the 31 endoscopists, 11 were "more experienced", and performed 48% of the endoscopies. The most common causes of bleeding were peptic ulcer (47.7%), malignancy (22.2%) and esophagitis (12.4%). Most bleedings originated from the upper GI tract (95.0%). Hemospray® was used as a salvage therapy in 60.8% of cases. Other hemostatic techniques were used in 52.9% of cases. Immediate bleeding cessation was noted in 79.0% of cases, recurrence in 39.9% of cases, and 26.4% of patients benefited from a repeat endoscopic hemostasis. 34 (23.0%) patients required a non-endoscopic treatment. At day 30, the survival rate was 71.6%. One complication was reported (perforation). CONCLUSIONS Hemostatic powder application by on-call endoscopists outside regular hours is technically feasible, but comes with a high risk of rebleeding in severely ill patients.
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22
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Birda CL, Kumar A, Samanta J. Endotherapy for Nonvariceal Upper Gastrointestinal Hemorrhage. JOURNAL OF DIGESTIVE ENDOSCOPY 2021; 12:078-092. [DOI: 10.1055/s-0041-1731962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AbstractNonvariceal upper gastrointestinal hemorrhage (NVUGIH) is a common GI emergency with significant morbidity and mortality. Triaging cases on the basis of patient-related factors, restrictive blood transfusion strategy, and hemodynamic stabilization are key initial steps for the management of patients with NVUGIH. Endoscopy remains a vital step for both diagnosis and definitive management. Multiple studies and guidelines have now defined the optimum timing for performing the endoscopy after hospitalization, to better the outcome. Conventional methods for achieving endoscopic hemostasis, such as injection therapy, contact, and noncontact thermal therapy, and mechanical therapy, such as through-the-scope clips, have reported to have 76 to 90% efficacy for primary hemostasis. Newer modalities to enhance hemostasis rates have come in vogue. Many of these modalities, such as cap-mounted clips, coagulation forceps, and hemostatic powders have proved to be efficacious in multiple studies. Thus, the newer modalities are recommended not only for management of persistent bleed and recurrent bleed after failed initial hemostasis, using conventional modalities but also now being advocated for primary hemostasis. Failure of endotherapy would warrant radiological or surgical intervention. Some newer tools to optimize endotherapy, such as endoscopic Doppler probes, for determining flow in visible or underlying vessels in ulcer bleed are now being evaluated. This review is focused on the technical aspects and efficacy of various endoscopic modalities, both conventional and new. A synopsis of the various studies describing and comparing the modalities have been outlined. Postendoscopic management including Helicobacter pylori therapy and starting of anticoagulants and antiplatelets have also been outlined.
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Affiliation(s)
- Chhagan L. Birda
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Antriksh Kumar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Razavilar N, Taleshi JM. Cost-Effectiveness Analysis of Transcatheter Arterial Embolization Techniques for the Treatment of Gastrointestinal Bleeding in the United States. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:477-485. [PMID: 33840425 DOI: 10.1016/j.jval.2020.10.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 09/04/2020] [Accepted: 10/30/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Gastrointestinal (GI) bleeding is a common medical emergency associated with significant mortality. Transcatheter arterial embolization first was introduced by Rosch et al as an alternative to surgery for upper GI bleeding. The clinical success in patients with GI bleeding treated with transcatheter arterial embolization previously has been reported. However, there are no cost-effectiveness analyses reported to date. Here we report cost-effectiveness analysis of N-butyl 2-cyanoacrylate glue (NBCA) and ethylene-vinyl alcohol copolymer (Onyx) versus coil (gold standard) for treatment of GI bleeding from a healthcare payer perspective. METHODS Fixed-effects modeling with a generalized linear mixed method was used in NBCA and coil intervention arms to determine the pooled probabilities of clinical success and mortality with complications with their confidence intervals, while the Clopper-Pearson model was used for Onyx to determine the same parameters. Models were provided by the "Meta-Analysis with R" software package. A decision tree was built for cost-effectiveness analysis, and Microsoft Excel was used for probabilistic sensitivity analysis. The cost-effective option was determined based on the incremental cost-effectiveness ratio and scatter plots of incremental cost versus incremental quality-adjusted life-years. RESULTS Comparing scatter plots and incremental cost-effectiveness ratio results, -$1024 and -$1349 per quality-adjusted life-year for Onyx and N-butyl 2-cyanoacrylate glue, respectively, Onyx was the least expensive and most effective intervention. CONCLUSION Onyx was the dominant strategy regardless of threshold values. Our analyses provide a framework for researchers to predict the target clinical effectiveness for early-stage TAE interventions and guide resource allocation decisions.
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Affiliation(s)
- Negin Razavilar
- RAZN Health Decision Modelling LTD, University of Alberta Health Accelerator, Edmonton, Canada; Faculty of Sciences, University of Alberta, Edmonton, Canada.
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24
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Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, Laursen SB, Radaelli F, Papanikolaou IS, Cúrdia Gonçalves T, Dinis-Ribeiro M, Awadie H, Braun G, de Groot N, Udd M, Sanchez-Yague A, Neeman Z, van Hooft JE. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021; 53:300-332. [PMID: 33567467 DOI: 10.1055/a-1369-5274] [Citation(s) in RCA: 251] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
1: ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3-5 days.Strong recommendation, moderate quality evidence. 3: ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4: ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5: ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6: ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 : ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8: ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9: ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (A): PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (B): High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10: ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.
