Peptic ulcers remain the most common cause of upper

Size: px
Start display at page:

Download "Peptic ulcers remain the most common cause of upper"

Transcription

1 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2009;7:33 47 STATE OF THE ART Endoscopic Therapy for Bleeding Ulcers: An Evidence-Based Approach Based on Meta-Analyses of Randomized Controlled Trials LOREN LAINE* and KENNETH R. MCQUAID, *Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California; Veterans Affairs Medical Center, San Francisco, California; and the Department of Medicine, University of California San Francisco, San Francisco, California See CME exam on page 2. See Cooper G et al on page 108 for companion article in the January 2009 issue of Gastroenterology. The aim of this study was to determine appropriate endoscopic treatment of patients with bleeding ulcers by synthesizing results of randomized controlled trials. We performed dual independent bibliographic database searches to identify randomized trials of thermal therapy, injection therapy, or clips for bleeding ulcers with active bleeding, visible vessels, or clots, focusing on results from studies without second-look endoscopy and re-treatment. The primary end point was further (persistent plus recurrent) bleeding. Compared with epinephrine, further bleeding was reduced significantly by other monotherapies (relative risk [RR], 0.58 [95% CI, ]; number-needed-to-treat [NNT], 9 [95% CI, 5 53]), and epinephrine followed by another modality (RR, 0.34 [95% CI, ]; NNT, 5 [95% CI, 5 7]); epinephrine was not significantly less effective in studies with second-look and re-treatment. Compared with no endoscopic therapy, further bleeding was reduced by thermal contact (heater probe, bipolar electrocoagulation) (RR, 0.44 [95% CI, ]; NNT, 4 [95% CI, 3 5]) and sclerosant therapy (RR, 0.56 [95% CI, ]; NNT, 5 [95% CI, 4 13]). Clips were more effective than epinephrine (RR, 0.22 [95% CI, ]; NNT, 5 [95% CI, 4 9]), but not different than other therapies, although the latter studies were heterogeneous, showing better and worse results for clips. Endoscopic therapy was effective for active bleeding (RR, 0.29 [95% CI, ]; NNT, 2 [95% CI, 2 2]) and a nonbleeding visible vessel (RR, 0.49; [95% CI, ]; NNT, 5 [95% CI, 4 6]), but not for a clot. Bolus followed by continuous-infusion proton pump inhibitor after endoscopic therapy significantly improved outcome compared with placebo/no therapy (RR, 0.40 [95% CI, ]; NNT, 12 [95% CI, 10 18]), but not compared with histamine 2 -receptor antagonists. Thermal devices, sclerosants, clips, and thrombin/fibrin glue appear to be effective endoscopic hemostatic therapies. Epinephrine should not be used alone. Endoscopic therapy should be performed for ulcers with active bleeding and nonbleeding visible vessels, but efficacy is uncertain for clots. Bolus followed by continuous-infusion intravenous proton pump inhibitor should be used after endoscopic therapy. Peptic ulcers remain the most common cause of upper gastrointestinal bleeding, accounting for approximately 30% to 60% of patients hospitalized for upper gastrointestinal bleeding. 1 5 Upper endoscopy is crucial in the diagnosis, stratification, and management of patients with bleeding ulcers, and endoscopic hemostatic therapy is the mainstay of treatment in patients with endoscopic findings that predict an increased risk of further bleeding. A variety of modalities currently are used for endoscopic therapy of ulcer bleeding, including thermal (eg, bipolar electrocoagulation, heater probe, argon plasma coagulation), injection (eg, epinephrine, sclerosants, thrombin/fibrin glue), mechanical (eg, clips), and combinations of these modalities. Numerous randomized controlled trials of endoscopic treatment for bleeding ulcers have been published. However, integrating the results of these studies is made difficult by variations in the populations enrolled, differences in methods, variations in definitions and end points, evaluation of multiple hemostatic modalities or combination of modalities, and use of mandatory second-look endoscopies with repeat therapy in some studies. Nevertheless, making sense of this large body of literature is extremely important for gastroenterologists because treatment of upper gastrointestinal bleeding remains the most common and important emergency procedure for our subspecialty. We therefore sought to develop an evidence-based approach to the endoscopic treatment of bleeding ulcers by performing a systematic review and meta-analyses to address clinically relevant questions regarding endoscopic treatment of bleeding ulcers. Our aims were to assess currently used techniques for the following: (1) to determine which techniques are better than no endoscopic therapy; (2) to compare different standard therapies; (3) to compare single and dual therapies; (4) to determine efficacy related to stigmata of hemorrhage; (5) to determine Abbreviations used in this paper: BPEC, bipolar electrocoagulation; CI, confidence interval; HP, heater probe; H2RA, histamine 2 -receptor antagonist; NNT, number-needed-to-treat; PPI, proton pump inhibitor; RR, relative risk by the AGA Institute /09/$36.00 doi: /j.cgh

2 34 LAINE AND MCQUAID CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 7,. 1 separately results of studies that did not use routine secondlook endoscopy with re-treatment (because these studies allow a better assessment of the efficacy of primary endoscopic therapy and reflect the current practice in the United States); and (6) to determine the utility of proton pump inhibitor (PPI) therapy as an adjunct to endoscopic therapy. Methods The study type we defined for inclusion was randomized controlled trials that compared one of the included interventions with no therapy or with a second included intervention. Studies with pseudorandomization (eg, day of the week, odd vs even patient number) were not included. The population defined for inclusion was patients presenting with bleeding from a gastric or duodenal ulcer and found to have active bleeding, a nonbleeding visible vessel, or a clot at endoscopy. Because patients with flat spots and clean-based ulcers have a very low rate of clinically important recurrent bleeding 6 and no investigators or publications suggest that endoscopic therapy be provided to such patients, we excluded studies including such patients unless data on patients with higher-risk stigmata could be separated from those with lowerrisk findings. We also excluded studies with bleeding lesions other than gastric or duodenal ulcers unless data for the gastric and duodenal ulcers were provided separately. Studies including only patients in a selected population (eg, elderly, inpatients, Helicobacter pylori infection) also were excluded. The interventions defined for inclusion were those in current use for bleeding ulcers: thermal contact devices (heater probe [HP] and bipolar electrocoagulation [BPEC]), argon plasma coagulation, injection (epinephrine, sclerosants including alcohol, thrombin, and fibrin glue), and clips. We did not include laser therapy, monopolar electrocoagulation, microwave, injection of water or saline, or injection of tissue adhesives. Studies that allowed the endoscopist to choose more than one technique (eg, clips or bands, clips epinephrine) in a treatment arm were not included. To assess the utility of PPI therapy after endoscopic therapy, we also included the intervention of PPI therapy versus control (no therapy, placebo, or histamine 2 - receptor antagonist [H2RA]) in patients with bleeding ulcers and active bleeding, visible vessels, or clots who all received one of our defined endoscopic therapies. The outcomes defined for inclusion were initial hemostasis in active bleeding, further bleeding, need for surgery, need for urgent intervention (subsequent endoscopic treatment with the same or different therapy, surgery, or interventional radiology), mortality, and complications (perforation, induction of bleeding that could not be controlled with the study-mandated endoscopic therapy). The primary end point was further bleeding, which included persistent bleeding and recurrent bleeding. We believe further bleeding provides the best overall assessment of a modality s hemostatic efficacy because it assesses both its initial hemostatic efficacy and its ability to prevent subsequent bleeding. Bleeding required clinical manifestations; identification of bleeding on scheduled second-look endoscopy without clinical evidence of bleeding was not included. We performed separate analyses for studies that did and did not include scheduled second-look endoscopies at which re-treatment was allowed or provided; if second-look endoscopies were performed but no indication of re-treatment at the second-look Table 1. Methodologic Quality Scoring System for Endoscopic Hemostatic Randomized Trials Methodologic Quality Criteria (1 point given for each) Randomized stated in article Randomization method described Concealed allocation Full accounting of all randomized subjects Clear, objective definitions of initial hemostasis or rebleeding Calculations performed for sample size determination Blinded observer managing/assessing patient after endoscopic therapy procedure was reported, the study was not considered a secondlook trial for purposes of our analysis. L.L. and K.R.M. independently performed searches of 2 bibliographic databases: MEDLINE (1950 March, 2008) and the Cochrane Central Register of Controlled Trials. The MeSH search terms gastrointestinal hemorrhage or hemostasis, endoscopic were used for both databases. For MEDLINE, the search was limited to the MeSH term clinical trial or randomized controlled trial, and also to the MeSH term metaanalysis or the non-mesh term systematic review to check these sources for randomized controlled trials missed by our search strategy. language restriction was incorporated. Independent review of titles and abstracts was performed by the 2 authors to identify potentially relevant articles for full review. Any article considered potentially relevant by one of the reviewers was reviewed in full. The authors independently reviewed the articles to identify all studies meeting inclusion criteria. Any disagreements were resolved by discussion and consensus. A data abstraction sheet to record information on study methodology, patient characteristics, and predefined outcomes was developed, pilot tested on known articles, and revised before formal use. The two authors independently completed a data abstraction sheet for each included article and then reviewed the other s sheet. Any disagreements were resolved by discussion and consensus. Studies were assessed for methodologic quality using a 7-point scoring system that incorporated the Jadad et al 7 criteria plus additional criteria (Table 1). We did not include double-blind in our scale because endoscopic treatment trials have not blinded the endoscopist performing the procedure. This is a methodologic shortcoming so a high score with our scale still falls short of the highest methodologic quality because of the absence of double-blinding. We did include one point if providers following up the patient after endoscopic treatment were blinded to the treatment. This methodologic quality score has not been previously used or validated. For studies comparing PPI with no PPI therapy after endoscopic therapy the quality score was modified to an 8-point scale: the blinded observer criterion was replaced by double-blind and mechanism of blinding described. All included studies were randomized, per our inclusion criteria, and therefore had a minimum score of 1. When only one study provided head-to-head comparison for an end point, the Fisher exact test was used for statistical analysis. Meta-analysis was performed when at least 2 studies provided head-to-head comparisons of the therapies of interest. A summary relative risk (RR) with 95% confidence intervals (CIs) was calculated with Review Manager software, version

