Impact of epinephrine volume on further bleeding due to high-risk peptic ulcer disease in the combination therapy era

BACKGROUND In monotherapy studies for bleeding peptic ulcers,large volumes of epinephrine were associated with a reduction in rebleeding.However,the impact of epinephrine volume in patients treated with combination endoscopic therapy remains unclear.AIM To assess whether epinephrine volume was associated with bleeding outcomes in individuals who also received endoscopic thermal therapy and/or clipping.METHODS Data from 132 patients with Forrest class Ia,Ib,and IIa peptic ulcers were reviewed.The primary outcome was further bleeding at 7 d;secondary outcomes included further bleeding at 30 d,need for additional therapeutic interventions,post-endoscopy blood transfusions,and 30-day mortality.Logistic and linear regression and Cox proportional hazards analyses were performed.RESULTS There was no association between epinephrine volume and all primary and secondary outcomes in multivariable analyses.Increased odds for further bleeding at 7 d occurred in patients with elevated creatinine values(aOR 1.96,95%CI 1.30-3.20;P<0.01)or hypotension requiring vasopressors(aOR 6.34,95%CI 1.87-25.52;P<0.01).Both factors were also associated with all secondary outcomes.CONCLUSION Epinephrine maintains an important role in the management of bleeding ulcers,but large volumes up to a range of 10-20 mL are not associated with improved bleeding outcomes among individuals receiving combination endoscopic therapy.Further bleeding is primarily associated with patient factors that likely cannot be overcome by increased volumes of epinephrine.However,in carefully-selected cases where ulcer location or size pose therapeutic challenges or when additional modalities are unavailable,it is conceivable that increased volumes of epinephrine may still be beneficial.

Characteristics of nonvariceal upper gastrointestinal hemorrhage in patients with chronic kidney disease

AIM:To evaluate the clinical characteristics of nonvariceal upper gastrointestinal hemorrhage(NGIH)in patients with chronic kidney disease(CKD).METHODS:From 2003 to 2010,a total of 72 CKD patients(male n=52,72.2%;female n=20,27.8%)who had undergone endoscopic treatments for NGIH were retrospectively identified.Clinical findings,endoscopic features,prognosis,rebleeding risk factors,and mortality-related factors were evaluated.The characteristics of the patients and rebleeding-related data were recorded for the following variables:gender,age,alcohol use and smoking history,past hemorrhage history,endoscopic findings(the cause,location,and size of the hemorrhage and the hemorrhagic state),therapeutic options for endoscopy,endoscopist experience,clinical outcomes,and mortality.RESULTS:The average size of the hemorrhagic site was 13.7±10.2 mm,and the most common hemorrhagic site in the stomach was the antrum(n=21,43.8%).The most frequent method of hemostasis was combination therapy(n=32,44.4%).The incidence of rebleeding was 37.5%(n=27),and 16.7%(n=12)of patients expired due to hemorrhage.In a multivariate analysis of the risk factors for rebleeding,alcoholism(OR=11.19,P=0.02),the experience of endoscopists(OR=0.56,P=0.03),and combination endoscopic therapy(OR=0.06,P=0.01)compared with monotherapy were significantly related to rebleeding after endoscopic therapy.In a risk analysis of mortality after endoscopic therapy,only rebleeding was related to mortality(OR=7.1,P=0.02).CONCLUSION:Intensive combined endoscopic treatments by experienced endoscopists are necessary for the treatment of NGIH in patients with CKD,especially when a patient is an alcoholic.

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.