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Affiliation(s)
- Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - A John Morris
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Marine Camus
- Sorbonne University, Endoscopic Unit, Saint Antoine Hospital Assistance Publique Hopitaux de Paris, Paris, France
| | - James Lau
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Angel Lanas
- Digestive Disease Services, University Clinic Hospital, University of Zaragoza, IIS Aragón (CIBERehd), Spain
| | - Stig B Laursen
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Franco Radaelli
- Department of Gastroenterology, Valduce Hospital, Como, Italy
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Tiago Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- School of Medicine, University of Minho, Braga/Guimarães, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Mario Dinis-Ribeiro
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Portugal
| | - Halim Awadie
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Georg Braun
- Medizinische Klinik 3, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Marianne Udd
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Andres Sanchez-Yague
- Gastroenterology Unit, Hospital Costa del Sol, Marbella, Spain
- Gastroenterology Department, Vithas Xanit International Hospital, Benalmadena, Spain
| | - Ziv Neeman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Diagnostic Imaging and Nuclear Medicine Institute, Emek Medical Center, Afula, Israel
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Wu XR, Lan N, Shen B. Endoscopic management of anastomotic bleeding in the ileal pouch with staples removal and clipping. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2013.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Objective Postoperative pouch bleeding is a rare but detrimental complication following ileal pouch surgery. It is usually self-limited, however continuous bleeding requires inter- vention. There is limited published data on its management.
Design Ileoscopy via stoma for loop ileostomy and pouchoscopy via anus for ileal pouch were performed under sedation for the purpose of diagnosis and management of postop- erative bleeding.
Results Ileoscopy demonstrated a large, long blood clot in the lumen of efferent limb, but no sign of active bleeding was identified. Pouchoscopy showed that lumen of pouch body as well as afferent limb was filled with maroon-colored liquid stool. Pouch and neo-terminal ileum mucosa was normal. Two dislodged staples at the anastomotic line with sharp tips towards the lumen were found, with activating bleeding at one site. The staples were re- moved by biopsy forceps, and active bleeding was successfully controlled by the deploy- ment of one endoclip.
Conclusions We reported the first case that postoperative pouch bleeding, which was caused by dislodged staples, was successfully managed by endoscopic removal of the staples com- bined with clipping.
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Affiliation(s)
- Xian-rui Wu
- Department of Colorectal Surgery, the Cleveland Clinic Foundation, Cleveland, USA
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Nan Lan
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bo Shen
- Department of Gastroenterology/Hepatology, the Cleveland Clinic Foundation, Cleveland, USA
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Lau LHS, Sung JJY. Treatment of upper gastrointestinal bleeding in 2020: New techniques and outcomes. Dig Endosc 2021; 33:83-94. [PMID: 32216134 DOI: 10.1111/den.13674] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/15/2020] [Accepted: 03/19/2020] [Indexed: 02/08/2023]
Abstract
The clinical outcome of upper gastrointestinal bleeding has improved due to advances in endoscopic therapy and standardized peri-endoscopy care. Apart from validating clinical scores, artificial intelligence-assisted machine learning models may play an important role in risk stratification. While standard endoscopic treatments remain irreplaceable, novel endoscopic modalities have changed the landscape of management. Over-the-scope clips have high success rates as rescue or even first-line treatments in difficult-to-treat cases. Hemostatic powder is safe and easy to use, which can be useful as temporary control with its high immediate hemostatic ability. After endoscopic hemostasis, Doppler endoscopic probe can offer an objective measure to guide the treatment endpoint. In refractory bleeding, angiographic embolization should be considered before salvage surgery. In variceal hemorrhage, banding ligation and glue injection are first-line treatment options. Endoscopic ultrasound-guided therapy is gaining popularity due to its capability of precise localization for treatment targets. A self-expandable metal stent may be considered as an alternative option to balloon tamponade in refractory bleeding. Transjugular intrahepatic portosystemic shunting should be reserved as salvage therapy. In this article, we aim to provide an evidence-based comprehensive review of the major advancements in endoscopic hemostatic techniques and clinical outcomes.
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Affiliation(s)
- Louis H S Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong
| | - Joseph J Y Sung
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong
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Xavier AT, Campos JF, Robinson L, Lima EJM, da Rocha LCM, Arantes VN. Endoscopic clipping for gastrointestinal bleeding: emergency and prophylactic indications. Ann Gastroenterol 2020; 33:563-570. [PMID: 33162733 PMCID: PMC7599350 DOI: 10.20524/aog.2020.0526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/26/2020] [Indexed: 12/26/2022] Open
Abstract
Endoscopic clipping has become a common practice among endoscopists. Several models are available, most frequently being introduced via the working channel of the endoscope (through-the-scope); however, larger clips can also be mounted onto the distal tip of the endoscope (over-the-scope). The main indications for endoclip placement include providing effective mechanical hemostasis for bleeding lesions and allowing endoscopic closure of gastrointestinal perforations. Endoclips can also be used prophylactically after endoscopic resection; however, this practice is still controversial. This review discusses the main indications for endoscopic clipping in the esophagus, stomach, duodenum and colon to manage acute bleeding lesions, and the criteria to be used in the prevention of delayed post-polypectomy bleeding.
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Affiliation(s)
- Amaury Teixeira Xavier
- Endoscopy Unit, Alfa Institute of Gastroenterology, Clinics Hospital, Federal University of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Vitor Nunes Arantes).,Endoscopy Unit, Military Hospital of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Elmar José Moreira Lima)
| | - Júlia Faria Campos
- Endoscopy Unit, Alfa Institute of Gastroenterology, Clinics Hospital, Federal University of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Vitor Nunes Arantes).,Endoscopy Unit, Military Hospital of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Elmar José Moreira Lima)
| | - Lucinda Robinson
- Department of Medicine, Flinders Medical Centre, Adelaide, Australia (Lucinda Robinson)
| | - Elmar José Moreira Lima
- Endoscopy Unit, Military Hospital of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Elmar José Moreira Lima)
| | | | - Vitor Nunes Arantes
- Endoscopy Unit, Alfa Institute of Gastroenterology, Clinics Hospital, Federal University of Minas Gerais, Belo Horizonte, Brazil (Amaury Teixeira Xavier, Júlia Faria Campos, Vitor Nunes Arantes)
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Xu Y, Zhong S, Liang W, Lin XL. The risk factors for delayed bleeding after endoscopic resection of colorectal tumors: a meta-analysis. Expert Rev Gastroenterol Hepatol 2020; 14:1083-1092. [PMID: 32721191 DOI: 10.1080/17474124.2020.1801416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The most common complication of post-colorectal endoscopic resection is delayed bleeding. The assessment of risk factors for delayed bleeding provides important and useful information in standard clinical operations. The risk factors have been previously reported; however, they remain inconsistent across different studies. AREAS COVERED In this meta-analysis, the patient conditions, lesion-related factors, and operation-related factors were compared between delayed bleeding and no bleeding. PubMed, Cochrane, Embase, China National Knowledge Infrastructure (CNKI), and Wanfang Database were searched to identify eligible studies. Pooled odds ratio (OR) and 95% confidence intervals (CI) were calculated along with heterogeneity. EXPERT OPINION This study is the first meta-analysis to investigate risk factors for colorectal delayed bleeding. We found several risk factors contributing to this condition: colorectal tumors located in the proximal colon, a history of antithrombotic drug use, high-grade intraepithelial neoplasia or early cancer, piecemeal resection, intraoperative hemorrhage, no clip placement, and severe submucosal fibrosis. Despite our findings, we also conclude that more high-quality, large-scale clinical randomized controlled studies are needed due to limited retrospective studies at present. Future therapeutic colonoscopies should focus on precise diagnosis, treatment safety, and management during the perioperative period.
