Hybrid argon plasma coagulation for the treatment of Barrett’s esophagus:A prospective,multicenter study

BACKGROUND The incidence of Barrett’s esophagus(BE)in China is lower compared to the Western populations.Hence,studies conducted in the Chinese population has been limited.The current treatment options available for BE treatment includes argon plasma coagulation(APC),radiofrequency ablation and cryoablation,all with varying degrees of success.AIM To determine the efficacy and safety of HybridAPC in the treatment of BE.METHODS The study cohort consisted of patients with BE who underwent HybridAPC ablation treatment.These procedures were performed by seven endoscopists from different tertiary hospitals.The duration of the procedure,curative rate,complications and recurrent rate by 1-year follow-up were recorded.RESULTS Eighty individuals were enrolled for treatment from July 2017 to June 2020,comprising of 39 males and 41 females with a median age of 54 years(range,30 to 83 years).The technical success rate of HybridAPC was 100%and the overall curative rate was 98.15%.No severe complications occurred during the operation.BE cases were classified as short-segment BE and long-segment BE.Patients with short-segment BE were all considered cured without complications.Thirty-six patients completed the one-year follow-up without recurrence.Twenty-four percent had mild dysplasia which were all resolved with one post-procedural treatment.The mean duration of the procedure was 10.94±6.52 min.CONCLUSION Treatment of BE with HybridAPC was found to be a simple and quick procedure that is safe and effective during the short-term follow-up,especially in cases of short-segment BE.This technique could be considered as a feasible alternative ablation therapy for BE.

Long-term follow-up after complete ablation of Barrett's esophagus with argon plasma coagulation

AIM: To report the long-term outcome of patients after complete ablation of non-neoplastic Barrett's esophagus (BE) with respect to BE relapse and development of intraepithelial neoplasia or esophageal adenocarcinoma. METHODS: In 70 patients with historically proven non neoplastic BE, complete BE ablation was achieved by argon plasma coagulation (APC) and high-dose proton pump inhibitor therapy (120 mg omeprazole daily). Sixty-six patients (94.4%) underwent further surveillance endoscopy. At each surveillance endoscopy four-quadrant biopsies were taken from the neo-squamous epithelium at 2 cm intervals depending on the pre-treatment length of BE mucosa beginning at the neo-Z-line, and from any endoscopically suspicious lesion. RESULTS: The median follow-up of 66 patients was 51 mo (range 9-85 mo) giving a total of 280.5 patient years. A mean of 6 biopsies were taken during surveillance endoscopies. In 13 patients (19.7%) tongues or islands suspicious for BE were found during endoscopy. In 8 of these patients (12.1%) non-neoplastic BE relapse was confirmed histologically giving a histological relapse rate of 3% per year. In none of the patients, intraepithelial neoplasia nor an esophageal adenocarcinoma was detected. Logistic regression analysis identified endoscopic detection of islands or tongues as the only positive predictor of BE relapse (P= 0.0004). CONCLUSION: The long-term relapse rate of non neoplastic BE following complete ablation with high-power APC is low (3% per year).

Endoscopic ablation of Barrett's esophagus using high power setting argon plasma coagulation: A prospective study

AIM: This prospective study evaluated the effectiveness of 90 W argon plasma coagulation (APC) for the ablation of Barrett's esophagus (BE) that is considered to be the main risk factor for the development of esophageal adenocarcinoma.METHODS: The results from 25 patients, observed at the First Department of General Surgery, University of Verona, Italy, from October 2000 to October 2003, who underwent APC for histologically proven BE were prospectively analyzed.RESULTS: The ablation treatment was completed in all the patients but one (96%). The mean number of APC sessions needed to complete ablation was 1.6 (total number: 40). The eradication was obtained in the majority of cases by one session only (60%), two sessions were required in 24% of the cases and three or more in 16%.About 43% of the sessions were complicated. Retrosternal pain (22.5%) and fever (17.5%) were the most frequent symptoms. Only one major complication occurred, it was an hemorrhage due to ulcer formation on the treated esophagus that required urgent endoscopic sclerosis and admission. The follow-up was accomplished in all the patients with a mean period of 26.3 mo and 20 patients (84%) with a follow-up period longer than 24 mo. Only one patient showed a relapse of metaplastic mucosa 12 mo after the completion of ablation. The patient was hence re-treated and now is free from recurrence 33 mo later.CONCLUSION: High power setting (90 W) APC showed to be safe and effective. The effects persist at a mean follow-up period of two years with a comparable cost in term of complications with respect to standard power settings. Further studies with greater number of patients are required to confirm these results and to assess if ablation reduces the incidence of malignant progression.

