Failure of endoscopic therapy in upper gastrointestinal hemorrhage due to duodenal ulcers.

OBJECTIVES: to evaluate the efficacy of endoscopic treatment in patients with upper gastrointestinal (UGIH) due to duodenal ulcer with high risk of persistent or recurrent bleeding and to determine the associated failure factors of this procedure. PATIENTS AND METHOD: three hundred and thirty-six patients with UGIH due to duodenal ulcer requiring endoscopic treatment were analyzed between January 1992 and December 2001. The patients were classified according to the endoscopic findings: a) patients with limited bleeding; and b) patients with persistent and/or recurrent bleeding due to therapeutic failure. The clinical guidelines followed in patients with endoscopic treatment failure were previously established in the internal protocol. The variables that obtained statistical significance in the univariate analysis were included in the logistic regression model to identify those with an independent predictive value for failure of the endoscopic treatment. RESULTS: mean age of the patients was 60 +/- 17 years, 271 (81%) were male. Bleeding with severe hemodynamic affectation was detected in 82 patients (24%). The most common location of the duodenal ulcer was on the anterosuperior part of the duodenal bulb (227 patients, 68%). In 43 patients (13%) the ulcer was larger than 2 cm. The bleeding stigmata were classified as: Forrest I in 125 (38%) and Forrest II in 211 (62%). It was initially reached in 297 patients (88%). Twenty-two patients required emergency surgery (6,5%) and the global mortality rate was 3%. Severe hemodynamic affectation at admission (OR 11.8, p>0.001), ulcers exceeding 2 cm (OR 6.95, p = 0.019) and the presence of active bleeding during endoscopy (Forrest I) (OR 3.55, p = 0.08) were the variables included in the multivariate analysis independently associated to endoscopic therapy failure. CONCLUSION: endoscopic therapy is an efficient treatment of upper gastrointestinal bleeding due to duodenal ulcer. By means of a clinical variable, the hemodynamic status and two endoscopies, bleeding stigmata and the size of the ulcer, a group of patients with high risk of endoscopic treatment failure can be selected.

Fracaso de la terapéutica endoscópica en enfermos con hemorragia digestiva por úlcera duodenal / No disponible

Objetivos: analizar la eficacia de la terapéutica endoscópica en enfermos con alto riesgo de persistencia y/o recidiva del sangrado específicamente en hemorragia digestiva alta (HDA) por úlcera duodenal y determinar los factores asociados al fracaso de esta técnica. Pacientes y método: se analizaron 336 enfermos con HDA por úlcera duodenal que requirieron terapéutica endoscópica, entre enero 1992 y diciembre 2001. Se clasificaron los enfermos en función de la respuesta al tratamiento endoscópico: a) pacientes con hemorragia limitada; y b) pacientes con persistencia y/o recidiva del sangrado por fracaso terapéutico. La pauta de actuación en los enfermos con fallo del tratamiento endoscópico se hizo en función de un protocolo previamente establecido. Las variables que alcanzaron significación estadística en el análisis univariante se incluyeron en un modelo de regresión logística para identificar aquellas con un valor predictivo independiente para el fracaso de la terapéutica endoscópica. Resultados: la edad media fue de 60 ± 17 años, 271 (81%) eran hombres. La hemorragia se presentó con afectación hemodinámica grave en 82 pacientes (24%). La localización más frecuente de la úlcera duodenal fue en cara anterosuperior de bulbo duodenal en 227 pacientes (68%). En 43 enfermos (13%) la úlcera era mayor de 2 cm. Los estigmas de sangrado encontrados en la endoscopia fueron: Forrest I, en 125 (38%) y Forrest II, 211 (62%). La hemostasia inicial se logró en 297 pacientes (88%). Requirieron cirugía urgente 22 enfermos (6,5%) y la mortalidad global de nuestra serie fue del 3%. En el análisis multivariante, las variables que se asociaron independientemente al fracaso de la terapéutica endoscópica fueron la afectación hemodinámica grave al ingreso (OR 11,8, p<0,001), el tamaño de la úlcera mayor a 2 cm (OR 6,95, p= 0,019) y la presencia de sangrado activo en la endoscopia (Forrest I) (OR 3,55, p=0,08). Conclusión: la terapéutica endoscópica es eficaz en la hemorragia digestiva alta por úlcera duodenal. Mediante una variable clínica, el estado hemodinámico y dos endoscópicas, los estigmas de sangrado y el tamaño de la úlcera, podemos seleccionar un grupo de enfermos con mayor riesgo de fracaso del tratamiento endoscópico (AU)