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Affiliation(s)
- Yanqin Xu
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital , Fuzhou, Fujian Province, China
| | - Shishun Zhong
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital , Fuzhou, Fujian Province, China
| | - Wei Liang
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital , Fuzhou, Fujian Province, China
| | - Xiao Lu Lin
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital , Fuzhou, Fujian Province, China
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Spraying rhubarb powder solution under gastroscope in the treatment of acute non-varicose upper gastrointestinal bleeding: A systematic review and meta-analysis of randomized controlled trials. Complement Ther Med 2020; 52:102476. [PMID: 32951726 DOI: 10.1016/j.ctim.2020.102476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 04/26/2020] [Accepted: 06/08/2020] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE Systematically assessing the safety and effectiveness of spraying rhubarb powder solution under gastroscope for the treatment of acute non-varicose upper gastrointestinal bleeding, and confirmation for further clinical research and application. METHODS We searched the following databases up till November 2019: PubMed, the Cochrane Library, EMBASE, CNKI, WanFang Data, VIP and SinoMed. Randomized controlled trials (RCTs) were used to compare the curative effect of spraying rhubarb powder solution with other drugs under gastroscope for the treatment of acute non-varicose upper gastrointestinal bleeding. RESULTS Out of 171 articles, 14 RCTs involving 1493 patients were included. All control groups included in the RCTs were treated with norepinephrine solution. The hemostatic effect of spraying rhubarb powder solution under gastroscope was examined for 24 h at high concentration (0.1 g/mL). The hemostatic effect at higher conc. (0.1 g/mL) found far more better than low conc.(RR = 1.48;95 %CI:1.25,1.75;P﹤0.00001) (0.03 g/mL)as homeostatic effect at low conc.is same that of norepinephrine solution (RR = 1.02;95 %CI:0.94,1.10;P = 0.62). Moreover within 48 h, rhubarb powder solution with 0.1 g/mL or 0.15 g/mL conc. have of significantly higher hemostatic effects than norepinephrine solution (RR = 1.18;95 % CI: 1.08, 1.30;P = 0.0003). Occurrence of rebleeding event within 48 h after successful hemostasis (RR = 0.42;95 %CI:0.24,0.74;P = 0.003) reduced exceptionally. After that the hemostatic effect of rhubarb powder solution with 0.1 g/mL conc.examined within 72 h again exhibited significant improvement than norepinephrine solution (RR = 1.19;95 %CI:1.12,1.26;P < 0.00001). On par with immediate hemostasis time, rhubarb powder solution took unprecedented less time than norepinephrine solution;(MD=-5.56S;95 %CI:-6.16, -4.95;P﹤0.00001). Additionally, the adverse reaction produced by rhubarb powder solution is much lower than norepinephrine solution (RR = 0.22;95 %CI:0.11,0.42;P < 0.00001). CONCLUSIONS According to meta-analysis, Spraying rhubarb powder solution under gastroscope in the treatment of acute non-varicose upper gastrointestinal bleeding is superior to norepinephrine solution in improving hemostasis effect. Shortening immediate hemostasis time and reducing rebleeding,and is safe to use. Based on the results of this study, physicians can treat patients with acute non-varicose upper gastrointestinal bleeding by spraying rhubarb powder solution under gastroscope according to the patients' condition.However, the sample size included in this study is small and of substandard quality qu, and a large sample size clinical trial with strict design and normative report is needed to verify the safety and efficacy of rhubarb powder solution under gastroscope for acute non-varicose upper gastrointestinal bleeding.
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Mullady DK, Wang AY, Waschke KA. AGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review. Gastroenterology 2020; 159:1120-1128. [PMID: 32574620 DOI: 10.1053/j.gastro.2020.05.095] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 12/19/2022]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and best practice advice statements regarding the use of endoscopic therapies in treating patients with non-variceal upper gastrointestinal bleeding. METHODS This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 10 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors who are gastroenterologists with extensive experience in managing and teaching others to treat patients with non-variceal upper gastrointestinal bleeding (NVUGIB). BEST PRACTICE ADVICE 1: Endoscopic therapy should achieve hemostasis in the majority of patients with NVUGIB. BEST PRACTICE ADVICE 2: Initial management of the patient with NVUGIB should focus on resuscitation, triage, and preparation for upper endoscopy. After stabilization, patients with NVUGIB should undergo endoscopy with endoscopic treatment of sites with active bleeding or high-risk stigmata for rebleeding. BEST PRACTICE ADVICE 3: Endoscopists should be familiar with the indications, efficacy, and limitations of currently available tools and techniques for endoscopic hemostasis, and be comfortable applying conventional thermal therapy and placing hemoclips. BEST PRACTICE ADVICE 4: Monopolar hemostatic forceps with low-voltage coagulation can be an effective alternative to other mechanical and thermal treatments for NVUGIB, particularly for ulcers in difficult locations or those with a rigid and fibrotic base. BEST PRACTICE ADVICE 5: Hemostasis using an over-the-scope clip should be considered in select patients with NVUGIB, in whom conventional electrosurgical coagulation and hemostatic clips are unsuccessful or predicted to be ineffective. BEST PRACTICE ADVICE 6: Hemostatic powders are a noncontact endoscopic option that may be considered in cases of massive bleeding with poor visualization, for salvage therapy, and for diffuse bleeding from malignancy. BEST PRACTICE ADVICE 7: Hemostatic powder should be preferentially used as a rescue therapy and not for primary hemostasis, except in cases of malignant bleeding or massive bleeding with inability to perform thermal therapy or hemoclip placement. BEST PRACTICE ADVICE 8: Endoscopists should understand the risk of bleeding from therapeutic endoscopic interventions (eg, endoluminal resection and endoscopic sphincterotomy) and be familiar with the endoscopic tools and techniques to treat intraprocedural bleeding and minimize the risk of delayed bleeding. BEST PRACTICE ADVICE 9: In patients with endoscopically refractory NVUGIB, the etiology of bleeding (peptic ulcer disease, unknown source, post surgical); patient factors (hemodynamic instability, coagulopathy, multi-organ failure, surgical history); risk of rebleeding; and potential adverse events should be taken into consideration when deciding on a case-by-case basis between transcatheter arterial embolization and surgery. BEST PRACTICE ADVICE 10: Prophylactic transcatheter arterial embolization of high-risk ulcers after successful endoscopic therapy is not encouraged.