Endoscopic hemoclip treatment for bleeding peptic ulcer

AIM To evaluate the efficacy of endoscopichemoclip in the treatment of bleeding pepticulcer.METHODS Totally,40 patients with F1a andFib hemorrhagic activity of peptic ulcers wereenrolled in this uncontrolled prospective studyfor endoscopic hemoclip treatment.We used anewly developed rotatable clip-device for theapplication of hemoclip(MD850)to stopbleeding.Endoscopy was repeated if there wasany sign or suspicion of rebleeding,and re-clipping was performed if necessary andfeasible.RESULTS Initial hemostatic rate by clippingwas 95%,and rebleeding rate was only 8%.Ultimate hemostatic rates were 87%,96%,and93% in the Fla and Flb subgroups,and totalcases,respectively.In patients with shock onadmission,hemoclipping achieved ultimatehemostasis of 71% and 83% in F1a and F1bsubgroups,respectively.Hemostasis reached100% in patients without shock regardless ofhemorrhagic activity being F1a or F1b.Theaverage number of clips used per case was 3.0(range 2-5).Spurting bleeders required moreclips on average than did oozing bleeders(3.4versus 2.8).We observed no obviouscomplications,no tissue injury,or impairmentof ulcer healing related to hemoclipping.CONCLUSION Endoscopic hemoclip placementis an effective and safe method.With theimprovement of the clip and application device,the procedure has become easier and much moreefficient.Endoscopic hemoclipping deservesfurther study in the treatment of bleeding pepticulcers.

Management of acute nonvariceal upper gastrointestinal bleeding:Current policies and future perspectives

Acute upper gastrointestinal bleeding(UGIB) is a gastroenterological emergency with a mortality of 6%-13%.The vast majority of these bleeds are due to peptic ulcers.Nonsteroidal anti-inflammatory drugs and Helicobacter pylori are the main risk factors for peptic ulcer disease.Endoscopy has become the mainstay for diagnosis and treatment of acute UGIB,and is recommended within 24 h of presentation.Proton pump inhibitor(PPI) administration before endoscopy can downstage the bleeding lesion and reduce the need for endoscopic therapy,but has no effect on rebleeding,mortality and need for surgery.Endoscopic therapy should be undertaken for ulcers with high-risk stigmata,to reduce the risk of rebleeding.This can be done with a variety of modalities.High-dose PPI administration after endoscopy can prevent rebleeding and reduce the need for further intervention and mortality,particularly in patients with high-risk stigmata.

Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis:A systematic review

BACKGROUND Acute non-variceal bleeding accounts for approximately 20%of all-cause bleeding episodes in patients with liver cirrhosis.It is associated with high morbidity and mortality therefore prompt diagnosis and endoscopic management are crucial.AIM To evaluate available data on the efficacy of endoscopic treatment modalities used to control acute non-variceal gastrointestinal bleeding(GIB)in cirrhotic patients as well as to assess treatment outcomes.METHODS Employing PRISMA methodology,the MEDLINE was searched through PubMed using appropriate MeSH terms.Data are reported in a summative manner and separately for each major non-variceal cause of bleeding.RESULTS Overall,23 studies were identified with a total of 1288 cirrhotic patients of whom 958/1288 underwent endoscopic therapy for acute non-variceal GIB.Peptic ulcer bleeding was the most common cause of acute non-variceal bleeding,followed by portal hypertensive gastropathy,gastric antral vascular ectasia,Mallory-Weiss syndrome,Dieaulafoy lesions,portal hypertensive colopathy,and hemorrhoids.Failure to control bleeding from all-causes of non-variceal GIB accounted for less than 3.5%of cirrhotic patients.Rebleeding(range 2%-25%)and mortality(range 3%-40%)rates varied,presumably due to study heterogeneity.Rebleeding was usually managed endoscopically and salvage therapy using arterial embolisation or surgery was undertaken in very few cases.Mortality was usually associated with liver function deterioration and other organ failure or infections rather than uncontrolled bleeding.Endoscopic treatment-related complications were extremely rare.Lower acute non-variceal bleeding was examined in two studies(197/1288 patients)achieving initial hemostasis in all patients using argon plasma coagulation for portal hypertensive colopathy and endoscopic band ligation or sclerotherapy for bleeding hemorrhoids(rebleeding range 10%-13%).Data on the efficacy of endoscopic therapy of cirrhotic patients vs non-cirrhotic controls with acute GIB are very scarce.CONCLUSION Endotherapy seems to be efficient as a means to control non-variceal hemorrhage in cirrhosis,although published data are very limited,particularly those comparing cirrhotics with noncirrhotics and those regarding acute bleeding from the lower gastrointestinal tract.Rebleeding and mortality rates appear to be relatively high,although firm conclusions may not be drawn due to study heterogeneity.Hopefully this review may stimulate further research on this subject and help clinicians administer optimal endoscopic therapy for cirrhotic patients.