No disponible

[Factors associated with failure of endoscopic therapy in gastric ulcer bleeding]. / Factores asociados al fracaso de la terapéutica endoscópica en la hemorragia digestiva por úlcera gástrica.

INTRODUCTION: Endoscopic therapy is an effective technique in the control of bleeding due to peptic ulcer. However, bleeding persists or recurs in as many as 10-30% of patients. Gastric and duodenal ulcers present different clinical and endoscopic features and consequently the efficacy of endoscopic therapy and the factors associated with its failure should be studied separately. OBJECTIVES: To analyze the efficacy of endoscopic therapy in patients at high risk of persistent or recurrent bleeding due to gastric ulcer and to identify the factors associated with the failure of this technique. PATIENTS AND METHODS: We performed a retrospective study based on a clinical intervention protocol. Two hundred eight patients admitted for bleeding secondary to gastric ulcer with active bleeding or stigmas of recent bleeding who received endoscopic therapy between January 1992 and December 2001 were analyzed. Clinical, laboratory and endoscopic variables on admission, as well as the medical treatment and endoscopic procedure applied, were registered. Endoscopy was performed within 12 hours of admission. Patients were classified according to their response to endoscopic therapy: a) patients with limited bleeding, and b) patients with persistent or recurrent bleeding due to therapeutic failure. Intervention in patients with therapeutic failure was performed according to a previously established protocol. Variables that were statistically significant in the univariate analysis were included in a logistic regression model to identify those with an independent predictive value for failure of endoscopic therapy. RESULTS: Definitive hemostasis was achieved after initial therapy in 181 patients (87%). The efficacy of a second procedure increased the percentage of hemostasis to 91% of the patients. In the logistic regression model, the only variables that were independently associated with initial therapeutic failure were: hemodynamic status on admission (p = 0.016; OR = 3.99), the need for transfusion of blood products prior to endoscopy (p = 0.025; OR = 3.48), upper localization of the gastric ulcer (p = 0.050; OR = 3.08) and unsatisfactory endoscopic therapy (p = 0.009; OR = 17.39). CONCLUSION: These variables could contribute to the early identification of a subgroup of patients, which would enable us to increase medical-surgical surveillance and offer them other therapeutic alternatives.

[Endoscopic dilatation of caustic esophageal strictures]. / Tratamiento mediante dilatación endoscópica de las estenosis esofágicas cáusticas.

OBJECTIVE: To evaluate the results of endoscopic dilatation in caustic esophageal strictures and to analyze the factors associated with a favorable response. PATIENTS AND METHOD: We performed a retrospective study of 33 patients who underwent dilatation with Savary bougie between 1989 and 2001. Response to initial dilatation and outcome during follow-up were analyzed. RESULTS: The mean age was 50 years (8-83) and 58% were women. Intake was accidental in 29 (88%). In all patients, the caustic substance ingested was alkali. Dilatation was started in the acute phase in 12 patients (36%) and 13 presented inflammatory phenomena adjacent to the stenosis. During initial dilatation, 2 1.6 sessions (2-18) were performed and a favorable response was obtained in 18 patients (54%). At the end of follow-up, 68% of the patients presented satisfactory health status. The comparative study revealed that statistically significant variables for a favorable response to treatment were: accidental alkali intake, instauration of treatment in the chronic phase, absence of inflammatory phenomena, and a small number of initial dilatation sessions. CONCLUSIONS: In our series, more than half the patients with esophageal stenosis due to intake of corrosive alkalis showed a favorable initial response. In these patients with acute-phase stenosis who required a greater number of initial dilatation sessions, endoscopic therapy was less effective.