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Affiliation(s)
- Daniel K Mullady
- Division of Gastroenterology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
| | - Kevin A Waschke
- Division of Gastroenterology, McGill University, Montreal, Quebec, Canada
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Systematic review and meta-analysis: monopolar hemostatic forceps with soft coagulation in the treatment of peptic ulcer bleeding. Eur J Gastroenterol Hepatol 2020; 32:678-685. [PMID: 32317587 DOI: 10.1097/meg.0000000000001738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Patel R, Mann S. Acute upper gastrointestinal bleeding: endoscopic assessment and treatment. GASTROINTESTINAL NURSING 2020; 18:S26-S35. [DOI: 10.12968/gasn.2020.18.sup1.s26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
Abstract
Acute upper gastrointestinal bleeding (AUGIB) represents 10% of medical emergencies in the UK and is associated with a significant mortality risk. Mortality has remained steady over the past 2 decades, at approximately 10%, with over 4000 deaths per annum in the UK. Patients with significant bleeding present with symptoms of haematemesis, melaena or haematochezia (rapid transit of red blood through the GI tract). An assessment of haemodynamic stability along with adequate resuscitation is vital prior to performing safe endoscopy. The performance of prompt upper gastrointestinal endoscopy is then necessary, as it has diagnostic, prognostic and therapeutic roles. Early identification of aetiology (variceal versus non-variceal bleeding) is important and directs endoscopic and medical treatment. An increasing number of endoscopic therapeutic options are now available.
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Affiliation(s)
| | - Steven Mann
- Consultant Gastroenterologist, both at Barnet Hospital, Royal Free London NHS Foundation Trust
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Zhong C, Tan S, Ren Y, Lü M, Peng Y, Fu X, Tang X. Clinical outcomes of over-the-scope-clip system for the treatment of acute upper non-variceal gastrointestinal bleeding: a systematic review and meta-analysis. BMC Gastroenterol 2019; 19:225. [PMID: 31870315 PMCID: PMC6929512 DOI: 10.1186/s12876-019-1144-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 12/15/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Conventional endoscopic treatments can't control bleeding in as many as 20% of patients with non-variceal gastrointestinal (GI) bleeding. Recent studies have shown that over-the-scope-clip (OTSC) system allowed for effective hemostasis for refractory GI bleeding lesions. So we aimed to conduct a systematic review to evaluate the effectiveness and safety of the OTSC system for management of acute non-variceal upper GI bleeding. METHOD A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane Library covering the period from January 2007 to May 2019. The literature was selected independently by two reviewers according to the inclusion and exclusion criteria. The statistical analysis was carried out using Comprehensive Meta-Analysis software version 3.0. RESULTS A total of 16 studies including 769 patients with 778 GI bleeding lesions were identified. Pooled technical success was achieved in 761 lesions [95.7%; 95% confidence interval (CI), 93.5-97.2%], and the pooled clinical success was achieved in 666 lesions (84.2, 95% CI, 77.4-89.2%). The incidence of re-bleeding was reported in 81 patients and the post-procedure mortality was 10.9% (n = 84). Only 2 (0.3%) patients occurred complications after OTSC system procedure. CONCLUSIONS Our study demonstrated that the OTSC system was a technically feasible modality and highly efficacious in achieving hemostasis in acute non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Chunyu Zhong
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Shali Tan
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Yutang Ren
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Muhan Lü
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Xiangsheng Fu
- Department of Gastroenterology, Affiliated Hospital of North Sichuan Medical College, Road Wenhua 63#, Region Shunqing, Nanchong, 637000, Sichuan, China.
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China.
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de Rezende DT, Brunaldi VO, Bernardo WM, Ribeiro IB, Mota RCL, Baracat FI, de Moura DTH, Baracat R, Matuguma SE, de Moura EGH. Use of hemostatic powder in treatment of upper gastrointestinal bleeding: a systematic review and meta-analysis. Endosc Int Open 2019; 7:E1704-E1713. [PMID: 31803822 PMCID: PMC6887646 DOI: 10.1055/a-0977-2897] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/27/2019] [Indexed: 02/07/2023] Open
Abstract
Abstract
Background and study aims TC-325 is a novel mineral hemostatic powder that creates a mechanical barrier by absorbing blood components and promoting clotting. Recently approved for use in humans, it has shown promise for treatment of upper gastrointestinal bleeding (UGIB). However, because there have been no large studies of TC-325, its true efficacy and safety profile remain unknown. We performed a systematic review and meta-analysis to determine the safety and efficacy of TC-325 in treating UGIB, based on rates of initial hemostasis, rebleeding, and adverse events (AEs).
