Endoscopic treatment of bleeding gastric ulcer causing gastric wall necrosis:A case report

BACKGROUND Gastric wall necrosis is a rare complication of endoscopic treatment for bleeding gastric ulcer,which may exacerbate the patient’s condition once it occurs and may even require surgical intervention for treatment.CASE SUMMARY A 59-year-old man was admitted to our department with melena.Endoscopy revealed a giant ulcer in the gastric antrum with a visible vessel in its center,which was treated with sclerosants and tissue glue injection and resulted in necrosis of the gastric wall.CONCLUSION Injection of sclerosants and tissue glue may lead to gastric wall necrosis,which is a serious complication.Therefore,before administering this treatment to patients,we should consider other more effective methods of hemostasis to avoid gastric wall necrosis.

Optimal injection volume of epinephrine for endoscopic treatment of peptic ulcer bleedinq

AIM： To define the optimal injection volume of epinephrine with high efficacy for hemostasis and low complication rate in patients with actively bleeding ulcers. METHODS： This prospective, randomized, comparative trial was conducted in a medical center. A total of 228 patients with actively bleeding ulcers （spurting or oozing） were randomly assigned to three groups with 20, 30 and 40 mL endoscopic injections of an 1：10000 solution of epinephrine. The hemostatic effects and clinical outcomes were compared between the three groups. RESULTS： There were no significant differences in all background variables between the three groups. Initial hemostasis was achieved in 97.4%, 98.7% and 100% of patients respectively in the 20, 30 and 40 mL epinephrine groups. There were no significant differences in the rate of initial hemostasis between the three groups. The rate of peptic ulcer perforation was significantly higher in the 40 mL epinephrine group than in the 20 and 30 mL epinephrine groups （P 〈 0.05）. The rate of recurrent bleeding was significantly higher in the 20 mL epinephrine group （20.3%） than in the 30 （5.3%） and 40 mL （2.8 %） epinephrine groups （P 〈 0.01）. There were no significant differences in the rates of surgical intervention, the amount of transfusion requirements, the days of hospitalization, the deaths from bleeding and 30 d mortality between the three groups. The number of patients who developed epigastric pain due to endoscopic injection, was significantly higher in the 40 mL epinephrine group （51/76） than in the 20 （2/76） and 30 mL （5/76） epinephrine groups （P 〈 0.001）. Significant elevation of systolic blood pressure after endoscopic injection was observed in the 40 mL epinephrine group （P 〈 0.01）. Significant decreasing and normalization of pulse rates after endoscopic injections were observed in the 20 mL and 30 mL epinephrine groups （P 〈 0.01）.CONCLUSION： Injection of 30 mL diluted epinephrine （1：10000） can effectively prevent recurrent bleeding with a low rate of complications. The optimal injection volume of epinephrine for endoscopic treatment of an actively bleeding ulcer （spurting or oozing） is 30 mL.

Long-term prognosis in patients continuing taking antithrombotics after peptic ulcer bleeding

AIM To investigate the long-term prognosis in peptic ulcer patients continuing taking antithrombotics after ulcer bleeding, and to determine the risk factors that influence the prognosis. METHODS All clinical data of peptic ulcer patients treated from January 1, 2009 to January 1, 2014 were retrospectively collected and analyzed. Patients were divided into either a continuing group to continue taking antithrombotic drugs after ulcer bleeding or a discontinuing group to discontinue antithrombotic drugs. The primary outcome of follow-up in peptic ulcer bleeding patients was recurrent bleeding, and secondary outcome was death or acute cardiovascular disease occurrence. The final date of follow-up was December 31, 2014. Basic demographic data, complications, and disease classifications were analyzed and compared by t- or χ2-test. The number of patients that achieved various outcomes was counted and analyzed statistically. A survival curve was drawn using the Kaplan-Meier method, and the differencewas compared using the log-rank test. COX regression multivariate analysis was applied to analyze risk factors for the prognosis of peptic ulcer patients. RESULTS A total of 167 patients were enrolled into this study. As for the baseline information, differences in age, smoking, alcohol abuse, and acute cardiovascular diseases were statistically significant between the continuing and discontinuing groups(70.8 ± 11.4 vs 62.4 ± 12.0, P < 0.001; 8(8.2%) vs 15(21.7%), P < 0.05; 65(66.3%) vs 13(18.8%), P < 0.001). At the end of the study, 18 patients had recurrent bleeding and three patients died or had acute cardiovascular disease in the continuing group, while four patients had recurrent bleeding and 15 patients died or had acute cardiovascular disease in the discontinuing group. The differences in these results were statistically significant(P = 0.022, P = 0.000). The Kaplan-Meier survival curve indicated that the incidence of recurrent bleeding was higher in patients in the continuing group, and the risk of death and developing acute cardiovascular disease was higher in patients in the discontinuing group(log-rank test, P = 0.000 for both). Furthermore, COX regression multivariate analysis revealed that the hazard ratio(HR) for recurrent bleeding was 2.986(95%CI: 067-8.356, P = 0.015) in the continuing group, while HR for death or acute cardiovascular disease was 5.216(95%CI: 1.035-26.278, P = 0.028).CONCLUSION After the occurrence of peptic ulcer bleeding, continuing antithrombotics increases the risk of recurrent bleeding events, while discontinuing antithrombotics would increase the risk of death and developing cardiovascular disease. This suggests that clinicians should comprehensively consider the use of antithrombotics after peptic ulcer bleeding.

