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PubMed2000

Relationship between clinical history, coagulation tests, and perioperative bleeding during tonsillectomies in pediatrics.

STUDY OBJECTIVE: To determine the value of clinical history and preoperative coagulation tests. DESIGN: Prospective, multicenter clinical investigation. SETTING: Twenty-four centers over a one-year period. PATIENTS: 1,706 children scheduled for tonsillectomy. In 1, 479 out of 1,706 children, studied age was ranged from 9 months to 15 years. Indications for surgery were tonsillar infection 54%, sleep apnea 33%, or both 13%. Surgical dissection was performed in 1, 284 cases (88%) and sluder technique in 172 cases (12%). MEASUREMENTS AND MAIN RESULTS: Clinical history of bleeding, preoperative coagulation tests, and perioperative bleeding were recorded. Clinical history of bleeding was positive in 13 patients; clinical history cannot predict abnormal coagulation tests. Coagulation tests were abnormal in 57 children (4%). Only 8 patients had disease-induced bleeding; five children had a preoperative correction of the deficiency in factor of coagulation or received desmopressin acetate prior to surgery in the case of von Willebrand's disease. Bleeding that occurred during the intraoperative period was assessed as abnormal by the surgeon in 101 children (7%) and during the postoperative period in 50 children (3%). Univariate analysis showed a relationship between intraoperative bleeding and age (p < 0.001), sluder technique (p < 0. 001), and abnormal preoperative coagulation tests (p < 0.05). Multivariate analysis showed the probability that bleeding was linked to the center where the surgery took place, the technique used, i.e., sluder technique, and the child's age, i.e., the older children. CONCLUSIONS: Preoperative assessment based on the history of bleeding cannot predict abnormal laboratory tests. Neither the history of bleeding or laboratory tests can predict postoperative bleeding.

Adolescent↗
PubMed2005

Stapled haemorrhoidectomy: bothersome staple line bleeding.

BACKGROUND: The stapled haemorrhoidectomy procedure has been popularized as a painless and effective treatment for prolapsing haemorrhoidal disease. We have noted that staple line bleeding is a contributory factor to postoperative morbidity. METHODS: This was a retrospective analysis of the clinical records of consecutive stapled haemorrhoidectomy procedures performed in patients over a 1-year period. The outpatient, operative and inpatient records were reviewed. We assessed the incidence of intraoperative staple line bleeding, its management and early postoperative outcomes in our patients undergoing stapled haemorrhoidectomy. RESULTS: From March 2000 to March 2001, 39 stapled haemorrhoidectomy procedures were performed. Intraoperative staple line bleeding was recorded in 17 patients (44%) and suture reinforcement of this staple line was required in 12 (31%). Nine patients (23%) were admitted for postoperative per rectal bleeding, four of whom required surgical haemostasis of bleeding points along the staple line. Delayed secondary haemorrhage was seen in one patient. The incidence of postoperative bleeding in patients with noted staple line bleeding was 35%, compared with 14% in those without evidence of bleeding. CONCLUSION: Staple line bleeding is a technical difficulty and complication associated with stapled haemorrhoidectomy. It should be managed with meticulous haemostatic suture placement in order to avoid postoperative bleeding and the morbidity of re-operation for haemostasis.

Adult↗
PubMed2000

Predictors of bleeding complications after rescue coronary interventions.

The purpose of this study was to determine predictors of bleeding complications after current rescue coronary interventions including stenting and adjunctive platelet inhibitors. Previous studies of rescue angioplasty for thrombolytic failure have identified variable rates of bleeding complications with balloon angioplasty alone. Although coronary stents and glycoprotein 2b/3a inhibitors have been shown to improve outcome in a wide variety of coronary interventions, the impact of these therapies on bleeding complications after rescue coronary intervention has not been determined. From 1996 through 1998, we treated 108 consecutive patients with rescue coronary intervention (defined as attempted coronary intervention within 12 hours of thrombolysis for ongoing symptoms or electrocardiogram [ECG] changes) including conventional percutaneous transluminal coronary artery (PTCA), stenting (n = 45), and glycoprotein 2b/3a inhibitor use (n = 31). In-hospital clinical outcomes were obtained in all patients, and univariate and multivariate predictors of bleeding complications were identified. In hospital, moderate to severe bleeding complications occurred in 17.6% of the cohort, but the rate of severe bleeding complications (2.7%) and vascular repair (1.9%) were low. Independent predictors of bleeding complications were age > 60y, female gender, cardiogenic shock, and streptokinase use. Neither the delayed use of abciximab (on average 4 hours after thrombolytic therapy initiation) nor the use of rescue stenting were predictors of increased moderate to severe bleeding complications. Current rescue coronary intervention, including stents and platelet inhibitors, is associated with a low rate of severe bleeding complications. Moderate to severe bleeding complications were more common in selected subgroups of patients but not increased significantly by stenting or delayed abciximab use.