Role of argon plasma coagulation in treatment of esophageal varices

With the development of endoscopic therapy,argon plasma coagulation(APC)has been widely used by endoscopists.It has many advantages,such as simple to operate,low cost,and minimal invasiveness.Because of its capability of lesion ablation and hemostasis,APC has several indications in the gastrointestinal tract.One of them is esophageal varices.The aim of this review is to summarize the research on APC in this field to provide a reference for clinical practice.

Endoscopic resolution and recurrence of gastric antral vascular ectasia after serial treatment with argon plasma coagulation

To evaluate long-term endoscopic resolution and recurrence rate of gastric antral vascular ectasia (GAVE) after argon plasma coagulation (APC) treatment. METHODSThis was an IRB-approved retrospective single center study that included patients endoscopically treated for GAVE between 1/1/2008 to 12/31/2014. The primary and secondary end points of the study were rate of endoscopic resolution of GAVE after APC treatment and recurrence rate of GAVE after endoscopic resolution, respectively. Endoscopic resolution of GAVE was defined as no endoscopic evidence of GAVE after treatment with APC. Recurrence of GAVE was defined as endoscopic reappearance of GAVE after prior resolution. RESULTSTwenty patients met the study criteria. Median age (range) of the patients was 59.5 years (42-74 years). GAVE was associated with underlying cirrhosis in 16 (80%) patients. Indications for initial esophagogastroduodenoscopy (EGD) included hematemesis and/or melena (9/20, 45%), iron deficiency anemia (6/20, 30%), screening or surveillance of varices (4/20, 20%), and occult gastrointestinal bleeding (1/20, 5%). The patients were treated with a total of 55 APC sessions (range 1-7 sessions). Successful endoscopic resolution of GAVE was achieved in 8 out of 20 patients (40%). There was no correlation between number of treatment sessions and GAVE treatment success (P = NS). Recurrence of GAVE was noted on a subsequent EGD in 2 out of 8 patients (25%) with prior endoscopic resolution of GAVE. Median follow-up period for the study population was 627 d (range 63-1953 d). CONCLUSIONEndoscopic resolution rate of GAVE was low (40%) with a 25% recurrence rate after treatment with APC. These rates suggest that APC treatment of GAVE may not be optimal in many circumstances.

Argon plasma coagulation for superficial esophageal squamous-cell carcinoma in high-risk patients

AIM: To evaluate the usefulness and safety of argon plasma coagulation (APC) for superficial esophageal squamous-cell carcinoma (SESC) in high-risk patients. METHODS: We studied 17 patients (15 men and 2 women, 21 lesions) with SESC in whom endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and open surgery were contraindicated from March 1999 through February 2009. None of the patients could tolerate prolonged EMR/ESD or open surgery because of severe concomitant disease (e.g., liver cirrhosis, cerebral infarction, or ischemic heart disease) or scar formation after EMR/ESD and chemoradiotherapy. After conventional endoscopy, an iodine stain was sprayed on the esophageal mucosa to determine the lesion margins. The lesion was then ablated by APC. We retrospectively studied the treatment time, number of APC sessions per site, complications, presence or absence of recurrence, and time to recurrence.RESULTS: The median duration of follow-up was 36 mo (range: 6-120 mo). All of the tumors were macroscopically classified as superficial and slightly depressed type (0-Ⅱc). The preoperative depth of invasion was clinical T1a (mucosal cancer) for 19 lesions and clinical T1b (submucosal cancer) for 2. The median treatment time was 15 min (range: 10-36 min). The median number of treatment sessions per site was 2 (range: 1-4). The median hospital stay was 14 d (range: 5-68 d). Among the 17 patients (21 lesions), 2 (9.5%) had recurrence and underwent additional APC with no subsequent evidence of recurrence. There were no treatment-related complications, such as bleeding or perforation. CONCLUSION: APC is considered to be safe and effective for the management of SESC that cannot be resected endoscopically because of underlying disease, as well as for the control of recurrence after EMR and local recurrence after chemoradiotherapy.

