Non-variceal upper gastrointestinal bleeding: Rescue treatment with a modified cyanoacrylate.

AIM: To evaluate the safety and efficacy of a modified cyanoacrylate [N-butyl-2-cyanoacrylate associated with methacryloxysulfolane (NBCA + MS)] to treat non-variceal upper gastrointestinal bleeding (NV-UGIB). METHODS: In our retrospective study we took into account 579 out of 1177 patients receiving endoscopic treatment for NV-UGIB admitted to our institution from 2008 to 2015; the remaining 598 patients were treated with other treatments. Initial hemostasis was not achieved in 45 of 579 patients; early rebleeding occurred in 12 of 579 patients. Thirty-three patients were treated with modified cyanoacrylate: 27 patients had duodenal, gastric or anastomotic ulcers, 3 had post-mucosectomy bleeding, 2 had Dieulafoy's lesions, and 1 had duodenal diverticular bleeding. RESULTS: Of the 45 patients treated endoscopically without initial hemostasis or with early rebleeding, 33 (76.7%) were treated with modified cyanoacrylate glue, 16 (37.2%) underwent surgery, and 3 (7.0%) were treated with selective transarterial embolization. The mean age of patients treated with NBCA + MS (23 males and 10 females) was 74.5 years. Modified cyanoacrylate was used in 24 patients during the first endoscopy and in 9 patients experiencing rebleeding. Overall, hemostasis was achieved in 26 of 33 patients (78.8%): 19 out of 24 (79.2%) during the first endoscopy and in 7 out of 9 (77.8%) among early rebleeders. Two patients (22.2%) not responding to cyanoacrylate treatment were treated with surgery or transarterial embolization. One patient had early rebleeding after treatment with cyanoacrylate. No late rebleeding during the follow-up or complications related to the glue injection were recorded. CONCLUSION: Modified cyanoacrylate solved definitively NV-UGIB after failure of conventional treatment. Some reported life-threatening adverse events with other formulations, advise to use it as last option.

Defining a proper setting for endoscopy in coeliac disease.

OBJECTIVE: As it has been demonstrated that a careful duodenal inspection during upper gastrointestinal endoscopy may be useful in predicting coeliac disease, we tried to define the usefulness of endoscopy in detecting unsuspected coeliac patients. DESIGN AND METHODS: We considered all the first diagnoses of coeliac disease from 1992 to 2001, i.e. 110 patients with a biopsy-proven diagnosis of coeliac disease. From 1992 to 1997, neither of the endoscopists paid careful attention to the endoscopic features of coeliac disease in the course of the examinations performed for indications other than coeliac disease. From 1998 to 2001, the same endoscopists looked very carefully at these endoscopic features, regardless of the indication for the procedure. RESULTS: Over the first period, 22/16,081 patients endoscoped for the first time had a histological diagnosis of coeliac disease, with a prevalence of 1/731. In all 22 patients the indication for the examination was the suspicion of coeliac disease. The endoscopic appearance of the duodenum was indicative in 16/22 (72.7%) patients. Over the second period, the diagnosis of coeliac disease was made in 88/10,410 patients endoscoped for the first time. The prevalence of the disease was 1/118 examinations performed. The endoscopic appearance of the duodenum was indicative in 70/88 (79.5%) patients. In 13/88 patients, the diagnosis of coeliac disease was presumed because of the macroscopic appearance of duodenum, lacking a past history suggestive of coeliac disease. CONCLUSIONS: Despite a still open controversy on the accuracy of endoscopic markers in the diagnosis of coeliac disease, we have found that in subjects not suspected for coeliac disease and undergoing an upper gastrointestinal endoscopy for other reasons, attention to the endoscopic pattern could facilitate the identification of a relevant number of cases.