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PubMed2006

Efficacy of a selective COX-2 inhibitor for controlling irregular uterine bleeding in DMPA users.

PURPOSE: This double-blind, placebo-controlled study was conducted to evaluate the efficacy of valdecoxib and placebo for controlling irregular uterine bleeding in depot-medroxyprogesterone acetate (DMPA) users. METHOD: A total of 51 DMPA users were enrolled. All subjects in the study had abnormal bleeding and were randomly divided into two groups. One group totaling 22 received valdecoxib, 40 mg, once a day for 5 days, and placebos were given to another 24 in the same manner; 5 subjects dropped out from the study. Analysis of the number of treatment days required for stopping the bleeding episode, percentage of women whose bleeding was stopped in 7 days, total number of bleeding-free days and length of the bleeding-free interval after the initial treatment was determined in the first and the fourth weeks. RESULTS: The percentage of the subjects whose bleeding was stopped during the first week after the initial treatment and the mean value of the bleeding-free days during the 28 days of the follow-up period were significantly higher in the valdecoxib group than in the placebo group (77.3% vs. 33.3%, p<.01; and 17.8 days vs. 11.5 days, p<.05, respectively). The mean duration of treatment days required for stopping the bleeding episode in the valdecoxib-treated group was 1.7 days, and the mean duration of the bleeding-free interval in valdecoxib-treated group was 18.6 days. CONCLUSION: Valdecoxib was more effective than placebo in the short-term control of irregular bleeding in DMPA users. The mechanism of nonsteroidal anti-inflammatory drugs (NSAIDs) for the reduction of endometrial bleeding is likely from COX-2 inhibition.

Adult↗
PubMed2026

Risk factors for bleeding after endoscopic retrograde cholangiopancreatography: a systematic review and meta-analysis.

BACKGROUND AND AIMS: ERCP is associated with adverse events, including bleeding, which occurs in up to 1.3% of cases. This meta-analysis aims to identify and quantify risk factors associated with post-ERCP bleeding. METHODS: A comprehensive literature search of electronic databases was conducted from inception to January 10, 2025. Studies were eligible if they used multivariate analysis to identify predictors of post-ERCP bleeding. Risk factors reported in at least 2 studies were pooled using a random-effects model to calculate odds ratios (ORs) with 95% CIs. A further subgroup analysis was performed, including risk factors for postsphincterotomy bleeding and postendoscopic papillectomy bleeding. RESULTS: Twenty-seven studies (4 prospective and 23 retrospective studies) comprising 149,870 patients were included, of whom 1865 experienced post-ERCP bleeding. Twenty potential risk factors were analyzed. The meta-analysis identified several factors significantly associated with increased odds of post-ERCP bleeding in the pooled adjusted analysis, including male gender (OR, 1.24; 95% CI, 1.05-1.46), anticoagulation therapy (OR, 2.75; 95% CI, 1.66-4.56), cirrhosis (OR, 2.54; 95% CI, 1.76-3.65), hemodialysis (OR, 5.82; 95% CI, 3.32-10.18), coagulopathy (OR, 11.01; 95% CI, 2.50-48.40), endoscopic sphincterotomy (EST) (OR, 3.19; 95% CI, 1.69-6.01), precut sphincterotomy (OR, 2.24; 95% CI, 1.52-3.30), and intraoperative bleeding (OR, 2.57; 95% CI, 1.80-3.66). Several factors in the pooled adjusted analysis were not found to be significantly associated with higher odds of post-ERCP bleeding, including high body mass index (BMI), nonsteroidal anti-inflammatory drug (NSAID) use, antiplatelet therapy, thrombocytopenia, common bile duct stones, cholangitis, endoscopic papillary balloon dilatation, and covered self-expandable metal stent insertion. CONCLUSIONS: This meta-analysis identified that the anticoagulation therapy, cirrhosis, hemodialysis, coagulation disorder, EST, precut sphincterotomy, and male gender are associated with increased odds of post-ERCP bleeding in the pooled adjusted analysis. Conversely, age, high BMI, cholangitis, choledocholithiasis, pancreatic duct stones, needle-knife sphincterotomy, NSAID use, and antiplatelet therapy were not significantly associated with higher odds of post-ERCP bleeding in the pooled adjusted analysis. Incorporating our results into a prediction model may assist in identifying patients at increased risk, optimizing informed consent, and guiding prevention and management strategies for post-ERCP bleeding.

