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PubMed2004

Sustained rise of portal pressure after sclerotherapy, but not band ligation, in acute variceal bleeding in cirrhosis.

During variceal bleeding, several factors may increase portal pressure, which in turn may precipitate further bleeding. This study investigates the early effects of endoscopic injection sclerotherapy (EIS) and endoscopic band ligation (EBL) on hepatic venous pressure gradient (HVPG) during acute bleeding and the possible influence in outcome. In 50 cirrhotic patients with bleeding esophageal varices treated with EIS (n = 25) or EBL (n = 25), we performed repeated HVPG measurements before and immediately after endoscopic treatment (time 0) and every 24 hours for a 5-day period. Endotherapy was continued until the varices were too small for further treatment. Both groups were comparable with regard to age, gender, Child-Turcotte-Pugh grade, and HVPG. In the EBL and EIS groups, a significant (P <.0001) increase was observed in mean portal pressure (20.7 mm Hg +/- 4.4 SD and 21.5 mm Hg +/- 4.5 SD, respectively) immediately after treatment (time 0) as compared with pretreatment (18.1 +/- 4.5 and 18.1 +/- 4.0). However, HVPG in the EBL group returned to baseline values within 48 hours after treatment, while in the EIS group it remained high during the 120-hour study period (P <.0001). Bleeding stopped in all patients after endotherapy. During the 42-day follow-up period, the rebleeding rate over time was lower in the EBL group compared with the EIS group (P =.024). Patients with an initial HVPG greater than 16 mm Hg had, despite endoscopic treatment, a significantly higher likelihood of death (P =.024) and overall failure (P =.037) [correction]. In conclusion, during acute variceal bleeding EIS, but not EBL, causes a sustained increase in HVPG, which is followed by a higher rebleeding rate.

Acute Disease↗
PubMed1997

Endoscopic variceal ligation in prophylaxis of first variceal bleeding in cirrhotic patients with high-risk esophageal varices.

To determine the efficacy of endoscopic variceal ligation (EVL) in prophylaxis on the rate of first esophageal variceal bleeding, we conducted a prospective, randomized trial in 126 cirrhotic patients with no history of previous upper gastrointestinal bleeding and with esophageal varices endoscopically judged to be at high risk of hemorrhage. The end-points of the study were bleeding and death. Life-table curves showed that prophylactic EVL significantly diminished the rate of variceal hemorrhage (12/62 [19%] vs. 38/64 [60%]; P = .0001) and overall mortality (17/62 [28%] vs. 37/64 [58%]; P = .0011). The 2-year cumulative bleeding rate was 19% (12/ 62) in the EVL group and 60% (38/64) in the control group. The 2-year cumulative mortality rate was 28% (17/62) in the EVL group and 58% (37/64) in the control group. Comparison of Kaplan-Meier estimates of the time to death of both groups showed significantly lower mortality in the ligation group (P = .001). Patients undergoing EVL had few treatment failures and died mainly of hepatic failure. The lower risk in the EVL group was attributed to a rapid reduction of variceal size. Prophylactic EVL was more efficient in preventing first bleeding in patients with good condition (Child A) than in those with decompensated disease (Child B and C). We conclude that prophylactic EVL can decrease the incidence of first variceal bleeding and death over a period of 2 years in cirrhotic patients with high-risk esophageal varices.

Aged↗
PubMed1999

Somatostatin alone or combined with emergency sclerotherapy in the treatment of acute esophageal variceal bleeding: a prospective randomized trial.

