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PubMed2001

Renal failure after upper gastrointestinal bleeding in cirrhosis: incidence, clinical course, predictive factors, and short-term prognosis.

To assess the incidence, clinical course, predictive factors, and prognosis of renal failure in patients with cirrhosis and gastrointestinal bleeding, 175 consecutive episodes of gastrointestinal bleeding in 161 patients were analyzed. Renal failure occurred in 20 (11%) episodes and was transient in 8 episodes and nontransient in 12. Renal failure was more common in patients with cirrhosis than in a control population of bleeding patients without cirrhosis matched by age and severity of the bleeding episode. Among 39 clinical and laboratory variables obtained at admission or during hospitalization related with the bleeding episode or with liver and renal function, the presence of hypovolemic shock, number of packed red blood cells transfused, Child-Pugh class at admission, and baseline platelet count were independent predictors of renal failure. The development of renal failure and hypovolemic shock was the only independent predictors of in-hospital mortality. Mortality rate among the 20 episodes with renal failure was 55% (11 deaths) as compared with only 3% (5 deaths) in the 155 episodes without renal failure (P <.01). The development of nontransient renal failure entailed a much greater mortality as compared with transient renal failure (10 of 12 [83%] vs. 1 of 8 [12%]; P <.01). In conclusion, renal failure is a common event in patients with cirrhosis and gastrointestinal bleeding, the occurrence of which is mainly related to the severity of bleeding and baseline liver function. Renal failure is a strong predictor of mortality in patients with cirrhosis and gastrointestinal bleeding.

Adolescent↗
PubMed2003

The kidney plays a major role in the hyperammonemia seen after simulated or actual GI bleeding in patients with cirrhosis.

Upper gastrointestinal (UGI) bleeding in cirrhosis is associated with enhanced ammoniagenesis, the site of which is thought to be the colon. The aims of this study were to evaluate interorgan metabolism of ammonia following an UGI bleed in patients with cirrhosis. Study 1: UGI bleed was simulated in 8 patients with cirrhosis and a transjugular intrahepatic portasystemic stent-shunt (TIPSS) by intragastric infusion of an amino acid solution that mimics the hemoglobin molecule. We sampled blood from the femoral artery and a femoral, renal, portal, and hepatic vein for 4 hours during the simulated bleed and measured plasma flows across these organs. Study 2: In 9 cirrhotic patients with an acute UGI bleed that underwent TIPSS insertion, blood was sampled from an artery and a hepatic, renal, and portal vein, and plasma flows were measured. Study 1: During the simulated bleed, arterial concentrations of ammonia increased significantly (P =.002). There was no change in ammonia production from the portal drained viscera, but renal ammonia production increased 6-fold (P =.008). In contrast to an unchanged ammonia removal by the liver, a significant increase in muscle ammonia removal was observed. Study 2: In patients with an acute UGI bleed, ammonia was only produced by the kidneys (572 [184] nmol/kg bw/min) and not by the splanchnic area (-121 [87] nmol/kg bw/min). In conclusion, enhanced renal ammonia release has an important role in the hyperammonemia that follows an UGI bleed in patients with cirrhosis. During this hyperammonemic state, muscle is the major site of ammonia removal.

Adult↗
PubMed1999

Endoscopic hemostasis in acute diverticular bleeding.

BACKGROUND AND STUDY AIMS: Early reports of urgent colonoscopy in acute lower intestinal bleeding suggest a role for endoscopic therapy for bleeding colonic lesions, but scant data exist on bleeding diverticula. We report our experience with endoscopic hemostasis in acute diverticular bleeding. PATIENTS AND METHODS: Bleeding diverticula were identified on urgent diagnostic endoscopy in five patients with acute gastrointestinal bleeding, two in the duodenum, and three in the colon. All patients had co-morbid conditions preventing more conventional therapeutic approaches. The five cases are described, including the technique of endoscopic hemostasis and outcome. RESULTS: Endoscopic therapy using epinephrine injection, thermal cautery and/or laser therapy successfully induced hemostasis in all patients. One patient died of co-morbid illness during the hospital stay, while the remaining four patients had no recurrent bleeding over a mean follow-up period of 20.6 months. CONCLUSION: Endoscopic therapy of bleeding diverticula is technically possible when the culprit diverticulum can be identified. This therapeutic modality may have a place in debilitated patients in whom other more invasive procedures are contraindicated, but further experience is needed to establish its safety.

