Hemostatic sprays to control active nonvariceal upper gastrointestinal bleeding

As nonvariceal upper gastrointestinal bleeding remains a critical health concern, there is a need for ongoing optimization of endoscopic hemostasis modalities. Current methods for endoscopic hemostasis include epinephrine injection, thermal coagulation, and mechanical clips. Although these modalities have proven efficacy, there are limitations to their use, including significant learning curves and the requirement of expert assistants. Moreover, there still remains an ongoing risk of rebleeding after therapy. Therefore, a need exists for a safe and easy-to-use method for endoscopic hemostasis, specifically in the setting where current methods for hemostasis are limited or in the setting when hemostasis has not been achieved despite their application. Hemostatic sprays have emerged as novel methods for achieving hemostasis. Therefore, we sought to appraise the evidence concerning the use of hemostatic sprays. Our review highlights that hemostatic spray is a safe and effective method for endoscopic hemostasis, specifically, when current methods are infeasible, unsuccessful, and in malignant nonvariceal upper gastrointestinal bleeding.     

Endoscopic advances in the management of non-variceal upper gastrointestinal bleeding:A review

Upper gastrointestinal bleeding is defined as the bleeding originating from the esophagus to the ligament of Treitz and further classified into variceal and nonvariceal gastrointestinal bleeding.Non-variceal upper gastrointestinal bleeding remains a common clinical problem globally.It is associated with high mortality,morbidity,and cost of the health care system.Despite the continuous improvement of therapeutic endoscopy,the 30-d readmission rate secondary to rebleeding and associated mortality is an ongoing issue.Available Food and Drug Administration approved traditional or conventional therapeutic endoscopic modalities includes epinephrine injection,argon plasma coagulation,heater probe,and placement of through the scope clip,which can be used alone or in combination to decrease the risk of rebleeding.Recently,more attention has been paid to the novel advanced endoscopic devices for primary treatment of the bleeding lesion and as a secondary measure when conventional therapies fail to achieve hemostasis.This review highlights emerging endoscopic modalities used in the management of non-variceal upper gastrointestinal related bleeding such as over-the-scope clip,Coagrasper,hemostatic sprays,radiofrequency ablation,cryotherapy,endoscopic suturing devices,and endoscopic ultrasound-guided angiotherapy.In this review article,we will also discuss the technical aspects of the common procedures,outcomes in terms of safety and efficacy,and their advantages and limitations in the setting of non-variceal upper gastrointestinal bleeding.     

Treatment of upper gastrointestinal bleeding in 2020: New techniques and outcomes

The clinical outcome of upper gastrointestinal bleeding has improved due to advances in endoscopic therapy and standardized peri‐endoscopy care. Apart from validating clinical scores, artificial intelligence‐assisted machine learning models may play an important role in risk stratification. While standard endoscopic treatments remain irreplaceable, novel endoscopic modalities have changed the landscape of management. Over‐the‐scope clips have high success rates as rescue or even first‐line treatments in difficult‐to‐treat cases. Hemostatic powder is safe and easy to use, which can be useful as temporary control with its high immediate hemostatic ability. After endoscopic hemostasis, Doppler endoscopic probe can offer an objective measure to guide the treatment endpoint. In refractory bleeding, angiographic embolization should be considered before salvage surgery. In variceal hemorrhage, banding ligation and glue injection are first‐line treatment options. Endoscopic ultrasound‐guided therapy is gaining popularity due to its capability of precise localization for treatment targets. A self‐expandable metal stent may be considered as an alternative option to balloon tamponade in refractory bleeding. Transjugular intrahepatic portosystemic shunting should be reserved as salvage therapy. In this article, we aim to provide an evidence‐based comprehensive review of the major advancements in endoscopic hemostatic techniques and clinical outcomes.     

Risk stratification and definitive hemostasis of nonvariceal upper gastrointestinal bleeding with blood flow detection and combination techniques

Nonvariceal upper gastrointestinal (UGI) hemorrhage remains a significant health and economic burden. As the use of urgent endoscopy for UGI hemorrhage has increased, there has been a decline in associated mortality. Endoscopic hemostasis is based on risk stratification of stigmata of recent hemorrhage. A Doppler endoscopic probe can provide further risk stratification by detecting arterial blood flow under the lesion and as a guide to successful endoscopic treatment. Standard treatment options for endoscopic hemostasis include submucosal injection therapy usually in combination with either thermal coagulation or through-the-scope clips. A large over-the-scope clip, which has been used to close fistulas and perforations, has been shown to be effective in cases of refractory nonvariceal UGI hemorrhage, and might also be useful in other types of gastrointestinal bleeding.     