3 January 2009 ENDOSCOPIC THERAPY FOR BLEEDING ULCERS 35 Table 2. Meta-Analyses for Epinephrine Monotherapy Versus Other Monotherapy and Versus Epinephrine Dual Therapy Comparison End point Number of comparisons RR (95% CI) NNT (95% CI) Monotherapy (BPEC, fibrin glue, clip) Further bleeding 3 50,54, ( ) 9 (5 53) v epinephrine (no second-look studies) Surgery 3 50,54, ( ) 10 (7 250) Urgent intervention 2 50, ( ) Mortality 3 50,54, ( ) Epinephrine second therapy (BPEC, Further bleeding 7 38,45,54, ( ) 5 (5 7) sclerosant, thrombin, clip Surgery 6 38,45,54, ( ) 13 (10 25) v epinephrine (no second-look studies) Urgent intervention 4 45, ( ) 6 (5 9) Mortality 6 38,45,54, ( ) Epinephrine second therapy (HP, BPEC, Further bleeding 7 52,53,55 57,62, ( ) sclerosant, thrombin, fibrin glue) Surgery 7 52,53,55 57,62, ( ) v epinephrine (second-look studies) Urgent intervention 2 53, ( ) Mortality 7 52,53,55 57,62, ( ) (Cochrane Collaboration, Oxford, UK). Heterogeneity was calculated using the chi-square test with n-1 degrees of freedom, where n represented the number of studies contributing to the meta-analysis. Significant heterogeneity was defined as a P value of.10 or less. A fixed-effect model was used when significant heterogeneity was absent, and a random-effects model was used when significant heterogeneity was noted. When a significant difference in an end point was identified, we determined the pooled incidence of end points in the control groups of the individual meta-analysis and multiplied this incidence by the relative risk reduction to estimate the absolute risk reduction and determine the number-needed-to-treat (NNT). Results The MEDLINE search produced 2044 citations and the Cochrane Central Registry search produced 1432 citations. A review of titles and abstracts led to 92 articles considered to be potentially relevant for full review. A review of the 92 full articles revealed 74 articles (75 studies) for inclusion Ten studies of endoscopic therapy were excluded for the following reasons: inability to distinguish outcomes in patients with bleeding from peptic ulcers versus bleeding from other sources, inability to distinguish outcomes in patients with high-risk versus low-risk stigmata, 83,84,86,87 lack of 2 standard endoscopic treatment arms, 88 lack of uniform/standardized endoscopic therapy in one arm, 89,90 and not a clinical trial. 91 Eight studies assessing the efficacy of PPIs after endoscopic therapy were excluded for the following reasons: preliminary report of another study, 92 not studies of endoscopic therapy, 93 lack of inclusion of a standard endoscopic treatment arm, 94 inability to distinguish outcomes in patients who did and did not receive endoscopic therapy, and nonstandard randomization scheme. 99 A review of the references from 16 systematic reviews/ meta-analyses identified in our search 91, yielded 2 additional articles that were reviewed, but neither met inclusion criteria. 115,116 In addition, communication with investigators in the field of ulcer bleeding revealed 2 studies in press or preparation Additional clarifying information was provided by Drs H. J. Lin, J. R. Saltzman, L. Cipolletta, L. Laine, and C. van Rensburg. Details on the component studies are provided in Appendices 1 and 2. Epinephrine Versus Therapy One trial reported 100% initial hemostasis of active bleeding with epinephrine injection. 15 The RR of further bleeding leading to surgery with epinephrine versus medical therapy was 0.36 (95% CI, ); however, this assessment was confounded by the fact that patients in the epinephrine group had a second-look endoscopy with re-treatment of active bleeding (6 of 34 were re-treated). A trial in 40 patients with nonbleeding visible vessels did not show a significant reduction in further bleeding (RR, 0.50; 95% CI, ) or surgery (RR, 0.29; 95% CI, ) with epinephrine. 45 Epinephrine Versus Other Monotherapy Six trials assessed epinephrine versus other monotherapy with HP, 14,63 BPEC, 60 fibrin glue, 31,50 or clip. 54 significant difference was found in initial hemostasis of active bleeding between monotherapy and epinephrine (RR, 0.93; 95% CI, ). Assessment of subsequent outcomes was confounded in 3 of these trials owing to second-look with retreatment. 14,31,63 Meta-analysis of the studies without secondlook 50,54,60 revealed significantly less further bleeding and surgery with monotherapy without a significant decrease in urgent intervention or mortality (Table 2). The one second-look study that allowed assessment of further bleeding 14 found no significant difference between HP and epinephrine (further bleeding: RR, 1.29; 95% CI, ). Epinephrine Versus Epinephrine Second Modality In 15 trials epinephrine was compared with epinephrine plus a second modality: sclerosant, 45,53,55,56,58,61,63,64 BPEC, 60 HP, 57 thrombin, 52,59 fibrin glue, 62 or clips (but with epinephrine injected after rather than before the clips). 38,54 Assessment was confounded by second look plus re-treatment in 8 trials. 52,53,55 57,62 64 Meta-analyses of the 7 studies without second look plus re-treatment 38,45,54,58-61 showed a significant benefit of adding the second modality for further bleeding, surgery, and urgent intervention (Table 2). Significant benefit was seen with dual therapy in those with active bleeding (further bleeding: RR, 0.40; 95% CI, ) 45,54,59,61 and those with nonbleeding visible vessels (further bleeding: RR, 0.35; 95% CI, ). 45,54,59 Results of the 7 second-look studies allowing assessment of outcomes beyond initial hemosta-

4 36 LAINE AND MCQUAID CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 7,. 1 Table 3. Meta-Analyses for Endoscopic Hemostatic Therapies Versus Endoscopic Therapy (Excluding Trials With Second- Look Endoscopies Specifying Re-Treatment) Comparison End point Number of comparisons RR (95% CI) NNT (95% CI) Thermal contact (HP, BPEC) Further bleeding 15 11,18,20,21,23,27,28,33 35,39,41, ( ) 4 (3 5) v no endoscopic therapy Surgery 14 11,18,20,21,23,27,28,33 35,41, ( ) 8 (6 10) Urgent intervention 14 11,18,20,21,23,27,28,33 35,41, ( ) 8 (6 11) Mortality 13 11,18,20,21,23,27,28,33 35, ( ) 33 ( ) Epinephrine thermal contact Further bleeding 3 65,71, ( ) 6 (5 9) v no endoscopic therapy Surgery 3 65,71, ( ) Urgent intervention 2 71, ( ) 6 (5 16) Mortality 3 65,71, ( ) Sclerosant Further bleeding 3 25,34, ( ) 5 (4 13) v no endoscopic therapy Surgery 3 25,34, ( ) 7 (6 15) Urgent intervention 3 25,34, ( ) 7 (5 125) Mortality 3 25,34, ( ) 9 (8 24) Epinephrine sclerosant Further bleeding 6 8,42,44,45,66, ( ) a v no endoscopic therapy Surgery 6 8,42,44,45,66, ( ) a Urgent intervention 6 8,42,44,45,66, ( ) 7 (5 20) Mortality 6 8,42,44,45,66, ( ) a Statistical heterogeneity (P.10) and random-effects model used. sis 52,53,55 57,62,64 showed no benefit of adding a second modality to epinephrine (Table 2). Thermal Contact Therapy Versus Therapy Thermal contact therapy with HP or BPEC versus no endoscopic therapy was assessed in 15 comparisons (10 HP, 5 BPEC) in 14 studies 11,18,20,21,23,27,28,33 35,39,41,77 (1 article comprised 2 studies 20 ); none reported second-look with re-treatment. Initial hemostasis for active bleeding, assessed in 4 trials, 18,21,28,34 was significantly better with thermal contact (RR, 11.70; 95% CI, ). Further bleeding, surgery, urgent intervention, and mortality also were decreased significantly (Table 3). HP and BPEC were directly compared in 3 trials 20,22,32 : RR for further bleeding with HP versus BPEC was 1.01 (95% CI, ). Epinephrine plus thermal therapy versus no endoscopic therapy was compared in 3 studies 65,71,78 : combination therapy was significantly better than no therapy for further bleeding and urgent intervention, but not for surgery or mortality (Table 3). Injection of Sclerosants Versus Therapy Sclerosant alone (absolute alcohol) was compared with no therapy in 4 trials, 25,34,44,72 one of which included secondlook endoscopy and re-treatment. 72 Initial hemostasis for active bleeding was evaluated in only 1 study, 34 with initial hemostasis in 13 (46%) of 28 treated patients versus 2 (8%) of 24 control patients (RR, 5.57; 95% CI, ). In the 3 trials without second-look and re-treatment, absolute alcohol injection was superior to no therapy for further bleeding, surgery, urgent intervention, and mortality (Table 3). The 6 trials that compared epinephrine plus sclerosant versus no therapy 8,42,44,45,66,67 showed a nonsignificant trend in favor of epinephrine plus sclerosant, although significant heterogeneity was present (Table 3). Urgent intervention was significantly less frequent with epinephrine plus sclerosant (Table 3). trials compared sclerosant alone with epinephrine alone. Thermal Contact Versus Sclerosant Injection Thermal contact was compared with sclerosant alone 26,34,36,49,51 or epinephrine plus sclerosant 13,20,21,37,63 in 10 studies; 3 were confounded by second look with re-treatment. 13,37,63 trial compared epinephrine plus thermal contact versus a sclerosant-containing regimen. Results for initial hemostasis with thermal versus sclerosant alone showed no significant difference (RR, 1.27; 95% CI, ), but were heterogeneous (P.0001). 26,34,36,49,51 Among other outcomes, only urgent intervention was significantly different, with thermal contact superior to sclerosant (Table 4). When thermal contact was compared with sclerosants with and without epinephrine, initial hemostasis results were again Table 4. Meta-Analyses Comparing Thermal Contact With Sclerosants (Excluding Trials With Second-Look Endoscopies Specifying Re-Treatment) Comparison End point Number of comparisons RR (95% CI) NNT (95% CI) Thermal contact Further bleeding 5 26,34,36,49, ( ) v sclerosant Surgery 4 26,34,49, ( ) Urgent intervention 3 26,34, ( ) 7 (5 29) Mortality 4 26,34,49, ( ) Thermal contact Further bleeding 7 20,21,26,34,36,49, ( ) v sclerosant epinephrine Surgery 6 20,21,26,34,49, ( ) Urgent intervention 5 20,21,26,34, ( ) 10 (7 143) Mortality 6 20,21,26,34,49, ( )

