Importance of risk assessment,endoscopic hemostasis,and recent advancements in the management of acute non-variceal upper gastrointestinal bleeding

Acute non-variceal upper gastrointestinal bleeding(ANVUGIB)is a common medical emergency in clinical practice.While the incidence has significantly reduced,the mortality rates have not undergone a similar reduction in the last few decades,thus presenting a significant challenge.This editorial outlines the key causes and risk factors of ANVUGIB and explores the current standards and recent updates in risk assessment scoring systems for predicting mortality and endoscopic treatments for achieving hemostasis.Since ANUVGIB predominantly affects the elderly population,the impact of comorbidities may be responsible for the poor outcomes.A thorough drug history is important due to the increasing use of antiplatelet agents and anticoagulants in the elderly.Early risk stratification plays a crucial role in deciding the line of management and predicting mortality.Emerging scoring systems such as the ABC(age,blood tests,co-morbidities)score show promise in predicting mortality and guiding clinical decisions.While conventional endoscopic therapies remain cornerstone approaches,novel techniques like hemostatic powders and over-the-scope clips offer promising alternatives,particularly in cases refractory to traditional modalities.By integrating validated scoring systems and leveraging novel therapeutic modalities,clinicians can enhance patient care and mitigate the substantial morbidity and mortality associated with ANVUGIB.

Advancements in endoscopic hemostasis for non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal(GI)bleeding is a significant cause of morbidity and mortality.Traditionally,through-the-scope(TTS)clips,thermal therapy,and injection therapies are used to treat GI bleeding.In this review,we provide an overview of novel endoscopic treatments that can be used to achieve hemostasis.Specifically,we discuss the efficacy and applicability of over-thescope clips,hemostatic agents,TTS doppler ultrasound,and endoscopic ultrasound,each of which offer an effective method of reducing rates of GI rebleeding.

Clinical characteristics of acute non-varicose upper gastrointestinal bleeding and the effect of endoscopic hemostasis

BACKGROUND Acute non-variceal upper gastrointestinal bleeding(ANVUGIB)constitutes a prevalent emergency within Gastroenterology,encompassing 80%-90%of all gastrointestinal hemorrhage incidents.This condition is distinguished by its abrupt onset,swift progression,and notably elevated mortality rate.AIM To gather clinical data from patients with ANVUGIB at our hospital in order to elucidate the clinical characteristics specific to our institution and analyze the therapeutic effectiveness of endoscopic hemostasis.METHODS We retrospectively retrieved the records of 532 patients diagnosed with ANVUGIB by endoscopy at our hospital between March 2021 and March 2023,utilizing our medical record system.Data pertaining to general patient information,etiological factors,disease outcomes,and other relevant variables were meticulously collected and analyzed.RESULTS Among the 532 patients diagnosed with ANVUGIB,the male-to-female ratio was 2.91:1,with a higher prevalence among males.Notably,43.6%of patients presented with black stool as their primary complaint,while 27.4%had hematemesis as their initial symptom.Upon admission,17%of patients exhibited both hematemesis and black stool,while most ANVUGIB patients primarily complained of overt gastrointestinal bleeding.Urgent routine blood examinations at admission revealed that 75.8%of patients had anemia,with 63.4%experiencing moderate to severe anemia,and 1.5%having extremely severe anemia(hemoglobin<30 g/L).With regard to etiology,53.2%of patients experienced bleeding without a definitive trigger,24.2%had a history of using gastric mucosa-irritating medications,24.2%developed bleeding after alcohol consumption,2.8%attributed it to improper diet,1.7%to emotional excitement,and 2.3%to fatigue preceding the bleeding episode.Drug-induced ANVUGIB was more prevalent in the elderly than middle-aged and young individuals,while bleeding due to alcohol consumption showed the opposite trend.Additionally,diet-related bleeding was more common among the young age group compared to the middle-aged group.Gastrointestinal endoscopy identified peptic ulcers as the most frequent cause of ANVUGIB(73.3%),followed by gastrointestinal malignancies(10.9%),acute gastric mucous lesions(9.8%),and androgenic upper gastrointestinal bleeding(1.5%)among inpatients with ANVUGIB.Of the 532 patients with gastrointestinal bleeding,68 underwent endoscopic hemostasis,resulting in an endoscopic treatment rate of 12.8%,with a high immediate hemostasis success rate of 94.1%.

Endoscopic hemostasis using self-expandable metal stent combinedwith PuraStat® for patient with high risk of post-endoscopicsphincterotomy bleeding (with video)

To the Editor:Endoscopic sphincterotomy(EST)is an established technique for removal of bile duct stones and self-expandable metal stent(SEMS)deployment.However,bleeding can be considered an adverse event after EST,particularly for patients with high risk of bleeding such as those on hemodialysis.Among the various techniques reported for obtaining endoscopic hemostasis[1-3].