Ligadura de varices en pacientes pediátricos / Variceal ligation in pedidatric patients

No disponible

[Role of early colonoscopy in severe acute lower gastrointestinal bleeding]. / Rendimiento de la colonoscopia precoz en la hemorragia digestiva baja aguda grave.

BACKGROUND: Severe acute lower gastrointestinal bleeding (SALGIB) accounts for 15% of cases of acute lower gastrointestinal bleeding (ALGIB). The incidence increases with age and comorbidity. Identification of the origin of bleeding may be difficult. Colonoscopy has been proposed as the primary investigative tool. AIM: To assess the role of early colonoscopy as the primary method of evaluation in patients with SALGIB. PATIENTS AND METHOD: Retrospective study based on a guideline for clinical practice approved in our institution. The study included 50 patients with SALGIB admitted to our gastrointestinal bleeding unit between January 1998 and April 2000. SALGIB was suspected when patients fulfilled two or more of the following criteria: 1) significant hemodynamic compromise, 2) decrease in hemoglobin 2 g/dl, and 3) transfusion requirement >= 2 blood units. Early colonoscopy was performed within 24 hours of onset of bleeding. An accurate endoscopic diagnosis was established if a lesion with active bleeding, visible non-hemorrhagic vessel or adherent red clot was identified. A presumptive diagnosis was made when hematochezia or fresh blood localized in a colonic segment, associated with a single, potentially hemorrhagic lesion, was observed and when the results of esophagogastroduodenoscopy were negative. Colonoscopy, esophagogastroduodenoscopy, barium studies, nuclear scan and angiography were performed. RESULTS: Two hundred twenty-two patients were admitted for ALGIB. Fifty patients(22%) fulfilled the SALGIB criteria. The male/female ratio was 1:1. Definitive diagnosis was accurate in 20 patients. The most frequent cause was angiodysplasia (6 patients) and rectal ulcer (6 patients). Eighteen patients had a presumptive diagnosis; of these 14 had diverticulosis. In 12 patients, no cause was identified. Colonoscopy was performed in 45 patients, of which 32 were performed early and 13 electively. Accurate endoscopic diagnosis was more frequently established with early colonoscopy than with elective colonoscopy (15 [47%] vs 2 [15%], p < 0.05). The results of urgent nuclear scans contributed to accurate diagnosis in 5 out of the 10 patients in whom this technique was performed. Angiography was performed in 2 patients. Endoscopic therapy was attempted in 4 patients, all during early colonoscopy. Ten patients (20%) underwent surgery and 3 patients (6%) died. CONCLUSIONS: In 22% of patients with ALGIB admitted to our hospital bleeding was severe. Colonoscopy is the diagnostic tool of choice. When performed within 24 hours of hospital admission, this technique provides more accurate diagnosis than when performed electively.

[Efficacy of fecal detection of Helicobacter pylori with the HpSA technique in patients with upper digestive hemorrhage]. / Eficacia de la determinación fecal de Helicobacter pylori mediante la técnica HpSA en enfermos con hemorragia digestiva alta.