Acute bleeding after argon plasma coagulation for weight regain after gastric bypass: A case report

BACKGROUND Roux-en-Y gastric bypass(RYGB) is the most commonly performed surgical procedure used to treat obesity worldwide. Despite satisfactory results in terms of weight loss, over time many patients experience weight regain. There are many factors that contribute to weight regain after RYGB, including the diameter of the gastric-jejunal anastomosis(GJA). One of the most commonly performed endoscopic procedures for weight regain after RYGB is argon plasma coagulation(APC). We report a case of hematemesis after outlet revision with APC. We highlight several treatment modalities that can be used to treat this complication.CASE SUMMARY A 45-year-old female with a history of weight regain after RYGB was referred for possible endoscopic treatment for weight regain. On endoscopic evaluation, the diameter of the GJA was 22 mm. Due to the dilated GJA, treatment with APC was performed. Several months later she reported a return of poor satiety and an increased appetite. A repeat endoscopy was then performed. The GJA was approximately 15 mm and was incompetent. APC was performed. One day post procedure she had four episodes of hematemesis. An endoscopy was performed and a large ulcer with a visible arterial vessel was visualized at the GJA.Coagulation was attempted using a Coagrasper and after initial contact with the vessel, the vessel started oozing. Due to fibrosis and the depth of ulceration in the area, clips and repeat APC could not be used. Therefore, an attempt to inject epinephrine injection was made. However, persistent oozing was noted. As a result, hemostatic powder was applied to the region of the bleeding vessel.Subsequently, no more bleeding was observed. On follow-up, the patient remained hemodynamically stable and a second look endoscopy was not performed. The patient was discharged three days later.CONCLUSION APC revision of the GJA is known to be a relatively safe and effective strategy to manage weight regain post RYGB. Anastomotic site bleeding is an infrequent and potentially life-threatening complication associated with this therapy. Endoscopic management is the first line therapy used to achieve hemostasis in these cases.

Endoscopic ablation of Barrett's esophagus using the second generation argon plasma coagulation:a prospective randomized controlled trail

Objective：To investigate the efficacy and safety of the second generation argon plasma coagulation（VIO APC） in the ablation of Barrett＇ s Esophagus. Methods：A total of 35 patients with uncomplicated Barrett＇ s esophagus entered into a prospective, randomized, unblinded study comparing the treatment VIO APC combined with a proton pump inhibiter with a proton pump inhibiter administered alone. VIO APC was performed at a power setting of 40W, and argon gas flow at 1.5-2.0 L/min, and＂ forced＂ mode. Ablative treatment was repeated until either no Barrett＇ s epithelium remained or a maximum of 5 treatment sessions occurred. Results：In the ablation group, macroscopic complete ablation was achieved in 14 of 18 patients, and complete ablation confirmed by histology in 12 of 18 patients （P 〈 0.01）. Buried glands were observed in 2 patients who had achieved macroscopic ablation. The Barrett＇s mucosa averaged a reduction of 65%（range 50-75%） in the remaining 4 patients. In the control group, only 2 patients had partial regression, median 30%（range 20-40%）. In the ablation group, post-treatment 4 patients had transient retrosternal pain, and 3 patients had mild epigastric discomfort. One patient had a small hemorrhage during the procedure, which ceased after norepinephrine and thrombosin were administered through the endoscope biopsy channel. No adverse events were observed in the control group. During 11.8（4-15） months follow-up, patients who had achieved the complete ablation have no evidence of relapse of Barrett＇ s esophagus. Conclusion：VIO APC with a relatively low power setting can effectively ablate the Barrett＇ s mucosa. No severe adverse events were observed. Long-term follow-up is needed to assess cancer prevention and the durability of the neo-squamous epithelium.

Rectal ulcer:Due to ketoprofen, argon plasma coagulation and prostatic brachytherapy

Prostatic brachytherapy with permanent seed implants is a recent and safe radiation therapy technique associated with radiation-induced digestive disease.Argon plasma coagulation procedure is a validated modality in the management of haemorrhagic radiation proctitis,which is known to occasionally induce chronic rectal ulcers.We report here an original case report of an acute painful rectal ulcer as a consequence of the combination of shortterm therapy with non-steroidal anti-inflammatory drugs therapy,prostatic brachytherapy with malposition of seed implants and argon plasma coagulation procedure in a patient with haemorrhagic radiation proctitis.The description of this clinical observation is essential to recommend the discontinuation of non-steroidal anti-inflammatory drugs therapy and the control of the position of seed implants in case of prostatic brachytherapy before argon plasma coagulation for radiation-induced proctitis.