Adverse events associated with the gold probe and the injection gold probe devices used for endoscopic hemostasis:A MAUDE database analysis

BACKGROUND Gastrointestinal(GI)bleeding accounts for over half a million admissions annually and is the most common GI diagnosis requiring hospitalization in the United States.Bipolar electrocoagulation devices are used for the management of gastrointestinal bleeding.There is no data on device-related adverse events for gold probe(GP)and injection gold probe(IGP).AIM To analyze this using the Food and Drug Administration(FDA’s)Manufacturer and User Facility Device Experience(MAUDE)database from 2013 to 2023.METHODS We examined post-marketing surveillance data on GP and IGP from the FDA MAUDE database to report devicerelated and patient-related adverse events between 2013-2023.The MAUDE database is a publicly available resource providing over 4 million records relating to medical device safety.Statistical analyses were performed using IBM SPSS Statistics V.27.0(IBM Corp.,Armonk,NY,United States).RESULTS Our search elicited 140 reports for GP and 202 reports for IGP,respec-tively,during the study period from January 2013 to August 2023.Malfunctions reportedly occurred in 130 cases for GP,and actual patient injury or event occurred in 10 patients.A total of 149 patients(74%)reported with Injection GP events suffered no significant consequences due to the device failure,but 53 patients(26%)were affected by an event.CONCLUSION GP and IGP are critical in managing gastrointestinal bleeding.This study of the FDA MAUDE database revealed the type,number,and trends of reported device-related adverse events.The endoscopist and support staff must be aware of these device-related events and be equipped to manage them if they occur.

Upper non-variceal gastrointestinal bleeding-review the effectiveness of endoscopic hemostasis methods

Upper non-variceal gastrointestinal bleeding is a conditionthat requires immediate medical intervention and has a high associated mortality rate(exceeding 10%). The vast majority of upper gastrointestinal bleeding cases are due to peptic ulcers. Helicobacter pylori infection, non-steroidal anti-inflammatory drugs and aspirin are the main risk factors for peptic ulcer disease. Endoscopic therapy has generally been recommended as the firstline treatment for upper gastrointestinal bleeding as it has been shown to reduce recurrent bleeding, the need for surgery and mortality. Early endoscopy(within 24 h of hospital admission) has a greater impact than delayed endoscopy on the length of hospital stay and requirement for blood transfusion. This paper aims to review and compare the efficacy of the types of endoscopic hemostasis most commonly used to control non-variceal gastrointestinal bleeding by pooling data from the literature.

Predictors of re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy bleeding

AIM: To predict the re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy(ES) bleeding.METHODS: Over a 15-year period, data from 161 patients with delayed post-ES bleeding were retrospectively collected from a single medical center. To identify risk factors for re-bleeding after initial successful endoscopic hemostasis, parameters before, during and after the procedure of endoscopic retrograde cholangiopancreatography were analyzed. These included age, gender, blood biochemistry, comorbidities, endoscopic diagnosis, presence of periampullary diverticulum, occurrence of immediate postES bleeding, use of needle knife precut sphincterotomy, severity of delayed bleeding, endoscopic features on delayed bleeding, and type of endoscopic therapy.RESULTS: A total of 35 patients(21.7%) had rebleeding after initial successful endoscopic hemostasis for delayed post-ES bleeding. Univariate analysis revealed that malignant biliary stricture, serum bilirubin level of greater than 10 mg/d L, initial bleeding severity, and bleeding diathesis were significant predictors of rebleeding. By multivariate analysis, serum bilirubin level of greater than 10 mg/d L and initial bleeding severity remained significant predictors. Re-bleeding was controlled by endoscopic therapy in a single(n = 23) or multiple(range, 2-7; n = 6) sessions in 29 of the 35 patients(82.9%). Four patients required transarterial embolization and one went for surgery. These five patients had severe bleeding when delayed post-ES bleeding occurred. One patient with decompensated liver cirrhosis died from re-bleeding.CONCLUSION: Re-bleeding occurs in approximately one-fifth of patients after initial successful endoscopic hemostasis for delayed post-ES bleeding. Severity of initial bleeding and serum bilirubin level of greater than 10 mg/d L are predictors of re-bleeding.