Age Factors↗
PubMed2001

Effect of nabumetone and aspirin on colonic mucosal bleeding time.

BACKGROUND: The management of patients taking aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) who require colonoscopy remains controversial because of concerns over bleeding after biopsy or polypectomy. AIM: To determine whether patients using the NSAID nabumetone, a non-acidic prodrug with mixed activity against cyclooxygenase-1 (COX-1) and COX-2, exhibited prolonged mucosal bleeding times and how this might compare with mucosal bleeding times in patients using aspirin. METHODS: We assessed triplicate mucosal bleeding times in patients undergoing screening flexible sigmoidoscopy. We compared 90 patients who had taken no aspirin or NSAIDs within the previous 2 weeks, to 60 patients who had received nabumetone 1 g b.d. by mouth for the previous 2 weeks, and 30 patients who had taken 325 mg aspirin daily for the previous 2 weeks. In each case, the investigator performing the study was blinded to the patient's medication. RESULTS: Mucosal bleeding times did not differ significantly among control or nabumetone-using patients. However, the patients receiving aspirin exhibited significant prolongation. Mucosal bleeding time correlated statistically significantly, but weakly, with skin bleeding time. CONCLUSIONS: Nabumetone does not appear to prolong mucosal bleeding time after mucosal pinch biopsy, and skin bleeding time does not reliably screen for prolonged mucosal bleeding time.

Administration, Oral↗
PubMed2000

Unexpected bleeding disorders: Algorithm for approach to therapy.

The management of unexpected bleeding must be directed at the specific abnormality identified, as there is no universally effective and safe procoagulant product. Where practical, a purely pharmaceutical approach obviates the residual risks of exposure to plasma-derived products. Desmopressin is often effective in bleeding due to mild haemophilia A, Type I von Willebrand's disease and some platelet function disorders. Where replacement therapy is necessary, it should be as specific as possible, preferably using purified components singly or in combination. Recombinant proteins provide the greatest margin of safety, but it must be borne in mind that these are biologicals, and that they may contain human and animal plasma-derived proteins. Where specific replacement is unavailable or impractical, plasma or crudely fractionated plasma derivatives may be used. In the case of inhibitor antibodies to factor VIII, high dose human factor VIII or porcine factor VIII may be used. Where replacement therapy is impossible due to a high inhibitory titre, it may be necessary to bypass the specific haemostatic defect using activated prothrombin complex concentrates or recombinant activated factor VIIa. The latter product is being studied in patients with various disorders of platelet function, and in the more global haemostatic failure that accompanies end-stage liver disease. Ancillary methods are often of great value in securing haemostasis. These may be derived from pharmacological or biological sources, and their sites of action may be systemic or topical. Examples include antifibrinolytic lysine analogues, corticosteroids where inflammation accompanies bleeding, and the topical application of fibrin sealants or thrombin. Simple physical measures such as pressure, ice, or splinting are also valuable adjunctive measures. Finally, it must be emphasized that the ultimate control of bleeding often depends upon effective management of the inciting cause, such as eliminating the trigger for DIC, or suppressing the causative antibody of ITP. These principles will be presented using a practical algorithmic approach. The initial question when considering treatment should be whether or not the patient is acutely unstable. Instability may be due to one of two causes: the volume of blood loss leading to a compromised cardio-vascular status, or the site of the bleed. The relevance of the site of the bleed is independent of the volume of blood loss, so for example, a closed bleed into CNS will cause critical functional compromise even though the volume of bleeding may be minimal. Similarly bleeding into a compartment, such as into a forearm or a calf will cause critical functional compromise irrespective of the volume of bleeding.

Algorithms↗
PubMed2000

Protease inhibitor therapy and bleeding.