Ablation of Barrett’s esophagus using the second-generation argon plasma coagulation

Objective To investigate the efficacy and safety of the second-generation argon plasma coagulation (VIO APC) in ablation of Barrett’s esophagus. Methods Eighteen patients with Barrett’s esophagus (12 males, median age of 55 years, median length of 2.1 cm,1 low-grade dysplasia, 13 cases of short segment Barrett’s esophagus) received VIO APC, which was performed at a power setting of 40W and argon gas flow at 1.5-2.0 L/min, "forced" mode, in 1-3 sessions (mean 1.3). All the patients received treatment with high-dose proton pump inhibitors. The main complaints before ablation were upper abdominal pain in 12 patients (66%), sour regurgitation in 14 patients (77%), and dysphagia or odynophagia in 7 patients (38%). Two patients (11%) had esophageal hiatal hernia. Results The percentage of patients in whom ablation was endoscopically achieved proximal to the gastroesophageal junction was 77.8% (14/18), and histologically achieved in 66.7% (12/18). Berried glands were observed in 2 patients who had achieved endoscopic ablation, the areas of Barrett’s mucosa were reduced by more than 60% in the other 4 patients. After treatment, 4 patients had transient retrosternal pain and 3 patients had mild epigastric discomfort. One patient had small amounts of hemorrhage during the process, and it ceased after norepinephrine and thrombosin were administered through endoscope biopsy channel. No esophageal stricture or other severe adverse events was observed. During 11.8 (4-15) months’ follow-up, the patients who had achieved the complete ablation had no evidence of relapse of Barrett’s esophagus. Conclusion VIO APC with a relatively low power setting can effectively ablate the Barrett’s mucosa with special intestinal metaplasia when standard APC has been done. No severe adverse events were observed. Long-term follow-up is needed to assess cancer prevention and the durability of the neo-squamous epithelium.

Endoscopic Treatment of 14 Cases of Small Subepithelial Lesions in the Gastrointestinal Tract Using a Combined Snare, Long Lucency Cap, and Argon Plasma Coagulation Technique

Subepithelial lesions(SEL)of the digestive tract refer to a series of benign and malignant subepithelial masses that appear smooth or rough under gastrointestinal endoscopy.Endoscopic resection of subepithelial lesions in the digestive tract is widely recognized due to its advantages of minimal trauma and rapid recovery.This paper reports and summarizes the experiences of using the combined snare,long lucency cap,and argon plasma coagulation technique to remove small subepithelial lesions in 14 patients.

Epinephrine plus argon plasma or heater probe coagulation in ulcer bleeding

AIM:To compare the effectiveness of argon plasma coagulation (APC) and heater probe coagulation (HPC) in non-variceal upper gastrointestinal bleeding.METHODS:Eighty-five (18 female,67 male) patients admitted for acute gastrointestinal bleeding due to gastric or duodenal ulcer were included in the study.Upper endoscopy was performed and HPC or APC were chosen randomly to stop the bleeding.Initial hemostasis and rebleeding rates were primary and secondary end-points of the study.RESULTS:Initial hemostasis was achieved in 97.7% (42/43) and 81% (36/42) of the APC and HPC groups,respectively (P < 0.05).Rebleeding rates were 2.4% (1/42) and 8.3% (3/36) in the APC and HPC groups,respectively,at 4 wk (P > 0.05).CONCLUSION:APC is an effective hemostatic method in bleeding peptic ulcers.Larger multicenter trials are necessary to confirm these results.