Acute Disease↗
PubMed1999

"Missed" upper gastrointestinal tract lesions may explain "occult" bleeding.

BACKGROUND AND STUDY AIMS: Enteroscopy has been shown to be an effective diagnostic method in patients with obscure gastrointestinal bleeding. Arteriovenous malformations (AVMs) of the small bowel are the most common lesions discovered at enteroscopy. However, bleeding lesions may still be detected in the upper gastrointestinal tract even in patients who have previously undergone esophagogastroduodenoscopy. The aim of this study was to focus on these "missed" upper gastrointestinal lesions. PATIENTS AND METHODS: A retrospective review was conducted of all enteroscopic examinations carried out in patients with suspected gastrointestinal bleeding or overt gastrointestinal bleeding treated at our institution between 1993 and 1997. All patients had previously undergone an esophagogastroduodenoscopy. The push enteroscope (Olympus XSIF-100) was used in all of them. RESULTS: Push enteroscopy was performed in 233 patients (124 men and 109 women; mean age 63). A suspected bleeding lesion was observed in 53 % of the cases. AVMs represented 63% of the detected lesions. "Missed" upper gastrointestinal lesions were described in 25 patients (10.2 %). In half of these cases, the lesion was located in the upper part of the fundus. Wirsungorrhagia was the cause of bleeding in two cases. CONCLUSIONS: The study confirmed that push enteroscopy is an effective method of detecting lesions responsible for occult gastrointestinal bleeding. In this study, the overall diagnostic yield was 53%. In 10% of the patients, the lesion was located in the upper gastrointestinal tract, despite an initial esophagogastroduodenoscopy. The lesions were mainly located in the fundus. Although it is a rare condition, Wirsungorrhagia must be considered in patients with occult gastrointestinal bleeding.

Adolescent↗
PubMed1999

Combined ligation and sclerotherapy versus ligation alone for eradication of bleeding esophageal varices: a randomized and prospective trial.

BACKGROUND AND STUDY AIMS: A number of trials have been reported in which a combination of ligation and sclerotherapy was compared with ligation alone, or with sclerotherapy alone. The present trial was carried out to assess whether the combined therapy might achieve more rapid eradication of bleeding esophageal varices. PATIENTS AND METHODS: One hundred and three patients with either active bleeding or stigma of recent bleeding from esophageal varices were randomly assigned to receive ligation plus sclerotherapy, or ligation alone. Ligation was performed with the technique introduced by Stiegmann. Sclerotherapy was carried out using low-volume (1 ml) 1% aethoxysclerol, which was injected into varices proximal to each ligature. Further treatment sessions were held seven days later, and then at two-week intervals, until eradication of the varices was achieved. Endoscopic follow-up examinations were carried out at three-month intervals, or immediately if there was any recurrent bleeding. The mean follow-up period was 14 months. RESULTS: There were no significant differences between the groups of patients compared with regard to the number of sessions required to eradicate the varices (2.4 +/- 0.7 in the combined group, and 2.3 +/- 0.7 in the ligation group; p>0.05). No significant differences were found between the groups with regard to recurrent bleeding (Fp = 2.882; p > 0.05). Three cases of recurrent bleeding (6%) from treatment-induced ulcers and two cases of recurrent bleeding (4%) from duodenal ulcers were observed with the combined therapy and ligation, respectively. No significant differences in the mortality were found between the groups (Fp = 1.145; p>0.05). Two percent of patients in the ligation group died due to bacterial peritonitis. CONCLUSION: Since ligation combined with low-volume sclerotherapy did not reduce the time required for variceal eradication, it can be concluded that the combined therapy is not superior to ligation alone. This mode of endoscopic therapy for the treatment of bleeding esophageal varices is therefore not recommended.

Combined Modality Therapy↗
PubMed2003

Helicobacter pylori infection does not affect the early rebleeding rate in patients with peptic ulcer bleeding after successful endoscopic hemostasis: a prospective single-center trial.