5 January 2009 ENDOSCOPIC THERAPY FOR BLEEDING ULCERS 37 heterogeneous (P.0001) without a significant difference (RR, 1.24; 95% CI, ). 21,26,34,36,37,49,51,63 Among other outcomes in studies without second-look and re-treatment, only urgent intervention was significantly different (Table 4). The 2 evaluable studies with second-look 13,37 had nearly identical outcomes for thermal versus epinephrine plus sclerosant (further bleeding: RR, 1.14; 95% CI, ). Injection Plus Thermal Contact Versus Thermal Contact Meta-analysis of the 2 studies comparing epinephrine injection preceding BPEC with BPEC monotherapy 10,60 revealed the following RRs: initial hemostasis, 1.31 (95% CI, ); further bleeding, 0.35 (95% CI, ); surgery, 0.33 (95% CI, ); urgent intervention, 0.37 (95% CI, ); and mortality, 0.49 (95% CI, ). The rates of initial hemostasis in the thermal monotherapy arms were 68% and 78%, and the rates of further bleeding in the thermal monotherapy arms were 25% and 34%. A large study of 247 patients, comparing HP plus thrombin versus heater probe plus placebo, was the only double-blind study of endoscopic therapy and the highest methodologic quality study we reviewed. However, it was not included in the meta-analysis because it included 9 patients with esophageal ulcers. 82 This comparison of injection plus thermal contact versus thermal showed no suggestion of a difference (further bleeding: RR, 1.03; [95% CI, ]). Clips study was identified that compared clip with no endoscopic therapy. Two studies compared clips with epinephrine, 38,54 with the latter study comparing epinephrine with clip followed by epinephrine. Meta-analysis of these studies revealed that further bleeding and surgery were decreased with clips, but mortality was not significantly different (Table 5). Another randomized trial comparing clips with injection of water was not included in our meta-analysis based on our inclusion criteria (injection of water not included), 88 but showed clips superior to water injection (further bleeding: RR, 0.34; 95% CI, ). Six studies compared clips with other standard therapies: HP, 16,29,30 epinephrine plus BPEC, 46 or sclerosants with 19 or without 47 epinephrine. Two of these were confounded by second-look and re-treatment. 19,47 Meta-analysis of studies without second-look and re-treatment showed that clips achieved initial hemostasis less frequently than other therapies (RR, 0.78; 95% CI, ). 16,29,30 Other outcomes are shown in Table 5. Although the summary estimate revealed no significant difference in further bleeding, marked heterogeneity was present. Clips were significantly better in one trial, 16 significantly worse in 2 trials, 29,30 and not significantly different in the fourth trial, 46 making aggregation of the individual studies problematic. Among the 2 studies with second-look and re-treatment, one showed no significant difference for clips versus alcohol (further bleeding: RR, 0.67; 95% CI, ) 47 whereas the other showed poorer outcome with clips versus epinephrine plus polidocanol (further bleeding: RR, 2.53; 95% CI, ). 19 Three studies assessed injection plus clips versus clips alone. The dual therapies were clips followed by epinephrine in hypertonic saline, 54 injection of epinephrine and polidocanol followed by clips, 19 or injection of alcohol either before or after clip application. 47 Meta-analysis of the 2 studies without second-look and re-treatment 19,54 revealed no significant difference in further bleeding (Table 5); other outcomes were not provided in both studies. The study with second-look and re-treatment 47 also showed no significant difference in further bleeding for combined versus monotherapy (RR, 0.75; 95% CI, ). Thrombin/Fibrin Glue Thrombin or fibrin glue was compared with no therapy in one trial. 24 Thrombin significantly decreased further bleeding and urgent intervention (RR, 0.10; 95% CI, ) without significant decrease in surgery or death. Fibrin glue was compared with epinephrine injection in 2 studies, 31,50 although one study had second look with re-treatments at different times in each group so it could be evaluated only for initial hemostasis. 31 Initial hemostasis with fibrin glue was reported in 27 of and 15 of versus 27 of 29 and 18 of 18 with epinephrine injection. Further bleeding was not significantly lower with fibrin glue (RR, 0.49; 95% CI, ) in the one evaluable study. 50 Epinephrine plus thrombin was significantly better than epinephrine in the single trial without second-look and retreatment (further bleeding: RR, 0.21; 95% CI, ). 59 Meta-analysis of the 2 second-look trials comparing epinephrine plus thrombin or fibrin glue versus epinephrine alone showed no significant difference (further bleeding: RR, 1.11; 95% CI, ). 52,62 Fibrin glue was not significantly different than polidocanol in a study 9 with second-look and retreatment (further bleeding: RR, 0.65; 95% CI, ), nor was epinephrine plus fibrin glue significantly different from Table 5. Meta-Analyses Assessing Clips (Excluding Trials With Second-Look Endoscopies Specifying Re-Treatment) Comparison End point Number of comparisons RR (95% CI) NNT (95% CI) Clips Further bleeding 2 38, ( ) 5 (4 9) v epinephrine a Surgery 2 38, ( ) 11 (9 50) Mortality 2 38, ( ) Clips Further bleeding 4 16,29,30, ( ) b v other standard therapies Surgery 4 16,29,30, ( ) Urgent intervention 2 16, ( ) b Mortality 4 16,29,30, ( ) Clips injection v clips alone Further bleeding 2 19, ( ) a One trial compared clips followed by epinephrine versus epinephrine. b Statistical heterogeneity (P.10) and random-effects model used.

6 38 LAINE AND MCQUAID CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 7,. 1 Table 6. Meta-Analyses Assessing Endoscopic Therapy Versus Endoscopic Therapy Related to Stigmata of Hemorrhage (Excluding Trials With Second-Look Endoscopies Specifying Re-Treatment) Stigmata End point Number of comparisons RR (95% CI) Pooled rate: no endoscopic therapy n/n (%) NNT (95% CI) Active bleeding Further bleeding 7 8,18,21,28,39, ( ) 77/95 (81%) 2 (2 2) Surgery 4 8,21, ( ) 33/47 (70%) 2 (2 3) Urgent intervention 4 8,21, ( ) 33/47 (70%) 2 (2 3) Mortality 5 8,18,21, ( ) 2/68 (3%) nbleeding visible vessel Further bleeding 20 20,23 25,27,35,39,41,42,44,45,66,67,77, ( ) 224/579 (39%) 5 (4 6) Surgery 18 20,23 25,27,35,42,44,45,66,67,77, ( ) a 91/508 (18%) 9 (7 19) Urgent intervention 18 20,23 25,27,35,42,44,45,66,67,77, ( ) 150/508 (30%) 7 (5 9) Mortality 16 20,23 25,27,35,42,44,45,66, ( ) 30/441 (7%) Clot Further bleeding 5 39,41,65,71, ( ) a 26/118 (22%) Surgery 3 65,71, ( ) 6/76 (8%) Mortality 2 65, ( ) 5/52 (10%) a Statistical heterogeneity (P.10) and random-effects model used. epinephrine plus polidocanol in a study with second-look and re-treatment (further bleeding: RR, 0.87; 95% CI, ). 43 Argon Plasma Coagulation Argon plasma coagulation was compared with epinephrine plus polidocanol 48 with no significant differences noted (further bleeding: RR, 0.80; 95% CI, ). Argon plasma coagulation was not significantly different from HP (further bleeding: RR, 0.76; 95% CI, ) in a second-look study 17 and epinephrine plus argon plasma coagulation was not significantly different from epinephrine plus HP (further bleeding: RR, 0.72; 95% CI, ) in a second-look study. 12 Endoscopic Therapy Versus Endoscopic Therapy Based on Stigmata of Active Bleeding, nbleeding Visible Vessel, or Adherent Clot in Studies Without Second- Look Endoscopy and Re-Treatment Specified Endoscopic therapy was significantly better than no therapy for active bleeding in all outcomes except mortality (Table 6). Initial hemostasis was significantly better in all 7 comparisons and the summary RR was 8.80 (95% CI, ). 8,18,21,28,34 Endoscopic therapy also was significantly better than no therapy for nonbleeding visible vessels in all outcomes except mortality (Table 6). Comparison of endoscopic therapy versus no endoscopic therapy for clots showed no significant benefit in any outcome (Table 6). However, these studies had markedly variable results and there was significant heterogeneity for further bleeding (P.03). One study had only 5 patients; of the other 4 studies, 2 favored endoscopic therapy (1 of 21 vs 12 of 35; RR, 0.14; 95% CI, ; and 0 of 15 vs 6 of 17; RR, 0.09; 95% CI, ; P ), one study found no significant difference for endoscopic therapy versus control (4 of 18 vs 5 of 39; RR, 1.73; 95% CI, ), 41 and 1 study, in which medical therapy included bolus followed by continuous infusion of intravenous PPI (after vigorous irrigation of the clot), revealed no further bleeding during hospitalization with or without endoscopic therapy (0 of 15 vs 0 of 24). 78 A study 72 included in a prior meta-analysis of clots 101 was not included here because the number used for rebleeding in that meta-analysis included patients with only endoscopic evidence of rebleeding (without clinical manifestations). Complications of Endoscopic Therapy Analysis of controlled trials revealed that complications of perforation and induced bleeding were more common with endoscopic therapy than no endoscopic therapy (RR, 2.12; 95% CI, ), 11,15,18,20,21,23 25,27,28,33 35,39 42,44,45,52,65 67,71,72,77,78 although the difference was not statistically significant. The pooled rates for complications in this comparison were 8 of 1044 (0.8%; 95% CI, ) versus 1 of 931 (0.1%; 95% CI, ). Pooled complications rates from the studies included in the systematic review for different modalities are epinephrine alone: 2 induced bleeding episodes in 958 cases (0.2%; 95% CI, ); sclerosant epinephrine: 6 perforations and 1 induced bleeding in 1339 cases (0.5%; 95% CI, ); HP epinephrine: 9 perforations (4 on second treatment and 2 others in second-look studies that did not state if these cases occurred on re-treatment) and 2 induced bleeding in 1070 cases (1.0%; 95% CI, ); BPEC epinephrine: 2 perforations and 1 induced bleeding in 580 cases (0.5%; 95% CI, ); thrombin or fibrin glue epinephrine: 3 perforations in 553 cases (0.5%; 95% CI, ); clips epinephrine: no complications in 373 cases (0; 95% CI, 0 1.0). Pooling of complications for all of these modalities combined revealed a rate of 26 of 4873 (0.5%; 95% CI, ). Proton Pump Inhibitor Therapy as an Adjunct to Endoscopic Therapy Four studies comparing bolus followed by continuous infusion of intravenous PPI with placebo or no treatment 68,74,81,118,119 showed a significant benefit in further bleeding, surgery, urgent intervention, and mortality (Table 7). An additional 3 studies compared this PPI regimen with H2RA therapy, 70,75,117 with no significant differences seen (Table 7). Five studies evaluated intermittent PPI therapy given as intravenous and/or oral boluses versus no therapy or placebo. 49,68,69,73,80 We included intravenous and oral bolus studies together because pharmacodynamic studies indicated no significant difference in antisecretory effect beyond the first hour of

7 January 2009 ENDOSCOPIC THERAPY FOR BLEEDING ULCERS 39 Table 7. Meta-Analyses for PPI Therapy as an Adjunct After Endoscopic Hemostatic Therapy Comparison End point Number of comparisons RR (95% CI) NNT (95% CI) Intravenous PPI: bolus plus continuous infusion v placebo Further bleeding 4 68,74,81,118, ( ) 12 (10 18) Surgery 3 74,81,118, ( ) 28 (21 67) Urgent intervention 3 68,74, ( ) 8 (7 12) Mortality 4 68,74,81,118, ( ) 45 (33 167) Intravenous PPI: bolus plus continuous infusion v H2RA Further bleeding 3 70,75, ( ) Surgery 2 75, ( ) Urgent intervention 2 75, ( ) a Mortality 3 70,75, ( ) PPI: oral or intermittent intravenous bolus v placebo Further bleeding 5 49,68,69,73, ( ) 10 (7 21) Surgery 4 49,69,73, ( ) Urgent intervention 2 68, ( ) Mortality 5 49,68,69,73, ( ) a Statistical heterogeneity (P.10) and random-effects model used. administration. 120 Further bleeding was decreased but significant differences were not seen in surgery, urgent intervention, or mortality (Table 7). An additional 2 studies evaluated intermittent PPI therapy versus H2RA control. 76,79 Addition of these trials did not appreciably alter the results for further bleeding (RR, 0.56; 95% CI, ), surgery (RR, 0.63; 95% CI, ), 49,69,73,76,79,80 or mortality (RR, 0.65; 95% CI, ), but did lead to a significant benefit for urgent intervention (RR, 0.63; 95% CI, ). 68,76,79,81 Discussion Meta-analyses dating back to the early l990s documented that endoscopic therapy overall was effective for patients with bleeding ulcers. 91,100 However, those analyses were driven by results from modalities that are not generally used at present (laser and monopolar electrocoagulation). Many more studies comparing endoscopic hemostatic therapies with no therapy or with one another have been published in the intervening years. We sought to broadly address the major clinically relevant questions regarding endoscopic hemostatic therapy for the treatment of bleeding ulcers. In addition, we wanted to avoid pitfalls encountered in some prior meta-analyses: failure to account for studies with routine second-look endoscopies and re-treatment, inclusion of rebleeding without clinical manifestations that is only identified at mandatory second-look endoscopy, assessment of rebleeding without noting initial hemostasis, use of terms such as rebleeding and further bleeding loosely and interchangeably, and unwarranted combinations of studies of different types of therapies together in one analysis. We also sought to provide clinically relevant end points, such as NNT, to assist the practicing endoscopist in assessing the results of endoscopic therapy. Limited data indicate that epinephrine is effective for initial hemostasis. However, epinephrine appears less effective in preventing further bleeding than other monotherapies (NNT, 9) and definitely is less effective than epinephrine followed by a second modality such as sclerosant or a thermal contact device (NNT, 5). When the analysis was restricted to studies that used routine second-look endoscopy with re-treatment of high-risk stigmata, epinephrine was not less effective than other monotherapies or epinephrine followed by a second modality (Table 2). Thus, routine second-look endoscopy with re-treatment can improve the results of endoscopic therapies and must be taken into consideration when reviewing trials of endoscopic therapy. Prior meta-analyses 103,107 also found that combined therapy was superior to epinephrine alone. Vergara et al 103 reported that combined therapy was significantly better in the actively bleeding group but not in those with nonbleeding visible vessels. However, their meta-analysis differed from ours as a result of different inclusion criteria, and they included studies with and without second-look endoscopy and re-treatment in their analysis related to stigmata. We showed that in trials without second-look and re-treatment, combined therapy was superior to epinephrine alone in patients with either active bleeding or nonbleeding visible vessels (Table 2). In contrast to Vergara et al, 103 our analysis showed no benefit of combined therapy versus epinephrine alone in studies that used a second-look endoscopy with re-treatment. Our results suggest again that performing second-look endoscopy with re-treatment can improve the results for a less-effective therapy and that such studies must be assessed separately from studies that did not include a second-look and re-treatment. A large number of studies documented the benefit of thermal contact devices, BPEC and HP, in improving outcomes of further bleeding, surgery, urgent intervention, and mortality. significant differences were identified between the 2 modalities. Results of 2 small studies did suggest a benefit of combination epinephrine plus BPEC as compared with BPEC alone, 10,60 but results with thermal monotherapy were poorer in these trials than in many other studies. A larger high-quality study found that injection of thrombin plus HP was not better than HP alone. 82 Thus, although limited information suggests that epinephrine followed by thermal contact therapy is efficacious, data are insufficient to recommend that thermal contact devices should not be used alone as monotherapy. Fewer studies compare sclerosants (often combined with epinephrine) with no therapy and data are somewhat more heterogeneous. Alcohol alone was clearly beneficial for all outcomes as compared with no therapy; however, when used alone it may not be ideal for initial hemostasis of actively bleeding ulcers, especially given the volume limitations because of concerns about tissue injury. In these situations, the use of epinephrine to decrease or stop bleeding before injection of a