Epinephrine injection therapy versus a combination of epinepnrine injection and endoscopic hemoclip in the treatment of bleeding ulcers

AIM: To assess the efficacy of hemoclip application in combination with epinephrine injection in the treatment of bleeding peptic ulcers and to compare the clinical outcomes between patients treated with such a combination therapy and those treated with epinephrine injection alone.METHODS: A total of 293 patients (211 males, 82females) underwent endoscopic therapy for bleeding peptic ulcers. Of these, 202 patients (152 males, 50females) received epinephrine injection therapy while 91patients (59 males, 32 females) received combination therapy. The choice of endoscopic therapy was made by the endoscopist. Hemostatic rates, rebleeding rates, need for emergency surgery and 30-d mortality were the outcome measures studied.RESULTS: Patients who received combination therapy were significantly older (mean age 66±16 years, range24-90 years) and more suffered from chronic renal failure compared to those who received epinephrine injection therapy alone (mean age 61±17 years, range 21-89 years).Failure to achieve permanent hemostasis was 4% in the group who received epinephrine injection alone and 11%in the group who received combination therapy. When the differences in age and renal function between the two treatment groups were taken into account by multivariate analysis, the rates of initial hemostasis,rebleeding rates, need for surgery and 30-d mortality for both treatment options were not significantly different.CONCLUSION: Combination therapy of epinephrine injection with endoscopic hemoclip application is an effective method of achieving hemostasis in bleeding peptic ulcer diseases. However, superiority of combination therapy over epinephrine injection alone, could not be demonstrated.

Scoring systems for peptic ulcer bleeding: which one to use?

AIM To compare the Glasgow-Blatchford score(GBS), Rockall score(RS) and Baylor bleeding score(BBS) in predicting clinical outcomes and need for interventions in patients with bleeding peptic ulcers. METHODS Between January 2008 and December 2013, 1012consecutive patients admitted with peptic ulcer bleeding(PUB) were prospectively followed. The pre-endoscopic RS, BBS and GBS, as well as the post-endoscopic diagnostic scores(RS and BBS) were calculated for all patients according to their urgent upper endoscopy findings. Area under the receiver-operating characteristics(AUROC) curves were calculated for the prediction of lethal outcome, rebleeding, needs for blood transfusion and/or surgical intervention, and the optimal cutoff values were evaluated.RESULTS PUB accounted for 41.9% of all upper gastrointestinal tract bleeding, 5.2% patients died and 5.4% patients underwent surgery. By comparing the AUROC curves of the aforementioned pre-endoscopic scores, the RS best predicted lethal outcome(AUROC 0.82 vs 0.67 vs0.63, respectively), but the GBS best predicted need for hospital-based intervention or 30-d mortality(AUROC0.84 vs 0.57 vs 0.64), rebleeding(AUROC 0.75 vs 0.61 vs 0.53), need for blood transfusion(AUROC 0.83 vs0.63 vs 0.58) and surgical intervention(0.82 vs 0.63 vs 0.52) The post-endoscopic RS was also better than the post-endoscopic BBS in predicting lethal outcome(AUROC 0.82 vs 0.69, respectively).CONCLUSION The RS is the best predictor of mortality and the GBS is the best predictor of rebleeding, need for blood transfusion and/or surgical intervention in patients with PUB. There is no one 'perfect score' and we suggest that these two tests be used concomitantly.