Shortly after the introduction of protease inhibitor drugs (PIs) for the treatment of human immunodeficiency virus infection an association between these drugs and an increased bleeding tendency in patients with hereditary bleeding disorders was observed. Not only do patients experience an increased bleed frequency in usual sites, but bleeds can also occur in unusual places such as the finger joints. Mucus membrane bleeding and haematuria are also common. Ritonavir appears to be associated with the highest risk of bleeding followed by indinavir. As yet there has not been enough experience with the newer PIs to assess fully their potential to induce increased bleeding, although nelfinavir seems to pose less of a risk than the original PIs. PI-associated bleeds tend to be more resistant to factor concentrate treatment and periods of prophylaxis may be required in individuals with frequent persistent bleeds. Patients continuing on PI therapy tend to develop a tolerance to this adverse effect with time. The mechanism of the bleeding tendency has not been elucidated. There is no consistent evidence of a disturbance of coagulation, fibrinolysis or platelet function which raises the possibility that PIs may exert a direct local effect on blood vessels. It is very important that this class-specific side-effect is recognized and understood by both treaters and patients.

HIV Protease Inhibitors↗
PubMed2003

Relationship between non-steroidal anti-inflammatory drug use and Helicobacter pylori infection in bleeding or uncomplicated peptic ulcers: A case-control study.

BACKGROUND AND AIMS: Non-steroidal anti-inflammatory drug (NSAID) use has been closely associated with an increased risk of bleeding peptic ulcers, while the prevalence of Helicobacter pylori infection has been reported to be lower in bleeding ulcers than in non-bleeding ones. However, whether an interaction exists between NSAID use and H. pylori infection has not clearly been elucidated yet. The aims of this study were to determine the frequency of NSAID use and H. pylori infection, to predict risk factors in bleeding peptic ulcers and to determine whether NSAID use and H. pylori infection interact with each other. METHODS: Ninety-six patients with bleeding ulcer were included in the study. The control group consisted of 106 patients with non-bleeding ulcer. Data were analyzed by using the chi-squared test, Fisher's exact test and logistic regression analysis with or without interaction term (H. pylori by NSAID). RESULTS: Non-steroidal anti-inflammatory drug use was significantly more common in patients with bleeding ulcers than in controls (79.2 vs 38.7%, unadjusted odds ratio (OR): 6.02, 95% confidence interval (CI): 3.21-11.29). The frequency of the H. pylori infection was significantly lower in patients with bleeding ulcers than in controls (66.7 vs 89.6%, unadjusted OR: 0.23, 95% CI: 0.10-0.49). In the logistic regression analysis with the interaction term, male sex (adjusted OR: 3.70, 95% CI: 1.65-8.29), multiplicity of ulcers (adjusted OR: 4.10, 95% CI: 1.02-16.45) and NSAID use (adjusted OR: 33.87, 95% CI: 4.36-262.97) were independent risk factors for bleeding ulcers. There was a negative interaction between H. pylori and NSAID use (adjusted OR: 0.09, 95% CI: 0.01-0.83). CONCLUSIONS: The negative interaction between the two variables suggests that the presence of H. pylori is associated with a lower risk of bleeding in ulcer patients taking NSAIDs.

Adult↗
PubMed2006

The role of nuclear medicine in the detection of acute gastrointestinal bleeding.

The clinical consequences of lower gastrointestinal bleeding range from trivial to life-threatening. Nuclear medicine imaging techniques allow identification of those patients who are actively bleeding. The demonstration of active bleeding not only provides important prognostic information but also allows for a coordinated imaging approach using angiography and aids localization of the bleeding site. (99m)Tc-labeled erythrocytes and (99m)Tc sulfur colloid are 2 commonly used techniques to detect active bleeding. Each has its respective advantages and disadvantages, but the medical literature indicates that both tests are useful. More prolonged or delayed imaging is possible using (99m)Tc-labeled erythrocytes but care is required to prevent misinterpretation of the bleeding location because of a higher likelihood of radiotracer movement through the bowel away from the bleeding site. These forms of scintigraphy may be helpful in risk-stratifying patients and planning radiological and surgical interventions. Careful selection of patients to include those who have a high likelihood of active bleeding greatly increases the clinical utility of these tests. In addition, (99m)Tc pertechnetate imaging may be diagnostic of ectopic gastric mucosa in a Meckel's diverticulum as a potential source of bleeding. Patients also should be carefully selected for this test, based on age and exclusion of other causes of bleeding.

Acute Disease↗
PubMed2005

[Gastrointestinal bleeding in portal hypertension in liver cirrhosis].