8 40 LAINE AND MCQUAID CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 7,. 1 sclerosant makes clinical sense, although data to support this benefit are not present in randomized trials. Comparisons between thermal contact and sclerosant therapy show a trend to less further bleeding and significantly fewer urgent interventions (NNT, 7) with thermal therapy (Table 4). Thus, thermal therapy may hold a slight advantage over sclerosant therapy. However, given the wide variation in study designs and methods used, we conclude that both forms of therapy should be considered appropriate in patients with bleeding ulcers. We do not believe the results are compelling enough to conclude that thermal contact devices are more effective than sclerosant therapy. Clips have been shown to be superior to therapy with injection of epinephrine (NNT, 5) (Table 5) or water. Although we did not find a difference in efficacy between clips and other standard therapies such as thermal contact or sclerosant, the marked heterogeneity in the results of different trials with clips significantly better and significantly worse suggests that success with clips may vary from endoscopist to endoscopist. In addition, most studies with clips used devices, now obsolete, which required repeated loading of clips onto a clip applicator. Clips have the theoretical advantage of not causing tissue damage, which is induced by thermal modalities and sclerosants. More trials with currently available clips are necessary to better define the role of clips in endoscopic hemostasis of ulcers. Injection of thrombin or fibrin glue (which includes thrombin and fibrinogen) produces hemostasis by formation of a fibrin clot. These modalities have the theoretical advantage of not causing tissue damage, although other safety concerns include viral transmission and allergic reactions to bovine thrombin. Although available, these products are not approved for injection therapy in the United States. Nevertheless, available data do suggest that these agents are effective for endoscopic therapy and can be considered roughly comparable with therapy with sclerosants. Argon plasma coagulation is a thermal modality that does not use tamponade as do BPEC and HP. Limited data from 3 trials suggest it is similar in efficacy to sclerosant or thermal contact therapy. We did not include 2 thermal therapies, monopolar electrocoagulation and laser photocoagulation, because they generally are not used for ulcer hemostasis at present owing to concerns about tissue injury and, for laser, expense and lack of portability. However, these therapies were shown to be effective in a prior meta-analysis 100 in reducing further bleeding and mortality. As the risk level of the stigmata of hemorrhage decreases so does the benefit of endoscopic therapy. Endoscopic therapy is definitely effective when used to treat ulcers with active bleeding or nonbleeding visible vessels, with greater benefit for active bleeding (NNT, 2) than nonbleeding visible vessels (NNT, 5) for prevention of further bleeding (Table 6). Current studies do not clearly document a benefit in patients with adherent clots, although results are quite heterogeneous, as previously noted by Kahi et al. 101 Two small studies reported high rates of recurrent bleeding with standard oral antisecretory therapy versus nearly 100% success at preventing recurrent bleeding with endoscopic therapy. Many patients in these studies were enrolled at tertiary care hospitals and had other comorbidities (eg, more than half in the medical therapy arm in one study 71 were already hospitalized for another problem when bleeding started). In contrast, a randomized trial revealed no rebleeding among 24 patients with clots resistant to vigorous irrigation who received bolus plus constant-infusion intravenous PPI and no endoscopic therapy. Results from this study were supported by a double-blind trial from Kashmir of oral omeprazole 40 mg twice daily with no endoscopic therapy, in which 0 of 64 patients with adherent clots had recurrent bleeding with the high-dose PPI regimen versus 13 (21%) of 61 receiving placebo. 121 Thus, endoscopic therapy may be beneficial in patients with a high risk of recurrent bleeding with clots (eg, serious concurrent illness), but intensive PPI therapy without endoscopic treatment may be sufficient in patients with adherent clots resistant to vigorous irrigation. Even after successful endoscopic hemostatic therapy, antisecretory therapy with PPI does appear beneficial (Table 7). The data appear strongest for bolus plus constant-infusion intravenous PPI given for 72 hours, which showed significant benefit after endoscopic therapy for all outcomes from further bleeding (NNT, 12) to mortality (NNT, 45). Constant-infusion PPI therapy was significantly more effective than placebo/no therapy but not more than H2RA controls. Prior meta-analysis has suggested that H2RA may have modest efficacy in reducing rebleeding and surgery in patients with bleeding gastric, but not duodenal ulcers, 122 potentially explaining our findings. Boluses of either oral or intravenous PPI also showed benefit in reducing further bleeding but not other outcomes. These studies are variable in the doses used and the populations studied. The theoretical goal of PPI therapy to reduce ulcer rebleeding is maintenance of intragastric ph greater than 6. However, no clinical data have documented the need for an intragastric ph greater than 6 to reduce rebleeding, and it is conceivable that lower ph thresholds (eg, 4 5 to prevent pepsin-induced clot lysis) may be sufficient. In addition, frequent oral dosing appears to provide a pharmacodynamic effect similar to constant infusion, 123 and initial data from randomized comparisons of bolus followed by constant-infusion PPI versus intermittent boluses of intravenous 68,124 or oral PPI 125,126 show no suggestion of a difference. We await further clinical trial data to confirm that boluses of oral or intravenous PPI will provide efficacy comparable with constant-infusion intravenous PPI before recommending intermittent dosing as first-line adjunctive therapy. The pooled complication rate for endoscopic therapies in our review was 0.5%, and the 95% CIs of the rates for individual modalities all overlapped. Clips and epinephrine generally had the lowest rates, with no perforations in either group. Approximately half of the HP perforations occurred in patients receiving 2 consecutive HP treatments, suggesting that HP therapy, and perhaps any modality that causes tissue injury, should not be used when endoscopic therapy is repeated a second time during a hospitalization. When treating recurrent bleeding in this situation, a therapy with limited tissue injury, such as clips, makes intuitive sense, although no studies provide direct information to inform this decision. Summary of Recommendations Epinephrine injection alone should not be used. Thermal therapy, sclerosant therapy, clips, and thrombin/ fibrin glue all appear to be effective endoscopic hemostatic therapies.

9 January 2009 ENDOSCOPIC THERAPY FOR BLEEDING ULCERS 41 Epinephrine injection before these therapies may be beneficial, especially for the actively spurting ulcer, but data supporting such a benefit are extremely limited. Endoscopic therapy should be used for ulcers with active bleeding and nonbleeding visible vessels. The role of endoscopic therapy for ulcers with adherent clots is uncertain. Endoscopic therapy may be considered, although intensive PPI therapy alone may be sufficient. PPIs should be given after endoscopic therapy for ulcers. Results are most consistent for bolus followed by continuous-infusion intravenous PPI for 72 hours. References 1. van Leerdam M, Vreeburg E, Rauws E, et al. Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and Am J Gastroenterol 2003;98: Thomopoulos K, Vagenas K, Vagianos C, et al. Changes in aetiology and clinical outcome of acute upper gastrointestinal bleeding during the last 15 years. Eur J Gastroenterol Hepatol 2004;16: Di Fiore F, Lecleire S, Merle V, et al. Changes in characteristics and outcome of acute upper gastrointestinal haemorrhage: a comparison of epidemiology and practices between 1996 and 2000 in a multicentre French study. Eur J Gastroenterol Hepatol 2005;17: Jensen D, Mawas I, Lousuebsakul V, et al. Changes in the prevalence of different diagnoses for UGI hemorrhage in the last two decades. Gastrointest Endosc 2003;57:AB Enestvedt B, Gralnek I, Mattek N, et al. An evaluation of endoscopic indications and findings related to nonvariceal upper-gi hemorrhage in a large multicenter consortium. Gastrointest Endosc 2008;67: Laine L, Peterson W. Bleeding peptic ulcers. N Engl J Med 1994;331: Jadad A, Moore R, Carroll D. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;17: Balanzó J, Sainz S, Such J, et al. Endoscopic hemostasis by local injection of epinephrine and polidocanol in bleeding ulcer. A prospective randomized trial. Endoscopy 1988;20: Berg P, Barina W, Born P. Endoscopic injection of fibrin glue versus polidocanol in peptic ulcer hemorrhage: a pilot study. Endoscopy 1994;26: Bianco M, Rotondano G, Marmo R, et al. Combined epinephrine and bipolar probe coagulation vs. bipolar probe coagulation alone for bleeding peptic ulcer: a randomized, controlled trial. Gastrointest Endosc 2004;60: Brearley S, Hawker P, Dykes P, et al. Per-endoscopic bipolar diathermy coagulation of visible vessels using a 3.2 mm probe a randomised clinical trial. Endoscopy 1987;19: Chau C, Siu W, Law B, et al. Randomized controlled trial comparing epinephrine injection plus heat probe coagulation versus epinephrine injection plus argon plasma coagulation for bleeding peptic ulcers. Gastrointest Endosc 2003;57: Choudari C, Rajgopal C, Palmer K. Comparison of endoscopic injection therapy versus the heater probe in major peptic ulcer haemorrhage. Gut 1992;33: Chung S, Leung J, Sung J, et al. Injection or heat probe for bleeding ulcer. Gastroenterology 1991;100: Chung S, Leung J, Steele R, et al. Endoscopic injection of adrenaline for actively bleeding ulcers: a randomized trial. Br Med J (Clin Res Ed) 1988;296: Cipolletta L, Bianco M, Marmo R, et al. Endoclips versus heater probe in preventing early recurrent bleeding from peptic ulcer: a prospective and randomized trial. Gastrointest Endosc 2001; 53: Cipolletta L, Bianco M, Rotondano G, et al. Prospective comparison of argon plasma coagulator and heater probe in the endoscopic treatment of major peptic ulcer bleeding. Gastrointest Endosc 1998;48: Fullarton G, Birnie G, Macdonald A, et al. Controlled trial of heater probe treatment in bleeding peptic ulcers. Br J Surg 1989;76: Gevers A, De Goede E, Simoens M, et al. A randomized trial comparing injection therapy with hemoclip and with injection combined with hemoclip for bleeding ulcers. Gastrointest Endosc 2002;55: Gralnek I, Jensen D, Gornbein J, et al. Clinical and economic outcomes of individuals with severe peptic ulcer hemorrhage and nonbleeding visible vessel: an analysis of two prospective clinical trials. Am J Gastroenterol 1998;93: Gralnek I, Jensen D, Kovacs T, et al. An economic analysis of patients with active arterial peptic ulcer hemorrhage treated with endoscopic heater probe, injection sclerosis, or surgery in a prospective, randomized trial. Gastrointest Endosc 1997;46: Hui W, Ng M, Lok A, et al. A randomized comparative study of laser photocoagulation, heater probe, and bipolar electrocoagulation in the treatment of actively bleeding ulcers. Gastrointest Endosc 1991;37: Jaramillo J, Carmona C, Gálvez C, et al. Efficacy of the heater probe in peptic ulcer with a non-bleeding visible vessel. A controlled, randomised study. Gut 1993;34: Juszkiewicz P, Wajda Z, Dobosz M, et al. The role of endoscopic thrombin injections in the treatment of gastroduodenal bleeding. S Afr J Surg 1993;31: Koyama T, Fujimoto K, Iwakiri R, et al. Prevention of recurrent bleeding from gastric ulcer with a nonbleeding visible vessel by endoscopic injection of absolute ethanol: a prospective, controlled trial. Gastrointest Endosc 1995;42: Laine L. Multipolar electrocoagulation versus injection therapy in the treatment of bleeding peptic ulcers. A prospective, randomized trial. Gastroenterology 1990;99: Laine L. Multipolar electrocoagulation in the treatment of peptic ulcers with nonbleeding visible vessels. A prospective, controlled trial. Ann Intern Med 1989;110: Laine L. Multipolar electrocoagulation in the treatment of active upper gastrointestinal tract hemorrhage. A prospective controlled trial. N Engl J Med 1987;316: Lin H, Perng C, Sun I, et al. Endoscopic haemoclip versus heater probe thermocoagulation plus hypertonic saline-epinephrine injection for peptic ulcer bleeding. Dig Liver Dis 2003;35: Lin H, Hsieh Y, Tseng G, et al. A prospective, randomized trial of endoscopic hemoclip versus heater probe thermocoagulation for peptic ulcer bleeding. Am J Gastroenterol 2002;97: Lin H, Hsieh Y, Tseng G, et al. Endoscopic injection with fibrin sealant versus epinephrine for arrest of peptic ulcer bleeding: a randomized, comparative trial. J Clin Gastroenterol 2002;35: Lin H, Wang K, Perng C, et al. Heater probe thermocoagulation and multipolar electrocoagulation for arrest of peptic ulcer bleeding. A prospective, randomized comparative trial. J Clin Gastroenterol 1995;21: Lin H, Wang K, Perng C, et al. Octreotide and heater probe thermocoagulation for arrest of peptic ulcer hemorrhage. A prospective, randomized, controlled trial. J Clin Gastroenterol 1995;21:95 98.