Humans↗
PubMed1998

Prospective evaluation of an index for predicting the risk of major bleeding in outpatients treated with warfarin.

PURPOSE: To evaluate the accuracy and clinical utility of the Outpatient Bleeding Risk Index for estimating the probability of major bleeding in outpatients treated with warfarin. The index was previously derived in a retrospective cohort of 556 patients from a different hospital (derivation cohort). SUBJECTS AND METHODS: We enrolled 264 outpatients starting warfarin (validation cohort) to validate the index prospectively. All patients were identified upon hospital discharge, and physician estimates of the probability of major bleeding were obtained before discharge in the validation cohort. RESULTS: Major bleeding occurred in 87 of 820 outpatients (6.5%/yr). The index included four independent risk factors for major bleeding: age 65 years or greater; history of gastrointestinal bleeding; history of stroke; and one or more of four specific comorbid conditions. In the validation cohort, the index predicted major bleeding: the cumulative incidence at 48 months was 3% in 80 low-risk patients, 12% in 166 intermediate-risk patients, and 53% in 18 high-risk patients (c index, 0.78). The index performed better than physicians, who estimated the probability of major bleeding no better than expected by chance. Of the 18 episodes of major bleeding that occurred in high-risk patients, 17 were potentially preventable. CONCLUSIONS: The Outpatient Bleeding Risk Index prospectively classified patients according to risk of major bleeding and performed better than physicians. Major bleeding may be preventable in many high-risk patients by avoidance of over-anticoagulation and nonsteroidal anti-inflammatory agents.

Aged↗
PubMed1999

Is tocolysis safe in the management of third-trimester bleeding?

OBJECTIVE: Expectant management is among the current treatment options for pregnancies complicated by third-trimester bleeding at <36 weeks' gestation. The use of tocolytic agents to stop associated contractions is still somewhat controversial, however, and the number of cases reported to date is small. The purpose of our study was to find a large number of cases of preterm third-trimester bleeding that was treated with tocolytic agents and evaluate them for any evidence of potential harm related to the use of these agents. STUDY DESIGN: Every case of third-trimester bleeding for a 6-year period was obtained from a perinatal database that was created as patients were hospitalized. Only cases of patients with onset of bleeding between 23 and 36 weeks' gestation were analyzed. Data collected included the gestational age at the time of first bleeding, the gestational age at delivery, whether tocolytic agents were used, the need for transfusion, maternal morbidity, and neonatal outcome. RESULTS: A total of 236 cases, consisting of 131 cases of abruptio placentae and 105 cases of placenta previa, met the study criteria. In the abruptio placentae group 95 women (73%) were treated with tocolytic agents. In this group the mean gestational age at the time of first bleeding was 28.9 weeks, the mean time from bleeding until delivery was 18.9 days, the median time from bleeding until delivery was 7 days, and the neonatal mortality rate was 51 deaths/1000 live births. In the placenta previa group 76 patients (72%) were treated with tocolytic agents. In this group the mean gestational age at first bleeding was 29.5 weeks, the mean time from bleeding until delivery was 29.3 days, the median time from bleeding until delivery was 22 days, and the neonatal mortality rate was 39 deaths/1000 live births. In both groups the need for transfusion and the incidence of fetal distress were not increased by the use of tocolytic agents. Among the 171 combined patients who underwent tocolysis, no maternal morbidity related to the tocolytic agents was found and no stillbirths occurred after admission. The neonatal deaths were all related to complications of prematurity. CONCLUSIONS: This is the largest series to date evaluating the use of tocolytic agents in preterm patients with third-trimester bleeding. From these data there does not appear to be any increased morbidity or mortality associated with tocolytic agent use in a controlled tertiary setting. A prospective randomized trial would be necessary to determine whether tocolytic use carries any benefits.

Abruptio Placentae↗
PubMed2003

Bleeding patterns and patient acceptability of standard or continuous dosing regimens of a low-dose oral contraceptive: a randomized trial.