There are three major goals in the prophylaxis and treatment of upper gastrointestinal bleeding in portal hypertensive patients: prophylaxis of the first bleeding episode, therapy of active bleeding and prophylaxis of recurrent bleeding. Several therapeutic options are available: non-selective beta-blockers are the treatment of choice in the primary prophylaxis of the first bleeding episode in patients with large esophageal varices. Alternatively, endoscopic band ligation therapy is an option. Acute bleeding varices should be treated by ligation pharmacological and antibiotic therapy. Prophylaxis of recurrent bleeding is patient-dependent: shunt surgery is an option in young patients in a good medical condition (Child-Pugh class A). In patients with refractory ascites and a bilirubin below 3 mg/dl, TIPS is a good option together with recurrent bleeding. At the moment, there are no trials showing that endoscopic ligation therapy is superior to prevent pharmacological therapy. Nevertheless, the first-line treatment in most patients in Germany is endoscopic band ligation. Bleeding from ectopic varices and bleeding from hypertensive gastropathy should be treated individually either by endoscopy, TIPS or drug therapy.

Adrenergic beta-Antagonists↗
PubMed2004

Detachable snare versus epinephrine injection in the prevention of postpolypectomy bleeding: a randomized and controlled study.

BACKGROUND AND STUDY AIMS: Several endoscopic techniques have been developed to prevent bleeding after the removal of large pedunculated polyps. PATIENTS AND METHODS: From January 1995 to December 2002, 488 consecutive patients with pedunculated colorectal polyps, the heads of which were larger than 10 mm in diameter, were randomly assigned to three groups. In group A (163 patients), detachable snares were placed at the base of the stalk and standard snares were then used for polypectomy. In group B (161 patients), the polyp stalk was injected with a 0.01 % epinephrine solution before conventional snare polypectomy. Group C (a control group including 164 patients) underwent conventional snare polypectomy without preventive measures. Early (< 24 h) and late (> 24 h - 30 days) bleeding complications were assessed. Each group was divided into two subgroups relative to the polyp size (polyps 1.0 - 1.9 cm and polyps > or = 2 cm). RESULTS: Overall bleeding complications occurred after 4.3 % of the polypectomies. Bleeding was successfully controlled in all patients, and no blood transfusions were required. There were three cases of bleeding in group A (1.8 %), five in group B (3.1 %), and 13 in group C (7.9 %). Early bleeding was more frequent than late bleeding (15 vs. six patients). In polyps > or = 2 cm (207 patients), postpolypectomy bleeding occurred in 14 patients (6.7 %): two (2.7 %) in the detachable snare group, two (2.9 %) in the epinephrine injection group, and 10 (15.1 %) in the control group. CONCLUSIONS: These results show that polypectomy of large pedunculated polyps is associated with a higher incidence of bleeding. Particularly in polyps larger than 2 cm, preventive measures can significantly reduce bleeding complications after polypectomy. This can be achieved with similar efficacy either by placing Endoloops or by injecting epinephrine.

Colonic Polyps↗
PubMed2004

Clinical usefulness of the endoscopic video capsule as the initial intestinal investigation in patients with obscure digestive bleeding: validation of a diagnostic strategy based on the patient outcome after 12 months.