ACG Clinical Guideline: Management of Patients with Ulcer Bleeding

ACG Clinical Guideline: Management of Patients with Ulcer Bleeding ACG Clinical Guideline: Management of Patients with Ulcer Bleeding Loren Laine, MD 1,2 and Dennis M. Jensen, MD 3 5 1 Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut,

More information

On-Call Upper GI Bleeding. Upper Gastrointestinal Bleeding

On-Call Upper GI Bleeding. Upper Gastrointestinal Bleeding On-Call Upper GI Bleeding John R Saltzman MD, FACG Director of Endoscopy Brigham and Women s Hospital Associate Professor of Medicine Harvard Medical School Upper Gastrointestinal Bleeding 300,000000 hospitalizations/year

More information

Scottish Medicines Consortium

Scottish Medicines Consortium Scottish Medicines Consortium esomeprazole, 40mg vial of powder for solution for intravenous injection or infusion (Nexium I.V. ) No. (578/09) AstraZeneca 09 October 2009 The Scottish Medicines Consortium

More information

Sangrado Gastrointestinal Alto Upper GI Bleeding

Sangrado Gastrointestinal Alto Upper GI Bleeding Sangrado Gastrointestinal Alto Upper GI Bleeding Curso Internacional Retos Clinicos en la Gastroenterologia de Urgencias Asociacion Colombiana de Gastroenterologia 31 de Agosto, 2012 Pereira, Risaralda

More information

Review article: management of peptic ulcer bleeding the roles of proton pump inhibitors and Helicobacter pylori eradication

Review article: management of peptic ulcer bleeding the roles of proton pump inhibitors and Helicobacter pylori eradication Aliment Pharmacol Ther 2004; 19 (Suppl. 1): 66 70. Review article: management of peptic ulcer bleeding the roles of proton pump inhibitors and Helicobacter pylori eradication G. HOLTMANN* & C. W. HOWDEN

More information

Comparison of adrenaline injection and bipolar electrocoagulation for the arrest of peptic ulcer bleeding

Comparison of adrenaline injection and bipolar electrocoagulation for the arrest of peptic ulcer bleeding Gut 1999;44:715 719 715 Division of Gastroenterology, Department of Medicine, Veterans General Hospital, Taipei, Taiwan, Republic of China H-J Lin G-Y Tseng C-L Perng F-Y Lee F-Y Chang S-D Lee Correspondence

More information

Intragastric ph With Oral vs Intravenous Bolus Plus Infusion Proton- Pump Inhibitor Therapy in Patients With Bleeding Ulcers

Intragastric ph With Oral vs Intravenous Bolus Plus Infusion Proton- Pump Inhibitor Therapy in Patients With Bleeding Ulcers Intragastric ph With Oral vs Intravenous Bolus Plus Infusion Proton- Pump Inhibitor Therapy in Patients With Bleeding Ulcers LOREN LAINE, ABBID SHAH, and SHAHROOZ BEMANIAN Division of Gastrointestinal

More information

Intermittent vs Continuous Proton Pump Inhibitor Therapy for High-Risk Bleeding Ulcers A Systematic Review and Meta-analysis

Intermittent vs Continuous Proton Pump Inhibitor Therapy for High-Risk Bleeding Ulcers A Systematic Review and Meta-analysis Research Original Investigation Intermittent vs Continuous Proton Pump Inhibitor Therapy for High-Risk Bleeding Ulcers A Systematic Review and Meta-analysis Hamita Sachar, MD; Keta Vaidya, MD; Loren Laine,

More information

Before Endoscopy? Indications Thermal Coagulation Injection Therapy Combination Therapy Fibrin Sealant Endoclips Argon Plasma Coagulation Lysine -

Before Endoscopy? Indications Thermal Coagulation Injection Therapy Combination Therapy Fibrin Sealant Endoclips Argon Plasma Coagulation Lysine - Dr Simon Smale Before Endoscopy? Indications Thermal Coagulation Injection Therapy Combination Therapy Fibrin Sealant Endoclips Argon Plasma Coagulation Lysine - Haemmostop Variceal Banding Histoacryl

More information

Original Article INTRODUCTION

Original Article INTRODUCTION Original Article Endoscopic treatment for high risk bleeding peptic ulcers: A randomized, controlled trial of epinephrine alone with epinephrine plus fresh Mahsa Khodadoostan, Mohammad Karami Horestani,

More information

Turning off the tap: Endoscopy Blood & Guts: Transfusion and bleeding in the medical patient

Turning off the tap: Endoscopy Blood & Guts: Transfusion and bleeding in the medical patient Turning off the tap: Endoscopy Blood & Guts: Transfusion and bleeding in the medical patient John Greenaway 1 Turning off the tap: Endoscopy Answer the questions Benefits and risks of endoscopy Urgency

More information

Outcome of endoscopic treatment for peptic ulcer bleeding: Is a second look necessary? A meta-analysis

Outcome of endoscopic treatment for peptic ulcer bleeding: Is a second look necessary? A meta-analysis Outcome of endoscopic treatment for peptic ulcer bleeding: Is a second look necessary? A meta-analysis Riccardo Marmo, MD, Gianluca Rotondano, MD, Maria Antonia Bianco, MD, Roberto Piscopo, MD, Antonio

More information

A bleeding ulcer: What can the GP do? Gastrointestinal bleeding is a relatively common. How is UGI bleeding manifested? Who is at risk?

A bleeding ulcer: What can the GP do? Gastrointestinal bleeding is a relatively common. How is UGI bleeding manifested? Who is at risk? Focus on CME at the University of British Columbia A bleeding ulcer: What can the GP do? By Robert Enns, MD, FRCP Gastrointestinal bleeding is a relatively common disorder affecting thousands of Canadians

More information

T he aim of a scheduled second endoscopy is to detect and

T he aim of a scheduled second endoscopy is to detect and 1403 STOMACH Effect of scheduled second therapeutic endoscopy on peptic ulcer rebleeding: a prospective randomised trial P W Y Chiu, C Y W Lam, S W Lee, K H Kwong, S H Lam, D T Y Lee, S P Y Kwok... See

More information

Systematic Review of the Predictors of Recurrent Hemorrhage After Endoscopic Hemostatic Therapy for Bleeding Peptic Ulcers

Systematic Review of the Predictors of Recurrent Hemorrhage After Endoscopic Hemostatic Therapy for Bleeding Peptic Ulcers American Journal of Gastroenterology ISSN 0002-9270 C 2008 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2008.02070.x Published by Blackwell Publishing CLINICAL REVIEWS Systematic Review of

More information

Upper gastrointestinal (GI) bleeding represents a substantial

Upper gastrointestinal (GI) bleeding represents a substantial Clinical Guidelines Consensus Recommendations for Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding Alan Barkun, MD, MSc; Marc Bardou, MD, PhD; and John K. Marshall, MD, MSc, for the Nonvariceal

More information

I ts annual incidence is estimated at 50 to 150

I ts annual incidence is estimated at 50 to 150 92 REVIEW Acute endoscopic intervention in non-variceal upper gastrointestinal bleeding R P Arasaradnam, M T Donnelly... Upper gastrointestinal bleeding is one of the commonest emergencies encountered

More information

Lower GI bleeding Management DR EHSANI PROFESSOR IN GASTROENTEROLOGY AND HEPATOLOGY

Lower GI bleeding Management DR EHSANI PROFESSOR IN GASTROENTEROLOGY AND HEPATOLOGY Lower GI bleeding Management DR EHSANI PROFESSOR IN GASTROENTEROLOGY AND HEPATOLOGY 15 FEB 2018 Sources Sources Sources Initial evaluation History Physical examination Laboratory evaluation Obtained at

More information

Endoclips vs large or small-volume epinephrine in peptic ulcer recurrent bleeding

Endoclips vs large or small-volume epinephrine in peptic ulcer recurrent bleeding Online Submissions: http://www.wjgnet.com/1007-9327office wjg@wjgnet.com doi:10.3748/wjg.v18.i18.2219 World J Gastroenterol 2012 May 14; 18(18): 2219-2224 ISSN 1007-9327 (print) ISSN 2219-2840 (online)

