Endoscopic Management of Peptic Ulcer Bleeding: Recent Advances

Bleeding peptic ulcers remained as one of the commonest causes of hospitalization worldwide. While endoscopic hemostasis serves as primary treatment for bleeding ulcers, rebleeding after endoscopic hemostasis becomes more and more difficult to manage as patients are usually poor surgical candidates with multiple comorbidities. Recent advances in management of bleeding peptic ulcers aimed to further reduce the rate of rebleeding through—(1) identification of high risk patients for rebleeding and mortality; (2) improvement in primary endoscopic hemostasis and; (3) prophylactic angiographic embolization of major arteries. The technique and clinical evidences for these approaches will be reviewed in the current article.

Utilidad del test rápido de ureasa para la detección de helicobacter pylori en la hemorragia digestiva alta por úlcera péptica / Utility of urease rapid test for detection of helicobacter pylori in patients with upper gastrointestinal bleeding from peptic ulcer

INTRODUCCIÓN: La enfermedad ulcerosa péptica es la principal causa de hemorragia digestiva alta (HDA), siendo la infección por Helicobacter pylori su principal etiología. La sensibilidad de los métodos diagnósticos es menor para la detección de H. pylori en pacientes con hemorragia digestiva alta, existiendo significativa variación entre ellos. OBJETIVO: Validar el test rápido de ureasa (TRU) en pacientes con HDA. MÉTODOS: Se incluyeron prospectivamente pacientes mayores de 14 años que presentaron HDA por úlcera péptica y que tuvieron estudios histológicos y TRU para la búsqueda deH. pylori. Se tomó como prueba de oro la histología. Se tomaron una biopsia de antro y otra de cuerpo para el TRU y dos de antro y dos de cuerpo para la histología. RESULTADOS: Se incluyeron 93 pacientes siendo la principal etiología la úlcera gástrica. Se diagnosticó H. pylori en 48 pacientes según la histología y 55 pacientes tuvieron resultado positivo según el TRU. La sensibilidad y especificidad calculada para el TRU fueron de 89.6% (IC 77.3-96.5) y 73.3% (IC 58.0-85.4) respectivamente. CONCLUSIÓN: El TRU tiene una alta sensibilidad para la detección de H. pylori en pacientes con hemorragia digestiva alta por enfermedad ulcerosa péptica.

BACKGROUND: Peptic ulcer disease is the main cause of upper gastrointestinal bleeding and Helicobacter pylori is its principal etiology. The sensitivity of the diagnostics tests is low for the detection of H. pylori en the setting of bleeding peptic ulcer. In addition there are different results among them. GOAL: To validate the rapid urease test (RUT) in patients with bleeding peptic ulcer.STUDY: We prospectively included patients older than 14 years old who presented with bleeding peptic ulcer and performed diagnostic studies of RUT and histology for the detection of H. pylori. Two biopsies were taken (one from the antrum and another one from the corpus) for RUT and four biopsies (two from both antrum and corpus) for histology. RESULTS Ninety-three patients were included, gastric ulcer was the most frequent site of the bleeding. 48 patients were positive for H. pylori by histology studies and 55 patients were positive to H. pylori by RUT. The sensitivity and specificity of the RUT were 89.6% (IC 77.3-96.5) y 73.3% (IC 58.0-85.4) respectively. CONCLUSION: The RUT has a high sensitivity for the detection of H. pylori en the setting of bleeding peptic ulcer.

Comparison of the Effectiveness of Interventional Endoscopy in Bleeding Peptic Ulcer Disease according to the Timing of Endoscopy

BACKGROUND/AIMS: The optimal timing for interventional endoscopy in bleeding peptic ulcer disease is controversial. This study compared the outcomes between early endoscopy and delayed endoscopy in patients with bleeding peptic ulcer disease. METHODS: We conducted a prospective analysis of data from 90 patients with bleeding peptic ulcer disease who visited the emergency room between May 2006 and September 2007. Patients were categorized into two groups: the early-endoscopy group (admitted during the daytime or at night with prompt endoscopic management) and the delayed-endoscopy group (admitted at night or during weekends, with endoscopic management delayed until the next day). We compared the clinical outcomes of endoscopy between the two groups. RESULTS: There were 49 patients in the early-endoscopy group and 41 patients in the delayed-endoscopy group. Patient demographics, clinical characteristics, bleeding control modality, and Rockall score did not differ between the two groups. There were also no significant differences between the early- and delayed-endoscopy groups in the re-bleeding rate (3/49 vs 5/41, p=0.313), the duration of hospital stay (10.7 vs 9.3 days, p=0.437), and the total amount of blood transfused (3.4 vs 2.7 units, p=0.240). CONCLUSIONS: The effectiveness of interventional endoscopy for patients with bleeding peptic ulcer disease is not significantly affected by the timing of endoscopy.