BACKGROUND AND STUDY AIMS: Eradication of Helicobacter pylori infection can reduce the rebleeding rate of peptic ulcer bleeding in the long term. There are few data on the influence of H. pylori on the rebleeding rate in the acute phase of bleeding however. We therefore prospectively investigated the influence of H. pylori infection on the early rebleeding rate in patients who had undergone successful endoscopic hemostasis treatment for peptic ulcer bleeding. PATIENTS AND METHODS: Between January 1996 and November 2000 all patients with peptic ulcer bleeding were evaluated consecutively. The diagnosis of H. pylori infection was made at index endoscopy, using histology and the rapid urease test. Bleeding activity was assessed using the Forrest classification. After successful endoscopic hemostasis all patients received omeprazole 40 mg or pantoprazole 40 mg, intravenously, twice a day for 3 days. Rebleeding episodes were recorded over 21 days following primary hemostasis. RESULTS: 344 patients were enrolled into the study. The prevalence of H. pylori infection was 62.9 %. A total of 51 patients showed rebleeding (14.8 %), of whom 31 were H. pylori-positive (60 %). There was no statistically significant difference between the H. pylori-positive and -negative patients, however. The rebleeding rate did not differ between patients with H. pylori infection alone and patients also using nonsteroidal anti-inflammatory drugs. When stratifying patients according to activity of bleeding at index endoscopy, we were also unable to find any significant influence of H. pylori infection on the outcome of Forrest class I and IIa bleedings. CONCLUSION: Based on our data, it can be concluded that H. pylori infection does not affect the early rebleeding rate in patients with peptic ulcer bleeding after successful endoscopic hemostasis.

Adolescent↗
PubMed2004

A prospective, randomized trial of endoscopic band ligation versus endoscopic hemoclip placement for bleeding gastric Dieulafoy's lesions.

BACKGROUND AND STUDY AIMS: Dieulafoy's lesion is a rare cause of massive gastrointestinal hemorrhage, most commonly in the proximal stomach. Mechanical endoscopic methods have recently become the standard therapeutic approach. However, there have been few studies comparing the efficacy of different mechanical endoscopic methods in treating gastric Dieulafoy's lesions. This study was therefore carried out to compare the hemostatic efficacy and safety of endoscopic band ligation (EBL) and endoscopic hemoclip placement (EHP) in the treatment of bleeding gastric Dieulafoy's lesions. PATIENTS AND METHODS: Between January 2002 and October 2003, 26 consecutive patients with bleeding gastric Dieulafoy's lesions were prospectively enrolled and were randomly assigned to undergo EBL (13 patients) or EHP (13 patients). Demographic characteristics, endoscopic variables, and outcome parameters, including rates of hemostasis and recurrent bleeding, were analyzed. RESULTS: One O-ring was applied in each case in the EBL group, and the median number of hemoclips applied was one (range one to four) in the EHP group. There were no significant differences between the groups with regard to age, sex, presence of shock, initial hemoglobin level, coagulopathy, concurrent diseases, location of the lesion, type of bleeding stigmata, blood transfusion requirements, or hospitalization periods. Primary hemostasis was achieved in all 26 patients. There was one case of recurrent bleeding in each group; secondary hemostasis was achieved with EBL in one of these patients and by endoscopic epinephrine injection in the other. There were no second episodes of recurrent bleeding, no procedure-related complications, no cases in which surgery was needed, and no bleeding-related deaths in either group. CONCLUSIONS: In this small study, no differences were detected in the efficacy or the safety of EBL vs. EHP in the management of bleeding gastric Dieulafoy's lesions.

Adult↗
PubMed2004

Efficacy of argon plasma coagulation in nonvariceal upper gastrointestinal bleeding.

BACKGROUND AND STUDY AIMS: Various methods of endoscopic hemostasis have been described. However, few reports have investigated the efficacy of argon plasma coagulation (APC) in the treatment of upper gastrointestinal bleeding. The aim of this study was to evaluate the efficacy of APC in various types of upper gastrointestinal bleeding. PATIENTS AND METHODS: The present study was designed as a prospective and observational study. A total of 254 consecutive patients with upper gastrointestinal bleeding (excluding variceal bleeding) were primarily treated using APC. If it was difficult to achieve complete hemostasis with APC alone, injection of a hypertonic saline-epinephrine solution and clipping were carried out. The initial hemostasis rate, rate of recurrent bleeding after APC, permanent hemostasis rate, and mean procedure time were evaluated. RESULTS: Initial hemostasis with APC alone was achieved in 193 of the 254 patients (75.9 %). With the assistance of other methods as well, initial hemostasis was achieved in 253 patients (99.6 %). Among the 193 patients treated with APC alone, recurrent bleeding was observed in 11 cases (11 of 193, 5.7 %). With one exception, these cases of recurrent bleeding were controlled with APC alone again; permanent hemostasis was thus ultimately achieved with APC alone in 192 of the 254 patients (75.5 %). The mean procedure time was 8 min. No complications (such as perforation) were observed with the APC treatment. CONCLUSIONS: These data indicate that APC is a safe, quick, and effective method of treating various types of nonvariceal upper gastrointestinal bleeding and that it can be a powerful tool for endoscopic hemostasis.