More information

A cute upper gastrointestinal haemorrhage is

A cute upper gastrointestinal haemorrhage is 399 BEST PRACTICE Management of haematemesis and melaena K Palmer... Acute upper gastrointestinal bleeding is a common medical emergency which carries hospital mortality in excess of 10%. The most important

More information

New Techniques. Incidence of Peptic Ulcer. Changing. Contents - with an emphasis on peptic ulcer bleeding. Cause of death in peptic ulcer bleeding

New Techniques. Incidence of Peptic Ulcer. Changing. Contents - with an emphasis on peptic ulcer bleeding. Cause of death in peptic ulcer bleeding Contents - with an emphasis on peptic ulcer bleeding New Techniques in Treating GI Bleeding Incidence and cause of death Acid suppression Endoscopic hemostasis Prediction of rebleeding and death Second

More information

Research Article Management of Peptic Ulcer Bleeding in Different Case Volume Workplaces: Results of a Nationwide Inquiry in Hungary

Research Article Management of Peptic Ulcer Bleeding in Different Case Volume Workplaces: Results of a Nationwide Inquiry in Hungary Gastroenterology Research and Practice Volume 2012, Article ID 956434, 6 pages doi:10.1155/2012/956434 Research Article Management of Peptic Ulcer Bleeding in Different Case Volume Workplaces: Results

More information

Nonvariceal upper gastrointestinal bleeding (UGIB) remains a common

Nonvariceal upper gastrointestinal bleeding (UGIB) remains a common Gastroenterol Clin N Am 34 (2005) 607 621 GASTROENTEROLOGY CLINICS OF NORTH AMERICA Nonvariceal Upper Gastrointestinal Bleeding: Standard and New Treatment Charles B Ferguson, MB, Robert M. Mitchell, MB*

More information

Addition of a Second Endoscopic Treatment Following Epinephrine Injection Improves Outcome in High-Risk Bleeding Ulcers

Addition of a Second Endoscopic Treatment Following Epinephrine Injection Improves Outcome in High-Risk Bleeding Ulcers GASTROENTEROLOGY 2004;126:441 450 Addition of a Second Endoscopic Treatment Following Epinephrine Injection Improves Outcome in High-Risk Bleeding Ulcers XAVIER CALVET,* MERCEDES VERGARA,* ENRIC BRULLET,*

More information

UGI Bleeding: Impact and Outcome of Early Endoscopy at the Referral Community Hospital ABSTRACT

UGI Bleeding: Impact and Outcome of Early Endoscopy at the Referral Community Hospital ABSTRACT Original Article Jewsuebpong T THAI J GASTROENTEROL 2008 Vol. 9 No. 2 May - Aug. 2008 67 UGI Bleeding: Impact and Outcome of Early Endoscopy at the Referral Community Hospital Jewsuebpong T ABSTRACT Background:

More information

Peptic ulcer bleeding remains the most common cause of hospitalization

Peptic ulcer bleeding remains the most common cause of hospitalization CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2009;7:311 316 Predicting Mortality in Patients With Bleeding Peptic Ulcers After Therapeutic Endoscopy PHILIP W. Y. CHIU,* ENDERS K. W. NG,* FRANCES K. Y. CHEUNG,*

More information

James Irwin Gastroenterology Department Palmerston North Hospital. Acute Medicine Meeting Hutt Hospital. June 21, 2015

James Irwin Gastroenterology Department Palmerston North Hospital. Acute Medicine Meeting Hutt Hospital. June 21, 2015 The Management of Acute Upper Gastrointestinal Bleeding James Irwin Gastroenterology Department Palmerston North Hospital Acute Medicine Meeting Hutt Hospital June 21, 2015 Outline Common Definitions and

More information

ACUTE UPPER GASTROINTESTINAL HEMORRHAGE: PHARMACOLOGIC MANAGEMENT

ACUTE UPPER GASTROINTESTINAL HEMORRHAGE: PHARMACOLOGIC MANAGEMENT DISCLAIMER: These guidelines were prepared by the Department of Surgical Education, Orlando Regional Medical Center. They are intended to serve as a general statement regarding appropriate patient care

More information

Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review)

Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review) Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review) Sreedharan A, Martin J, Leontiadis GI, Dorward S, Howden CW, Forman D, Moayyedi P This

More information

Upper GI Bleeding. HH Tsai MD FRCP FECG Consultant Gastroenterologist

Upper GI Bleeding. HH Tsai MD FRCP FECG Consultant Gastroenterologist Upper GI Bleeding HH Tsai MD FRCP FECG Consultant Gastroenterologist Financial Disclosures I have no financial relationship with any manufacturer or supplier of any product mentioned in this talk. GI Audits:

More information

Gastrointestinal Safety of Coxibs and Outcomes Studies: What s the Verdict?

Gastrointestinal Safety of Coxibs and Outcomes Studies: What s the Verdict? Vol. 23 No. 4S April 2002 Journal of Pain and Symptom Management S5 Proceedings from the Symposium The Evolution of Anti-Inflammatory Treatments in Arthritis: Current and Future Perspectives Gastrointestinal

More information

AN ANNOTATED ALGORITHMIC APPROACH TO UPPER GASTROINTESTINAL BLEEDING

AN ANNOTATED ALGORITHMIC APPROACH TO UPPER GASTROINTESTINAL BLEEDING American Society For Gastrointestinal Endoscopy AN ANNOTATED ALGORITHMIC APPROACH TO UPPER GASTROINTESTINAL BLEEDING Algorithms for appropriate utilization of endoscopy are based on a critical review of

More information

Emergency Surgery Board Department of General Surgery Rambam Health Care Campus

Emergency Surgery Board Department of General Surgery Rambam Health Care Campus Emergency Surgery Board Department of General Surgery Rambam Health Care Campus Surgical Complications of Peptic Ulcer Disease Bleeding Case Presentation and Review of the Literature Case Presentation

More information

Shou Jiang Tang, MD, FASGE. Director of Endoscopic Research Professor in Medicine

Shou Jiang Tang, MD, FASGE. Director of Endoscopic Research Professor in Medicine Shou Jiang Tang, MD, FASGE Director of Endoscopic Research Professor in Medicine Through-the-scope clipping devices Over-the-scope clipping devices First reported clipping device Hayshi T, Yonezawa M,

More information

Database of Abstracts of Reviews of Effects (DARE) Produced by the Centre for Reviews and Dissemination Copyright 2017 University of York.

Database of Abstracts of Reviews of Effects (DARE) Produced by the Centre for Reviews and Dissemination Copyright 2017 University of York. A comparison of the cost-effectiveness of five strategies for the prevention of non-steroidal anti-inflammatory drug-induced gastrointestinal toxicity: a systematic review with economic modelling Brown

More information

Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review)

Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review) Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review) Sreedharan A, Martin J, Leontiadis GI, Dorward S, Howden CW, Forman D, Moayyedi P This

More information

Helicobacter pylori. Objectives. Upper Gastrointestinal Bleeding Peptic Ulcer Disease

Helicobacter pylori. Objectives. Upper Gastrointestinal Bleeding Peptic Ulcer Disease Upper Gastrointestinal Bleeding Peptic Ulcer Disease Pharmacotherapy Issues in Acute Management and Secondary Prevention Peter J. Zed, B.Sc., B.Sc.(Pharm), Pharm.D. Pharmacotherapeutic Specialist - Emergency

More information

volume endoscopic injection of epinephrine for peptic ulcer bleeding

volume endoscopic injection of epinephrine for peptic ulcer bleeding A prospective, randomized trial of large- versus small-, volume endoscopic injection of epinephrine for peptic ulcer bleeding Hwaideng Lin, MD, FACG,Yu-Hsi Hsieh, MD, Guan-Ying Tseng, MD, Chin-Lin Perng,

More information

Eugenia Lauret, Jesús Herrero, Lorena Blanco, Olegario Castaño, Maria Rodriguez, Isabel Pérez, Verónica Alvarez, Adolfo Suárez, and Luis Rodrigo

Eugenia Lauret, Jesús Herrero, Lorena Blanco, Olegario Castaño, Maria Rodriguez, Isabel Pérez, Verónica Alvarez, Adolfo Suárez, and Luis Rodrigo Gastroenterology Research and ractice Volume 2013, Article ID 584540, 5 pages http://dx.doi.org/10.1155/2013/584540 Clinical Study Epidemiological Clinical Features and Evolution of Gastroduodenal Ulcer

More information

Effect of oral omeprazole in reducing re-bleeding in bleeding peptic ulcers: a prospective, double-blind, randomized, clinical trial

Effect of oral omeprazole in reducing re-bleeding in bleeding peptic ulcers: a prospective, double-blind, randomized, clinical trial Aliment Pharmacol Ther 2003; 17: 211 216. doi: 10.1046/j.0269-2813.2003.01416.x Effect of oral omeprazole in reducing re-bleeding in bleeding peptic ulcers: a prospective, double-blind, randomized, clinical

More information

Efficacy of dual therapy (APC & Adrenaline) in high risk peptic ulcer bleeding

Efficacy of dual therapy (APC & Adrenaline) in high risk peptic ulcer bleeding ISSN: 2347-3215 Volume 2 Number 7 (July-2014) pp. 203-208 www.ijcrar.com Efficacy of dual therapy (APC & Adrenaline) in high risk peptic ulcer bleeding Saleh Azad Bakht*, Manouchehr Khoshbaten, Kamal Bostani,

More information

Improved risk assessment in upper GI bleeding

Improved risk assessment in upper GI bleeding EDITORIAL Improved risk assessment in upper GI bleeding Acute upper GI bleeding is the most common GI emergency, with a reported incidence in various epidemiological studies ranging from 50 to over 100

More information

Clinical Study Effect of High-Dose Oral Rabeprazole on Recurrent Bleeding after Endoscopic Treatment of Bleeding Peptic Ulcers

Clinical Study Effect of High-Dose Oral Rabeprazole on Recurrent Bleeding after Endoscopic Treatment of Bleeding Peptic Ulcers Gastroenterology Research and Practice Volume 2012, Article ID 317125, 8 pages doi:10.1155/2012/317125 Clinical Study Effect of High-Dose Oral Rabeprazole on Recurrent Bleeding after Endoscopic Treatment

More information

SUMMARY INTRODUCTION. Accepted for publication 11 May 2005

SUMMARY INTRODUCTION. Accepted for publication 11 May 2005 Aliment Pharmacol Ther 2005; 22: 169 174. doi: 10.1111/j.1365-2036.2005.02546.x Systematic review and meta-analysis: proton-pump inhibitor treatment for ulcer bleeding reduces transfusion requirements

More information

Risk factors of the rebleeding according to the patterns of nonvariceal upper gastrointestinal bleeding

Risk factors of the rebleeding according to the patterns of nonvariceal upper gastrointestinal bleeding Gastrointestinal Tract Risk factors of the rebleeding according to the patterns of nonvariceal upper gastrointestinal bleeding Ji Hyung Nam 1, Tae Joo Jeon 2, Jae Hee Cho 3, Jae Hak Kim 1 1 Department

More information

We are IntechOpen, the world s leading publisher of Open Access books Built by scientists, for scientists. International authors and editors

We are IntechOpen, the world s leading publisher of Open Access books Built by scientists, for scientists. International authors and editors We are IntechOpen, the world s leading publisher of Open Access books Built by scientists, for scientists 4,000 116,000 120M Open access books available International authors and editors Downloads Our

More information

Nonvariceal Upper Gastrointestinal Bleeding

Nonvariceal Upper Gastrointestinal Bleeding Nonvariceal Upper Gastrointestinal Bleeding Stephen R. Rotman and John R. Saltzman 2 Introduction Upper gastrointestinal bleeding (UGIB) is defined as bleeding in the gastrointestinal tract originating

More information

Management of acute upper gastrointestinal bleeding

Management of acute upper gastrointestinal bleeding 1 Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow G4 OSF, UK 2 Section of Digestive Diseases, Yale School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Connecticut,

More information

Pantoprazole infusion as adjuvant therapy to endoscopic treatment in patients with peptic ulcer bleeding: Prospective randomized controlled trial

Pantoprazole infusion as adjuvant therapy to endoscopic treatment in patients with peptic ulcer bleeding: Prospective randomized controlled trial Blackwell Publishing AsiaMelbourne, AustraliaJGHJournal of Gastroenterology and Hepatology0815 93192006 Blackwell Publishing Asia Pty Ltd200621716721Original Article Pantoprazole in bleeding peptic ulcerssa

More information

Anticoagulants are a contributing factor. Other causes are Mallory-Weiss tears, AV malformations, and malignancy and aorto-enteric fistula.