Mucosal polymerase chain reaction for diagnosing Helicobacter pylori infection in patients with bleeding peptic ulcers

AIM: Helicobacter pylori (H pylon) has been linked to chronic gastritis, peptic ulcers, gastric cancer and MALT-lymphoma. Conventional invasive tests are less sensitive than non-invasive tests in diagnosing H pylori infection in patients with bleeding peptic ulcers. Polymerase chain reaction is a sensitive and accurate method for diagnosing H pylori infection. The aim of this study was to evaluate the diagnostic role of mucosai polymerase chain reaction for H pylori infection in patients with bleeding peptic ulcers. METHODS: In patients with bleeding, non-bleeding peptic ulcers and chronic gastritis, we checked rapid urease test, histology, bacterial culture and mucosai polymerase chain reaction fordetecting H pylori infection. Positive H pylori infection was defined as positive culture or both a positive histology and a positive rapid urease test. For mucosai polymerase chain reaction of H pylori, we checked vacA (s1a, s1b, s1c, s2, m1, m1T, m2), iceA1, iceA2. and cag A. RESULTS: Between October 2000 and April 2002,88 patients with bleeding peptic ulcers (males/females: 60/28, gastric ulcers/duodenal ulcers: 55/33), 81 patients with non-bleeding peptic ulcers (males/females: 54/27, gastric ulcers/duodenal ulcers: 45/36) and 37 patients with chronic gastritis (males/ females: 24/13) were enrolled in this study. In patients with bleeding peptic ulcers, non-bleeding peptic ulcers and chronic gastritis, 45 patients (51%), 71 patients (88%) and 20 patients (54%) respectively were found to have positive H pylori infection (P<0.001). In patients with bleeding peptic ulcers, non-bleeding peptic ulcers and chronic gastritis, polymerase chain reaction for H pylori infection was positive in 54 patients (61%), 70 patients (86%) and 20 patients (54%) respectively (P<0.001). The sensitivity, positive predictive value and diagnostic accuracy of mucosai polymerase reaction for H pylori infection were significantly lower in patients with bleeding peptic ulcers (84%, 79% and 81%) than in patients with non-bleeding peptic ulcers (99%, 99% and 98%) (P<0.001, P<0.01 and P<0.001 respectively). The sensitivity, negative predictive value and diagnostic accuracy of mucosal polymerase reaction for H py/ori were significantly lower in patients with bleeding peptic ulcers (84%, 83% and 81%) than in patients with chronic gastritis (100%, 100% and 100%) (P= 0.02, P= 0.02 and P=0.001). CONCLUSION: Mucosal polymerase chain reaction for detecting H pylori infection is not reliable in patients with bleeding peptic ulcers.

Polymerase chain reaction: A sensitive method for detecting Helicobacter pyloriinfection in bleeding peptic ulcers

AIM: To assess the sensitivity and specificity of polymerase chain reaction (PCR) in detecting Helicobacter pylori(H pylon) infection in patients with bleeding peptic ulcers, and to compare its diagnostic efficacy with other invasive and non-invasive tests. METHODS: From April to September 2002, H pylori status in 60 patients who consecutively presented with gastroduodenal ulcer bleeding was examined by rapid urease tests (RUT), histology, culture, PCR, serology and urea breath tests (UBT). RESULTS: The sensitivity of PCR was significantly higher than that of RUT, histology and culture (91% vs 66%, 43% and 37%, respectively; P = 0.01, <0.001, <0.001, respectively), but similar to that of serology (94%) and UBT (94%). Additionally, PCR exhibited a greater specificity than serology (100% vs 65%, P<0.01). However, the specificity of PCR did not differ from that of other tests. Further analysis revealed significant differences in the sensitivities of RUT, culture, histology and PCR between the patients with and those without blood in the stomach (P<0.01, P= 0.09, P<0.05, and P<0.05, respectively). CONCLUSION: PCR is the most accurate method among the biopsy-based tests to detect H pylori infection in patients with bleeding peptic ulcers. Blood may reduce the sensitivities of all biopsy-based tests.