Histologyassessmentofbipolarcoagulationandargonplasmacoagulationon digestivetract

AIM: To analyze the effect of bipolar electrocoagula-tion and argon plasma coagulation on fresh specimens of gastrointestinal tract. METHODS: An experimental evaluation was performed at Hospital das Clinicas of the University of So Paulo, on 31 fresh surgical specimens using argon plasma coagulation and bipolar electrocoagulation at different time intervals. The depth of tissue damage was his-topathologically analyzed by single senior pathologist unaware of the coagulation method and power setting applied. To analyze the results, the mucosa was divided in superficial mucosa (epithelial layer of the esophagus and superficial portion of the glandular layer of the stomach and colon) intermediate mucosa (until thelamina propria of the esophagus and until the bottom of the glandular layer of the stomach and colon) and muscularis mucosa. Necrosis involvement of the layers was compared in several combinations of power and time interval. RESULTS: Involvement of the intermediate mucosa of the stomach and of the muscularis mucosa of the three organs was more frequent when higher amounts of en-ergy were used with argon plasma. In the esophagus and in the colon, injury of the intermediate mucosa was frequent, even when small amounts of energy were used. The use of bipolar electrocoagulation resulted in more frequent involvement of the intermediate mucosa and of the muscularis mucosa of the esophagus and of the colon when higher amounts of energy were used. In the stomach, these involvements were rare. The risk of injury of the muscularis propria was significant only in the colon when argon plasma coagulation was em-ployed.CONCLUSION: Tissue damage after argon plasma coagulation is deeper than bipolar electrocoagulation. Both of them depend on the amount of energy used.

Blue rubber bleb nevus syndrome complicated with disseminated intravascular coagulation and intestinal obstruction: A case report

BACKGROUND Blue rubber bleb nevus syndrome is a rare vascular malformation syndrome with unclear etiopathogenesis and noncurative treatments.It is characterized by multiple vascular malformations of the skin,gastrointestinal tract,and other visceral organs.The most common symptoms are intermittent gastrointestinal bleeding and secondary iron deficiency anemia,thus requiring repeated blood transfusions and hospitalizations.It is easily missed and misdiagnosed,and there is no specific treatment.CASE SUMMARY We report a case of blue rubber bleb nevus syndrome combined with disseminated intravascular coagulation and efficacy of treatment with argon plasma coagulation under enteroscopy and sirolimus.A 56-year-old female patient was admitted to the hospital with 3-year history of fatigue and dizziness that had aggravated over the past 10 d with melena.The patient had a history of repeated melena and multiple venous hemangiomas from childhood.After treatment with argon plasma coagulation combined with sirolimus for nearly 8 wk,the patient’s serum hemoglobin increased to 100 g/L.At the 12-mo follow-up,the patient was well with stable hemoglobin(102 g/L)and no recurrent intestinal bleeding.CONCLUSION Argon plasma coagulation and sirolimus may be an efficacious and safe treatment for blue rubber bleb nevus syndrome,which currently has no recommended treatments.

Endoscopic management of chronic radiation proctitis

Chronic radiation proctopathy occurs in 5%-20% of patients following pelvic radiotherapy. Although many cases resolve spontaneously,some lead to chronic symptoms including diarrhea,tenesmus,urgency and persistent rectal bleeding with iron deficiency anemia requiring blood transfusions. Treatments for chronic radiation proctitis remain unsatisfactory and the basis of evidence for various therapies is generally insuff icient. There are very few controlled or prospective trials,and comparisons between therapies are limited because of different evaluation methods. Medical treatments,including formalin,topical sucralfate,5-amino salicylic acid enemas,and short chain fatty acids have been used with limited success.Surgical management is associated with high morbidity and mortality. Endoscopic therapy using modalities such as the heater probe,neodymium:yttrium-aluminium-garnet laser,potassium titanyl phosphate laser and bipolar electrocoagulation has been reported to be of some benef it,but with frequent complications.Argon plasma coagulation is touted to be the preferred endoscopic therapy due to its eff icacy and safety profile.Newer methods of endoscopic ablation such as radiofrequency ablation and cryotherapy have been recently described which may afford broader areas of treatment per application,with lower rate of complications.This review will focus on endoscopic ablation therapies,including such newer modalities,for chronic radiation proctitis.

Colonic gas explosion during therapeutic colonoscopy with electrocautery

Therapeutic colonoscopy with electrocautery is widely used around the world. Adequate colonic cleansing is considered a crucial factor for the safety of this procedure. Colonic gas explosion, although rare, is one of the most frightening iatrogenic complications during colonoscopy with electrocautery. This complication is the result of an accumulation of colonic gases to explosive concentrations, but may be prevented by meticulous bowel preparation. The purpose of.this review is to discuss the indications and the types of bowel preparations for therapeutic colonoscopy, and to contribute recommendations for the adequate bowel preparation for colonoscopy with electrocautery.