Recent trials have shown that somatostatin (SMT) is as effective as sclerotherapy in the treatment of acute variceal bleeding and that the combination of both treatments is more effective than sclerotherapy alone. To assess whether the addition of sclerotherapy improves the efficacy of SMT alone, all patients admitted to our unit with gastrointestinal bleeding and with suspected cirrhosis received a continuous infusion of SMT (250 micrograms/h). Endoscopy was performed between 1 and 5 hours later, and patients with esophageal variceal bleeding were randomized to receive or not to receive sclerotherapy. In both groups, SMT infusion was continued for 5 days. Fifty patient admissions were allocated to each group. Therapeutic failure occurred in 21 cases of the SMT group and in 7 cases of the combined-therapy group (P =.002). Failure to control the acute episode occurred in 24% vs. 8% (P =.03) and early rebleeding in 24% vs. 7% (P =.03), respectively. Transfusional requirements were significantly higher in the SMT group, while the incidence of complications was lower (8% vs. 24%; P =.029). In the multivariate analysis, the presence of shock at admission and active bleeding during endoscopy were the variables that better predicted the failure of therapy with SMT alone. Mortality at 6 weeks was similar. These data demonstrate that the addition of sclerotherapy significantly improves the efficacy of SMT alone for the treatment of acute variceal bleeding, although it also increases the rate of complications. Patients with shock and those with active bleeding are more likely to benefit from this combined therapy.

Acute Disease↗
PubMed2006

Hospital-acquired gastrointestinal bleeding outside the critical care unit: risk factors, role of acid suppression, and endoscopy findings.

BACKGROUND: Risk factors for hospital-acquired gastrointestinal bleeding in the intensive care unit are established, and acid-suppressive prophylaxis has been advocated for certain subsets of critically ill patients. In contrast, risk factors and appropriate prevention strategies are not yet established for general medical patients. The objective of this study was to identify risk factors for nosocomial gastrointestinal bleeding (GIB) in non-critically ill medical patients, to evaluate the utility of prophylactic gastric acid suppression, and to characterize the endoscopic lesions. METHODS: This was a retrospective case-control study that took place at a U.S. tertiary care center. All patients admitted to the General Medicine ward for nongastrointestinal disorders who developed clinically relevant gastrointestinal bleeding during admission or within 4 weeks of discharge were considered cases. Clinically relevant bleeding was defined as any bleeding requiring esophagogastroduodenoscopy (EGD). Random controls were matched to cases by date of hospitalization in a 1:1 ratio. Clinical information was extracted by chart review. RESULTS: Of 17,707 patients admitted to the General Medicine ward over a 4-year period, 73 (0.41%) met the case definition. The main risk factor for nosocomial GIB was treatment with full dose anticoagulants or clopidogrel (OR = 5.4; 2.6-11.7; P < .0001). Use of aspirin, nonsteroidal anti-inflammatory medications, and glucocorticoids did not differ significantly between cases and controls. De novo acid-suppressive prophylaxis was not protective (OR = 1.0; 95% CI: 0.4-2.4; P = 0.97). Endoscopic abnormalities were noted in 74% of patients; many cases had lesions unlikely to be prevented by acid blockade. CONCLUSIONS: Hospital-acquired gastrointestinal bleeding is uncommon in non-critically ill patients. Anticoagulation appears to be the most important risk factor for nosocomial GIB. Routine use of acid suppressant medications for prophylaxis is unnecessary in most hospitalized patients.

Aged↗
PubMed2002

Outcomes after emergency surgery for gastric perforation or severe bleeding in patients with gastric cancer.

BACKGROUND AND OBJECTIVES: Free perforation and major bleeding in patients with gastric cancer are rare but serious conditions with potentially dangerous effects. To clarify the clinicopathologic characteristics of patients with these conditions and to determine the optimum management, we reviewed 16 cases of perforation and 13 cases of major bleeding in patients with gastric cancer who required emergency surgery. METHODS: We compared the clinical and histologic features of the patients with perforation and those with bleeding. Cox's multivariate regression analysis was used to compare survival rates between patients who underwent single-step surgery or a two-step radical procedure, between patients with stage I or II and stage III or IV cancer, between patients who underwent complete (R0) and incomplete (R1 or R2) resection, and between patients with bleeding and those with perforation. RESULTS: Many of the patients had advanced disease. There were no significant differences in clinicopathologic findings or survival between patients with gastric perforation and those with major bleeding. Patients who had major bleeding tended to have larger cancers. In the univariate analysis, gastrectomy (vs. no gastrectomy), R0 (vs. R1 or R2) resection, and lower stage (vs. higher stage) were highly correlated with improved survival time. CONCLUSIONS: Overall, patients with gastric cancers who underwent emergency gastrectomy had a poor prognosis, but it was better than that of patients who could not have gastrectomy because of the prXesence of advanced cancer. However, the survival rate was excellent in patients with early-stage cancer who underwent complete (R0) resection. We recommend complete resection when possible.