Methods We searched the MEDLINE/PubMed, EMBASE, CENTRAL, Latin-American and Caribbean Health Sciences Literature databases, as well as the gray literature, to identify articles describing use of TC-325 up to October 2018. Primary outcomes were initial hemostasis and rebleeding. AEs were described as a secondary outcome. Risk of bias was assessed with international scores.
Results We identified 2077 records after removal of duplicates. We included 50 studies, involving a collective total of 1445 patients, in the quantitative synthesis. Primary hemostasis and rebleeding rates were 90.7 % and 26.1 %, respectively. Subgroup analyses showed similar results. Only eight AEs were reported.
Conclusions TC-325 appears to be a safe, effective treatment for UGIB. The overall rate of initial hemostasis after TC-325 use is high, regardless of etiology of bleeding or whether TC-325 is used as a primary or rescue therapy. Although it is also associated with high rebleeding rates, rates of AEs and equipment failure after TC-325 use are extremely low.
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Affiliation(s)
- Daniel Tavares de Rezende
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Vitor Ottoboni Brunaldi
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Raquel Cristina Lins Mota
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Felipe Iankelevich Baracat
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Renato Baracat
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Sergio Eiji Matuguma
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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Abstract
PURPOSE OF REVIEW Upper gastrointestinal bleeding (UGIB) is a common and life-threatening condition in the United States and worldwide. RECENT FINDINGS There have been several exciting recent advances in the endoscopic management of UGIB. One such advance is the recent approval of Hemospray by US Food and Drug Administration in May 2018. Another one is the emerging role of video capsule endoscopy as a triage and localization tool for UGIB patients. Finally, the development of new reversal agents for antithrombotic medications is an important advance in the management of life-threatening upper gastrointestinal bleed. SUMMARY In this article, we will broadly review the management of nonvariceal UGIB, focusing primarily on the data addressing these new advances.
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Chiu PW. Endoscopic Management of Peptic Ulcer Bleeding: Recent Advances. Clin Endosc 2019; 52:416-418. [PMID: 31405266 PMCID: PMC6785411 DOI: 10.5946/ce.2018.182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 05/30/2019] [Indexed: 12/16/2022] Open
Abstract
Bleeding peptic ulcers remained as one of the commonest causes of hospitalization worldwide. While endoscopic hemostasis serves as primary treatment for bleeding ulcers, rebleeding after endoscopic hemostasis becomes more and more difficult to manage as patients are usually poor surgical candidates with multiple comorbidities. Recent advances in management of bleeding peptic ulcers aimed to further reduce the rate of rebleeding through-(1) identification of high risk patients for rebleeding and mortality; (2) improvement in primary endoscopic hemostasis and; (3) prophylactic angiographic embolization of major arteries. The technique and clinical evidences for these approaches will be reviewed in the current article.
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Affiliation(s)
- Philip Wy Chiu
- Department of Surgery, Institute of Digestive Disease, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
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Vafaeimanesh J, Rakhshandeh H, Pourakbar A, Hosseini SM. The Effect of Hemostasis Powder® on Treatment of Bleeding from Benign Ulcers of Upper Gastrointestinal Tract; A Pilot Study. Middle East J Dig Dis 2019; 11:84-89. [PMID: 31380004 PMCID: PMC6663293 DOI: 10.15171/mejdd.2018.132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 02/10/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Gastrointestinal (GI) bleeding is one of the most prevalent internal medical emergencies. Despite using several methods of treatment, effective treatment cannot be achieved in some patients. Hemostasis powder® is a mineral-herbal product. This emulsion was able to coagulate blood in, in vitro studies and also was effective in the treatment of mucosal and cutaneous bleeding in animal studies, without any toxicity. We decided to compare its effect on the treatment of human GI bleeding with the other common method for treatment of GI bleeding "argon plasma coagulation plus epinephrine injection" in a pilot randomized clinical trial. METHODS The patients with GI bleeding who were admitted to the emergency wards of Ghaem and Imam-Reza Hospitals in Mashhad were randomized to treatment with Hemostasis powder® or "argon plasma coagulation plus epinephrine injection" method, with randomized doctors, after complete testimonial sheet. The patients underwent re-endoscopy to evaluate the ulcers 3 days later, and were under observation for 3 months. After achieving the number of patients that was planned (20 patients), all data were entered to SPSS software version 20 and were analyzed with parametric and non-parametric tests. RESULTS The treatment success was 95% in both groups. There was no complication after treatment of GI bleeding in the two groups after 3 months. No rebreeding was reported in Hemostasis powder® group but 10 % was reported in "argon plasma coagulation plus epinephrine injection" group. CONCLUSION It seems that if the successful results occur in the future complimentary studies, Hemostasis powder® can be used as a new, effective, available, and inexpensive measure in the treatment of GI bleeding and also in the GI bleedings that cannot be treated with common available methods.
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Affiliation(s)
- Jamshid Vafaeimanesh
- Associate professor, Gastroenterology and Hepatology Disease Research Center, Qom University of Medical Sciences, Qom, Iran.,Gastrointestinal and Liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hassan Rakhshandeh
- Pharmacological Research Center of Medicinal Plants, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Pourakbar
- Department of Internal Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed MousalReza Hosseini
- Department of Internal Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Kichler A, Jang S. Endoscopic Hemostasis for Non-Variceal Upper Gastrointestinal Bleeding: New Frontiers. Clin Endosc 2019; 52:401-406. [PMID: 31309768 PMCID: PMC6785418 DOI: 10.5946/ce.2018.103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 03/16/2019] [Indexed: 12/14/2022] Open
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) refers to blood loss from the gastrointestinal tract proximal to the ligament of Treitz due to lesions that are non-variceal in origin. The distinction of the bleeding source as non-variceal is important in numerous aspects, but none more so than endoscopic approaches for successful hemostasis. When a patient presents with acute overt blood loss, NVUGIB is a medical emergency, which requires immediate intervention. There have been major strides in pharmacologic and endoscopic interventions for successful induction and remission of hemostasis in the last two decades. Despite achieving tangible improvements, the burden of the disease and the consequent mortality remain high. To address endoscopic outcomes better, several new technologies have emerged and have been subsequently incorporated to the armamentarium of hemostatic tools. This study aims to provide a succinct review on novel technologies for endoscopic hemostasis.