Endoscopic mucosal ablation-an alternative treatment for colonic polyps:Three case reports

BACKGROUND Endoscopic resection of non-invasive lesions is now the standard of care for lesions in the GI tract.However,resection techniques require extensive training,are not available in all endoscopy centers and are prone to complications.Endoscopic mucosal ablation(EMA)is a combination of resection and ablation techniques and it may offer an alternative in the management of such lesions.CASE SUMMARY In this case series we report the successful treatment of three flat colonic polyps using the EMA technique.Two lesions were treatment naïve and 1 was a recurrence after an endoscopic mucosal resection.The sizes ranged from 2 to 4 cm.All three polyps were ablated successfully with no immediate or delayed complications.The recurrence rate at 1 year of follow up was 0%.CONCLUSION Based on this initial experience,we conclude that EMA is a safe and effective technique for the treatment of non-invasive colonic polyps when endoscopic resection techniques are not available.

Successful treatment of refractory gastric antral vascular ectasia by distal gastrectomy:A case report

Gastric antral vascular ectasia (GAVE) is an uncommon and often neglected cause of gastric hemorrhage. The treatments for GAVE include surgery, endoscopy and medical therapies. Here, we report an unusual case of GAVE. A 72-year-old man with a three-month history of recurrent melena was diagnosed with GAVE. Endoscopy revealed the classical &#x0201c;watermelon stomach&#x0201d; appearance of GAVE and complete pyloric involvement. Melena reoccurred three days after argon plasma coagulation treatment, and the level of hemoglobin dropped to 47 g/L. The patient was then successfully treated with distal gastrectomy with Billroth II anastomosis. We propose that surgery should be considered as an effective option for GAVE patients with extensive and severe lesions upon deterioration of general conditions and hemodynamic instability.

Esophageal squamous papillomas with focal dermal hypoplasia and eosinophilic esophagitis

Focal dermal hypoplasia(FDH) is a rare disorder of the mesodermal and ectodermal tissues. Here we present an eight-year-old female known to have FDH who presents with poor weight gain and dysphagia. She was diagnosed with multiple esophageal papillomas and eosinophilic esophagitis. She was successfully treated with argon plasma coagulation and ingested fluticasone propionate, which has not been described previously in a child.

Influences of etiology and endoscopic appearance on the long-term outcomes of gastric antral vascular ectasia

BACKGROUND Gastric antral vascular ectasia(GAVE)has diverse associations and presumed causes,which include liver cirrhosis,chronic kidney disease,and autoimmune disease.This heterogeneity of underlying disorders suggests that the pathogenesis of GAVE may be variable.AIM To compare the clinical features and long-term outcomes of GAVE according to endoscopic patterns and etiologies.METHODS The medical records and endoscopic images of 23 consecutive patients diagnosed with GAVE by endoscopy at Yeungnam University Hospital from January 2006 to December 2020 were retrospectively reviewed.Patients were allocated to cirrhosis(16 patients)and non-cirrhosis groups(7 patients).GAVE subtypes,as determined by endoscopy,were categorized as punctate(a diffuse,honeycomb-like appearance,17 patients)or striped(a linear,watermelon-like appearance,6 patients).RESULTS All GAVE patients with cirrhosis(16/16,100%)had a punctate pattern by endoscopy,whereas the majority of patients(6/7,85.7%)without cirrhosis had a striped pattern(P<0.001).Overt GAVE bleeding(10/23,43%)was significantly more common in the non-cirrhosis group than in the cirrhosis group(6/7,85.7%vs 4/16,25.0%;P=0.019),and more common in the striped group than in the punctate group(5/6,83.3%vs 5/17,29.4%;P=0.052).However,mean numbers of admissions due to GAVE bleeding and argon plasma coagulation(APC)sessions to address overt bleeding were similar in the cirrhosis and non-cirrhosis groups and in the punctate and striped groups.All patients with GAVE bleeding were successfully treated by APC,and no patient died from GAVE-related blood loss during a median follow-up of 24 mo.CONCLUSION Punctate-type GAVE is strongly associated with liver cirrhosis,and GAVE patients without cirrhosis tend to be more prone to overt bleeding.However,the presence of cirrhosis and endoscopic patterns did not influence long-term clinical courses or outcomes in cases of overt bleeding.