Endoscopic hemostasis techniques for upper gastrointestinal hemorrhage: A review

Upper gastrointestinal hemorrhage (UGIH) is an urgent disease that is often encountered in daily medical practice. Endoscopic hemostasis is currently indispensable for the treatment of UGIH. Initially, when UGIH is suspected, a cause of UGIH is presumed from the medical interview and physical findings. After ample primary treatment, urgent endoscopy is performed. Many methods of endoscopic hemostasis are in wide use, including hemoclip, injection and thermo-coagulation methods. Although UGIH develops from a wide variety of diseases, such as esophageal varices and gastric and duodenal ulcer, hemostasis is almost always possible. Identification of the causative diseases, primary treatment and characteristic features of endoscopic hemostasis are needed to allow appropriate treatment.

Accurate hemostasis with a new endoscopic overtube for emergency endoscopy

Endoscopic hemostasis performed in the emergency room is difficult due to the presence of blood clots and food residue that makes obtaining a clear view of the bleeding vessel difficult. We experienced the efficacy of a newly developed inverted overtube to shorten the hemostatic time and obtain a clear endoscopic view with upper gastrointestinal bleeding patient who were transferred by ambulance car and required emergency endoscopy. The technique improved the endoscopic views and enabled us to perform the hemostatic procedures from the conventional standing position while freely and easily changing the patient's position. The presence of blood clots and food residue in the gastric fornix or upper gastric body makes identifying a bleeding exposed vessel impossible. This set-up significantly shortened the procedure time. The inverted overtube helped us obtain a clear view in patients who were laid in the right lateral position. Rapid identification of ex-posed vessels resulted in success of hemostasis.

Endoscopic hemostasis state of the art-Nonvaricealbleeding

New endoscopic techniques for hemostasis in nonvariceal bleeding were introduced and known methods further improved. Hemospray and Endoclot are two new compounds for topical treatment of bleeding. Initial studies in this area have shown a good hemostatic effect, especially in active large scale oozing bleeding, e.g., tumor bleedings. For further evaluation larger prospective studies comparing the substanced with other methods of endoscopic hemostasis are needed. For localized active arterial bleeding primary injection therapy in the area of bleeding as well as in the four adjacent quadrants offers a good method to reduce bleeding activity. The injection is technically easy to learn and practicable. After bleeding activity is reduced the bleeding source can be localized more clearly for clip application. Today many different through-thescope(TTS) clips are available. The ability to close and reopen a clip can aid towards good positioning at the bleeding site. Even more important is the rotatability of a clip before application. Often multiple TTS clips are required for secure closure of a bleeding vessel. One model has the ability to use three clips in series without changing the applicator. Severe arterial bleeding from vessels larger than 2 mm is often unmanageable with these conventional methods. Here is the over-the-scopeclip system another newly available method. It is similar to the ligation of esophageal varices and involves aspiration of tissue into a transparent cap before closure of the clip. Thus a greater vascular occlusion pressure can be achieved and larger vessels can be treated endoscopically. Patients with severe arterial bleeding from the upper gastrointestinal tract have a very high rate of recurrence after initial endoscopic treatment. These patients should always be managed in an interdisciplinary team of interventional radiologist and surgeons.

Endoscopic hemostasis for hemorrhage from an ileal diverticulum

Hemorrhage from a non-Meckelian jejunoileal diverticulum is rare, and it is generally difficult to diagnose the source of the bleeding. Here, we report the case of a 59- year-old male with hemorrhage from an ileal diverticulum. Contrast computed tomography scans demonstrated the ileal diverticulum and extravasation of the contrast medium around it. The diagnosis was then made by computed tomography scans, and endoscopic mechanical hemostasis was performed under colonoscopy with three metal clips. The management of hemorrhage from jejunoileal diverticula is discussed.

Successful endoscopic hemostasis for gastric arterial bleeding due to invasion of malignant lymphoma

A 75-year-old male with malignant lymphoma (ML) accompanied with gastric lesion was treated with combination chemotherapy. The patient produced tarry stool on the 4th d, and emergency gastroscopy showed arterial bleeding from the lesion. Hemostasis was achieved by injecting pure ethanol and using hemostatic clips. There is only one previous report on endoscopic hemostasis being effective for bleeding due to lymphoma. Since gastric bleeding causes significant mortality, endoscopic hemostasis should be considered as first-line treatment for ML patients who were treated with chemotherapy.