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

AIM:To compare the recurrent bleeding after endoscopic injection of different epinephrine volumes with hemoclips in patients with bleeding peptic ulcer.METHODS:Between January 2005 and December 2009,150 patients with gastric or duodenal bleeding ulcer with major stigmata of hemorrhage and nonbleeding visible vessel in an ulcer bed(Forrest Ⅱa) were included in the study.Patients were randomized to receive a small-volume epinephrine group(15 to 25 mL injection group;Group 1,n = 50),a large-volume epinephrine group(30 to 40 mL injection group;Group 2,n = 50) and a hemoclip group(Group 3,n = 50).The rate of recurrent bleeding,as the primary outcome,was compared between the groups of patients included in the study.Secondary outcomes compared between the groups were primary hemostasis rate,permanent hemostasis,need for emergency surgery,30 d mortality,bleeding-related deaths,length of hospital stay and transfusion requirements.RESULTS:Initial hemostasis was obtained in all patients.The rate of early recurrent bleeding was 30%(15/50) in the small-volume epinephrine group(Group 1) and 16%(8/50) in the large-volume epinephrine group(Group 2)(P = 0.09).The rate of recurrent bleeding was 4%(2/50) in the hemoclip group(Group 3);the difference was statistically significant with regard to patients treated with either small-volume or large-volume epinephrine solution(P = 0.0005 and P = 0.045,respectively).Duration of hospital stay was significantly shorter among patients treated with hemoclips than among patients treated with epinephrine whereas there were no differences in transfusion requirement or even 30 d mortality between the groups.CONCLUSION:Endoclip is superior to both small and large volume injection of epinephrine in the prevention of recurrent bleeding in patients with peptic ulcer.

Management of Peptic Ulcer Bleeding Refractory to Endoscopic Treatment

Background: Before the advent of transcatheter arterial embolization (TAE), emergency surgery was the only choice for patients with peptic ulcer bleeding refractory to endoscopic therapy. This study compared the effectiveness of TAE and surgery in patients with peptic ulcer bleeding refractory to endoscopic hemostasis. Materials and Methods: This was a retrospective analysis of 116 patients with peptic ulcer bleeding refractory to endoscopic treatment at our institution. Eighty-three cases were treated with surgery, and 33 cases were managed with TAE. Clinical outcomes were evaluated. Results: There were no differences between groups with respect to the mortality rate (p > 0.05), length of hospital stay, or medical diseases related to mortality. The TAE group exhibited a significantly higher rebleeding rate (p < 0.05). Rebleeding predominantly occurred in patients with type Ia peptic ulcers (Forrest classification) irrespective of the treatment approach. The rebleeding rates in such patents were 30.2% and 56.3% in the surgery and TAE groups, respectively. Patients with rebleeding after further therapy showed high mortality rates (68.6%). The rebleeding rate was not significantly different between the subgroups of patients with type Ia lesions, although there was a higher mortality rate in the TAE group (27.9% vs. 75%, p = 0.001). Conclusions: TAE may be the first-choice therapy for patients with peptic ulcer bleeding refractory to endoscopic treatment, whereas emergency surgery may be used as an alternative in patients with type Ia bleeding at institutions with no 24-hour radiology service or when no experienced radiologist is available.

Factors associated with complicated erosive esophagitis: A Japanese multicenter, prospective, cross-sectional study