The purpose of this study is to compare bleeding patterns and acceptability of a contraceptive regimen of combined 20 microg ethinyl estradiol/100 microg levonorgestrel taken with and without a hormone-free interval. Thirty-two women desiring oral contraception were randomized to six 28-day cycles (standard group) or 168 days without a pill-free interval (continuous group). Participants kept a daily bleeding calendar documenting bleeding events (none, spotting or required sanitary protection) and side effects (headache, nausea, breast tenderness, depression, premenstrual syndrome and bloating). Primary outcome was number of bleeding days. Secondary outcomes included bleeding days requiring sanitary protection, amenorrhea, patient acceptability of bleeding patterns, method satisfaction and affective side effects. There were no differences in the baseline characteristics of the two groups. Although total bleeding days were fewer in the continuous group (mean = 25.9 vs. 34.9 days), this result did not reach statistical significance. However, women in the continuous group reported significantly fewer bleeding days that required protection (18.4 vs. 33.8 days, p < 0.01), and were more likely to have amenorrhea. Although both groups reported a high level of satisfaction with bleeding patterns and side effect profiles, women in the continuous group reported significantly fewer days of bloating (0.7 vs. 11.1 days, p = 0.04), and menstrual pain (1.9 vs. 13.3 days, p < 0.01). Continuous use of 20 microg ethinyl estradiol/100 microg levonorgestrel is associated with less bleeding requiring protection, and more amenorrhea than standard administration. Taken with or without a hormone-free interval, this oral contraceptive formulation is highly acceptable with regard to bleeding patterns and side effect profile. The continuous group had fewer light and moderate bleeding days, less bloating and menstrual pain. For patients who are seeking these results, this method may be more desirable.

Adult↗
PubMed1998

RETRACTED: An integrated analysis of vaginal bleeding patterns in clinical trials of Implanon.

The vaginal bleeding patterns observed during the use of the single-rod progestin-only implant, Implanon, compared with those seen during the use of the six-capsule implant, Norplant, have been analyzed. The acceptability of these bleeding patterns was also assessed. An integrated analysis of 13 different trials was done, studying reference periods (RP) of 90 days. These trials included totals of 1716 Implanon users and 689 Norplant users. There were statistically significant lower mean values over RP 2-8 the range over RP 2-8 is presented) for Implanon, for the number of bleeding-spotting days (15.9-19.3 vs 19.4-21.6; p = 0.0169), the number of bleeding days (7.5-10.0 vs. 11.7-13.1; p < 0.001), and the number of bleeding-spotting episodes (2.2-2.7 vs. 3.1-3.3; p < 0.0001). The bleeding patterns of Implanon users appeared to be more variable than those observed with Norplant: Implanon users had more amenorrhea, and slightly more infrequent bleeding, frequent bleeding, and prolonged bleeding than Norplant users. The difference was only statistically significant for amenorrhea (17.9%-24.8% with Implanon compared with 2.0%-7.0% for Norplant over RP 2-8). There were no statistically significant differences in the acceptability of the two products as indicated by the discontinuation rates, which were 30.2% and 0.9% in Europe and Southeast Asia, respectively, for Implanon, and 22.5% and 1.4%, respectively, in the two regions, for Norplant. The individual bleeding pattern was not predictable. However, in general, it can be stated that women initially without bleeding or with infrequent bleeding have only a small chance of becoming frequent bleeders, and vice versa. Dysmenorrhea clearly improved during use of both Implanon and Norplant. Neither Implanon nor Norplant caused anemia.

Adolescent↗
PubMed1997

Gastrointestinal bleeding in cirrhotic patients with hepatocellular carcinoma undergoing intrahepatic artery chemotherapy.