Adult↗
PubMed2005

Developing an animal model of massive ulcer bleeding for assessing endoscopic hemostatic devices.

BACKGROUND: Existing animal models of ulcerative bleeding are not suitable for endoscopic investigation. We describe a new porcine model of massive arterial bleeding in the stomach and its use for assessing a novel endoscopic suturing device. METHODS: Two animal models were investigated. In model 1, the short gastric artery (mean diameter 2 mm) was divided near its gastric end. A mucosal defect was created near the greater curve and the divided artery was brought into the lumen of the stomach through a submucosal tunnel. An inflatable plastic cuff was placed around the base of the artery. Cuff deflation led to massive bleeding. In model 2, the short gastric artery was carefully exposed along a segment of 2 cm on the side facing the stomach. It was then anchored to a small gastrostomy made at the posterior wall near the vessel. At endoscopy an ulcer-like lesion could be seen with a pulsatile vessel at the base and brisk bleeding could be started by cutting a hole in the artery using endoscissors. The pigs were heparinized by an intravenous bolus of 110-300 units per kilogram, in both models. A prototype suturing device, the Eagle Claw, was inserted using a gastroscope and the curved needle was driven around the bleeding artery. Extracorporeal knotting or intracorporeal ligation was done endoscopically. RESULTS: Pulsatile arterial bleeding was successfully created in four pigs using model 1, and in another four pigs using model 2. Model 2 was more reproducible and less time-consuming to create. Endoscopic suturing controlled arterial bleeding in five out of eight pigs with a single stitch and in another three pigs with an additional stitch. CONCLUSION: This animal model provides reproducible massive hemorrhage suitable for endoscopic studies. Control of gastric bleeding from large arteries by endoscopic suturing is possible.

Animals↗
PubMed2006

Use of anticoagulation during wireless capsule endoscopy for the investigation of recurrent obscure gastrointestinal bleeding.

Detecting the source of obscure gastrointestinal bleeding can be difficult. Capsule endoscopy is a promising diagnostic tool for investigating patients with this condition, although identifying the source of intermittent or low-grade bleeding remains a diagnostic challenge. We present case reports of two patients with obscure gastrointestinal bleeding, in whom the source of recurrent bleeding episodes was diagnosed by capsule endoscopy while they were on anticoagulation therapy. The first patient, an 81-year-old white woman, was on long-term oral anticoagulation because she had chronic atrial fibrillation. Capsule endoscopy demonstrated a bleeding tumor in the region of the terminal ileum. The second patient, a 59-year-old white man, underwent an initial capsule endoscopy, which was negative. After initiation of anticoagulation with heparin, a second capsule endoscopy procedure in this patient revealed several small bleeding lesions in the proximal small bowel. In both cases a gastrointestinal stromal tumor was identified as the bleeding source and was resected. These two cases demonstrate that provocation of bleeding during capsule endoscopy may increase its sensitivity.

Aged, 80 and over↗
PubMed2006

The use of self-expanding metal stents to treat acute esophageal variceal bleeding.