Adult↗
PubMed2005

Emergency splenic arterial embolization for massive variceal bleeding in liver recipient with left-sided portal hypertension.

Splenic vein thrombosis with gastric variceal bleeding is difficult to manage, and splenectomy may be necessary to stop variceal bleeding. The authors report the case of a post-orthotopic liver transplant patient with bleeding gastric varices secondary to splenic vein thrombosis treated by partial splenic artery embolization. Successful embolization was performed via transcatheter approach depositing Gianturco coils into the intrasplenic artery resulting in immediate cessation of variceal bleeding. No recurrence of bleeding was noted postembolization. In conclusion, splenic artery embolization can be used as treatment for postliver transplant variceal bleeding with hypersplenism.

Adult↗
PubMed2002

Risk factors for hospitalized upper or lower gastrointestinal tract bleeding in treated hypertensives.

BACKGROUND: We examined risk factors for hospitalized gastrointestinal bleeding among health maintenance organization (HMO) members with hypertension. METHODS: Case subjects (n = 199) were patients with hypertension hospitalized for confirmed gastrointestinal bleeding in 1992-1994. Control hypertensive subjects (n = 821) were selected from ongoing studies. Medical records and computerized pharmacy data were used to assess risk factors. Adjusted relative risks (RRs) were estimated using logistic regression models. RESULTS: In multivariate-adjusted models, significant risk factors for upper gastrointestinal bleeding (n = 111 cases) were hepatic disease (RR = 2.85), elevated creatinine (RR = 2.45), nonsteroidal anti-inflammatory drug use (RR = 2.28), smoking (RR = 1.93), cardiovascular disease (RR = 1.89), and physical inactivity (RR = 1.70). Risk factors for lower gastrointestinal bleeding (n = 43 cases) in multivariate-adjusted analyses were anticoagulant or thrombolytic therapy (RR = 3.80), elevated creatinine (RR = 2.31), and physical inactivity (RR = 2.10). CONCLUSIONS: This study confirmed several known risk factors for hospitalized gastrointestinal bleeding, including hepatic disease, renal dysfunction, and medication use, and also identified smoking and physical inactivity as independent risk factors. The magnitude of the relative risks associated with these behavioral factors suggests that lifestyle modification may substantially reduce the risk of gastrointestinal bleeding.

Adult↗
PubMed1988

The use of 99mTc-DTPA for detection and localization of site of acute gastrointestinal bleeding.

Intravenously injected 99mTc-DTPA was evaluated in 64 patients for its efficiency in detecting and localizing sites of acute upper and lower gastrointestinal (G.I.) bleeding. These studies were correlated with endoscopic and surgical findings. There were 34 bleeders and 30 non bleeders giving a sensitivity of 90%, specificity of 82% and accuracy of 86%. Of these, 49 were upper G.I. studies (stomach 21 and duodenum 28) and 15 were lower G.I. studies (small intestine 8, large bowel 7). Of the 49 upper G.I. studies, 27 showed active bleeding while 22 showed no bleeding at the time of the study resulting in a sensitivity of 87.5%, specificity of 76% and accuracy of 82%. Of the 15 lower G.I. studies, 7 were bleeders while 8 were non bleeders. All the lower G.I. bleeding sites were accurately localized with the 99mTc-DTPA. An incidental finding of these studies was the localization of 99mTc-DTPA in the site of inflammatory and malignant lesions of the G.I. tract. Of the 64 studies, 18 inflammatory and malignant lesions were detected with the IV injected 99mTc-DTPA; 10 were bleeders while 8 were non bleeders. Image subtraction of early from delayed images was helpful to differentiate bleeding from non bleeding cases in this last group of studies.