Endoscopic Hemostasis of Nonvariceal Gastrointestinal Bleeding

We investigated 2668 patients with non-variceal upper gastrointestinal bleeding and 660 patients with lower gastrointestinal bleeding treated between 1987 and 2011 in our hospital. Upper gastrointestinal bleeding was associated with gastric ulcer, duodenal ulcer, Mallory-Weiss syndrome, esophageal disease, and others. Endoscopic hemostasis was performed in approximately 67% of all cases with upper gastrointestinal bleeding and approximately 90% of cases with ulcer. The hemostasis success rate was over 90% for ulcer bleeding, and was also generally high for other diseases. The total number of patients with lower gastrointestinal bleeding was lower, with it being approximately 20% of those with upper gastrointestinal bleeding. Endoscopic hemostasis was performed in approximately 30% of the patients with lower gastrointestinal bleeding. The hemostasis success rate was generally high, but treatment switch to surgery or interventional radiology (IVR) was observed in some cases with colorectal diverticular bleeding.

Second-look endoscopy with prophylactic hemostasis is still effective after endoscopic submucosal dissection for gastric neoplasm

AIM: The clinical value of second-look endoscopy(SLE) after endoscopic submucosal dissection(ESD) has been doubted continuously. The aim of this study was to assess the effectiveness of SLE based on the risk of delayed bleeding after ESD. METHODS: A total of 310 lesions of gastric epithelial neoplasms treated by ESD were reviewed. The lesions were divided into two groups based on the risk of postprocedural bleeding estimated by Forrest classification. The high risk of rebleeding group(Forrest?Ⅰa,?Ⅰb and Ⅱa) required endoscopic treatment, while the low risk of rebleeding group(Forrest Ⅱb, Ⅱc and Ⅲ) did not. Delayed bleeding after ESD was investigated. RESULTS: Sixty-six lesions were included in the high risk of rebleeding group and 244 lesions in the low risk of rebleeding group. There were no significant differences in delayed bleeding between the high risk group(1/66) and the low risk group(1/244)(P = 0.38). The high risk of rebleeding group tended to be located more often in the mid-third and had higher appearance of flat or depressed shape than the low risk group(P = 0.004 and P = 0.006, respectively). CONCLUSION: SLE with pre-emptive prophylactic endoscopic treatment is still effective in preventing delayed bleeding after ESD.

Propensity score matching analysis for clinical impact of braided-type versus laser-cut-type covered self-expandable metal stents for endoscopic ultrasound-guided hepaticogastrostomy

Background:To prevent stent migration during endoscopic ultrasound-guided hepaticogastrostomy(EUS-HGS),intra-scope channel release technique is important,but is unfamiliar to non-expert hands.The self-expandable metal stent(SEMS)is an additional factor to prevent stent migration.However,no compara-tive studies of laser-cut-type and braided-type during EUS-HGS have been reported.The aim of this study was to compare the distance between the intrahepatic bile duct and stomach wall after EUS-HGS among laser-cut-type and braided-type SEMS.Methods:To evaluate stent anchoring function,we measured the distance between the hepatic parenchyma and stomach wall before EUS-HGS,one day after EUS-HGS,and 7 days after EUS-HGS.Also,propensity score matching was performed to create a propensity score for using laser-cut-type group and braided-type group.Results:A total of 142 patients were enrolled in this study.Among them,24 patients underwent EUS-HGS using a laser-cut-type SEMS,and 118 patients underwent EUS-HGS using a braided-type SEMS.EUS-HGS using the laser-cut-type SEMS was mainly performed by non-expert endoscopists(n=21);EUS-HGS using braided-type SEMS was mainly performed by expert endoscopists(n=98).The distance after 1 day was significantly shorter in the laser-cut-type group than that in the braided-type group[2.00(1.70-3.75)vs.6.90(3.72-11.70)mm,P<0.001].In addition,this distance remained significantly shorter in the laser-cut-type group after 7 days.Although these results were similar after propensity score matching analysis,the distance between hepatic parenchyma and stomach after 7 days was increased by 4 mm compared with the distance after 1 day in the braided-type group.On the other hand,in the laser-cut-type group,the distance after 1 day and 7 days was almost the same.Conclusions:EUS-HGS using a laser-cut-type SEMS may be safe to prevent stent migration,even in non-expert hands.

Endoscopic band ligation or endoscopic tissue adhesive injection in the treatment of gastric varices:Which is better?

The combination of endoscopic ultrasound with endoscopic treatment of type 1 gastric variceal hemorrhage may improve the robustness and generalizability of the findings in future studies.Moreover,the esophageal varices should also be included in the evaluation of treatment efficacy in subsequent studies to reach a more convincing conclusion.

Advances in endoscopic diagnosis and management of colorectal cancer

Colorectal cancer(CRC)is a leading global health concern,and early identification and precise prognosis play a vital role in enhancing patient results.Endoscopy is a minimally invasive imaging technique that is crucial for the screening,diagnosis,and treatment of CRC.This editorial discusses the importance of advances in endoscopic techniques,the integration of artificial intelligence,and the potential of novel technologies in enhancing the diagnosis and management of CRC.