BACKGROUND: Hepatocellular carcinoma in cirrhotic patients increases the risk of variceal bleeding. We sought to characterize bleeding in a cirrhotic patient population undergoing intrahepatic artery chemotherapy for hepatocellular carcinoma and to determine the possible influence of this treatment on gastrointestinal bleeding. METHODS: We retrospectively reviewed 179 patients with hepatocellular carcinoma who underwent intrahepatic artery doxorubicin and cis-platinum chemotherapy to determine the incidence of gastrointestinal bleeding and compared them with 434 hepatocellular carcinoma historic controls not undergoing regional chemotherapy. RESULTS: Of the 179 patients, 27 patients (15.1%) developed upper gastrointestinal bleeding over a mean follow-up of 15.2 months; 18 of the 27 (66.7%) bled from a variceal source and 9 (33.3%) bled from a nonvariceal source: ulcer (n = 6), gastropathy (n = 1), Mallory-Weiss (n = 1), erosive gastritis (n = 1). Twenty-one patients developed bleeding after initiation of chemotherapy (14 variceal and 7 nonvariceal). The number of chemotherapy sessions among patients with variceal and nonvariceal bleeding was similar (2.1 +/- 0.4 and 4.0 +/- 1.2; p = Not significant). Patients with variceal and nonvariceal bleeding were comparable with respect to Child-Pugh classification, pTNM stage, age, time to bleeding, and gender. CONCLUSIONS: Regional intra-arterial chemotherapy for hepatocellular carcinoma is associated with a low risk of variceal bleeding. Nonvariceal sources of upper gastrointestinal bleeding in this population account for a significant component of bleeding episodes.

Adolescent↗
PubMed1996

Stress and incidence of bleeding in children and adolescents with hemophilia.

OBJECTIVE: To examine the relationship of stress and incidence of bleeding in boys with hemophilia. STUDY DESIGN: We conducted a 6-month longitudinal study of 97 subjects (ages 4 to 16 years) from six hemophilia centers. Diaries recorded bleeding episodes (including site and history of previous trauma) and both child and parent daily stress. Parent and child stressful life event measures were obtained monthly. Socioeconomic data and clotting factor level were determined at enrollment. Logistic regression models examined the influence of recent stress on likelihood of bleeding on each day, controlling for factor level and socioeconomic data. We also determined associations of aggregated previous month's events with bleeding likelihood in the succeeding month. RESULTS: Fifty-eight percent of study participants had severe hemophilia. The sample population averaged nine bleeding episodes per 6 months; of these; two thirds of bleeding incidents occurred into joints and 44% after injury. Factor level strongly predicted bleeding incidence (p < 0.0001). Increased parent stress was associated with increased bleeding in general (odds ratio = 1.37, p < 0.003) and with injury (odds ratio = 1.65, p < 0.001), but not bleeding into joints. Similar findings followed parent reports of positive life events. Increased parent negative life events in 1 month were associated with increased bleeding in the succeeding month (p < 0.05). CONCLUSION: Short- and long-term parental stress may lead to increased bleeding incidence in hemophilia, although factor level much more strongly predicts bleeding.

Adolescent↗
PubMed2002

Bleeding patterns of the hormone replacement therapies in the postmenopausal estrogen and progestin interventions trial.

OBJECTIVE: To explore whether significant differences exist between bleeding patterns with common regimens of hormone replacement therapy using two different progestogens. METHODS: A total of 875 women in the Postmenopausal Estrogen and Progestin Interventions Trial took either placebo, conjugated equine estrogen 0.625 mg, conjugated equine estrogen 0.625 mg plus medroxyprogesterone acetate 2.5 mg in a continuous fashion, or conjugated equine estrogen 0.625 mg daily plus either cyclical medroxyprogesterone acetate 10 mg or cyclical micronized progesterone 200 mg/day for 12 days per month. Bleeding days, amounts, and episodes were recorded in diaries and aggregated by 6-month intervals for 3 years for the 596 participants with a uterus. Any bleeding for women on continuous regimens, or more than 6 episodes of bleeding per 6-month period for cyclical regimens, was considered excess. RESULTS: Conjugated equine estrogen plus micronized progesterone cyclical was associated with fewer excess episodes of bleeding than conjugated equine estrogen plus medroxyprogesterone acetate continuous in the first 6 months. Quantities of bleeding for conjugated equine estrogen plus micronized progesterone cyclical were less than for conjugated equine estrogen plus medroxyprogesterone acetate cyclical through 30 months and for the number of bleeding days through study end. The 3-year cumulative quantities, days, and episodes of bleeding were significantly lower for conjugated equine estrogen plus micronized progesterone cyclical than for conjugated equine estrogen plus medroxyprogesterone acetate cyclical. Placebo treated women had scant bleeding and conjugated equine estrogen had modest amounts relative to the combination therapies. CONCLUSION: The bleeding measures for conjugated equine estrogen plus micronized progesterone cyclical showed consistent advantages over those for cyclical conjugated equine estrogen plus medroxyprogesterone acetate in terms of quantity, length, and episodes of bleeding. In the first 6 months, conjugated equine estrogen plus micronized progesterone cyclical had fewer excess bleeding episodes than continuous conjugated equine estrogen plus medroxyprogesterone acetate.

