Urgent bedside endoscopy for clinically significant upper gastrointestinal hemorrhage after admission to the intensive care unit.

OBJECTIVE: To investigate the sources of hemorrhage and use of endoscopic hemostasis in patients with clinically significant upper gastrointestinal (UGI) hemorrhage after admission to the intensive care unit (ICU). DESIGN AND SETTING: Prospective study, 123 beds of ICU in a 1,629-bed medical center. MEASUREMENTS AND RESULTS: Of the 9,512 consecutive admissions over a 2-year period 105 UGI hemorrhage patients underwent urgent bedside UGI endoscopy. We compared two groups of these patients, one receiving and the other not receiving endoscopic hemostasis. Ulcers with profusely bleeding stigmata occurred in 31 patients (29.5%), ulcers with clean bases or firmly adherent blood clots in 27 (25.7%), stress-related mucosal diseases in 23 (21.9%), esophageal varices in 5 (4.8%), malignancy in 4 (3.8%), and no detectable bleeding site in 15 (14.3%). Endoscopic hemostasis was attempted in 34 patients (32.4%). Primary hemostasis for them was achieved in 67.6% and the rebleeding rate was 30.4%. In-hospital mortality rate was 77.1% and death related to hemorrhage 6.2%. Length of ICU stay before endoscopic diagnosis was significantly shorter in those who underwent endoscopic hemostasis than those who did not (28.2+/-26.3 vs. 41.2+/-57.5 days). CONCLUSIONS: Endoscopic hemostasis may be more beneficial when the period between ICU admission and development of hemorrhage is shorter. Bleeders can be more readily identified and controlled endoscopically in such patients. A significant proportion of bleeding sites cannot be identified by UGI endoscopy. It may indicate higher risk of small bowel hemorrhage in these critically ill patients.

Correlation between serum levels of interleukin-6 and vascular endothelial growth factor in gastric carcinoma.

BACKGROUND AND AIM: Vascular endothelial growth factor (VEGF) and interleukin-6 (IL-6) are associated with the disease status of gastric carcinoma. However, their relationship remains unclear. This study aims to determine and correlate serum levels of VEGF and IL-6 in gastric carcinoma. METHODS: A total of 107 patients receiving gastrectomy entered this study. Serum levels of VEGF and IL-6 were measured by using ELISA, and were analyzed by using the Student's t-test to compare means and by Pearson correlation analysis to calculate correlation coefficients with respect to pathological characteristics including depth of tumor invasion, Laurén's classification, tumor location, Borrmann classification, and the status of lymph node metastasis. RESULTS: Serum VEGF levels were significantly higher in patients with mixed type carcinoma (387.5 +/- 176.9 vs 255.3 +/- 154.1 pg/mL, P = 0.047) or lymph node metastasis (339.1 +/- 205.1 vs 223.2 +/- 197.4 pg/mL, P = 0.007). Serum IL-6 levels were significantly higher in patients with Borrmann type IV carcinoma, compared with Borrmann type II and III carcinoma. In general, no correlation was noted between serum VEGF levels and IL-6 levels (r = 0.142, P = 0.145), but significant correlation was found in patients with early gastric carcinoma (r = 0.627, P = 0.004) or mixed type carcinoma (r = 0.804, P = 0.016). CONCLUSIONS: This study supports the correlation between serum VEGF and IL-6 levels in distinct subsets of gastric carcinoma patients, and indicates that IL-6 may play a role for the angiogenesis of gastric carcinoma via modulation of VEGF.

Endoscopic hemostasis of a bleeding marginal ulcer: hemoclipping or dual therapy with epinephrine injection and heater probe thermocoagulation.

BACKGROUND AND AIMS: Endoscopic hemoclipping and dual therapy with epinephrine injection and heater probe thermocoagulation have been proven effective in the hemostasis of bleeding peptic ulcers. However, the hemostatic efficacy has not been investigated in bleeding marginal ulcers. The aim of this study is to investigate the hemostatic efficacy of endoscopic hemoclipping and dual therapy with epinephrine injection and heater probe thermocoagulation in bleeding marginal ulcers. METHODS: From November 1997 to July 2000, 50 patients with active marginal ulcer bleeding underwent either hemoclipping (20 patients) or dual therapy (30 patients) for hemostasis. The demographic data, clinicopathological characteristics, endoscopic findings, initial hemostatic rates, rebleeding rates, amount of blood transfusion, the need of surgery, and mortality rates were collected and analyzed. RESULTS: Marginal ulcers were located at the anastomotic site (64%), saddle portion (22%), efferent loop (10%), or at the afferent loop (4%). The bleeding stigmata were classified into spurting artery (32%), oozing vessel (38%), visible vessel (20%), and blood clot adhesion (10%). The overall therapeutic results in 50 patients were initial hemostasis (100%), rebleeding rate (22%), need for surgery (4%), and hospital mortality rate (4%). There was no significant difference in demographic data and clinicopathological characteristics between the two modes of treatments, whereas recurrent bleeding developed in 5% in the hemoclipping group and 33% in the dual therapy group. No complication related to the procedure occurred in either mode of therapy. The hospital mortality rates were 0 and 6.7%, respectively. CONCLUSION: Endoscopy is effective in achieving initial hemostasis from bleeding marginal ulcers. However, the rebleeding rate remains high and repeated endoscopy may be needed to arrest the hemorrhage.

Endoscopic hemoclip placement and epinephrine injection for Mallory-Weiss syndrome with active bleeding.

BACKGROUND: Mallory-Weiss syndrome with active bleeding requires effective hemostasis. This is an investigation of the respective efficacy and safety of endoscopic hemoclip placement and endoscopic epinephrine injection in Mallory-Weiss syndrome. METHODS: Thirty-five patients with Mallory-Weiss syndrome with spurting vessels or oozing in a university hospital were enrolled prospectively and randomly assigned to endoscopic hemoclip placement (18 patients) or endoscopic epinephrine injection (17 patients) performed by 4 endoscopists with similar clinical experiences. Demographic characteristics, endoscopic variables, and outcome parameters as well as rates of hemostasis and recurrent bleeding were analyzed. RESULTS: The mean (SD) number of hemoclips applied was 2.5 (1.2) and the mean volume of injection was 7.9 (4.3) mL. Primary hemostasis was achieved in all 35 patients. In each group there was 1 case of recurrent bleeding. Secondary hemostasis was achieved by repeating the same procedures as at randomization in both cases. There were no significant differences in age, gender, prior ingestion of alcohol, presenting symptoms, hemoglobin level, shock, comorbid diseases, bleeding stigmata, tear location, blood transfusion, or hospitalization between the groups. There were no procedure-related complications in either group; surgery was not required in any patient. For both groups, there were no second episodes of recurrent bleeding, procedure-related complication, or need of operation. CONCLUSION: Endoscopic hemoclip placement and endoscopic epinephrine injection are equally effective and safe for the management of active bleeding in Mallory-Weiss syndrome, even in patients with shock or comorbid diseases.