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Affiliation(s)
- Adam Kichler
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sunguk Jang
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
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ASGE technology committee, Parsi MA, Schulman AR, Aslanian HR, Bhutani MS, Krishnan K, Lichtenstein DR, Melson J, Navaneethan U, Pannala R, Sethi A, Trikudanathan G, Trindade AJ, Watson RR, Maple JT, ASGE Technology Committee Chair. Devices for endoscopic hemostasis of nonvariceal GI bleeding (with videos). VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2019; 4:285-299. [PMID: 31334417 PMCID: PMC6616320 DOI: 10.1016/j.vgie.2019.02.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Endoscopic intervention is often the first line of therapy for GI nonvariceal bleeding. Although some of the devices and techniques used for this purpose have been well studied, others are relatively new, with few available outcomes data. METHODS In this document, we review devices and techniques for endoscopic treatment of nonvariceal GI bleeding, the evidence regarding their efficacy and safety, and financial considerations for their use. RESULTS Devices used for endoscopic hemostasis in the GI tract can be classified into injection devices (needles), thermal devices (multipolar/bipolar probes, hemostatic forceps, heater probe, argon plasma coagulation, radiofrequency ablation, and cryotherapy), mechanical devices (clips, suturing devices, banding devices, stents), and topical devices (hemostatic sprays). CONCLUSIONS Endoscopic evaluation and treatment remains a cornerstone in the management of nonvariceal upper- and lower-GI bleeding. A variety of devices is available for hemostasis of bleeding lesions in the GI tract. Other than injection therapy, which should not be used as monotherapy, there are few compelling data that strongly favor any one device over another. For endoscopists, the choice of a hemostatic device should depend on the type and location of the bleeding lesion, the availability of equipment and expertise, and the cost of the device.
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Key Words
- ABS, Ankaferd blood stopper
- APC, argon plasma coagulation
- ASGE, American Society for Gastrointestinal Endoscopy
- CPT, Current Procedural Terminology
- CSEMS, covered self-expandable metallic stent
- EBL, endoscopic band ligation
- EDP, endoscopic Doppler probe
- GAVE, gastric antral vascular ectasia
- HP, heater probe
- LGIB, lower GI bleeding
- MPEC, multipolar electrocoagulation
- OTSC, over-the-scope clip
- PTFE, polytetrafluoroethylene
- RCT, randomized controlled trial
- TTS, through-the-scope
- U.S. FDA, United States Food and Drug Administration
- UGIB, upper GI bleeding
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Affiliation(s)
| | - Mansour A. Parsi
- Section for Gastroenterology & Hepatology, Tulane University Health Sciences Center, New Orleans, LA
| | - Allison R. Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Harry R. Aslanian
- Section of Digestive Diseases, Department of Internal Medicine, Yale University, New Haven, CT
| | - Manoop S. Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Kuman Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - David R. Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, IL
| | | | - Rahul Pannala
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, New York-Presbyterian/Columbia University Medical Center, New York, NY
| | | | - Arvind J. Trindade
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, NY
| | - Rabindra R. Watson
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, CA
| | - John T. Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Ofosu A, Ramai D, Latson W, Adler DG. Endoscopic management of bleeding gastrointestinal tumors. Ann Gastroenterol 2019; 32:346-351. [PMID: 31263356 PMCID: PMC6595926 DOI: 10.20524/aog.2019.0391] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/01/2019] [Indexed: 02/07/2023] Open
Abstract
Bleeding due to primary or metastatic gastrointestinal (GI) tumors remains clinically challenging. Bleeding is further complicated in the setting of underlying friable neovascularization of tumors and coagulopathy. Endoscopic hemostatic therapeutic options have traditionally involved the use of thermal/mechanical therapy in conjunction with injection therapy. This review looks at the role of endoscopy in managing tumor-related GI bleeding, specifically contact and non-contact thermal therapy, radiofrequency ablation, endoloops, epinephrine and ethanol injection, and, most recently, Hemospray. Overall, current data show that endoscopic therapy is limited, with high rebleeding rates and a failure to improve overall outcomes. Larger clinical trials are needed to determine the efficacy of current techniques and establish therapeutic algorithms, with the goal of achieving primary hemostasis and reducing rebleeding rates.
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Affiliation(s)
- Andrew Ofosu
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, NY (Andrew Ofosu, Will Latson)
| | - Daryl Ramai
- Department of Medicine, The Brooklyn Hospital Center, NY (Daryl Ramai)
| | - Will Latson
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, NY (Andrew Ofosu, Will Latson)
| | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Huntsman Cancer Center, Salt Lake City, Utah (Douglas G. Adler), USA
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Turan AS, Ultee G, Van Geenen EJM, Siersema PD. Clips for managing perforation and bleeding after colorectal endoscopic mucosal resection. Expert Rev Med Devices 2019; 16:493-501. [PMID: 31109217 DOI: 10.1080/17434440.2019.1618707] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The most commonly used treatment for advanced colorectal adenomas is endoscopic mucosal resection (EMR). The increased number of EMRs since the introduction of the screening program for colorectal cancer has resulted in an increase in EMR-related complications. This review summarizes the current knowledge for the use of clips for the treatment and prevention of complications after EMR. AREAS COVERED The historical development of clips is summarized and their properties are evaluated. An overview is presented of the evidence for therapeutic and prophylactic clipping for bleeding or perforation after EMR in the colon. Several clipping techniques are discussed in relation to the efficacy of wound closure. Furthermore, new techniques that will likely influence the use of clips in the future endoscopic practice, such as endoscopic full-thickness resection (eFTR) are also highlighted. EXPERT COMMENTARY Most research focuses on prophylactic clipping for delayed bleeding after EMR of large adenomas. We advocate a distance of 0.5-1.0 cm between aligning clips. This focus may likely shift from bleeding to perforation. Here, endoscopic treatment with through-the-scope clips and large-diameter clips may well replace surgery. The future role of clips will also depend on the further development of new endoscopic technologies, such as eFTR.