Aged↗
PubMed1989

Colonoscopic diagnosis and treatment of lower gastrointestinal bleeding.

Methods of diagnosis and treatment of lower gastrointestinal bleeding depend on the rate of bleeding and the amount of blood lost. If bleeding is occult, colonoscopy is the single best way to determine the source, if bleeding is gross but mild, causing melena or small amounts of hematochezia, colonoscopy or a combination of flexible sigmoidoscopy and double-contrast barium enema should be used to evaluate the colon. In most patients with melena, the upper tract must be examined endoscopically. Acute lower gastrointestinal bleeding stops spontaneously in 75 to 90 per cent of patients, permitting preparation of the colon before colonoscopy. If bleeding is continuing, diagnostic options include colonoscopy with no preparation of the colon, relying on the cathartic effect of blood, or a red cell radionuclide scan followed by angiography if the scan is positive. A bleeding lesion seen on angiography is usually treated by infusion of vasopressin. Colonoscopic treatment of a bleeding site uses the BICAP probe, heater probe, or argon laser. Patients who bleed severely and those who do not respond to treatment or rebleed after treatment are candidates for operation. Segmental resection is preferred if the bleeding site is known. If not, total colectomy with ileorectal anastomosis may be necessary. A mortality rate of 10 to 15 per cent in patients with severe bleeding reflects the advanced age of many of these patients and the difficulty of managing gastrointestinal bleeding in the presence of associated medical conditions.

Acute Disease↗
PubMed2002

Bleeding patterns in peri and postmenopausal women taking a continuous combined regimen of estradiol with norethisterone acetate or a conventional sequential regimen of conjugated equine estrogens with medrogestone.

OBJECTIVES: The aim of this study was to compare the incidence of women presenting irregular bleeding episodes following 9 months of treatment with a low dose continuous combined hormone replacement therapy consisting of estradiol (E(2)) and norethisterone acetate (NETA) versus a sequential hormone replacement therapy consisting of conjugated equine estrogens (CEE) and medrogestone (MG). Secondary aims were to establish the relationship between menopausal age and the occurrence of irregular bleeding for both therapies and to assess the efficacy of both therapies in alleviating menopausal symptoms. METHODS: This was a stratified and randomised, open label study conducted with late peri and postmenopausal women at 35 sites in Austria and Germany. A total of 446 women were randomly allocated into two cohorts based on time since last bleeding and then stratified to either a low dose continuous combined therapy consisting of 1 mg E(2) and 0.5 mg NETA for 28 days or a sequential therapy consisting of 0.625 mg CEE for 28 days and 5 mg MG for the final 14 days. Bleeding and menopausal complaints were continuously assessed. Treatments were administered for 9 lunar months. RESULTS: The incidence rate of women presenting irregular bleeding episodes including spotting during cycle 9 was 12.2% with 1mgE(2)/0.5mgNETA and 25.8% with 0.625mgCEE/5mgMG (P = 0.0014). In the group of postmenopausal women (time since last bleeding > or = 12 months) the incidence of irregular bleeding during cycle 9 was 11.0% for 1mgE(2)/0.5mgNETA and 25.0% for 0.625mgCEE/5mgMG). In the group of late perimenopausal women (time since last bleeding 6-11 months) the incidence of irregular bleeding was similar for both treatments at cycle 3, but markedly less in patients with 1mgE(2)/0.5mgNETA at cycle 6 and 9, being significantly different compared to patients with 0.625mgCEE/5mgMG at cycle 6 (P < 0.05). The cumulative rate of amenorrhea (no bleeding or spotting) achieved with 1mgE(2)/0.5mgNETA was 89% for the postmenopausal women and 83.7% for the late perimenopausal women. Both treatments relieved menopausal complaints equally effective. CONCLUSIONS: Regarding the occurrence of irregular bleeding, the low dose continuous combined therapy was superior to the sequential therapy (0.625mgCEE/5mgMG). The low dose continuous combined E(2)/NETA regimen is also suitable for late perimenopausal women since more than 80% of the women had no bleeding or spotting after 9 months of treatment.