Effect of endoscopic sphincterotomy and endoscopic papillary balloon dilation endoscopic retrograde cholangiopancreatographies on the sphincter of Oddi

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP),with its clinical ad-vantages of less trauma and faster recovery,has become the primary treatment for choledocholithiasis.AIM To investigate the effects of different ERCP procedures on the sphincter of Oddi.METHODS The clinical data of 91 patients who underwent ERCP at Yixing Hospital of Traditional Chinese Medicine between February 2018 and February 2021 were analyzed retrospectively.The patients were divided into endoscopic sphinc-terotomy(EST,n=24)and endoscopic papillary balloon dilation(EPBD,n=67)groups.The duration of operation,pancreatic development,pancreatic sphinc-terotomy,intubation difficulties,stone recurrence,and incidence of reflux cho-langitis and cholecystitis were statistically analyzed in patients with a history of choledocholithiasis,pancreatitis,and Oddi sphincter dysfunction in the EST and EPBD groups.RESULTS Differences in hypertension,diabetes,increased bilirubin,small diameter of the common bile duct,or ampullary diverticulum between the two groups were not significant.Statistically significant differences were observed between the two groups concerning sex and age(<60 years).Patients with a history of choledocholithiasis,pancreatitis,and Oddi sphincter dysfunction were higher in the EST group than in the EPBD group.The number of cases of pancreatic development,pancreatic duct sphincterotomy,and difficult intubation were higher in the EST group than in the EPBD group.The number of Oddi’s sphincter manometries,ERCP surgical outcomes,and guidewires entering the pancreatic duct several times in EST group were lower than those in the EPBD group.The numbers of stone recurrences,reflux cholangitis,and cholecystitis were higher in the EST group than in the EPBD group.CONCLUSION In summary,common bile duct stones,pancreatitis history,and multiple guided wire introductions into the pancreatic duct are independent risk factors for EST and EPBD.Based on this evidence,this study can provide actionable insights for clinicians and researchers.

Early endoscopic management of an infected acute necrotic collection misdiagnosed as a pancreatic pseudocyst: A case report

BACKGROUND Infected acute necrotic collection(ANC)is a fatal complication of acute pancre-atitis with substantial morbidity and mortality.Drainage plays an exceedingly important role as the first step in invasive intervention for infected necrosis;however,there is great controversy about the optimal drainage time,and better treatment should be explored.CASE SUMMARY We report the case of a 43-year-old man who was admitted to the hospital with severe intake reduction due to early satiety 2 wk after treatment for acute pancre-atitis;conservative treatment was ineffective,and a pancreatic pseudocyst was suspected on contrast-enhanced computed tomography(CT).Endoscopic ultra-sonography(EUS)suggested hyperechoic necrotic tissue within the cyst cavity.The wall was not completely mature,and the culture of the puncture fluid was positive for A-haemolytic Streptococcus.Thus,the final diagnosis of ANC in-fection was made.The necrotic collection was not walled off and contained many solid components;therefore,the patient underwent EUS-guided aspiration and lavage.Two weeks after the collection was completely encapsulated,pancreatic duct stent drainage via endoscopic retrograde cholangiopancreatography(ERCP)was performed,and the patient was subsequently successfully discharged.On repeat CT,the pancreatic cysts had almost disappeared during the 6-month fo-llow-up period after surgery.CONCLUSION Early EUS-guided aspiration and lavage combined with late ERCP catheter drainage may be effective methods for intervention in infected ANCs.

Practical approach to linear endoscopic ultrasound examination of the gallbladder

The gallbladder(GB)is a susceptible organ,prone to various pathologies that can be identified using different imaging techniques.Transabdominal ultrasound(TUS)is typically the initial diagnostic method due to its numerous well-established advantages.However,in cases of uncertainty or when a definitive diagnosis cannot be established,computed tomography(CT)or magnetic resonance imaging may be employed to provide more detailed information.Nevertheless,CT scans may sometimes offer inadequate spatial resolution,which can limit the differentiation of GB lesions,particularly when smaller yet clinically relevant abnormalities are involved.Conversely,endoscopic ultrasound(EUS)provides higher frequency compared to TUS,superior spatial resolution,and the option for contrast-enhanced harmonic imaging,enabling a more comprehensive examination.Thus,EUS can serve as a supplementary tool when conventional imaging methods are insufficient.This review will describe the standard EUS examination of the GB,focusing on its endosonographic characteristics in various GB path-ologies.