BACKGROUND AND STUDY AIMS: In patients with obscure digestive bleeding, the bleeding source is frequently located in the small bowel. Capsule endoscopy (CE) is an effective method of investigating the whole small bowel in such patients. In the present study, a diagnostic approach was tested in patients with obscure digestive bleeding in which CE was included as the initial examination of the small bowel when the esophagogastroduodenoscopy (EGD) and colonoscopy findings were normal. PATIENTS AND METHODS: Patients admitted between October 2000 and February 2002 for obscure digestive bleeding underwent CE as the initial intestinal investigation, and the further management was decided on the basis of the results. After 12 months, follow-up data were obtained from all patients and referring physicians. The positive predictive value was calculated as the percentage of patients in whom CE detected a relevant lesion, and the negative predictive value as the percentage of patients with normal CE in whom no intestinal lesion was detected during the follow-up period. RESULTS: Forty-four patients (21 men, 23 women, aged 63 +/- 17 y) were included in the study. Twenty-two had overt bleeding and 22 had occult bleeding. CE detected an intestinal lesion in 18 patients (41.9 %)-- nine with angiomas, five with ulcers, one with a tumor, two with portal hypertension, and one with ischemic ileitis. The findings were normal in 17 patients (39.5 %). CE detected upper gastrointestinal lesions missed at EGD in four patients and blood in the stomach in two patients or in the proximal colon in three, leading to new endoscopies. Intestinal lesions detected at CE were treated as follows: push enteroscopy with treatment in eight patients, surgery in four, and medical treatment in six. In eight patients who underwent push enteroscopy, the procedure did not reveal lesions missed by CE. After 1 year, 15 of the 18 patients treated for intestinal lesions had no further bleeding and no anemia; one died after surgery (for resection of an ischemic intestinal loop), one relapsed, and one was diagnosed with a different intestinal condition. In all patients with extraintestinal lesions or blood detected at CE, further endoscopies led to diagnosis and therapy, with a favorable outcome. In patients with normal CE, no intestinal lesion was detected, but an extraintestinal source of bleeding was diagnosed and treated in nine patients (in the upper gastrointestinal tract in five cases and in the colon in four). Three patients had anemia of hematological origin and four had inadequate iron intake. The positive predictive value of CE was 94.4 % in patients with intestinal lesions, and the negative predictive value was 100 % in patients with normal CE findings. CONCLUSIONS: In patients with obscure digestive bleeding, CE positively predicted the intestinal diagnosis or normal status in 95.5 % of cases. A diagnostic approach to obscure digestive bleeding that includes CE after the initial endoscopic work-up thus appears to be a valid strategy for small-bowel examinations.

Adult↗
PubMed2005

Endoscopic band ligation as salvage therapy in patients with bleeding peptic ulcers not responding to injection therapy.

BACKGROUND AND STUDY AIM: Endoscopic band ligation has recently been used to control bleeding from a variety of nonvariceal upper gastrointestinal sources. However, it has not been used as salvage therapy in patients with peptic ulcer in whom injection therapy has failed to control bleeding. The objective was to study the role of band ligation in patients with bleeding peptic ulcer where injection therapy had failed. PATIENTS AND METHODS: Endoscopic band ligation was attempted in patients with upper gastrointestinal bleeding from peptic ulcers in whom at least two attempts to control bleeding by injection therapy failed. Anti- Helicobacter pylori therapy was given to patients who were infected with the bacteria. RESULTS: Endoscopic band ligation could be performed in all the 11 patients in whom it was attempted. It was successful in controlling the bleeding in all patients. Over a mean (SD) follow-up of 23.1 (14.8) months none of the patients had recurrence of ulcer or bleeding. CONCLUSIONS: Endoscopic band ligation is an effective means of controlling bleeding in patients with bleeding peptic ulcer in whom injection therapy is not successful. Band ligation followed by anti- H. pylori therapy is useful in preventing recurrence of ulcer and bleeding in such patients.

Adult↗
PubMed1989

Is the Forrest classification a useful tool for planning endoscopic therapy of bleeding peptic ulcers?

A prospective controlled study was carried out to determine the validity of the Forrest classification in terms of improved laser therapy. Out of 153 consecutive patients with bleeding peptic ulcers, 137 patients--74 with arterial ulcer bleeding and 63 with non-arterial ulcer bleeding--were included in the trial. In arterial ulcer bleeding a significantly lower rate of permanent hemostasis was achieved, and the frequency of urgent surgery and mortality was higher than in non-arterial ulcer bleeding. Patients with spurting arterial bleeding (Forrest Ia) and those with large non-bleeding visible vessels (Forrest IIa) include almost all patients at risk of further bleeding and death. Combined laser therapy clearly minimizes the risk of rebleeding and death in small non-bleeding visible vessels (Forrest IIa). In contrast, decreased hemoglobin and a requirement for blood transfusion are of limited prospective value for the individual emergency patient. Overall, our results demonstrate that Forrest criteria are essential for proper planning of endoscopic therapy and urgent surgery in bleeding peptic ulcers. Emergency endoscopy must therefore be performed as early as possible.

Clinical Trials as Topic↗
PubMed1994

Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group.