Adult↗
PubMed1997

Immunohistochemical demonstration of bleeding in decomposed bodies by using anti-glycophorin A monoclonal antibody.

The usefulness of glycophorin A (GPA) as a marker of bleeding was investigated in decomposed bodies by using anti-human GPA monoclonal antibody immunohistochemically. Ninety-one specimens consisting of 37 skin and 54 muscle specimens were obtained from 21 autopsy cases with various degree of decomposition, which ranged from 12 h up to 2-3 months after death. The presence or absence of the bleeding in the specimens was evaluated macroscopically and was divided as follows: (1) specimens without bleeding (31 specimens), (2) specimens with bleeding (15 specimens), and (3) suspect specimens (45 specimens), in which the bleeding was not clear. By a peroxidase-labeled streptavidin-biotin method, positive reaction products for GPA were observed only within the blood vessels in the specimens without bleeding. On the other hand, in the specimens with bleeding, positive reaction products for GPA were seen not only within the blood vessels but also the extravascular tissues. Therefore, a specimen can be diagnosed as bleeding when GPA is distributed both within blood vessels and tissue outside the vessels. In application of GPA to 45 suspect specimens, 42 specimens (93%) were distinguished from the specimens with bleeding or without bleeding. These results prove that GPA is very useful as a marker of bleeding. The detection of GPA by the immunohistochemical method will help to differentiate between bleeding and hemoglobin (Hb) diffusion from blood vessels in a decomposed body.

Adult↗
PubMed2003

Ulcers and nonvariceal bleeding.

Peptic ulcer remains the commonest and most significant cause of nonvariceal upper gastrointestinal bleeding. The incidence of peptic ulcer bleeding is rising in elderly patients, particularly for duodenal ulcer. Patients presenting with upper gastrointestinal bleeding who have low Rockall scores are at low risk of rebleeding and death. These patients currently utilize considerable health-care resources, but could safely be managed at home. The Rockall score can be used to predict the risk of rebleeding and death following variceal bleeding, but for patients with ulcer bleeding, its ability to predict death is questioned. Acid suppression is effective in preventing rebleeding from peptic ulcer. Standard doses of intravenous omeprazole may be as effective as high-dose regimens. Oral omeprazole also reduces rebleeding following endoscopic therapy for peptic ulcer. Mallory-Weiss tears result in significant bleeding in 23 % of cases. Endoscopic therapy may only be required in cases in which active bleeding is present. Endoscopic therapy is effective and safe in patients with major peptic ulcer bleeding who are over 80 years old. For peptic ulcer, injection of larger volumes of epinephrine (adrenaline; mean 16.5 ml) are more effective than small volumes (mean 8 ml). Injection of normal saline alone is less effective than bipolar electrocoagulation. The addition of fibrin glue to epinephrine injection does not confer an additional benefit over epinephrine alone. Argon plasma coagulation can be used to treat a range of lesions in the gastrointestinal tract. It is also effective for treatment of bleeding ulcer, but is no better than established methods. Haemoclips may be useful in bleeding Mallory-Weiss tears, but their use is difficult in patients bleeding from peptic ulcer. The presence of a large ulcer and active bleeding at the time of endoscopy are independent predictors of failure of endoscopic therapy.

Anti-Ulcer Agents↗
PubMed1994

Management of clinically relevant bleeding following endoscopic sphincterotomy.