A Case of Extensive Necrosis of the Gastric Mucosa Following Ethanol Injection Therapy / 대한소화기내시경학회지

A bleeding peptic ulcer is the most common cause of upper gastrointestinal bleeding as well as for hospitalization and death. Many endoscopic methods of treating bleeding peptic ulcers are currently being studied and developed. Among them, the endoscopic pure ethanol injection therapy is favored because of its high efficacy, low cost, and rapid administration. Pure ethanol is an excellent agent to stop bleeding and manifests itslef by inducing tissue dehydration, fixation and vessel compression, which in turn causes arterial coagulation and tissue necrosis. However, an excessive injection volume may bring about extensive mucosal necrosis; hence, caution should be taken when deciding upon the injection volume and depth. We report a case of extensive necrosis of the gastric mucosa following endoscopic ethanol injection therapy of a bleeding peptic ulcer along with a review of the relevant literature.

Is Routine Second-Look Endoscopy Necessary for All Bleeding Peptic Ulcers? / 대한소화기내시경학회지

BACKGROUND/AIMS: Second-look endoscopy is generally performed to prevent rebleeding in patients with bleeding peptic ulcers. However, considering recent technologic advances of endoscopic hemostasis and decreasing rate of rebleeding, a small benefit with second-look endoscopy is suggested. Prospective study was carried out to evaluate the efficacy of second-look endoscopic examinations. METHODS AND RESULTS: One hundred thirty six patients with bleeding from peptic ulcer were included. Emergency endoscopic treatments consisting of the injection of hypertonic saline-epinephrine (HSE), band ligation and/or clipping were performed in patients with Forrest class I-IIb. They were scheduled to receive second-look endoscopy in 48 hours after initial endoscopy. Nine patients (6.6%) received endoscopic retreatment during second-look endoscopy and emergency endoscopic retreatment was required before scheduled endoscopy in six patients (4.4%) because of the evidence of rebleeding. Factors influencing retreatment were Forrest classification of initial endoscopy and methods of hemostasis. None of the patients with Forrest class IIb-III and the patients receiving endoscopic band ligation or clipping on initial endoscopy required retreatment during follow-up endoscopy. CONCLUSION: Routine second-look endoscopy may not be recommended after initial successful endoscopic treatment of peptic ulcer bleeding, especially in case of Forrest class IIb, IIc or III and in the patients treated with band ligation or clipping.

What is the best method to diagnose Helicobacter infection in bleeding peptic ulcers?: a prospective trial

BACKGROUND: It has been debated which diagnostic test should be preferred for the diagnosis of Helicobacter pylori (HP) in patients with peptic ulcer diseases. Several limitations are reported in bleeding peptic ulcers because of intragastric blood and possibility of changed numbers of organisms by medication. This study was designed to find out the best method for diagnosis of HP infection, in aspect of deciding the times of detection and the specific tests in bleeding peptic ulcers. METHODS: We prospectively examined histology, rapid urease test (CLO test), urea breath test (13C-UBT) and serology in HP diagnostics in 32 patients with bleeding peptic ulcers to detect HP infection. Each test was performed two times (four methods at first 24 hours and former three methods at 7th day after initial therapeutic endoscopy). We evaluated the sensitivity of each test, compared the two-times results and evaluated the effect of these tests to an outcome of endoscopic hemostasis. RESULTS: Diagnostic sensitivities of histology, CLO test, 13C-UBT and serology are 75%, 67.8%, 100% and 100% at first endoscopy, and 71.4%, 78.5%, 89.3% at 7th day endoscopy, respectively. Histologic study and CLO test had diagnostic limitation at emergent first endoscopy contrary to UBT (p < 0.01). Histologic study, CLO test and UBT have limitations at 7th day endoscopy. Only 3 patients (9.4%) rebled with subsequent complete endoscopic hemostasis and all diagnostic tests at initial endoscopy did not influence the outcome of hemostasis. CONCLUSION: First day histologic and CLO tests are inadequate methods in detecting HP infection in patients with bleeding peptic ulcers. 7-day histologic, CLO test and UBT have a low sensitivity. First-day UBT can be a standard test to diagnose HP infection in patients with bleeding peptic ulcers.

Long-Term Recurrent Bleeding Rate of Bleeding Peptic Ulcer / 대한소화기내시경학회지

BACKGROUND AND AIMS: Bleeding from a peptic ulcer is one of the common and serious complications associated with the rate of reported mortality, which ranges from 5% to 10%. Endoscopic therapy is effective in controlling active bleeding and reducing the emer-gency surgery, the immediate mortality rate and the incidence of early rebleeding. But few recent studies have documented the long-term recurrent bleeding rate after discharge in patients with bleeding peptic ulcers. The aim of this study was to determine the long-term recurrent bleeding rate and factors predisposing to recurrent bleeding. METHODS: Eighty-eight patients with bleeding peptic ulcers discharged after medical treatment between Dec. 1990 and Jul. 1992 were included in this study and retrospectively followed up with medical records and telephone interviews. The end point of follow-up was recur-rent hemorrhage, surgery for treatment of ulcer complication, or death. RESULTS: By July 1997, retrospective follow-up was available in 76 patients. Recurrent bleeding occurred in 23 patients (30.3%) with bleeding peptic ulcers and the median follow-up period was 69 months (range, 1 ~79 months). The estimated cumulative recurrent bleeding rate after 1, 2, 3, 4, 5 and 6 years was 11.8%, 14.5%, 19.9%, 24.2%, 27.2% and 34.2%, respectively. There was no difference between the recurrent bleeding group and the non-recurrent bleed-ing group according to age, sex, prior NSAIDs use, previous history of bleeding or pepticulcer, site of ulcer, stigmata of recent hemorrhage at initial examination, method of treatment and amount of transfusion. CONCLUSION: Recurrent bleeding occurred in one-third of patients with bleeding peptic ulcers after 6 years of follow-up and one-third of recurrent bleeders rebled within 1 year. The factors predisposing to recurrent bleeding in the long-term follow-up could not be found. Therefore, further studies designed to identify factors predisposing to recurrent bleeding are needed and the evaluation of Helicobacter pylori status in bleeding peptic ulcer is needed because Helicobacter pylori is an important factor of peptic ulcer recurrence.