BACKGROUND AND STUDY AIMS: Acute variceal bleeding is a life-threatening complication of liver cirrhosis. Essential factors for survival after variceal bleeding are the rapidity and efficacy of initial primary hemostasis. Endoscopic and vasoactive therapy is the gold standard in the management of acute variceal hemorrhage. The primary aim of this study was to evaluate the use of self-expandable metallic stents to arrest uncontrollable acute variceal bleeding. PATIENTS AND METHODS: Between November 2002 and May 2005, esophageal stents were implanted in 20 patients (18 men, two women; mean age 52, range 27-87) with massive ongoing bleeding from esophageal varices, as an alternative treatment to balloon tamponade. The patients had not been successfully managed with prior pharmacologic or endoscopic therapy. They had had one to five previous bleeding episodes (mean 2.4). Eight of the patients were in Child-Pugh grade B and 12 in grade C. A new type of stent with special introducers was developed that allowed placement without radiographic assistance. RESULTS: The stents were successfully placed in all of the patients and were left in place for 2-14 days. Bleeding from the esophageal varices ceased immediately after implantation of the stent in all cases. While the stent was in place, further diagnostic steps were carried out to optimize management of the patients' illness and portal hypertension. No recurrent bleeding, morbidity, or mortality occurred during treatment with the esophageal stent. All of the stents were extracted without any complications after definitive treatment had been started. CONCLUSIONS: In this pilot study, the new method of implantation of an esophageal stent was found to be a safe and effective treatment for massive bleeding from esophageal varices in patients with liver cirrhosis. These initial clinical results will of course have to be confirmed in comparative studies including a large number of patients.

Acute Disease↗
PubMed1998

The evolution of stigmata of hemorrhage in bleeding peptic ulcers: a sequential endoscopic study.

BACKGROUND AND STUDY AIMS: Stigmata of hemorrhage in bleeding peptic ulcers have prognostic characteristics. In the present study, the evolution of these stigmata was studied prospectively using daily endoscopic examinations. PATIENTS AND METHODS: From January 1989 to October 1989, 778 consecutive patients with bleeding peptic ulcers underwent endoscopy within 24 hours of admission. The bleeding peptic ulcers were assigned by three endoscopists to five categories, those with: a) active bleeding, b) a nonbleeding visible vessel, c) adherent clot, d) dot, or e) a clean base. Actively bleeding ulcers were treated by epinephrine injection. Ulcers with nonbleeding visible vessels, adherent clots, or dots were left untreated. Daily endoscopic examinations were carried out for three subsequent days, or until the ulcer base became clean. RESULTS: On day 0, there were 56 actively bleeding ulcers (7%), 62 ulcers with visible vessels (8%), 104 with adherent clots (13%), 182 with flat dots (23%), and 374 with a white base (48%). On the subsequent three days, 24 of 62 ulcers with visible vessels (39%), 30 of 104 with adherent clots (29%), 24 of 182 with dots (13%), and 19 of 374 with a clean base (5%) on day 0 re-bled endoscopically or clinically, or both. The overall rebleeding risk was 9.9%, 4.9%, and 2.7% on days 1, 2, and 3, respectively. CONCLUSIONS: Stigmata of hemorrhage in bleeding peptic ulcers are predictive of rebleeding. They represent intermediate phases in the evolution of bleeding vessels into clean-based ulcers. The associated rebleeding risk diminishes as the vessel disappears from the ulcer base.

Endoscopy, Gastrointestinal↗
PubMed1997

Treatment of bleeding esophageal varices with cyanoacrylate and polidocanol, or polidocanol alone: results of a prospective study in an unselected group of patients with cirrhosis of the liver.

BACKGROUND AND STUDY AIMS: Data concerning the results with emergency and further elective therapy of esophageal varices using polidocanol and cyanoacrylate, or polidecanol alone, in an unselected group of patients with liver cirrhosis have not previously been available. The aim of the present prospective study was to evaluate acute and repeated cyanoacrylate and polidocanol therapy in the emergency and long-term elective management of esophageal varices. METHODS: In accordance with the protocol of the present prospective study, acutely bleeding esophageal varices of grades 1 to 3 were treated endoscopically with polidocanol injection, while grade 4 varices, large solitary varices (over 5 mm) and otherwise uncontrollable cases of variceal bleeding were treated by injection of cyanoacrylate and polidocanol. Over a period of 62 months, 112 patients (65 men, 47 women) with acute bleeding from esophageal varices due to cirrhosis of the liver (69% alcohol-related) underwent a total of 245 treatment sessions in hospital. The average age of the patients was 62.0 +/- 12.3 years (58.1% were 60 or older). Hepatic function corresponded to Child-Pugh class A in 38 patients (33.9%), Child-Pugh class B in 68 patients (60.7%), and Child-Pugh class C in six (4.5%). RESULTS: Sixty-eight patients (60.7%) were treated with polidocanol alone, and 44 (39.3%) with cyanoacrylate and polidocanol. Acute hemostasis was achieved in all cases. In 5.7% of the sclerotherapy procedures, bleeding ulcers were observed, and a pleural effusion was seen in one case. The hospital mortality rate was 24.1%, resulting from the bleeding in 2.7% and due to liver failure in the remaining cases. Recurrent bleeding occurred within 24 hours in four patients (3.6%), and during the later course of the hospital stay in a further 11 patients (9.8%). The mean survival time was 13.7 +/- 17.7 months. Over the entire observation period of 23 +/- 21 months, 67 patients died (59.8%); the cause of death was hemorrhage in 4.5%, the underlying hepatic disease in 65.7%, and non-hepatic causes in 29.8%. Recurrent bleeding occurred in 58 patients (51.7%). The cumulative survival rate in the patients treated with cyanoacrylate and polidocanol was 66 +/- 15% and 26 +/- 32% after one and five years, respectively, and 56 +/- 13% and 33 +/- 19% in those treated with polidocanol alone. CONCLUSIONS: Endoscopic treatment of esophageal varices with cyanoacrylate and polidocanol, or polidocanol alone, is effective in controlling bleeding, and the complication rate is tolerable. The short-term and long-term mortality rates are determined largely by the underlying liver disease.

