Therapeutic endoscopic modalities for acute non-variceal upper gastrointestinal bleeding
Ramadani A 1, Spasovski G 2
1.University Clinic of Gastroenterohepatology, Skopje , Macedonia
2. University Clinic of Nephrology, Skopje, Macedonia
Introduction: Upper gastrointestinal bleeding (UGIB) is a relatively common, potentially life-threatening condition and continues to be one of the most frequent and emergent conditions in everyday clinical practice. Once haemodynamic stability has been achieved, therapeutic endoscopy is vital in control and arrest of bleeding (17). Peptic ulcer is responsible for more than half of acute UGIB and is the most frequent cause of severe non-variceal bleeding, with duodenal ulcer being far more frequent as compared to stomach ulcer. The introduction of endoscopic hemostasis (endoscopic injection, thermal coagulation, placement of clips or their combination) during the last decades has improved the clinical outcome especially for patients with high-risk stigmata, decreasing the rebleeding rate, blood transfusions requirements, time of hospitalization of patients, the need for urgent surgical haemostasis and probably the mortality rate.
Methods: In this one year retrospective study the records of 102 patients with non variceal UGI bleeding, admitted in the Endoscopy Unit of our Clinic, all of them underwent endoscopic hemostatic treatment, were analyzed. The patients were divided into three groups according to the type of the endoscopic hemostatic treatment: gorup A - 47 patients had received only injection of adrenaline; gorup B - 42 patients recived adrenaline + sclerosant agent polydocanol , and group C - 13 patients treated wih adrenaline + clipsing. In all cases intravenous acid-suppressing drugs were used until hemostasis was confirmed by endoscopy. After confirmation of hemostasis, regular meals and oral acid-suppressing drugs were started. Informed consent was obtained from each patient before the procedure. Outcome was measured and followed by: rebleeding rate (confirmed endoscopically or by recurrent hematemesis or melena with drifting vital signs); blood transfusion requirement; duration of hospital stay and the need for urgent surgical haemostasis. As showen in table 1 the dominantnumberof patientswere males (80/102), with malevs.female ratio 3.85 : 1. The average age was54.9 (the youngest patien was 20 and the oldest 83 years old).
Results:
Most common cause of non varicealUGIBwerepepticulcerations ( n=74, 72.5%), with duodenal ulceras the most common location (n=46, 62.2%).
Table 2 shows the hemostatic methods that were chosen and the clasification of the patients into three groups according to the type of the endoscopic hemostatic treatment.
Rebleedingoccured in 9 (19.1%) patinets in group A, in 3 (7.15%) patients in grpup B, and in 2(15.3%) patients in group C. The mean duration of hospitalization was 7.5 days for group A, 5.5 for group B and 5.1 days for group C. Only 8/102 (7.84%)patientsrequiredurgentsurgicalhemostasis; fromgroup A5(10.6%) patients; from group B2 (4.75%) patients and groupC1 (7.7% ) patient. Blood transfusion requirement for group A was1.91 bloodunits, 1.83 for group B and 1.45 blood units for group C.
Discusion:
Upper gastrointestinal bleeding (UGIB) is a relatively common, potentially life-threatening condition and continues to be one of the most frequent and emergent conditions in everyday clinical practice (lit). Patient with upper gastrointestinal bleeding can present with various symptoms such as hematemesis, hematochezia, melena, or progressive anemia. When such patient admited to the hospital, urgent endoscopy shoul be perfomd as soon as posible to detect the bleeding lession and to perform endoscopic therapy when requered (lit). Often resuscitation is needed which includes intravenous administration of fluids, and supplemental oxygen, correction of severe coagulopathy, and blood transfusion. The threshold for blood transfusion depends on the underlying condition, rate of bleeding, and vital signs of the patient, but is generally set at a hemoglobin level of ≤ 70 g/L (1,2).
Relevant medical data showed that peptic ulcer is responsible for more than half of acute UGIB and is the most frequent cause of severe non-variceal bleeding, with duodenal ulcer being far more frequent as compared to stomach ulcer. The most common risk raktors assosiated with non-variecal upper gastrointestinal bleeding are Helicobacter pylori infection and the use of nonsteroidal antiinflamamtory drugs and alcohol. The eradication of H. pylori, the increased awareness of potential danger of nonsteroidal antiinflammatory drugs and the widespread use of H2 receptor blockers and proton pump inhibitors (PPIs) in recent years account for the reduction in the number of patients hospitalized for upper gastrointestinal bleeding from ulcers (3, 4).