Acute Disease↗
PubMed1982

[Results of the surgical treatment of bleeding gastroduodenal ulcers].

Within 11 years 279 operations for acute bleeding from gastroduodenal ulcers were performed at the surgical University Clinic in Würzburg. Of the 279 patients, 140 had to be operated on immediately because of acute severe bleeding. Of the 158 bleeding duodenal ulcers, 104 had a selective proximal vagotomy (SPV), 29 had gastric resection, and in 25 the ulcer was simply closed. The overall mortality after SPV was 8.6%, 62% after gastric resection, and 40% after simple suture ligation. Recurrent bleeding occurred in 8.7% after SPV, 10.3% after gastric resection, and in 24% after suture ligation. Of the 89 bleeding gastric ulcers, 25 had a selective proximal vagotomy, 30 a gastric resection, and 34 excision of the ulcer. The overall mortality after SPV was 16%; after gastric resection it was 23.3% and 41.2% after ulcer excision. Recurrent bleeding was observed in 8% after SPV, in 10% after gastric resection and in 11.7% after ulcer excision.

Female↗
PubMed1978

Transcatheter therapy of gastrointestinal arterial bleeding.

Transcatheter therapy for arteriocapillary gastrointestinal bleeding is often an effective form of treatment. The choice of transcatheter therapy (ie, vasoconstrictor or occlusive) often is dependent on the etiology and location of bleeding. Vasopressin is a generally safe form of treatment which is often successful in treating bleeding secondary to gastritis, Mallory-Weiss mucosal tears, and diverticular disease. It is less effective in treating bleeding peptic ulcers, neoplastic bleeding, or bleeding when clotting abnormalities exist. Occlusive therapy is an effective alternate form of therapy in selected circumstances. Ischemic complications from vasoconstrictor and embolic therapy may occur and require appropriate caution and discretion with their use.

Aged↗
PubMed1982

Control of upper gastrointestinal bleeding with a microcrystalline collagen hemostat.

A microcrystalline collagen hemostat (MCH) widely used in general surgery was tested in the control of bleeding from experimentally produced gastric ulcers. Five dogs had a gastrotomy and were given heparin. Using the standard "ulcer maker," three sets of three ulcers were made in the gastric mucosa of each animal. Blood from each ulcer was collected for a 5-min period to allow for stabilization of bleeding. MCH powder or slurry or no MCH was placed directly on one ulcer of each set in random order. The bleeding rate for the next 10 min was measured. Mean decrements in the bleeding rate for slurry MCH and dry MCH-treated ulcers were 87% and 81%, respectively, compared with 51% for controls, P less than 0.05. Twelve MCH-treated ulcers, but no control ulcer, stopped bleeding completely, P less than 0.01. Preliminary observations show that MCH slurry can be applied through an endoscope and may be hemostatically effective in man. MCH may have a role in the endoscopic control of gastrointestinal bleeding.

Animals↗
PubMed1992

Changes in CSF pressures during experimental acute arterial subdural bleeding in pig.

The effects of acute arterial subdural bleeding on cerebrospinal fluid (CSF) pressure and 12 other vital parameters were studied in spontaneously breathing pigs (group 1, n = 9) and in mechanically ventilated pigs (group 2, n = 18) to analyze quantitatively the bleeding course and the lethal mechanism. Spontaneously breathing animals all succumbed after a mean bleeding volume of 45.6 +/- 8.9 ml, corresponding to about 50 per cent of the intracranial volume, and a mean bleeding duration of 11.0 +/- 2.6 min. Rapid rise in CSF pressures, marked transtentorial pressure gradients, and progressive reductions of cerebral perfusion pressure leading to a permanently iso-electric EEG, apnoea and to a terminal rise in arterial pressure (Cushing response), was the rule in these animals. The mechanically ventilated animals had smaller bleeding volumes (34.3 +/- 8.1 ml), but longer bleeding durations (13.8 +/- 5.8 min). In this group 7 animals survived. They had no pressure gradients, and only moderate changes in arterial pressure and EEG. The 11 animals that succumbed had marked transtentorial pressure gradients, but smaller increments in arterial pressure than the spontaneously breathing animals. At autopsy, subdurally located blood was found throughout the intracranial and spinal subdural compartments and along the spinal nerve roots in both groups. The results of this study suggest that survival after acute subdural haematoma is influenced by the presence of transtentorial pressure gradients and by the spinal sac acting as a space for expansion. The beneficial effect of artificial ventilation is discussed.