BACKGROUND: The efficacy of prophylaxis against stress ulcers in preventing gastrointestinal bleeding in critically ill patients has led to its widespread use. The side effects and cost of prophylaxis, however, necessitate targeting preventive therapy to those patients most likely to benefit. METHODS: We conducted a prospective multicenter cohort study in which we evaluated potential risk factors for stress ulceration in patients admitted to intensive care units and documented the occurrence of clinically important gastrointestinal bleeding (defined as overt bleeding in association with hemodynamic compromise or the need for blood transfusion). RESULTS: Of 2252 patients, 33 (1.5 percent; 95 percent confidence interval, 1.0 to 2.1 percent) had clinically important bleeding. Two strong independent risk factors for bleeding were identified: respiratory failure (odds ratio, 15.6) and coagulopathy (odds ratio, 4.3). Of 847 patients who had one or both of these risk factors, 31 (3.7 percent; 95 percent confidence interval, 2.5 to 5.2 percent) had clinically important bleeding. Of 1405 patients without these risk factors, 2 (0.1 percent; 95 percent confidence interval, 0.02 to 0.5 percent) had clinically important bleeding. The mortality rate was 48.5 percent in the group with bleeding and 9.1 percent in the group without bleeding (P < 0.001). CONCLUSIONS: Few critically ill patients have clinically important gastrointestinal bleeding, and therefore prophylaxis against stress ulcers can be safely withheld from critically ill patients unless they have coagulopathy or require mechanical ventilation.

Aged↗
PubMed1997

A comparison of omeprazole and placebo for bleeding peptic ulcer.

BACKGROUND: The role of medical treatment for patients with bleeding peptic ulcers is uncertain. METHODS: We conducted a double-blind, placebo-controlled trial in 220 patients with duodenal, gastric, or stomal ulcers and signs of recent bleeding, as confirmed by endoscopy. In 26 patients the ulcers showed arterial spurting, in 34 there was active oozing, in 35 there were nonbleeding, visible vessels, and in 125 there were adherent clots. The patients were randomly assigned to receive omeprazole (40 mg given orally every 12 hours for five days) or placebo. The outcome measures studied were further bleeding, surgery, and death. RESULTS: Twelve of the 110 patients treated with omeprazole (10.9 percent) had continued bleeding or further bleeding, as compared with 40 of the 110 patients who received placebo (36.4 percent) (P<0.001). Eight patients in the omeprazole group and 26 in the placebo group required surgery to control their bleeding (P<0.001). Two patients in the omeprazole group and six in the placebo group died. Thirty-two patients in the omeprazole group (29.1 percent) and 78 in the placebo group (70.9 percent) received transfusions (P<0.001). A subgroup analysis showed that omeprazole was associated with significant reductions in recurrent bleeding and surgery in patients with nonbleeding, visible vessels or adherent clots, but not in those with arterial spurting or oozing. CONCLUSIONS: In patients with bleeding peptic ulcers and signs of recent bleeding, treatment with omeprazole decreases the rate of further bleeding and the need for surgery.

Adult↗
PubMed2001

Preventing recurrent upper gastrointestinal bleeding in patients with Helicobacter pylori infection who are taking low-dose aspirin or naproxen.

BACKGROUND: Many patients who have had upper gastrointestinal bleeding continue to take low-dose aspirin for cardiovascular prophylaxis or other non-steroidal antiinflammatory drugs (NSAIDs) for musculoskeletal pain. It is uncertain whether infection with Helicobacter pylori is a risk factor for bleeding in such patients. METHODS: We studied patients with a history of upper gastrointestinal bleeding who were infected with H. pylori and who were taking low-dose aspirin or other NSAIDs. We evaluated whether eradication of the infection or omeprazole treatment was more effective in preventing recurrent bleeding. We recruited patients who presented with upper gastrointestinal bleeding that was confirmed by endoscopy. Their ulcers were healed by daily treatment with 20 mg of omeprazole for eight weeks or longer. Then, those who had been taking aspirin were given 80 mg of aspirin daily, and those who had been taking other NSAIDs were given 500 mg of naproxen twice daily for six months. The patients in each group were then randomly assigned separately to receive 20 mg of omeprazole daily for six months or one week of eradication therapy, consisting of 120 mg of bismuth subcitrate, 500 mg of tetracycline, and 400 mg of metronidazole, all given four times daily, followed by placebo for six months. RESULTS: We enrolled 400 patients (250 of whom were taking aspirin and 150 of whom were taking other NSAIDs). Among those taking aspirin, the probability of recurrent bleeding during the six-month period was 1.9 percent for patients who received eradication therapy and 0.9 percent for patients who received omeprazole (absolute difference, 1.0 percent; 95 percent confidence interval for the difference, -1.9 to 3.9 percent). Among users of other NSAIDs, the probability of recurrent bleeding was 18.8 percent for patients receiving eradication therapy and 4.4 percent for those treated with omeprazole (absolute difference, 14.4 percent; 95 percent confidence interval for the difference, 4.4 to 24.4 percent; P=0.005). CONCLUSIONS: Among patients with H. pylori infection and a history of upper gastrointestinal bleeding who are taking low-dose aspirin, the eradication of H. pylori is equivalent to treatment with omeprazole in preventing recurrent bleeding. Omeprazole is superior to the eradication of H. pylori in preventing recurrent bleeding in patients who are taking other NSAIDs.