内镜下注射硬化剂聚桂醇治疗消化性溃疡出血的效果观察

目的观察内镜下注射硬化剂聚桂醇治疗消化性溃疡出血的临床效果。方法将100例消化性溃疡出血的患者随机分为观察组与对照组,每组50例。观察组给予内镜下注射硬化剂聚桂醇治疗,对照组患者给予内镜下注射肾上腺素治疗。比较两组患者的即时止血率、转手术率、再出血率、止血时间、住院时间、住院费用及不良反应发生率。结果观察组的即时止血率高于对照组,再出血率、止血时间、住院时间均低于或短于对照组,住院费用少于对照组(均P<0.05),但两组转手术率差异无统计学意义(P>0.05)。结论内镜下注射聚桂醇治疗消化性溃疡出血患者可提高即时止血率,降低再出血率,缩短止血时间和住院时间,减少住院费用。

康复新液联合兰索拉唑三联疗法对消化性溃疡合并上消化道出血的治疗效果研究

目的探究康复新液+兰索拉唑三联疗法对消化性溃疡合并上消化道出血的治疗效果。方法92例消化性溃疡合并上消化道出血患者作为研究对象,以入院顺序奇偶法分为对照组和观察组,各46例。对照组采用兰索拉唑三联疗法治疗,观察组对照组基础上联合康复新液治疗。比较两组治疗效果、治疗4周后微血管网情况、幽门螺杆菌(Hp)根除率及不良反应发生情况。结果观察组治疗总有效率为97.83%,高于对照组的86.96%,差异具有统计学意义(P<0.05)。治疗4周后,观察组规则血管网占比为84.78%,高于对照组的60.87%,差异具有统计学意义(P<0.05)。观察组Hp根除率为89.13%(41/46),与对照组的84.78%(39/46)比较差异无统计学意义(P>0.05);两组治疗期间均未见严重不良反应。结论消化性溃疡合并上消化道出血患者应用兰索拉唑三联疗法联合康复新液治疗,可提升治疗效果、改善胃黏膜质量,治疗安全性良好。

1000例上消化道出血的内镜检查

目的利用内镜了解上消化道出血的主要病因组成．方法对1000例因上消化道出血入院的患者，在距首次出血72h以内进行内镜检查．男603例，女397例，年龄16岁～87岁，平均年龄40．9岁．部分病例诊断经手术或内镜活检后确诊．所有患者均作Hp检测．结果食管癌14例，食管炎10例，食管溃疡8例；食管静脉曲张破裂52例，责门粘膜撕裂症11例胃溃疡189例，胃癌102例，胃炎91例，出血性胃炎50例，残胃炎25例，胃异位胰腺2例，胃底血管畸形5例，吻合口溃疡1且例十二指肠溃疡227例，复合性溃疡45例，出血性十二指肠炎31例，肠蛔虫症7例，十二指肠憩室5例，十二指肠脉瘤样息肉6例，荨麻诊6例，肝胆胰疾病17例（胰头癌3例，胆管胆囊结石8例，肝癌4例，肝脓疡2例）．不明69例．镜检阳性率93．1％．Hp阳性率62．1％．结论出血病因依次为：十二指肠溃疡、胃溃疡、胃炎（慢性胃炎、出血性胃炎）胃癌、食管静脉曲张破裂、其他．消化性溃疡为出血首位病因．

消化内镜联合四联疗法治疗胃溃疡出血的临床疗效及再出血的因素

目的：探讨消化内镜联合四联疗法治疗胃溃疡出血的临床疗效及再出血的因素。方法选取2012年5月--2014年5月来我院救治的胃溃疡出血患者80例，按照随机数字分为研究组及对照组各40例。对两组患者的临床疗效，Hp根除标准，再出血的单因素及多因素进行比较。结果研究组的总有效率为92.5%，对照组为80.0%，两组比较差异有统计学意义（P＜0.05）。连续两次尿素呼气试验阴性确定Hp根除，观察组清除38例，清除率为95.0%；对照组清除33例，清除率为82.5%，两组比较，差异有统计学意义（χ2=7.654， P＜0.05）。影响再出血的因素的单因素中，A、B两组的年龄、性别比比较，差异无统计学意义（P＞0.05）， A组溃疡A1期人数百分比及出血量远远大于B组（P均＜0.05），A组血红蛋白血小板、是否内镜治疗人数百分比均小于B组（P＜0.05）。影响再出血的多因素危险因素主要包括内镜治疗，血红蛋白低，溃疡A1期。结论内镜合并四联疗法治疗胃溃疡出血效果好，再出血的危险因素包括内镜治疗，血红蛋白低，溃疡A1期。