BACKGROUND: The rapid urease test is the most commonly used test in the diagnosis of Helicobacter pylori infection in patients with upper gastrointestinal hemorrhage. However, some studies have suggested that results of this test are frequently false negative when blood is present. An effective new enzyme immunoassay for determining H. pylori antigens in stools has recently begun to be used. AIM: To determine the efficacy of the H. pylori stool antigen test (HpSAT) in patients with upper gastrointestinal hemorrhage. PATIENTS AND METHODS: Thirty-two patients with upper gastrointestinal hemorrhage were prospectively studied from November 1998 to April 1999. In all patients the following tests were performed in the first 72 hours after onset of bleeding and 24 hours after hospital admission: upper gastrointestinal endoscopy, biopsy samples for the rapid urease test and histological study, blood samples for serology, stool samples for HpSAT, and the 13C urea breath test. Criteria for infection was a positive result in at least two of the four diagnostic techniques, except in the case of HpSAT. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. RESULTS: Of the 32 patients, 23 (71.8%) were infected. The results of four HpSAT (12.5%) were negative and 28 were positive (87.5%). HpSAT showed high sensitivity (95.6%) but low specificity (33.3%). The PPV and NPV were 78.5% and 75% respectively. Of the 32 HpSAT, 25 (78.1) were performed in melenic stools: 22 were positive and 3 were negative. Seventy-five percent of negative HpSAT and 78.5% of positive HpSAT corresponded to melenic stools. CONCLUSIONS: HpSAT is a rapid, non-invasive technique that does not appear to be influenced by the presence of blood. Consequently, it can be applied in patients with upper gastrointestinal hemorrhage. The rapid urease test showed high sensitivity, specificity and PPV and should remain the first-line test in patients with upper gastrointestinal hemorrhage. HpSAT is appropriate as a second-line technique and is useful when the rapid urease test is negative and infection is strongly suspected, when no samples for the rapid urease test have been taken and when endoscopy cannot be performed. The result obtained in the present study should be confirmed in future studies with larger samples.

[The predictive factors of a good response to the transfusion of erythrocyte concentrates in patients with controlled digestive hemorrhage]. / Factores predictivos de buena respuesta a la transfusión de concentrados de hematíes en pacientes con hemorragia digestiva controlada.

INTRODUCTION: Not all patients respond the same to the transfusion of erythrocyte concentrates (EC) after achieving the control of gastrointestinal bleeding. AIM: The aim of the present study was to analyze the predictive factors of good response to EC transfusion in patients with controlled gastrointestinal hemorrhage and determine the stability of transfusion performance. PATIENTS AND METHODS: A prospective study was carried out in 61 patients with controlled gastrointestinal bleeding. The epidemiologic data were compared and prior to transfusion different analytical and hemodynamic variables were compared basally. On completion of the transfusion analytical controls were performed at 4 and 24 hours. The response was considered as optimum when pretransfusional basal hemoglobin (Hb) increased at least 1 g and the hematocrit (HCT) rose 3 points for each EC administered. RESULTS: The response to transfusion was optimum in 29 patients and bad in 32. The women responded significantly better than the men (p < 0.05), as did patients with lower weight (p < 0.05) and body surface (p < 0.05). The mean age of the responding patients was greater (p = 0.06) and the height, to the contrary, lower (p = 0.09). No significant differences were observed in the presence or not of associated disease, type of lesion causing the hemorrhage, or number of EC transfused. Likewise, no differences were found with regard to the pretransfusional values of TAM, TAS, FC, PVC, Hb, HCT, VCM, HCM, urea and creatinine. The only variables with independent predictive value of good response were female sex and low body surface. The difference between the Hb and HCT values at 4 and 24 h after transfusion did not achieve statistical significance. CONCLUSIONS: 1. The hemodynamic state and the degree of basal anemia do not condition response to EC transfusion in controlled gastrointestinal bleeding. 2. The response to the administration of EC is better in women and subjects of lower body surface. 3. Postransfusional analytical control at 4 hours allows early evaluation of the effects of the transfusion in patients at risk of recurrent hemorrhage.

Iron-deficiency anemia due to chronic gastrointestinal bleeding.