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Affiliation(s)
- A S Turan
- a Department of Gastroenterology and Hepatology , Radboud University Medical Centre , The Netherlands
| | - G Ultee
- a Department of Gastroenterology and Hepatology , Radboud University Medical Centre , The Netherlands
| | - E J M Van Geenen
- a Department of Gastroenterology and Hepatology , Radboud University Medical Centre , The Netherlands
| | - P D Siersema
- a Department of Gastroenterology and Hepatology , Radboud University Medical Centre , The Netherlands
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Endoscopic management of nonvariceal upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2019; 42-43:101608. [PMID: 31785733 DOI: 10.1016/j.bpg.2019.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 04/15/2019] [Indexed: 01/31/2023]
Abstract
Endoscopic therapy is the mainstay of treatment for nonvariceal upper gastrointestinal bleeding (NVUGIB). Injection plus mechanical or thermal therapy continues to be the most widely used option. New endoscopic devices such as the use of an inert powder or a new class of over-the-scope clip system have demonstrated encouraging results as a rescue therapy for difficult hemostasis. Emerging data suggest that Doppler ultrasound-guided endoscopic therapy may improve the outcome of peptic ulcer bleeding. This review sumarizes the recent advances in the management of NVUGIB. With increasing use of anti-platelet agents and anti-coagulants, the management of NVUGIB in patients on anti-thrombotic therapy is also discussed.
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43
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Tang RSY, Lau JYW. Monopolar hemostatic forceps with soft coagulation: earning a place in the endoscopic hemostasis repertoire for peptic ulcer bleeding. Gastrointest Endosc 2019; 89:803-805. [PMID: 30902204 DOI: 10.1016/j.gie.2018.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 12/05/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Raymond S Y Tang
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - James Y W Lau
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong
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Raña-Garibay R, Salgado-Nesme N, Carmona-Sánchez R, Remes-Troche J, Aguilera-Carrera J, Alonso-Sánchez L, Arnaud-Carreño C, Charúa-Guindic L, Coss-Adame E, de la Torre-Bravo A, Espinosa-Medina D, Esquivel-Ayanegui F, Roesch-Dietlen F, López-Colombo A, Muñoz-Torres J, Noble-Lugo A, Rojas-Mendoza F, Suazo-Barahona J, Stoopen-Rometti M, Torres-Flores E, Vallejo-Soto M, Vergara-Fernández O. The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2019.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Toka B, Eminler AT, Karacaer C, Uslan MI, Koksal AS, Parlak E. Comparison of monopolar hemostatic forceps with soft coagulation versus hemoclip for peptic ulcer bleeding: a randomized trial (with video). Gastrointest Endosc 2019; 89:792-802. [PMID: 30342026 DOI: 10.1016/j.gie.2018.10.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/02/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Bilal Toka
- Department of Gastroenterology, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Ahmet Tarik Eminler
- Department of Gastroenterology, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Cengiz Karacaer
- Department of Internal Medicine, Sakarya Education and Training Hospital, Sakarya, Turkey
| | - Mustafa Ihsan Uslan
- Department of Gastroenterology, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Aydin Seref Koksal
- Department of Gastroenterology, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Erkan Parlak
- Department of Gastroenterology, Sakarya University Faculty of Medicine, Sakarya, Turkey
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Raña-Garibay R, Salgado-Nesme N, Carmona-Sánchez R, Remes-Troche JM, Aguilera-Carrera J, Alonso-Sánchez L, Arnaud-Carreño C, Charúa-Guindic L, Coss-Adame E, de la Torre-Bravo A, Espinosa-Medina D, Esquivel-Ayanegui F, Roesch-Dietlen F, López-Colombo A, Muñoz-Torres JI, Noble-Lugo A, Rojas-Mendoza F, Suazo-Barahona J, Stoopen-Rometti M, Torres-Flores E, Vallejo-Soto M, Vergara-Fernández O. The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2019; 84:220-240. [PMID: 31014749 DOI: 10.1016/j.rgmx.2019.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/05/2018] [Accepted: 01/10/2019] [Indexed: 06/09/2023]
Abstract
Since the publication of the 2008 guidelines on the diagnosis and treatment of diverticular disease of the colon by the Asociación Mexicana de Gastroenterología, significant advances have been made in the knowledge of that disease. A systematic review of articles published in the medical literature from January 2008 to July 2018 was carried out to revise and update the 2008 guidelines and provide new evidence-based recommendations. All high-quality articles in Spanish and English published within that time frame were included. The final versions of the 43 statements accepted in the three rounds of voting, utilizing the Delphi method, were written, and the quality of evidence and strength of the recommendations were established for each statement, utilizing the GRADE system. The present consensus contains new data on the definition, classification, epidemiology, pathophysiology, and risk factors of diverticular disease of the colon. Special emphasis is given to the usefulness of computed tomography and colonoscopy, as well as to the endoscopic methods for controlling bleeding. Outpatient treatment of uncomplicated diverticulitis is discussed, as well as the role of rifaximin and mesalazine in the management of complicated acute diverticulitis. Both its minimally invasive alternatives and surgical options are described, stressing their indications, limitations, and contraindications. The new statements provide guidelines based on updated scientific evidence. Each statement is discussed, and its quality of evidence and the strength of the recommendation are presented.
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Affiliation(s)
| | - N Salgado-Nesme
- División de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - R Carmona-Sánchez
- Unidad de Médica Ambulatoria Christus Muguerza, San Luis Potosí, S.L.P., México.
