Efficacy of ethanol and hypertonic saline-epinephrine injection therapy for peptic ulcer bleeding / 대한내과학회지

BACKGROUND: One of simple, inexpensive, readily available treatments for treating peptic ulcer bleeding is injection of the lesion with a sclerosing substance such as ethanol and hypertonic saline-epinephrine. The aim of this study was to compare the hemostatic efficacy of endoscopic injection therapy with ethanol, hypertonic saline-epinephrine, and ethanol plus hypertonic saline- epinephrine. METHODS: 173 patients with active bleeding or nonbleeding visible vessels were classified into three groups based on treatment modality as follows; ethanol injection group (n=67), hypertonic saline-epinephrine injection group (n=16) or ethanol plus hypertonic saline-epinephrine injection group (n=33). RESULTS: No difference in initial hemostasis, rebleeding, need for operation, transfusion requirement, hospital stay and mortality was observed among the ethanol, hypertonic saline-epinephrine and ethanol plus hypertonic saline-epinephrine group. The rate of initial hemostasis in patients with Dieulafoy ulcer bleeding was significantly lower than patients with non-Dieulafoy ulcer bleeding. The rate of initial hemostasis failure, rebleeding rate, need for operation, transfusion requirement and mortality were higher in patients with spurting hemorrhage than patients with visible vessels. Hypertension, diabetus mellitus, smoking and alcohol drinking did not influence therapeutic effect of injection therapy. CONCLUSION: There is no difference in the therapeutic effect of endoscopic injection for peptic ulcer bleeding among ethanol, hypertonic saline-epinephrine and ethanol plus hypertonic saline-epinephrine group, but the therapeutic effect of injection therapy is low in patients with Dieulafoy ulcer bleeding and spurting hemorrhage. Therefore, combination therapy with injection therapy and another endoscopic therapy or another endoscopic therapy alone should be considered.

2 Cases of Endoscopic Ligation Therapy of a Dieulafoy Ulcer / 대한소화기내시경학회지

A dieulafoy ulcer is rarely recognized but is not an uncommon cause of massive, recurrent and frequently fatal gastrointestinal bleeding resulting from the erosion of an unusually large submucosal artery. Although the lesion has been predominantly found in the proximal stomach, it has also been detected throughout the gastrointestinal tract. Diagnosis can be made by observation of protruding and eroded arteries with pulsatile bleeding, or through detection of an adherent thrombus using an endoscopy. In the past, surgical intervention was believed to be the best treatment, but currently, therapeutic endoscopy is more favored, due to its recent success in achieving permanent hemostasis. We experienced 2 cases of Dieulafoy's ulcer of the stomach. Endoscopic ligations using an O ring were performed successfully.

Endoscopic Ligation Therapy of Dieulafoy Ulcer / 대한소화기내시경학회지

Dieulafoy ulcer is an unusual cause of massive, recurrent and frequently fatal gastrointestinal hemorrhage that results from erosion of abnormally large submucosal artery. Although the lesion has been found throughout the gastrointestinal tract, it most commonly occurs in the proximal stomach. Diagnosis depends on the observation of protruding and eroded artery with pulsatile bleeding or adherent thrombus by endoscopy. Even during active bleeding, the endoseopic examination can be negative if intraluminal blood or clots obscure the source of bleeding. If the bleeding has stopped, the small mucosal lesion can be easily overlooked. Unlike peptic ulceration, there is no excavation of the mucosa. A 76-year-old man presented with massive hematemesis and melena. The patient had no previous history of peptic ulcer disease. He did not drink alcohol and use aspirin or NSAIDs. Physical examination revealed a pale, severely diaphoretic male with hypotension and melenic stools. He was found to have hemoglobin 4.0 g/dL and hematocrit 12.7%. We performed emergency endoscopy which showed a pulsatile and bleeding exposed artery without evidence of surrounding ulcerative lesion on the posterior wall of upper body of stomach. Endoscopic ligation using O ring of Stiegman-Goff endoscopic ligator kit was done successfully and the bleeding stopped immediately after ligation. Ten days after treatment, endoscopy showed artificial ulcerative lesion on previous ligated site and no evidence of bleeding. Another endoscopy four days later revealed healing ulcerative lesion. After improvement, the patient was discharged and rebleeding has not occurred to date.