We report here on our experience of clinically relevant bleeding after endoscopic sphincterotomy (ES). Relevant bleeding was defined by the occurrence of (a) hematemesis or melena and (b) at least a two-point drop in hemoglobin, with no other bleeding source on endoscopy. These two criteria were met in 16 patients between 1983 and 1992. They represented 0.65% of all ES procedures performed during this period. Bleeding occurred immediately after ES in five cases, and was delayed in 11 cases from one to eight days (mean two days). Patients were retrospectively classified into three groups according to the severity of bleeding and subsequent clinical management. In six cases (group 1), bleeding developed slowly without shock and stopped spontaneously. In five cases (group 2), bleeding developed rapidly with melena and a drop in hemoglobin, but without shock. These patients were successfully managed with sclerotherapy without any further complications. The five patients in Group 3 had brisk bleeding with hematemesis and shock. Endoscopic hemostasis could not be performed; emergency arteriography disclosed active bleeding in four patients, and embolization of the gastroduodenal artery was performed. Bleeding stopped in all patients. Billroth II anastomosis appeared to be the only factor associated with an increased risk of clinically relevant bleeding. It was possible to control bleeding following ES using endoscopic or angiographic hemostasis, surgery being avoided in all cases.

Adult↗
PubMed1995

[Multicenter prospective study of the current status of treatment for bleeding ulcer in Germany].

The current state of ulcer treatment in Germany was analysed in a prospective multi-centre study. It was based on 1139 consecutive patients admitted to the participating hospitals because of upper gastrointestinal bleeding. The source of the bleeding was identified by diagnostic endoscopy in 1075 patients (94%), from a gastric and/or duodenal ulcer in 546 of them (mean age 62 +/- 18 years). Using Forrest's classification, 4% of patients were in bleeding stage Ia, 17% in stage Ib, 16% stage IIa, 30% stage IIb and 33% stage III. An attempt to arrest bleeding through the endoscope was made in 233 patients (43%): more often with tissue-preserving substances (epinephrine +/- NaCl in 36%, fibrin glue +/- epinephrine in 24%) than with tissue-damaging procedures (epinephrine + polidocanol +/- NaCl in 26%, epinephrine + thermocoagulation in 7%). Primary haemostasis was achieved in 219 patients (94%). There was a total of 66 recurrences of bleeding (12%), but the rate was 18% after endoscopic haemostasis. 64 patients (12%) required operative intervention, including initial emergency operations. Severe complications (infections, organic failure) occurred in 82 patients (16%). 114 of the 546 patients were in the high risk group (older than 60 years; high amount of bleeding). Their bleeding recurrence and mortality rates (27 and 22%, respectively) were significantly higher (P < 0.01) than those of the total group. Overall mortality rate was 11% (58 patients). The mortality rate depended on the severity of initial bleeding (26% for Forrest group Ia). After recurrent bleeding the mortality rate was 34% with conservative and 33% with operative treatment. 7% of all deaths were the direct result of bleeding. The following factors prognostically closely correlated with mortality rate: age of patient (P < 0.01); haemoglobin < 8 g/dl on admission (P < 0.05); initial severity of bleeding (Forrest group I; P < 0.05); and recurrence of bleeding (P < 0.001).

Age Factors↗
PubMed2000

[Clinical value of scintigraphy for gastrointestinal bleeding. Experiences in a large community hospital].

BACKGROUND AND OBJECTIVE: In the majority of cases of gastrointestinal bleeding the site and cause can be determined by gastroscope. If this is unsuccessful, radiological and nuclear-medical tests are available. This study was undertaken to determine the value of scintigraphy in diagnosing of the site of gastrointestinal bleeding. PATIENTS AND METHODS: The data on 155 patients who, between 1984 and 1988, had undergone 161 scintigraphies (with 99mTc-labelled erythrocytes, 5 with 99mTc-Sn colloid) were retrospectively analysed. The results were compared with other diagnostic tests that had been performed, with the definitive diagnosis and, where applicable, the findings at surgery. RESULTS: 78 scintigrams (47%) provided positive results. The site of bleeding had been demonstrated ca. 20 hours after the diagnostic studies had begun. In 47 of the cases the diagnosis was confirmed by additional tests. The intestine was the most common site of bleeding. Localization of the source of bleeding by scintigraphy and other diagnostic tests succeeded in 34 cases, with a 82% concordance between the tests. No bleeding was demonstrated in 88 scintigrams (53%), including all those done with Sn-colloid. In 13 cases the final diagnosis suggested that there had been no previous bleeding and in 43 cases the source of bleeding could not be determined. In 32 scintigraphically negative cases the source of bleeding was demonstrated by other tests. But only 2 of the 13 angiograms and none of the 33 double-contrast studies of the small intestine gave positive results. Among the total number of cases in which bleeding was demonstrated, scintigraphy had a sensitivity of 71%. CONCLUSION: Because of the long duration of observation, scintigraphy with 99mTc-labelled erythrocytes proved superior to other diagnostic tests in the demonstration of the bleeding. By localizing the source of bleeding in a definite part of the gastrointestinal tract, scintigraphy points the way to choosing other diagnostic methods or treatment. If the initial endoscopy has failed, scintigraphy, a method of low invasiveness, should be included when further tests are planned.