AIMS: chronic gastrointestinal bleeding is the most common cause of iron deficiency anemia (IDA) in the general population. The objectives of this study were to determine the most frequent gastrointestinal lesions in IDA, the frequency and localization of potentially bleeding lesions, the value of the clinical history in diagnosis, the value of fecal occult blood testing, and the most appropriate diagnostic procedure for these patients. METHODS: we prospectively studied 80 patients older than 40 years with IDA, using upper gastrointestinal tract (GI) endoscopy and colonoscopy, beginning with the former (group A) or the latter (group B) depending on the clinical findings. Barium enema was done when colonoscopy was incomplete or unsatisfactory. If all these tests were negative, conventional barium contrast study of the small intestine and arteriography were done, if necessary. RESULTS: upper GI endoscopy found at least one lesion in 50 patients (72%), 13 in association with a colonic lesion (26%). Colonoscopy detected at least one lesion in 31 patients (45%), among whom 11 had another upper GI lesion (35.5%). Barium enema was positive in 4 out of 24 patients (17%). Barium contrast study of the small intestine detected lesions in 1 out of 7 patients (14%), and arteriography in 1 out of 4 patients (25%). The most common upper GI lesions were of peptic origin (esophagitis in 10, gastroduodenal erosions in 10, and peptic ulcer in 8). Neoplasms (17 cancers and 3 polyps) were the most common colonic lesion. Thirteen out of 38 patients (34%) with a potentially bleeding benign upper GI lesion had another lesion in the colon. The fecal occult blood test was positive in 9 out of 10 patients with colonic cancer and in 5 out of 9 with gastric cancer (74% positive predictive value). Nonsteroid antiinflammatory drug use did not correlate with the presence, location or type of lesion. The reliability of the clinically suspected origin of bleeding was 96% sensitivity, 43% specificity and 74% positive predictive value in group A, and 34%, 93% and 80% respectively in group B. CONCLUSIONS: lesions that cause chronic bleeding were more frequently located in the upper digestive tract than in the colon. There was a high prevalence of neoplasms in patients with IDA. One-third of the patients with a potentially bleeding benign lesion in the upper digestive tract had another lesion in the colon. A positive fecal occult blood test correlated highly with neoplastic lesions, and the presence of blood in the stool did not indicate whether bleeding originated in the upper or lower GI tract. Clinical history was of limited value in predicting the location of a bleeding lesion, but can be suggestive of a prior upper GI tract exploration. These patients need a complete study of both the upper and lower GI tracts. In patients in whom the aforementioned explorations are negative, the small bowel should be studied.

[An analysis of a general prospective series of 3270 upper digestive hemorrhages]. / Análisis de una serie general prospectiva de 3,270 hemorragias digestivas altas.

The results of a global (general series of 3,270 episodes of upper gastrointestinal haemorrhage (UGH) admitted to our unit between the 15th of April 1983 and the 15th of April 1988 have been analyzed. All the patients entered a prospective protocol with 29 variables. Diagnostic and therapeutic approaches had previously been defined. The incidence of UGH in this area was 160 bleeding episodes/100,000 inhabitants/year. Mean age was 57 +/- 16.8 years and male/female ratio was 2.66/1. The percentage of patients older than 65 years was 33.85%. A history of non-steroidal anti-inflammatory drugs (NSAID) intake within 48 hours before the bleeding episode was obtained in 27.63%. Continued alcohol ingestion was observed in 25.96% and 34.37% of patients gave a history of a previous episode of bleeding. UGH presented with haematemesis and melena in 56% of cases, and 44% only with melena. On admission the bleeding was haemodynamically severe in 12.96% and a 19.69% of the patients had severe associated diseases. Early endoscopy in cases with UGH due to peptic ulcer revealed active bleeding in 16.35% (2.87% in jet and 13.48% oozing) and recent clot/visible vessel in 31.7%. The major causes of bleeding were peptic ulcer (54.31%), esophageal and gastric varices (10.73%) and acute lesions of the gastric mucosa (ALGM) (6.72%). Etiology of the haemorrhage could not be established in 8% of cases. Bleeding was persistent in 20.75% and limited in 79.25% of patients. Emergency surgery was needed in 14.43% of cases. The global mortality of the series was 7.65%.(ABSTRACT TRUNCATED AT 250 WORDS)