A randomized study has shown that when intravenous PPIs are combined with endoscopic therapy, the rebleeding rate can be reduced to a minimal level (5). In a systematic review including 9 trials (1829 patients) with either placebo or H2-receptor antagonists as control, the use of PPIs was associated with 50% reductions in the rate of recurrent bleeding and the need for surgery (6).
The optimum timing of endoscopy remains a balance between clinical need and resources, but when endoscopic treatment performed within 24 hours of hospital admission has shown that it controls the bleeding in up to 90% and it reduces significantly the rates of further bleeding, the need for blood transfusions, hospital costs and emergency surgery (4).
The rates of rebleeding and mortality are different depending on the presence of risk factors. Age, shock, comorbidity, diagnosis of the origin of bleeding, and major stigmata of recent bleeding are regarded as risk factors of rebleeding and mortality (7, 8).
There are virieties of endoscopic treatment methods for treatment of upper gastrointestinal bleeding (endoscopic injection, thermal coagulation, placement of clips or their combination) and which one of these methods is superior remains controversial, since comparative studies have not shown any superiority of one technique over another.
Adrenaline injection results in haemostasis in up to100% of patients with bleeding peptic ulcers, probably by a combination of vascular tamponade and vasoconstriction, with a concomitant reduction in re-bleeding rates from 40 to 15% (9, 10, 11). Although injection with adrenaline is successful in achieving initial haemostasis it is not adequate to provide definitive hemostasis and rebleeding occurs in high percent of the patients.
Sclerosants such as ethanol, polidocanol and ethanolamine are equally effective as adrenaline and most other published studies showed that the use of a only sclerosant agent achieves similar haemostasis as adrenaline alone. Combination therapy with adrenaline and ethanol may improve haemostasis and shorten hospital stay for patients with spurting haemorrhage (11, 12).
Endoclips are deployed on a visible vessel to achieve vascular compression and can achieve homeostasis in up to 100% of cases (13).
The additional benefit of adrenaline with a mechanical method is unclear, although one randomised comparative study of combination epinephrine-polidocanol injection and Hemoclip versus Hemoclip alone for bleeding peptic ulcers showed clipping to be inferior to combination therapy (11, 14).
In this study, the rate of rebleeding was 19.1% (9 patinets) in group A, 7.15% (3 patients) in grpup B, and in 15.3% (2 patients) in group C wich showes that combined endoscopic therapy
(andrenalin injection with sclerosant agent or adrenalin injection with clipsing) has better outcome and decreasses the rebleeding rate, blood transfusion requirement, duration of hospitalization and the requirement of surgical intervention.
Interventions such as surgery or angiography are indicated if the bleeding persists or rebleeding occurs after several therapeutic endoscopies. Surgery and transcatheter arterial embolization (TAE) are equally effective for patients who fail therapeutic endoscopy (8, 15, 16).
Conclusions: Therapeutic endoscopy in acute non-variceal UGIB reduce need for surgery. Combined endoscopic therapy showed supremacy against single therapy, decreasing the rebleeding rate, blood transfusion requirement and duration of hospitalization.
References:
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Tabl.1 The characteristics of the patients
No. Procedures102
Age (range; years)54.9 (20-83)
Sex (n) male/female80/22
Diseases (n)
Gastric ulcers28 (27,45 %)
Duodenal ulcers46 (45,09 %)
Anastomotic ulcers 2 (1,96 %)
Others26 (25,49 %)
Tabl.2 The hemostasis methods that were chosen
Endoscopic therapy patientsgroupe
Adrenalin injection 47 (46,07 %)A
Adrenalin injection+sclerosant agent42 (41,17 %)B
Adrenalin injection+clipsing13 (12,74 %)C
Tabl.3 Results of endoscopic hemostasis
Groupe of patientsABC
The rate of rebleeding9 (19.1%)3 (7.15%)2 (15.3%)
Need of surgical hemostasis5 (10.6%)2 (4.75%)1 (7.7%)
Need of blood transfusion1.91 b.u1.83 b.u1.45 b.u
Duration of hospital stay7.5 days5.5 days5.1 days