Animals↗
PubMed1983

Comparative analysis of experimental epidural and subarachnoid bleedings in dogs.

The difference in the course and the lethal mechanism between intracranial, subarachnoid and epidural bleedings was studied in a dog model under varying conditions. Subarachnoid bleedings were usually shortlasting, self-restricting, and generally survivable. The epidural bleedings differed quantitatively and qualitatively from the subarachnoid bleedings in being larger and having a longer duration. The difference seems related mainly to the development of an arterio-venous shunt in the epidural space during the bleeding. It is suggested that the epidural arterio-venous shunt may be of importance for the course and the lethal mechanism in epidural bleeding.

Animals↗
PubMed1993

Studies on supratentorial subdural bleeding using a porcine model.

A porcine model for an acute lethal arterial subdural bleeding in man is presented. Blood from the abdominal aorta was led via an electronic drop recorder into a collapsed intracranial subdural rubber balloon. Systemic arterial pressure (SAP), two intracranial pressures and 6 other vital parameters were monitored continuously in spontaneously breathing (n = 4) and mechanically ventilated (n = 4) pigs. In both animal groups bleeding caused an immediate rise in intracranial pressures (ICP) with transtentorial pressure gradients developing. As a result the cerebral perfusion pressures (CPP) decreased progressively, leading to an isoelectric EEG. In spontaneously breathing animals, the pressure changes resulted in apnoea within 2-4 minutes, irregularities in heart rhythm and in a marked rise in SAP (the Cushing reaction). A final collapse of all pressures occurred after 222 +/- 68 sec at a mean bleeding volume of 10.3 +/- 1.9 ml. In contrast, in mechanically ventilated animals, the course of bleeding was less dramatic. No change in cardiac rhythm or rise in SAP appeared despite a larger mean bleeding volume (12.0 +/- 1.6 ml). Instead, SAP slowly fell, reaching a level of approximately 40 mm Hg within 1 hour, while CPP concomitantly decreased from 120 mm Hg to 15 mm Hg. The findings in this and in a parallel study are explained in terms of the intracranial volume tolerance concept (Zwetnow et al. 1986). The beneficial effect of assisted ventilation on the course of subdural bleeding is multifactorial, involving both metabolic and mechanical mechanisms.

Animals↗
PubMedDate not supplied

Endoscopic treatment of bleeding peptic ulcers.

Since June, 1979, patients with upper gastrointestinal bleeding, other than of the varices, have been subjected to the procedure of endoscopic hemostasis with injection of absolute ethanol. This method is based on the principle of tissue dehydration and fixation with absolute ethanol. In this procedure, the bleeding vessels are dehydrated and fixed with consequent vasoconstriction and necrosis of the vascular wall, including its endothelial lining, thereby facilitating thrombogenesis and hemostasis. We have applied this method in 147 cases of upper gastrointestinal bleeding, obtaining a successful temporary hemostasis in all cases. Rebleeding from the same site occurred in 5 cases and new bleeding from another site occurred in 6 cases; however, in these cases, hemostasis was successfully obtained by reinjecting ethanol. After hemostasis, 6 patients received elective surgery and another 2 were operated on due to perforation of the stomach. Of the patients treated by this method, 11 died due to causes unrelated to gastrointestinal bleeding. After the hemostatic procedure, cure of the ulcer by conservative treatment was attained in the remaining 136 cases. Therefore, the local injection of absolute ethanol is an effective hemostatic method for upper gastrointestinal bleeding.