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - J Aguilera-Carrera
- Hospital de Especialidades Médicas de la Salud, San Luis Potosí, S.L.P., México
| | | | - C Arnaud-Carreño
- Departamento de Cirugía, Hospital General «Dr. Aurelio Valdivieso», Secretaría de Salud del Estado de Oaxaca, Oaxaca, Oaxaca, México
| | | | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | | | | | - F Esquivel-Ayanegui
- Hospital General «Dr. Miguel Silva», Secretaría de Salud de Michoacán, Morelia, Michoacán, México
| | - F Roesch-Dietlen
- Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - A López-Colombo
- Direccción de Educación e Investigación, UMAE Hospital de Especialidades CMN Manuel Ávila Camacho, Instituto Mexicano del Seguro Social, Puebla, Puebla, México
| | - J I Muñoz-Torres
- Facultad de Medicina, Universidad Autónoma de Baja California, Mexicali, BC, México
| | | | | | - J Suazo-Barahona
- Centro de Enfermedades Digestivas, Hospital del Valle, San Pedro Sula, Honduras
| | - M Stoopen-Rometti
- Departamento de Radiología e Imagen, CT Scanner Lomas Altas, Ciudad de México, México
| | - E Torres-Flores
- Hospital General de Zona # 1, Instituto Mexicano del Seguro Social, Pachuca, Hidalgo, México
| | | | - O Vergara-Fernández
- División de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
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Alzoubaidi D, Lovat LB, Haidry R. Management of non-variceal upper gastrointestinal bleeding: where are we in 2018? Frontline Gastroenterol 2019; 10:35-42. [PMID: 30651955 PMCID: PMC6319149 DOI: 10.1136/flgastro-2017-100901] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/10/2018] [Accepted: 01/21/2018] [Indexed: 02/04/2023] Open
Abstract
Acute upper gastrointestinal bleeding (AUGIB) is one of the most common medical emergencies in the UK. Despite advancement in technology the management of AUGIB remains a challenge. The clinical community recognise the need for improvement in the treatment of these patients. AUGIB has a significant impact on resources. Endoscopic therapy is the gold standard treatment. The mortality in AUGIB is rarely related to the presenting bleed but significantly associated with concurrent comorbidities. The cost of blood transfusion in the management of patients with AUGIB is significant and misuse of blood products has been documented nationally. Risk stratification tools such as Glasgow-Blatchford Score, Rockall Score and the AIMS65 score have allowed clinicians to triage patients appropriately in order to deliver endoscopic therapy within a suitable time frame. Endoscopic therapeutic modalities such as epinephrine injection, heat thermocoagulation and mechanical clips have had a positive impact on patient's management. However, in order to continue to improve patient's outcomes, further developments are needed.
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Affiliation(s)
- Durayd Alzoubaidi
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Laurence B Lovat
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Rehan Haidry
- Division of Surgery and Interventional Science, University College London, London, UK
- GI Services, University College London Hospital, London, UK
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There Is No Excuse for Mortality Due to Lack of Competency and Training of Paediatric Endoscopists in Gastrointestinal Bleeding Therapy in 2018. J Pediatr Gastroenterol Nutr 2018; 67:684-688. [PMID: 30211844 DOI: 10.1097/mpg.0000000000002148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Acute upper gastrointestinal bleeding in children is possibly the last medical emergency which continues to lead to the death of a child due to the lack of competency/clinical judgement of the doctor, as opposed to the disease itself, leading to mortality despite optimum medical intervention. This is unacceptable in any circumstances in 2018. It occurs due to a number of conspiring factors including lack of appreciation of the clinical presentation requiring urgent endoscopic intervention; misapprehension of the urgency of timing required of such an intervention predicated on the severity of the gastrointestinal (GI) bleed; lack of application of a paediatric-specific validated score predicting for such endoscopic intervention; lack of skill in endo-haemostatic intervention techniques by paediatric endoscopists; poor training in such techniques among paediatric endoscopists; paucity of cases with lack of exposure of the paediatric endoscopist regularly to enable skills to be maintained, once acquired; reluctance of adult endoscopists in many centres to support paediatric GI bleeding services. In essence then the paediatric GI community urgently needs to identify centres of excellence to whom these children should be transferred. Transfer is safe in all but the most critical cases once stabilised with transfusion, octreotide/terlipressin and iv proton pump inhibitors. The resources are country-dependent but this is really no excuse. We must not let this parlous state of affairs continue. Solutions are explored in this article and please let this serve as a call to action for all those involved in this continuing debacle in order to save "save-able" lives.
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Gweon TG, Kim J. Comprehensive review of outcomes of endoscopic treatment of gastrointestinal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Tae-Geun Gweon
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Jinsu Kim
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Safety analysis of endoscopic haemostasis using a high-frequency live tissue electric welding device - EKVZ300 PATONMED. GASTROENTEROLOGY REVIEW 2018; 13:234-237. [PMID: 30302170 PMCID: PMC6173082 DOI: 10.5114/pg.2018.78289] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 06/07/2018] [Indexed: 11/17/2022]
Abstract
Introduction The method of a bipolar high-frequency welding (HFEW) of soft living tissues of animals and humans has been used in various areas of surgery. However, it has not been utilized in endoscopic gastrointestinal procedures yet. HFEW has strong potential to be used in gastrointestinal endoscopic procedures due to the competitive cost of generator devices and due to its proven ability to coagulate vessels of wide diameter as compared to standard electrocautery devices. Aim To investigate the effectiveness of the endoscopic haemostasis using HFEW generator device – 300 PATONMED – in a porcine model of arterial gastrointestinal bleeding. Material and methods A porcine model of arterial gastrointestinal bleeding was created. A 300 PATONMED set to the “welding” regime and a flexible 7 Fr bipolar coagulation probe with two electrodes on the tip fashioned spirally attached to convey energy were tested. Once bleeding from the artery had been initiated, the bipolar probe was applied to coagulate the bleeding site. Animals were observed for clinical evidence of recurrent bleeding and subsequently were euthanised for histological examination. Results A total of 10 experiments were successfully completed. An optimal haemostatic effect was achieved with durations of cautery of five to eight seconds in all animals. Continuous observation after haemostasis revealed no evidence of re-bleeding. No systemic side-effects of the technique were observed. Histological examination has shown that the peripheral thermal injury area that surrounded the coagulation zone did not spread beyond the mucosal layer in depth and 2 mm in width. Conclusions This animal study provided evidence for the safety of an HFEW in the treatment of gastrointestinal bleeding. The advantages of this technology are smokeless operative area, no tissue overheating, minimal necrosis and damage to surrounding gastric tissue, and the fact that the area of HFEW is confined to the area of the electrodes.
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