Adult↗
PubMed1997

Comparison of the hemostatic effect of endoscopic injection with fibrin glue and hypertonic saline-epinephrine for peptic ulcer bleeding: a prospective randomized trial.

BACKGROUND AND STUDY AIMS: Although endoscopic injection therapy using various agents has been considered the least expensive and most effective technique in obtaining hemostasis in peptic ulcer bleeding, most of these agents induce tissue necrosis or degeneration. Theoretically the injection of fibrin glue (FG) to halt peptic ulcer bleeding may be safer than the use of other agents, but randomized clinical trials to compare the efficacy of FG and other agents are rare. The aim of this study was to compare the hemostatic efficacy between FG and hypertonic saline-epinephrine (HSE) in peptic ulcer bleeding. PATIENTS AND METHODS: From March 1992 to December 1993 we conducted a prospective randomized trial in 127 patients with peptic ulcer bleeding, in whom a visible vessel or active bleeding was identified. Patients were randomized into two groups, an FG group comprising 64 patients who received FG injections, and an HSE group, comprising 63 patients who received HSE injections. RESULTS: The two groups were comparable with regard to age, sex, bleeding focus and bleeding stigma. Permanent hemostasis using only endoscopic treatment was achieved in 59 cases (92.2 %) in the FG group and in 54 cases (85.7 %) in the HSE group. Rebleeding occurred in seven cases (10.9%) in the FG group and in 14 cases (22.2%) in the HSE group (P=0.087); emergency surgery was undertaken in four (6.3%) and seven cases (11.1%), respectively (P = 0.33); death occurred in one case (1.6%) and four cases (6.3%), respectively (P = 0.165). CONCLUSIONS: These results suggest that endoscopic injection of FG is an effective method in the control of peptic ulcer bleeding. However, even though there is a strong trend supporting the hypothesis that fibrin glue is superior to HSE, no statistically significant differences are noted. A trial involving larger numbers may produce a positive result.

Epinephrine↗
PubMed1996

Severe upper gastrointestinal tumor bleeding: endoscopic findings, treatment, and outcome.

BACKGROUND AND STUDY AIMS: The aim of the present study was to review endoscopic findings, treatment, and clinical outcomes in patients with severe upper gastrointestinal bleeding due to tumors. PATIENTS AND METHODS: A retrospective analysis was made of prospectively gathered data on all patients with severe upper gastrointestinal bleeding who were admitted to two large referral centers during a 45-month period. RESULTS: Nine hundred thirty-five patients had severe upper gastrointestinal bleeding, of whom 42 (5%) were found to have tumors. Histologically, nearly all of the tumors were of a malignant type. Fifty-two percent of the patients had acute severe upper gastrointestinal bleeding as the initial presentation of their tumor. The most common tumor was gastric adenocarcinoma, and all of these cases were at advanced stages. Endoscopic hemostasis with thermal probes or epinephrine injection, or both, was carried out in seven patients (17%), with successful hemostasis in all of the tumors. Regardless of the treatment given, patients with upper gastrointestinal tumor bleeding, had a 30-day surgery rate of 43%, a 30-day rebleed rate of 33%, a 30-day mortality rate of 10%, and a 1-year mortality rate of 89%. CONCLUSIONS: Most tumors that cause severe upper gastrointestinal bleeding are of a malignant histologic type and are already at an advanced stage. Endoscopic hemostasis of bleeding upper gastrointestinal tumors is safe and initially effective, and may provide time for elective surgical palliation. Regardless of therapy, upper gastrointestinal tumors with severe bleeding have a poor one-year survival.