内镜下用药治疗消化性溃疡并发上消化道出血的临床疗效及安全性观察

目的分析消化性溃疡并发上消化道出血使用内镜下用药治疗的临床效果与安全性。方法 84例消化性溃疡并发上消化道出血患者,采用随机数字表法分为对照组和实验组,每组42例。对照组采用常规药物治疗,实验组采用内镜下用药治疗。比较两组患者的临床疗效、不良反应发生情况及治疗前后血红蛋白(HGB)、红细胞比容(HCT)。结果实验组患者治疗总有效率为92.86%,高于对照组的76.19%,差异有统计学意义(P<0.05)。治疗后,实验组患者HGB、HCT分别为(88.96±8.11)g/L、(35.41±3.81)%,高于对照组的(81.62±8.51)g/L、(31.28±3.76)%,差异有统计学意义(P<0.05)。两组患者不良反应发生率比较差异无统计学意义(P>0.05)。结论对消化性溃疡并发上消化道出血患者开展内镜下用药治疗,能够有效提升治疗效果,安全性较高。

硝苯吡啶治疗上消化道出血38例

目的观察硝苯吡啶对上消化道出血的治疗效果，以评价其临床使用价值．方法将38例上消化道出血患者随机分为门脉高压食管胃底静脉曲张破裂出血组和消化性溃疡等出血组，分别在常规治疗的基础上加用硝苯吡啶治疗，其中门脉高压食管胃底静脉曲张破裂13例（34．2％），消化性溃疡18例（47．4％），急性出血性胃炎6例（15．8％），胃癌1例（2．6％）．男26例，女12例，年龄20岁～63岁，其中20岁～49岁者31例（81．6％），病程6mo～13a，临床表现为大量呕血和（或）柏油样便，出血量1000mL～2500mL，血压下降（＜12／8kPa），心率加快（＞100次／min），血红蛋白40g／L～80g／L，24h～72h疗程，疗程结束后，对患者的临床症状改善情况与相应的对照组进行对比分析．结果经硝苯吡啶治疗72h后，消化性溃疡等出血组显效8例，有效12例，无效5例，总有效率为80％，18例消化性溃疡中有6例24h内出血停止，血压、脉搏恢复正常．9例于72h内无活动性出血，3例无改善，总有效率为83．3％；6例急性出血性胃炎中有2例于24h内出血停止，血压、脉搏恢复正常，3例于48h内无活动性出血，1例无改善，总有效率为83．3％；1例胄癌无改善；门脉高压食管胃底静脉曲张破裂出血中有3例于24h内出血停止，血压、脉搏恢复正常。

内镜介入联合质子泵抑制剂三联疗法治疗消化性溃疡合并上消化道出血患者的效果

目的:观察内镜介入联合质子泵抑制剂三联疗法治疗消化性溃疡合并上消化道出血患者的效果。方法:选取80例消化性溃疡合并上消化道出血患者作为研究对象,按照随机数字表法分为对照组和观察组各40例。两组均行补液、吸氧和止血等基础处理,在此基础上,对照组予以质子泵抑制剂三联疗法治疗,观察组在对照组基础上联合内镜介入治疗,比较两组临床疗效,皮质醇(Cor)、肿瘤坏死因子-α(TNF-α)和C反应蛋白(CRP)水平,以及不良反应/并发症发生率。结果:观察组治疗总有效率为95.00%,明显高于对照组的77.50%,差异有统计学意义(P<0.05);治疗后,观察组Cor、TNF-α和CRP水平均低于对照组,差异有统计学意义(P<0.05);观察组不良反应/并发症发生率为2.50%,明显低于对照组的20.00%,差异有统计学意义(P<0.05)。结论:内镜介入联合质子泵抑制剂三联疗法治疗消化性溃疡合并上消化道出血患者可提高治疗总有效率,降低Cor、TNF-α、CRP水平和不良反应/并发症发生率,其效果优于单纯质子泵抑制剂三联疗法治疗。