Adolescent↗
PubMedDate not supplied

Emergency endoscopy: a basis for therapeutic decisions in the treatment of severe gastroduodenal bleeding.

This prospective study compares 3 different consecutive treatment protocols of gastroduodenal hemorrhage. Three hundred sixty-one patients underwent emergency endoscopy as the basis for further treatment. Clinical and endoscopic findings, such as site and type of the bleeding source, bleeding activity and intensity, age, and concomitant diseases of the patient were scored between 0 and 6 points, the higher number indicating a higher risk. The mean values of the total score of the 7 risk factors were comparable in the 3 treatment protocols. In period I (n = 77), a total of 16 patients (20.8%) underwent emergency operations because of severe bleeding, 27 (35%) were operated on after cessation of the bleeding, and 34 (44.2%) were treated conservatively. The mortality was 16.9%. In period II (n = 116), patients with actively bleeding lesions (n = 38) underwent endoscopic sclerotherapy, with a primary rate of hemostasis in 95%. As a result, the rate of emergency surgery could be reduced to 12.9% and the mortality for the entire group was reduced to 9.5%. The problem in this protocol was the rate of recurrent bleeding after primary endoscopic hemostasis: 13/116 (11.2%). Eleven of the 13 rebleeders presented with a lesion either on the back wall of the duodenum or with a visible vessel. In period III (n = 168), a total of 83 patients (50%) underwent endoscopic injection therapy with a primary success in 93%. Sixteen patients (9.5%) with lesions of high rebleeding risk (duodenal ulcer on the posterior wall or visible vessel) were scheduled for urgent elective operation after volume resuscitation within 24 hours of emergency endoscopy (mortality, 6.3%).(ABSTRACT TRUNCATED AT 250 WORDS)

Duodenal Diseases↗
PubMedDate not supplied

Menstrual bleeding patterns in untreated women and with long-acting methods of contraception. Task Force on Long-Acting Systemic Agents for Fertility Regulation.

The bleeding patterns recorded by women using one of two new types of long-acting hormonal contraception, a levonorgestrel-releasing vaginal ring or a monthly injectable, have been compared with those in an untreated group and those experienced by women using either a combined oral contraceptive (OC) or depot-medroxyprogesterone acetate (DMPA). The frequency of bleeding was very similar between the combined pill users, the ring users and the untreated women, who all recorded an average of 3.2-3.3 bleeding/spotting episodes every 90 days. Monthly injectable users had slightly fewer episodes. Women using a monthly injectable or a vaginal ring had longer bleeding/spotting episodes (5 days) than combined pill users (4 days). However, the untreated women and DMPA users had the longest episodes, averaging 6 days. The median value of the within-woman mean length of bleeding-free intervals was 20.6 days among ring users, 22.3 days in the untreated group, 23.6 days among women given a combined OC or a monthly injectable, and 27.4 days in the DMPA group. Women using any of the long-acting methods had more variable bleeding patterns than untreated women or combined pill users. Over a year of method use, however, the lengths of the bleeding-free intervals recorded by vaginal ring and monthly injectable users became more predictable. It is concluded that these newer methods do not produce the marked bleeding disturbances seen with DMPA.

Adolescent↗
PubMed1992

Identification of the site of severe colon bleeding by technetium-labeled red-cell scan.

In cases of severe colon bleeding, it is more important to know the site than the cause, in case surgery is required. Technetium-labeled red-cell scan (TLRCS) is known to identify the site of bleeding at the rate of 0.1 ml per minute or more. The aim of this retrospective study was to see whether TLRCS was a reliable indicator of the site of severe colon bleeding. A retrospective study was made of patients investigated in this way for acute, severe colon bleeding at St. Vincent's Hospital, Melbourne, from 1984 to 1988 (five years). TLRCS identified the site of bleeding in less than half of the cases but correctly identified the site in all nine patients in whom bleeding was so severe as to require emergency surgery, avoiding total colectomy in eight cases.

Aged↗