Endoscopy, Digestive System↗
PubMed1993

Endoscopic hemoclip treatment for gastrointestinal bleeding.

We conducted an uncontrolled study to evaluate an improved metallic clip (Olympus hemoclip) for the endoscopic treatment of nonvariceal gastrointestinal bleeding. A total of 88 patients (mean age 63 +/- 14, 60 males) with bleeding from a wide range of sources were treated. Seventy-eight patients had active bleeding (spurting in 50, oozing in 28) and 10 patients had a nonbleeding visible vessel. Initial hemostasis was achieved in all patients with active bleeding. A total of 255 clips were placed (average of 2.9 clips per patient, range of 1-10 clips). Spurting arterial bleeders required more clips on average than oozing bleeders (3.2 versus 2.7); active bleeders required more clips than cases with nonbleeding visible vessels (3.0 versus 2.2). Mean follow-up was 397 +/- 148 days. Recurrent bleeding was observed in 5 patients, all of whom had active bleeding on initial presentation. Re-bleeding was successfully treated with hemoclips in 4 patients and one patient underwent surgery. Clips appeared to be retained well; early clip dislodgement resulted in rebleeding in only 1 patient. No complications resulted from this treatment. Clips did not impair healing of peptic ulcers. We conclude that endoscopic hemoclip placement is a highly effective and safe method for treating nonvariceal gastrointestinal bleeding and deserves comparative studies with other methods of endoscopic hemostasis.

Evaluation Studies as Topic↗
PubMed1988

Local epinephrine injection improves the therapeutic effect of Nd-YAG laser treatment of arterial peptic ulcer bleeding.

Nd-YAG laser therapy has been shown to be effective in the treatment of gastrointestinal ulcer bleeding. However, a breakdown by bleeding severity shows that its benefit is doubtful in bleeds classified as Forrest Ia and IIa. In a prospective study, we therefore tested a new therapeutic approach combining epinephrine injection into the bleeding site, with subsequent laser coagulation. Thirty-two patients with Forrest Ia and IIa bleeding from gastric or small intestinal ulcers were compared with 51 own historical controls treated by laser coagulation alone. In the combined therapy group, a significantly higher rate of permanent hemostasis was achieved, and mortality and frequency of emergency surgery were significantly reduced. Furthermore bleeding recurred more rarely and only during the later course of the disease. Finally, following epinephrine injection fewer Forrest IIa ulcer bleeds were reactivated by laser treatment, and all of these bleeds were stopped by further laser coagulation. Overall, our results demonstrate a clear-cut therapeutic improvement when laser coagulation is preceded by local epinephrine injection.

Combined Modality Therapy↗
PubMed1991

[Diagnosis of rare causes of upper gastrointestinal tract bleeding].

Possible errors in diagnosing rare sources of bleeding were analysed in 433 consecutive patients examined for upper gastrointestinal bleeding between May 1987 and June 1990. Rare lesions not necessarily recognizable as sources of bleeding were found in 14 patients (8 women and 6 men; mean age 66 [46-82] years). In 9 of the 14 the lesion was above the ligament of Treitz and thus accessible to routine esophagogastroduodenoscopy. Nonetheless, in 4 of these 9 cases the source of bleeding was not recognized at the first gastroscopy. They were all lesion in the region of the horizontal duodenum or Treitz's ligament (3 duodenal carcinomas, 1 aortoduodenal fistula). This finding indicates that, if the deep duodenum cannot be assessed with certainty in the initial gastroduodenoscopy, the region should be selectively studied endoscopically or radiologically before more invasive examinations are undertaken. In the remaining 5 of the 14 patients the source of bleeding was distal to Treitz's ligament. After the usual diagnostic tests (esophagogastroduodenoscopy, coloscopy, small intestine double-contrast imaging, angiography, scintigraphy) the sources of bleeding (angiodysplasias, jejunitis, enteritis) were confirmed in four patients by intraoperative ileo-jejunoscopy. In three of the latter cases bleeding did not recur after operative intervention, in one patient with multiple angiodysplasias severe bleeding recurred immediately after operation.

Aged↗