去甲肾上腺素喷洒加微波处理治疗消化性溃疡出血69例

目的比较应用去甲肾上腺素喷洒，微波处理治疗及联合上述两种方法治疗消化性溃疡出血的治疗效果．方法消化性溃疡并发出血69例，男53例，女16例，年龄18岁～62岁．去甲肾上腺素喷洒治疗组（Ⅰ组）22例：在内镜直视下对准出血灶喷洒用生理盐水稀释为80mg％的去甲肾上腺素；微波治疗组（Ⅱ组）21例：在内镜直视下，微波治疗仪天线头接触出血点凝固止血，波长12cm，频率2450MHz，功率60W，接触时间一般为3s；去甲肾上腺素喷洒加微波治疗组（Ⅲ组）26例：方法同Ⅰ加Ⅱ组，观察24h止血情况和1wk内再出血情况．结果Ⅰ组24h止血18例，止血率81．8％，1wk内再出血4例，再出血率22．2％；Ⅱ组24h止血18例，止血率85．7％，再出血2例．再出血率11．1％；Ⅲ组24h止血25例，止血率96．1％，1wk内再出血1例，再出血率4％，经2检验．Ⅰ组和Ⅱm组之间、Ⅱ组和Ⅲ组之间均有显著差异，P＜0．05．结论去甲肾上腺素喷洒加微波治疗方法明显优于去甲肾上腺素喷洒治疗法或单纯微波治疗．

西双版纳地区上消化道出血的发病规律及诊治

1 材料和方法1.1 材料 1988-01/1997-10住我院内科经内镜或钡餐明确诊断的上消化道出血患者1000例.其出血判断标准为患者有呕血和(或)黑便(包括潜血阳性),排除服用铁剂及进食动物血等情况.1.2 方法根据患者临床情况和内镜/钡餐所见从7个方面对发病规律进行分析.即:性别、年龄、出血原因、烟酒史、气象、血型、种族.根据内镜和钡餐使用情况和诊断率对比及内科保守、内镜下治疗、外科治疗三种方法疗效对比,对本地区上消化道出血的诊治情况进行分析.

奥美拉唑、凝血酶和立止血联合治疗消化性溃疡并上消化道出血26例

目的观察奥美拉唑、凝血酶和立止血联合治疗消化性溃疡并上消化道出血的治疗效果．方法把我院内科1996－11确诊为消化性溃疡并上消化道出血患者随机分为治疗组26例和对照组32例，治疗组中男20例，女6例，平均出血次数2．3次，失血＜500mL者5例，500mL～1000mL者9例，＞1000mL者12例．对照组32例，男22例，女10例，平均年龄45．5岁，平均出血次数2．8次，出血量＜500mL者7例，500mL～1000mL者10例，＞1000mL者15例．治疗组给予奥美拉唑（阿斯特拉制药公司）80mg加生理盐水150mL静滴，1次／d,20min～30min滴完，凝血酶500单位，2次／d，po，立止血1克氏单位，静注，2次／d，止血48h后停药．对照组：甲氰咪胍0．8加生理盐水300mL静滴，1次／d,“冰盐水”（0．9％盐水50mL，去甲肾上腺素8mg）1次／8h，po，云南白药0．2g，3次／d，po，治疗后对两组患者的疗效情况进行比较分析．结果治疗组26例，治愈22例，治愈率89％，平均止血时间2d．对照组32例，治愈22例，治愈率80％，平均止血天数3．5d．两组的止血时间有明显差异（P＜0．01），治疗组止血时间较对照组明显缩短，但治愈率无明显差异（P＞0．05），复发率未做随访比较．结论奥美拉唑、凝血酶加立止血对消化性溃疡合并上消化道出血疗效显著，临床上有应?