Angiography↗
PubMed2003

Predictors of bleeding after endoscopic mucosal resection of gastric tumors.

BACKGROUND: Endoscopic mucosal resection has been increasingly used to treat gastric tumors. Bleeding is the major complication of endoscopic mucosal resection. This study evaluated risk factors for bleeding associated with endoscopic mucosal resection. METHODS: Four hundred seventy-seven patients who underwent endoscopic mucosal resection of gastric tumors during the past 10 years were studied retrospectively. Bleeding encountered during endoscopic mucosal resection was termed immediate; bleeding after endoscopic mucosal resection was termed delayed. Univariate and multivariate analyses were used for determination of the factors related to delayed bleeding. One case of perforation was excluded. RESULTS: Delayed bleeding occurred in 25 (5.3%) of 476 patients. The only factor found to be significantly different between cases with and without delayed bleeding was the occurrence of immediate bleeding during endoscopic mucosal resection (p < 0.001). Sites where immediate bleeding occurred were not the same as those where delayed bleeding arose. There were no significant differences in other factors. CONCLUSIONS: When immediate bleeding occurs during endoscopic mucosal resection, there is an increased risk of delayed bleeding.

Adenocarcinoma↗
PubMed2005

A pilot study to assess the effect of three short-term treatments on frequent and/or prolonged bleeding compared to placebo in women using Implanon.

BACKGROUND: The major side-effect of progestogen-only contraception is disruption of menstrual bleeding patterns, which can lead to a high incidence of early discontinuation. The aim of this study was to compare three treatments with placebo on the duration and recurrence of frequent and/or prolonged bleeding in Implanon users. METHOD: Women between the ages of 18 and 45 years, who had used Implanon for > or =3 months and were experiencing prolonged or frequent bleeding patterns, were recruited at four Australian sites. Subjects were randomized to treatment using computer-generated random number table if they met the World Health Organization criteria for prolonged and/or frequent bleeding in the previous 90 days [Belsey, E.M., Pinol, A.P.Y. and Taskforce on Long-Acting Systemic Agents for Fertility Regulation, World Health Organization (1997) Contraception 55,57-65]. Treatments were: (1) mifepristone 25 mg given twice on day 1 followed by 4 days of twice daily placebo; (2) mifepristone 25 mg given twice on day 1 followed by 4 days of ethinyl estradiol (EE) 20 microg in the morning and placebo at night; (3) doxycycline 100 mg twice daily for 5 days; and (4) placebo twice daily for 5 days. Analysis was by intention to treat. The primary endpoint was the number of days of bleeding and spotting immediately following initiation of the 5 day course of each active therapy compared with placebo. RESULTS: A total of 179 women was assigned to treatment. Both mifepristone in combination with EE and doxycycline alone were significantly more effective in stopping an episode of bleeding {mean 4. 3 days [confidence interval (CI) 3.5-5.2], and 4.8 days (CI 3.9-5.8) respectively} than mifepristone alone or placebo [5.9 days (CI 4.8-7.2) and 7.5 days (CI 6.1-9.1) respectively]. No effect on subsequent bleeding patterns was observed in any treatment group. CONCLUSION: Both mifepristone plus EE and doxycycline alone were significantly more effective than placebo in terminating an episode of bleeding in women with prolonged and/or frequent bleeding using Implanon. We believe that the observed reduction in the number of bleeding days by almost 50% compared to placebo in both the mifepristone combination group and the doxycycline group demonstrates a clinically significant improvement in bleeding patterns and that further trials are needed to compare different combinations of therapy as well as multiple dosing regimens in order to establish which is the most effective treatment option. The effect of repeat administration or combinations of these preparations on long-term bleeding patterns requires further investigation.

Adolescent↗