Anticoagulants are a contributing factor. Other causes are Mallory-Weiss tears, AV malformations, and malignancy and aorto-enteric fistula. Upper GI Bleeding EMU2018 Dr. Walter Himmel MD Incidence: In non-cirrhotics, the commonest causes are peptic ulcer disease (50%) followed by erosive gastritis. In cirrhotic patients, variceal bleeding

More information

Upper gastrointestinal bleeding in children. Nguyễn Diệu Vinh, MD Department of Gastroenterology

Upper gastrointestinal bleeding in children. Nguyễn Diệu Vinh, MD Department of Gastroenterology Upper gastrointestinal bleeding in children Nguyễn Diệu Vinh, MD Department of Gastroenterology INTRODUCTION Upper gastrointestinal (UGI) bleeding : arising proximal to the ligament of Treitz in the distal

More information

Multipolar Electrocoagulation in the Treatment of Peptic Ulcers with Nonbleeding Visible Vessels

Multipolar Electrocoagulation in the Treatment of Peptic Ulcers with Nonbleeding Visible Vessels Multipolar Electrocoagulation in the Treatment of Peptic Ulcers with Nonbleeding Visible Vessels A Prospective, Controlled Trial Loren Laine, MD Study Objective: To assess the efficacy and safety of treatment

More information

British Society of Gastroenterology. St. Elsewhere's Hospital. National Comparative Audit of Blood Transfusion

British Society of Gastroenterology. St. Elsewhere's Hospital. National Comparative Audit of Blood Transfusion British Society of Gastroenterology UK Com parat ive Audit of Upper Gast roint est inal Bleeding and t he Use of Blood Transfusion Extract December 2007 St. Elsewhere's Hospital National Comparative Audit

More information

Endoscopic Management of Tumor Bleeding from Inoperable Gastric Cancer

Endoscopic Management of Tumor Bleeding from Inoperable Gastric Cancer FOCUSED REVIEW SERIES: Endoscopic Management of Upper Gastrointestinal Bleeding Clin Endosc 2015;48:121-127 Print ISSN 2234-2400 / On-line ISSN 2234-2443 http://dx.doi.org/10.5946/ce.2015.48.2.121 Open

More information

Acute Upper Gastro Intestinal (UGI) Bleeding

Acute Upper Gastro Intestinal (UGI) Bleeding T Acute Upper Gastro Intestinal (UGI) Bleeding University Hospitals of Leicester NHS Trust Guidelines for Management of Acute Medical Emergencies 1. Has there been a GI bleed? There are also UHL trust

More information

Drug Class Review on Proton Pump Inhibitors

Drug Class Review on Proton Pump Inhibitors Drug Class Review on Proton Pump Inhibitors Final Report Update 4 July 2006 Original Report Date: November 2002 Update 1 Report Date: April 2003 Update 2 Report Date: April 2004 Update 3 Report Date: May

More information

ORIGINAL INVESTIGATION

ORIGINAL INVESTIGATION ORIGINAL INVESTIGATION A Prospective Randomized Comparative Trial Showing That Prevents Rebleeding in Patients With Bleeding Peptic Ulcer After Successful Endoscopic Therapy Hwai-Jeng Lin, MD, FACG; Wen-Ching

More information

Hydrogen Peroxide Improves the Visibility of Ulcer Bases in Acute Non-variceal Upper Gastrointestinal Bleeding: A Single-Center Prospective Study

Hydrogen Peroxide Improves the Visibility of Ulcer Bases in Acute Non-variceal Upper Gastrointestinal Bleeding: A Single-Center Prospective Study Dig Dis Sci (2009) 54:2427 2433 DOI 10.1007/s10620-009-0948-4 ORIGINAL ARTICLE Hydrogen Peroxide Improves the Visibility of Ulcer Bases in Acute Non-variceal Upper Gastrointestinal Bleeding: A Single-Center

More information

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

Comparison of the Effectiveness of Interventional Endoscopy in Bleeding Peptic Ulcer Disease according to the Timing of Endoscopy Gut and Liver, Vol. 3, No. 4, December 2009, pp. 266-270 original article Comparison of the Effectiveness of Interventional Endoscopy in Bleeding Peptic Ulcer Disease according to the Timing of Endoscopy

More information

Simon Everett. Consultant Gastroenterologist, SJUH, Leeds. if this is what greets you in the morning, you probably need to go see a doctor

Simon Everett. Consultant Gastroenterologist, SJUH, Leeds. if this is what greets you in the morning, you probably need to go see a doctor Simon Everett Consultant Gastroenterologist, SJUH, Leeds if this is what greets you in the morning, you probably need to go see a doctor Presentation Audit data and mortality NICE guidance Risk assessment

More information

UGI BLEED. Dr. KPP Abhilash Associate Professor Department of Emergency Medicine Christian Medical College, Vellore

UGI BLEED. Dr. KPP Abhilash Associate Professor Department of Emergency Medicine Christian Medical College, Vellore UGI BLEED Dr. KPP Abhilash Associate Professor Department of Emergency Medicine Christian Medical College, Vellore Outline UGI bleed: etiology and presentation Management: Non variceal / variceal bleed

More information

Non-variceal upper gastrointestinal haemorrhage: guidelines

Non-variceal upper gastrointestinal haemorrhage: guidelines iv1 GUIDELINES Non-variceal upper gastrointestinal haemorrhage: guidelines British Society of Gastroenterology Endoscopy Committee... 1.0 INTRODUCTION Acute upper gastrointestinal bleeding is the commonest

More information

Oral versus intravenous proton pump inhibitors in preventing re-bleeding for patients with peptic ulcer bleeding after successful endoscopic therapy

Oral versus intravenous proton pump inhibitors in preventing re-bleeding for patients with peptic ulcer bleeding after successful endoscopic therapy Yen et al. BMC Gastroenterology 2012, 12:66 RESEARCH ARTICLE Open Access Oral versus intravenous proton pump inhibitors in preventing re-bleeding for patients with peptic ulcer bleeding after successful

More information

Systematic Review and Meta-analysis of Adverse Events of Low-dose Aspirin and Clopidogrel in Randomized Controlled Trials

Systematic Review and Meta-analysis of Adverse Events of Low-dose Aspirin and Clopidogrel in Randomized Controlled Trials The American Journal of Medicine (2006) 119, 624-638 REVIEW Systematic Review and Meta-analysis of Adverse Events of Low-dose Aspirin and Clopidogrel in Randomized Controlled Trials Kenneth R. McQuaid,

More information

Systematic reviews and meta-analyses of observational studies (MOOSE): Checklist.

Systematic reviews and meta-analyses of observational studies (MOOSE): Checklist. Systematic reviews and meta-analyses of observational studies (MOOSE): Checklist. MOOSE Checklist Infliximab reduces hospitalizations and surgery interventions in patients with inflammatory bowel disease:

More information

Digestive and Liver Disease

Digestive and Liver Disease Digestive and Liver Disease 46 (2014) 313 317 Contents lists available at ScienceDirect Digestive and Liver Disease jou rnal h om epage: www.elsevier.com/locate/dld Alimentary Tract Time trends and outcome

More information

Management of Bleeding Gastroduodenal Ulcers

Management of Bleeding Gastroduodenal Ulcers Complications in Oesophageal and Gastric Surgery Dig Surg 2002;19:99 104 Management of Bleeding Gastroduodenal Ulcers J.J.B. van Lanschot a M. van Leerdam b O.M. van Delden c P. Fockens b Departments of

More information

The New England Journal of Medicine

The New England Journal of Medicine The New England Journal of Medicine Copyright, 2000, by the Massachusetts Medical Society VOLUME 343 A UGUST 3, 2000 NUMBER EFFECT OF INTRAVENOUS OMEPRAZOLE ON RECURRENT BLEEDING AFTER ENDOSCOPIC TREATMENT

More information

Is a Second-Look Endoscopy Necessary after Endoscopic Submucosal Dissection for Gastric Neoplasm?

Is a Second-Look Endoscopy Necessary after Endoscopic Submucosal Dissection for Gastric Neoplasm? Gut and Liver, Vol. 9, No. 1, January 2015, pp. 52-58 ORiginal Article Is a Second-Look Endoscopy Necessary after Endoscopic Submucosal Dissection for Gastric Neoplasm? Eun Ran Kim*, Jung Ha Kim*, Ki Joo

More information

prospective, randomised controlled trial

prospective, randomised controlled trial Gut, 1990,31,753-757 Division of Gastroenterology, Departments of Medicine and Emergency, Veterans General Hospital, Taipei, Taiwan, Republic of China H J Lin F Y Lee W M Kang Y T Tsai S D Lee C H Lee

More information

Endoscopic dual versus monotherapy in patients bleeding from high-risk peptic ulcers

Endoscopic dual versus monotherapy in patients bleeding from high-risk peptic ulcers J Unexplored Med Data 2017;2:20-5 DOI: 10.20517/2572-8180.2016.11 Short Communication Journal of Unexplored Medical Data www.jumdjournal.net Open Access Endoscopic dual versus monotherapy in patients bleeding

More information

COPYRIGHTED MATERIAL. 1 Approach to the patient with gross gastrointestinal bleeding. Grace H. Elta, Mimi Takami

COPYRIGHTED MATERIAL. 1 Approach to the patient with gross gastrointestinal bleeding. Grace H. Elta, Mimi Takami 1 Approach to the patient with gross gastrointestinal bleeding Grace H. Elta, Mimi Takami Gastrointestinal (GI) bleeding is a common clinical problem that requires more than 300 000 hospitalizations annually

More information

Complicated issues in GI bleeding for internists? Nonthalee Pausawasdi, M.D. Faculty of Medicine Siriraj Hospital

Complicated issues in GI bleeding for internists? Nonthalee Pausawasdi, M.D. Faculty of Medicine Siriraj Hospital Complicated issues in GI bleeding for internists? Nonthalee Pausawasdi, M.D. Faculty of Medicine Siriraj Hospital Complicated issues in GI bleeding; Survey results from internists Optimal resuscitation

More information

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE SCOPE

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE SCOPE NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE 1 Guideline title SCOPE Gastrointestinal bleeding: the management of acute upper gastrointestinal bleeding 1.1 Short title Acute upper GI bleeding

More information

Perforated peptic ulcer

Perforated peptic ulcer Perforated peptic ulcer - Despite the widespread use of gastric anti-secretory agents and eradication therapy, the incidence of perforated peptic ulcer has changed little, age limits increase NSAIDs elderly

More information

Review. CB Ferguson, RM Mitchell

Review. CB Ferguson, RM Mitchell 32 Ulster Med J 2006; 75 (1) 32-39 The Ulster Medical Journal Review Non-variceal upper gastrointestinal bleeding CB Ferguson, RM Mitchell Accepted 15 November 2005 INTRODUCTION Non-variceal upper gastrointestinal

More information

Juan G Martínez-Cara, Rita Jiménez-Rosales, Margarita Úbeda-Muñoz, Mercedes López de Hierro, Javier de Teresa and Eduardo Redondo-Cerezo.