AIMTo assess the clinical characteristics of patients with complicated erosive esophagitis (EE) and their associated factors.METHODSThis prospective, cross-sectional study included patients diagnosed with EE by upper gastrointestinal endoscopy between October 2014 and March 2015 at 106 Japanese hospitals. Data on medical history, general condition, gastrointestinal symptoms, lifestyle habits, comorbidities, and endoscopic findings were collected using a standard form to create a dedicated database. Logistic regression analysis was used to calculate adjusted odds ratios (aOR) and 95%CI for the association with complicated EE.RESULTSDuring the study period, 1749 patients diagnosed with EE, 38.3% of whom were prescribed proton pump inhibitors (PPIs) were included. Of them, 143 (8.2%) had EE complications. Esophageal bleeding occurred in 84 (4.8%) patients, esophageal strictures in 45 (2.6%) patients, and 14 (0.8%) patients experienced both. Multivariate analysis showed that increased age (aOR: 1.05; 95%CI: 1.03-1.08), concomitant use of psychotropic agents (aOR: 6.51; 95%CI: 3.01-13.61), and Los Angeles grades B (aOR: 2.69; 95%CI: 1.48-4.96), C (aOR: 15.38; 95%CI: 8.62-28.37), and D (aOR: 71.49; 95%CI: 37.47-142.01) were significantly associated with complications, whereas alcohol consumption 2-4 d/wk was negatively associated (aOR: 0.23; 95%CI: 0.06-0.61). Analyzing associated factors with each EE complication separately showed esophageal ulcer bleeding were associated with increased age (aOR: 1.05; 95%CI: 1.02-1.07) and Los Angeles grades B (aOR: 3.60; 95%CI: 1.52-8.50), C (aOR: 27.61; 95%CI: 12.34-61.80), and D (aOR: 119.09; 95%CI: 51.15-277.29), while esophageal strictures were associated with increased age (aOR: 1.07; 95%CI: 1.04-1.10), gastroesophageal reflux symptom (aOR: 2.51; 95%CI: 1.39-4.51), concomitant use of psychotropic agents (aOR: 11.79; 95%CI: 5.06-27.48), Los Angeles grades C (aOR: 7.35; 95%CI: 3.32-16.25), and D (aOR: 20.34; 95%CI: 8.36-49.53) and long-segment Barrett&#x02019;s esophagus (aOR: 4.63; 95%CI: 1.64-13.05).CONCLUSIONAging and severe EE were common associated factors, although there were more associated factors in esophageal strictures than esophageal ulcer bleeding. Despite the availability and widespread use of PPIs, EE complications are likely to remain a problem in Japan owing to the aging population and high-stress society.

The therapeutic effect of high-dose esomeprazole on stress ulcer bleeding in trauma patients

Purpose： To compare the therapeutic effects of different doses of intravenous esomeprazole on treating trauma patients with stress ulcer bleeding. Methods： A total of 102 trauma patients with stress ulcer bleeding were randomly divided into 2 groups： 52 patients were assigned to the high-dose group who received 80 mg intravenous esomeprazole, and then 8 mg/h continuous infusion for 3 days; 50 patients were assigned to the conventional dose group who received 40 mg intravenous esomeprazole sodium once every 12 h for 72 h. Results： Compared with the conventional dose group, the total efficiency of the high-dose group and conventional dose group was 98.08% and 86.00%, respectively （p 〈 0.05）, the hemostatic time was 22.10 h ± 5.18 h and 28.27 h ± 5.96 h, respectively （p 〈 0.05）. Conclusion： Both doses of intravenous esomeprazole have good hemostatic effects on stress ulcer bleeding in trauma patients. The high-dose esomeprazole is better for hemostasis.

Case Control Study of Post-endoscopic Variceal Ligation Bleeding Ulcers in Severe Liver Disease: Outcomes and Management

Background and Aims:The management of post-endoscopic variceal ligation(EVL)bleeding ulcers(PEBUs)is currently based on local expertise and patients liver disease status.The present retrospective study investigated associations between the endoscopic morphology of PEBUs and patient outcomes.Methods:Patients underwent EVL(primary or secondary),from January 2015 to January 2018,in two tertiary care hospitals in India(ILBS New Delhi and Dharamshila Narayana New Delhi).Mortality rates were determined at post-EVL day five and week six.PEBUs were typified based on Jamwal&Sarin classification system as follows:A,ulcer with active spurting;B,ulcer with ooze;C,ulcer base with visible vessel or clot;and D,clean or pigmented base.Results:Of 3854 EVL procedures,141(3.6%)patients developed PEBU,and 46/141(32.6%)suffered mortality.Among the former,the PEBU types A,B,C,and D accounted for 17.7,26.2,36.3,and 19.8%,respectively.Of those who died,39.1,30.4,21.7,and 8.8%had PEBU types A,B,C,and D.Treatments included transjugular intrahepatic portosystemic shunts(TIPS),esophageal self-expandable metal stent(SEMS),glue and sclerosant injection,Sengstaken-Blakemore tube placement and liver transplant.On univariate analysis,no correlation with hepatic venous pressure gradient,TIPS placement,size of varices,or number of bands was found.The Model for EndStage Liver Disease(MELD)-sodium score correlated positively with outcome.After adjusting for MELD-sodium score,mortality was best predicted by type-A ulcer(p=0.024;OR 8.95,CI 1.34-59.72).Conclusions:PEBU occurred in 3.6%of a large EVL cohort.Stratifying patients based on PEBU type can help predict outcomes,independent of the MELD-sodium score.Classifying PEBUs by endoscopic morphology may inform treatment strategies,and warrants further validation.