Can proton pump inhibitors reduce rebleeding following Histoacryl sclerotherapy for gastric variceal hemorrhage?

BACKGROUND/AIMS: To evaluate the efficacy of proton pump inhibitors (PPIs) in reducing rebleeding and bleeding-related death rates after endoscopic gastric variceal obliteration (GVO) using N-butyl-2-cyanoacrylate (NBC). METHODS: This study enrolled 341 patients who were consecutively diagnosed with and treated for bleeding gastric varices. The patients were divided into PPI and non-PPI groups, and their endoscopic findings, initial hemostasis outcomes, rebleeding and bleeding-related death rates, and treatment-related complications were analyzed. RESULTS: The rate of initial hemostasis was 97.1%. rebleeding occurred in 2.2% of patients within 2 weeks, 3.9% of patients within 4 weeks, 18.9% of patients within 6 months, and 27.6% of patients within 12 months of the GVO procedure. A previous history of variceal bleeding (relative risk [RR], 1.955; 95% confidence interval [CI], 1.263 to 3.028; p = 0.003) and use of PPIs (RR, 0.554; 95% CI, 0.352 to 0.873; p = 0.011) were associated with rebleeding. Child-Pugh class C (RR, 10.914; 95% CI, 4.032 to 29.541; p < 0.001), failure of initial hemostasis (RR, 13.329; 95% CI, 2.795 to 63.556; p = 0.001), and the presence of red-colored concomitant esophageal varices (RR, 4.096; 95% CI, 1.320 to 12.713; p = 0.015) were associated with bleeding-related death. CONCLUSIONS: The prophylactic use of PPIs reduces rebleeding after GVO using NBC in patients with gastric variceal hemorrhage. However, prophylactic use of PPIs does not reduce bleeding-related death.

Predictors of rebleeding after endoscopic haemostasis of bleeding peptic ulcers

The effectiveness of endoscopic manipulation in the control of bleeding in peptic ulcers have been established amid currently early endoscopy is the best management for acute ulcer bleeding. During endoscopy we can identify the bleeding site and stratify the risk of recurrent bleeding. To study endoscopic findings as factors for prediction of rebleeding after endoscopic hemostasis of bleeding peptic ulcers. These factors were evaluated versus clinical factors. This study was performed in Assuit University Hospital. and included 71 cases with bleeding peptic ulcer. All patients' were subjected to thorough history and clinical examination,written consent, laboratory investigations as live,' functions, prothrombin time and full blood count, and upper endoscopy. Initial hemostasis was achieved in 67[94.4%] cases while permanent hemostasis in 63[88.7%] cases. 20[28.2%] cases experienced rebleeding. The risk factors for rebleeding were age above 55 years 11[55%] and shock at the onset of bleeding which was observed in 19[95%] rebleeders. Endoscopic evaluation revealed that duodenal ulcer was observed more than gastric ulcer in the rebleeder as 12[60%]cases had duodenal ulcer versus 8[40%,] had gastric ulcer. Also, the presence of the ulcer in the posterior wall of the duodenum 10 [83.3%] compared to only 2[12.7%] in the anterior wall was statistically significant P<0.00.Spurting was detected in 8[40%,] of rebleeding cases and in one [1%] case in the patients who did not rebleed with a highly statistical significant P<0.000. The ulcer size was >1.5 cm in 14[70%] out of the 20 bleeders and <1.5 cm in 6[30%] of them with statistical significance P=0.01. On the other hand oilier factors as the shape, depth, vessel color, shape of margin and color of ulcer base showed no statistical significance. On performing multiregression analysis the risk factors for rebleeding included the site of the ulcer being more in the rebleeders in case of duodenal ulcer especially in the posterior wall P<0.001 and the presence of spurting as a risk for rebleeding P<0.001. Age above 55 years, shock on admission are important predictors of rebleeding after endoscopic hemostasis of bleeding ulcers hut endoscopic features as type of ulcer, size and site of ulcer and spurting activity are in ore important predictors of rebleeding after endoscopic hemostasis

High frequency of bacteremia with endoscopic treatment of esophageal varices in advanced cirrhosis.

OBJECTIVES: The fregency of bacteremia after endoscopic variceal band ligation (EVL) is reported to be lower when compared to that after endoscopic variceal sclerotherapy (EVS). However, there are conflicting reports on the infectious sequelae after EVL. AIM: To compare the frequency on bacteremia and infectious sequelae after EVL and EVS in patients with cirrhosis of liver. METHODS: Bacteremia and infectious sequelae were studied in 32 sessions of EVL in 18 cirrhotic patients (Child-Pugh class A-6, B-5, C-7), 30 sessions of EVS in 22 cirrhotic patients (Child-Pugh class A-2, B-5, C-15) and 14 diagnostic upper gastrointestinal endoscopies. Blood cultures were collected before, during and 30 minutes after the procedure. Patients were observed for infectious sequelae during subsequent hospitalization. RESULTS: Before the procedure, bacteremia was present in 7/62 (11%) sessions. Significant bacteremia during and 30 min post-procedure developed in 8/32 (25%) and 12/30 (40%) of EVL and EVS sessions, respectively (p = ns), and in 1/14 (7%) upper gastrointestinal endoscopy sessions. There was more frequent bacteremia with severe liver disease (Child-Pugh class A-0/6, B-1/5. C-7/21; p = 0.09) in the EVL but not in the EVS group (Child-Pugh class A-1/3, B-2/5, C-9/22; p = ns). The incidence was higher with emergency sclerotherapy compared to elective sclerotherapy (6/8 [75%] vs 6/22 [27%]; p <0.01). One patient in the EVS group developed spontaneous bacterial peritonitis. CONCLUSIONS: Bacteremia occurs frequently following EVL and EVS in patients with advanced liver diseases. In the EVS group it is more common after emergency sclerotherapy. This bacteremia is rarely associated with significant infectious sequelae.

Tratamiento endoscópico por infiltración de hemorragias digestivas altas: experiencias en el Instituto Gastroenterológico Boliviano Japoes 1991-1995 / Endoscopic treatment with infiltration of upper digestive hemorrhage

Nuestro estudio busco determinar el número y tipo de complicaciones en el tratamiento endoscópico de la hemorragia digestiva alta tanto por lesiones varicosas como no varicosas para lo cual se incluyó a 387 pacientes ingresados en el Instsituto Gastroenterológico Boliviano-Japones de Cochabamba, con diagnóstico de H.D.A. desde el año 1991 al 1995 diagnósticando la etiología del sangrado por endocopía, seleccionando a 129 pacientes a quienes se les realizo infiltración endoscópica de las lesiones, utilizandose como sustancias esclerosantes el alcohol absoluto, adrenalina o la combinación de estas drogas. De slos 129 pacientes que se les realizo infiltración endoscópica en 3 (2.32 por ciento) presentaron complicaciones graves que fueron del tipo de perforación esofágica (un caso) y perforación gástrica (dos casos), demostrándose la eficacia del procedimiento y las bajas tasas de complicaciones que son iguales a las descritas en otros centros.