Juan G Martínez-Cara, Rita Jiménez-Rosales, Margarita Úbeda-Muñoz, Mercedes López de Hierro, Javier de Teresa and Eduardo Redondo-Cerezo. Original Article Comparison of AIMS65, Glasgow Blatchford score, and Rockall score in a European series of patients with upper gastrointestinal bleeding: performance when predicting in-hospital and delayed

More information

The New England Journal of Medicine URGENT COLONOSCOPY FOR THE DIAGNOSIS AND TREATMENT OF SEVERE DIVERTICULAR HEMORRHAGE

The New England Journal of Medicine URGENT COLONOSCOPY FOR THE DIAGNOSIS AND TREATMENT OF SEVERE DIVERTICULAR HEMORRHAGE URGENT COLONOSCOPY FOR THE DIAGNOSIS AND OF SEVERE DIVERTICULAR HEMORRHAGE DENNIS M. JENSEN, M.D., GUSTAVO A. MACHICADO, M.D., ROME JUTABHA, M.D., AND THOMAS O.G. KOVACS, M.D. ABSTRACT Background Although

More information

Clinical guideline Published: 13 June 2012 nice.org.uk/guidance/cg141

Clinical guideline Published: 13 June 2012 nice.org.uk/guidance/cg141 Acute upper gastrointestinal bleeding in over 16s: management Clinical guideline Published: June 2012 nice.org.uk/guidance/cg141 NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-ofrights).

More information

Comparison of Endoscopic Injection Sclerotherapeutic Agents in Nonvariceal Upper GI Bleeding: A Retrospective Study

Comparison of Endoscopic Injection Sclerotherapeutic Agents in Nonvariceal Upper GI Bleeding: A Retrospective Study Article ID: WMC002108 2046-1690 Comparison of Endoscopic Injection Sclerotherapeutic Agents in Nonvariceal Upper GI Bleeding: A Retrospective Study Corresponding Author: Dr. Ibrahim Masoodi, Gastroenterologist,

More information

ICU Volume 14 - Issue 2 - Summer Matrix

ICU Volume 14 - Issue 2 - Summer Matrix ICU Volume 14 - Issue 2 - Summer 2014 - Matrix Upper Gastrointestinal Bleeding Authors David Osman, MD Medical Intensive Care Unit Paris-South University Hospitals Assistance Publique-Hôpitaux de Paris

More information

Evaluation and Management of Gastrointestinal Bleeding Part 2: Lower and Obscure Gastrointestinal Bleeding

Evaluation and Management of Gastrointestinal Bleeding Part 2: Lower and Obscure Gastrointestinal Bleeding Evaluation and Management of Gastrointestinal Bleeding Part 2: Lower and Obscure Gastrointestinal Bleeding Edward Lung, MD, MPH ABSTRACT This article, the second in a 2-part series, provides information

More information

Pharmacoeconomic comparison of treatments for the eradication of Helicobacter pylori Taylor J L, Zagari M, Murphy K, Freston J W

Pharmacoeconomic comparison of treatments for the eradication of Helicobacter pylori Taylor J L, Zagari M, Murphy K, Freston J W Pharmacoeconomic comparison of treatments for the eradication of Helicobacter pylori Taylor J L, Zagari M, Murphy K, Freston J W Record Status This is a critical abstract of an economic evaluation that

More information

When to Scope in Lower GI Bleeding: It Must Be Done Now. Lisa L. Strate, MD, MPH Assistant Professor of Medicine University of Washington, Seattle, WA

When to Scope in Lower GI Bleeding: It Must Be Done Now. Lisa L. Strate, MD, MPH Assistant Professor of Medicine University of Washington, Seattle, WA When to Scope in Lower GI Bleeding: It Must Be Done Now Lisa L. Strate, MD, MPH Assistant Professor of Medicine University of Washington, Seattle, WA Outline Epidemiology Overview of available tests Urgent

More information

Looking at the surface of the gastrointestinal (GI)

Looking at the surface of the gastrointestinal (GI) Imaging and Advanced Technology Nonvariceal Upper Gastrointestinal Hemorrhage: Probing Beneath the Surface RICHARD C.K. WONG Division of Gastroenterology and Liver Disease, Department of Medicine, University

More information

Management for non-variceal upper gastrointestinal bleeding in elderly patients: the experience of a tertiary university hospital

Management for non-variceal upper gastrointestinal bleeding in elderly patients: the experience of a tertiary university hospital Original Article on Endoscopic Therapy Page 1 of 7 Management for non-variceal upper gastrointestinal bleeding in elderly patients: the experience of a tertiary university hospital Koichiro Kawaguchi,

More information

Proton Pump Inhibitors- Questions & Controversies. Farah Kablaoui, PharmD, BCPS, BCCCP

Proton Pump Inhibitors- Questions & Controversies. Farah Kablaoui, PharmD, BCPS, BCCCP Proton Pump Inhibitors- Questions & Controversies Farah Kablaoui, PharmD, BCPS, BCCCP Disclosure Information Proton Pump Inhibitors: Questions & Controversies Farah Kablaoui I have no financial relationship

More information

Review of the endoscopic and medical management of non-variceal Upper Gastro-intestinal Bleeding

Review of the endoscopic and medical management of non-variceal Upper Gastro-intestinal Bleeding Article ID: WMC005455 ISSN 2046-1690 Review of the endoscopic and medical management of non-variceal Upper Gastro-intestinal Bleeding Peer review status: No Corresponding Author: Dr. Mohammad Fawad Khattak,

More information

Pre-endoscopic erythromycin administration in upper gastrointestinal bleeding: an updated meta-analysis and systematic review

Pre-endoscopic erythromycin administration in upper gastrointestinal bleeding: an updated meta-analysis and systematic review ORIGINAL ARTICLE Annals of Gastroenterology (2016) 29, 1-6 Pre-endoscopic erythromycin administration in upper gastrointestinal bleeding: an updated meta-analysis and systematic review Rubayat Rahman a,

More information

Changes in the Clinical Outcomes of Variceal Bleeding in Cirrhotic Patients: A 10-Year Experience in Gangwon Province, South Korea

Changes in the Clinical Outcomes of Variceal Bleeding in Cirrhotic Patients: A 10-Year Experience in Gangwon Province, South Korea Gut and Liver, Vol. 6, No. 4, October 2012, pp. 476481 ORiginal Article Changes in the Clinical Outcomes of Variceal Bleeding in Cirrhotic Patients: A 10Year Experience in Gangwon Province, South Korea

More information

ENDOSCOPIC INJECTION OF DILUTED ADRENALINE FOR TREATMENT OF BLEEDING DUODENAL ULCER IN COMPARISON WITH SURGERY.

ENDOSCOPIC INJECTION OF DILUTED ADRENALINE FOR TREATMENT OF BLEEDING DUODENAL ULCER IN COMPARISON WITH SURGERY. Basrah Journal of Surgery ENDOSCOPIC INJECTION OF DILUTED ADRENALINE FOR TREATMENT OF BLEEDING DUODENAL ULCER IN COMPARISON WITH SURGERY. CABS, FICMS, Lecturer, Dep.of Surgery, University of Basrah, College

More information

Journal of Clinical Gastroenterology and Hepatology ISSN

Journal of Clinical Gastroenterology and Hepatology ISSN Research Article imedpub Journals www.imedpub.com DOI: 10.21767/2575-7733.1000030 Journal of Clinical Gastroenterology and Hepatology Endoscopic Collagen Spray A Novel Method Which can be Used as an Adjunct

More information

Short-Term Healing Process of Artificial Ulcers after Gastric Endoscopic Submucosal Dissection

Short-Term Healing Process of Artificial Ulcers after Gastric Endoscopic Submucosal Dissection Gut and Liver, Vol. 5, No. 3, September 2011, pp. 293-297 ORiginal Article Short-Term Healing Process of Artificial Ulcers after Gastric Endoscopic Submucosal Dissection Osamu Goto*, Mitsuhiro Fujishiro,

More information

Controlled Study of Different Sclerosing Agents for Coagulation of Cahine Gut Arteries

Controlled Study of Different Sclerosing Agents for Coagulation of Cahine Gut Arteries GASTROENTEROLOGY 1989;96:1274-81 Controlled Study of Different Sclerosing Agents for Coagulation of Cahine Gut Arteries GAYLE M. RANDALL, DENNIS M. JENSEN, KENNETH HIRABA Y ASHI, and GUSTAVO A. MACHICADO

More information

Treatment of Helicobacter pylori in Patients With Duodenal Ulcer Hemorrhage A Long-Term Randomized, Controlled Study

Treatment of Helicobacter pylori in Patients With Duodenal Ulcer Hemorrhage A Long-Term Randomized, Controlled Study THE AMERICAN JOURNAL OF GASTROENTEROLOGY Vol. 95, No. 9, 2000 2000 by Am. Coll. of Gastroenterology ISSN 0002-9270/00/$20.00 Published by Elsevier Science Inc. PII S0002-9270(00)01041-8 Treatment of Helicobacter

More information

Gastrointestinal bleeding, the most common cause of hospitalization

Gastrointestinal bleeding, the most common cause of hospitalization The new england journal of medicine Clinical Practice Caren G. Solomon, M.D., M.P.H., Editor Upper Gastrointestinal Bleeding Due to a Peptic Ulcer Loren Laine, M.D. This Journal feature begins with a case

More information

High Dose versus Low Dose Intravenous Pantoprazole in Bleeding Peptic Ulcer: A Randomized Clinical Trial

High Dose versus Low Dose Intravenous Pantoprazole in Bleeding Peptic Ulcer: A Randomized Clinical Trial Original Article 137 High Dose versus Low Dose Intravenous Pantoprazole in Bleeding Peptic Ulcer: A Randomized Clinical Trial Abdol Rahim Masjedizadeh 1,2*, Eskandar Hajiani 1,2, Pezhman Alavinejad 1,2,

More information

The Role of Endoscopy in the Diagnosis and Management of Upper Gastrointestinal Bleeding.

The Role of Endoscopy in the Diagnosis and Management of Upper Gastrointestinal Bleeding. Original Article ISSN (O):2395-2822; ISSN (P):2395-2814 The Role of Endoscopy in the Diagnosis and Management of Upper Gastrointestinal Bleeding. Faroze A. Khan 1, M. H. Raza 2, Vikrant 1 1 Senior Resident,

More information

Hemostatic powder application for control of acute upper gastrointestinal bleeding in patients with gastric malignancy

Hemostatic powder application for control of acute upper gastrointestinal bleeding in patients with gastric malignancy Original article Hemostatic powder application for control of acute upper gastrointestinal bleeding in patients with gastric malignancy Authors Yeong Jin Kim, Jun Chul Park, Eun Hye Kim, Sung Kwan Shin,

More information

EndoClot PHS A medical application on 74 patients march 2013

EndoClot PHS A medical application on 74 patients march 2013 EndoClot PHS A medical application on 74 patients march 2013 EndoClot PHS as a new method to achieve hemostasis of gastrointestinal bleeding Evaluation of a medical application involving 74 patients. Introduction

More information