Anti-Bacterial Agents↗
PubMed2001

Endoscopic ligation compared with combined treatment with nadolol and isosorbide mononitrate to prevent recurrent variceal bleeding.

BACKGROUND: After an episode of acute bleeding from esophageal varices, patients are at high risk for recurrent bleeding and death. We compared two treatments to prevent recurrent bleeding--endoscopic ligation and combined medical therapy with nadolol and isosorbide mononitrate. METHODS: We randomly assigned 144 patients with cirrhosis who were hospitalized with esophageal variceal bleeding to receive treatment with endoscopic ligation (72 patients) or the combined medical therapy (72 patients). Sessions of ligation were repeated every two to three weeks until the varices were eradicated. The initial dose of nadolol was 80 mg orally once daily, with adjustment according to the resting heart rate; isosorbide mononitrate was given in increasing doses, beginning at 20 mg once a day at bed time and rising over the course of one week to 40 mg orally twice a day, unless side effects occurred. The primary end points were recurrent bleeding, complications, and death. RESULTS: The median follow-up period was 21 months. A total of 35 patients in the ligation group and 24 in the medication group had recurrent bleeding. The probability of recurrence was lower in the medication group, both for all episodes related to portal hypertension (P=0.04) and for recurrent variceal bleeding (P=0.04). There were major complications in nine patients treated with ligation (seven had bleeding esophageal ulcers and two had aspiration pneumonia) and two treated with medication (both had bradycardia and dyspnea) (P=0.05). Thirty patients in the ligation group died, as did 23 patients in the medication group (P=0.52). The probability of recurrent bleeding was lower for patients with a hemodynamic response to therapy, defined as a decrease in the hepatic venous pressure gradient of more than 20 percent from the base-line value or to less than 12 mm Hg (18 percent, vs. 54 percent in patients with no hemodynamic response at one year; P<0.001), and the probability of survival was higher (94 percent vs. 78 percent at one year, P=0.02). CONCLUSIONS: Combined therapy with nadolol and isosorbide mononitrate is more effective than endoscopic ligation for the prevention of recurrent bleeding and is associated with a lower rate of major complications. A hemodynamic response to treatment is associated with a better long-term prognosis.

Actuarial Analysis↗
PubMed2000

EUS-guided injection of cyanoacrylate for bleeding gastric varices.

BACKGROUND: Bleeding gastric varices is a highly fatal condition. Recurrent bleeding after hemostasis achieved by endoscopic methods is common, and obliteration of gastric varices is difficult to assess. Our aim was to investigate the use of endosonography (EUS) in monitoring cyanoacrylate injection to obliterate gastric varices. METHODS: Patients who presented with bleeding gastric varices were treated with bolus injection(s) of cyanoacrylate (0.5 mL cyanoacrylate mixed with 0.7 mL Lipiodol) until bleeding was controlled; 47 patients received "on-demand" injection only in response to recurrent bleeding (on-demand group). Another group of 54 patients underwent biweekly EUS followed by repeated injection of cyanoacrylate (repeated-injection group) until all gastric varices were obliterated. The primary outcome was recurrent bleeding-free interval and survival rate. RESULTS: The two groups of patients were comparable demographically. Although the rates of early (</=48 hour) bleeding recurrence were similar with repeated or on-demand injection (7.4% versus 12.8%, p = 0.5), late recurrence of bleeding (>48 hour) was significantly reduced in the repeated-injection group (18.5% versus 44.7%, p = 0.0053, odds ratio 0.28 (95% CI [0.12, 0. 69]). Cumulative probability of recurrent bleeding-free interval was higher in the repeated-injection than the on-demand group (log-rank test, p = 0.0053). There was a numeric trend toward improved survival in the repeated-injection group. CONCLUSION: Gastric varices obliteration with cyanoacrylate under EUS monitoring reduces recurrent bleeding and may improve survival.

Adult↗