Comparison of Various Endoscopic Injection Therapy and Hemoclipping for Bleeding Peptic Ulcers / 대한소화기내시경학회지

BACKGROUND/AIMS: Widely practiced endoscopic methods for hemastasis of bleeding peptic ulcer include thermal application (laser, heater probe) and local injection (epi- nephrine, fibrine-glue or various sclerosing agents). Studies evaluating these modalities have presented high success rates for achieving initial hemostasis. Recently, endoscopic hemoclipping is considered to be a safe and effective hemostatic method for upper gas- trointestinal bleeding. The aim of this study was to compare various hemostatic modalities for bleeding peptic ulcer. METHODS: Over a three year period between June 1994 and October 1997, a total of 133 patients with bleeding peptic ulcer were included in this study, We have conducted clinical trials and a retrospective analysis. All of the patients we selected had either active bleeding or a nonbleeding visible vessel on endoscopy. Endoscopy was performed on an emergency basis within 12 hours of hospital arrival.

Hemostatic Effect of Endoscopic Hemoclip Method, Hypertonic Saline Epinephrine Injection Method and Their Combined Method for Bleeding Peptic Ulcer / 대한소화기내시경학회지

BACKGROUND: Bleeding peptic ulcer is the most common cause of upper gastrointestinal bleeding. Various different endoscopic hemostatic methods were introduced to treat bleeding peptic ulcer. Many studies reported the efficacy and comparision of various methods. Endoscopic injection therapy is the most comman method among them because it is inexpensive and easy in use. Complications of injection therapy such as aggravation of bleeding, tissue neerosis and perforation were repoted rarely. Recently endoscopic hemoclipping method is considered to be safe and effective hemostatic method for upper gastrointestinal bleeding. METHODS: During the period between January 1993 and August 1996, we have conducted clinical trial and retrospective analysis among 100 patients in whom active bleeding or visible vessel was identified. RESULTS: 1) Three groups was divided, Hemoclip group 26 cases, Hypertonic Saline Epinephrine(HSE) group 59 cases, Combination group 15 cases. 2) The sources of bleeding in Hemoclip group were gastric ulcer in 23 Cases and duodenal ulcer in 3 cases, and in HSE group, gastric ulcer in 44 case, duodenal ulcer 14 cases and stomal ulcer in one case, and in combination group, gastric ulcer in 10 cases, duodenal ulcer in 3 cases and stomal ulcer in two cases. HSE and combination method were performed more than Hemoclip method in duodenal ulcer(23.7% and 20.0% versus 11.5%). 3) As the stigmata of bleeding in Hemoclip and HSE and Combination group, spurting were seen in 5 cases and 3 cases and 4 cases, and oozing in 10 cases and 17 cases and 3 cases, and nonbleeding visible vessel in 11 cases and 39 cases and 8 cases, respectively. Hemoclip method was performed more than HSE method in active bleeding state(57.6% versus 33.9%). 4) Initial hemostasis was achieved in 24 cases(92.3%) in Hemoclip group and 52 cases(88.1%) in HSE group, 13 cases(86.7%) in Combination group. 5) The rebleeding developed in 1 case(4.2%) in Hemoclip group and 8 cases(15.4%) in HSE group and 1 case(7.6%) in Combination group, the emergent operation was undewent 2 cases(7.7%) in Hemoclip group and 10 cases(17.0%) in HSE group and 1 case(6.7%) in Combination group, respectively. 6) The death was noticed in 1 cases(3.9%) in Hemoclip group and 2 cases(3.4%) in HSE group and 2 case(13.3%) in Combination group, repectively. 7) Permanent hemostasis by only endoscopic treatment was achieved in 24 cases(92.3%) in Hemoclip group and 48 cases(81.4%) in HSE group, 12 cases(80.0%) in Combination group. 8) Complication was noticed only in HSE group, aggravation of bleeding in one case and hematoma in two cases. CONCLUSION: Hemoclip method was effective hemostatic method same as HSE injection method, and safe method weth low complication in bleeding peptic ulcer. We suggest more detail selection of endoscopic hemostatic method in variously individualized endoscopic features.