内镜下氩离子凝固术与注射术治疗非食管静脉曲张性上消化道出血疗效分析

目的探讨内镜下氩离子凝固术（argon plasma coagulation,APC）治疗上消化道出血的临床应用价值。方法采用氩气刀对非食管静脉曲张性上消化道出血患者进行治疗（APC组）,以内镜下注射肾上腺素止血为对照组（注射组）,比较两组的有效止血率。结果注射组的患者中,112例患者未再出血。4例患者再出血,总有效率96．6％。APC组的患者中,119例患者未再出血,2例患者再出血,总有效率98．3％。结论APC组及注射组止血有效率高,无明显差异性（P〉0．05）。但内镜下氩离子凝固术治疗非食管静脉曲张性上消化道出血具有疗效确切,安全快速,并发症少,患者痛苦小等特点,临床应用价值较高。     

Efficacy of Argon Plasma Coagulation for Bleeding Gastroduodenal Ulcers

Background: Argon plasma coagulation (APC) can achieve an effective coagulation of large areas with a relatively shallow but well‐controlled and uniform coagulation depth. There are only a few reports of APC therapy applied to bleeding peptic ulcers, especially ulcers with exposed vessels. Methods: The aim of this study is to evaluate the usefulness of APC as a means of achieving endoscopic hemostasis for bleeding gastroduodenal ulcers. Thirty‐nine patients having these ulcers were treated with APC. Results: The success rates for initial hemostasis and complete hemostasis with APC are 87% and 97.4%, respectively. These results are almost equal to those of injection therapy and hemoclip. Six cases that re‐bled after other hemostatic procedures obtained complete hemostasis finally with APC. In one ineffective case of APC, complete endoscopic hemostasis was achieved with hemoclip. Conclusion: Argon plasma coagulation therapy is an effective therapeutic alternative in endoscopic hemostasis for bleeding peptic ulcers.     

EFFECT OF ARGON PLASMA COAGULATION IN PATIENTS WITH UPPER GASTROINTESTINAL ACTIVE HEMORRHAGE

Background: Acute upper gastrointestinal hemorrhage is a common and life‐threatening medical emergency. Despite a large number of endoscopic methods for hemostasis, active bleeding lacks an adequate therapeutic remedy. The aim of the present study was to evaluate the hemostatic effect of argon plasma coagulation on upper gastrointestinal active bleeding, especially in comparison with heater probe and pure ethanol injection therapy. Methods: Sixty‐eight patients with 77 lesions presenting active bleeding were treated endoscopically and divided into three groups depending on the procedures, that is, argon plasma coagulation group (27 patients with 32 lesions), heater probe group (20 patients with 22 lesions) and pure ethanol injection group (21 patients with 23 lesions). The three groups were similar with respect to all background variables. Episodes of rebleeding were retreated with the same modality as used previously. Results: The primary hemostatic rate in the argon plasma coagulation group was 81.3%, that in the heater probe group was 77.3%, and that in the pure ethanol injection group was 87.0%. The permanent hemostatic rate in the argon plasma coagulation group was 75.0%, that in the heater probe group was 63.6%, and that in the pure ethanol injection group was 78.3%. When examined in terms of Forrest's criteria, the argon plasma coagulation group in Forrest's type I b and the pure ethanol injection group in type I a showed the highest permanent hemostatic rate. Conclusions: Argon plasma coagulation is most suitable in arresting oozing hemorrhage. If pure ethanol injection therapy is possible, it is more effective than other therapies in the case of spurters.     

Gastrointestinale Blutungen

Structured patient management of suspected gastrointestinal bleeding necessitates a rapid risk stratification, if necessary stabilization of the patient, pre-endoscopic proton pump inhibitor and sometimes erythromycin. The transfusion regimen should be used restrictively. A suspected variceal bleeding should prompt administration of vasoconstrictors and antibiotics, which if confirmed should be continued after hemostasis. Emergency endoscopy can be performed independently of the coagulation status of the patient. Hemostasis of gastrointestinal bleeding is routinely performed endoscopically, e.?g. using hemoclips and if necessary combined with injection techniques. Novel treatment modalities, such as over-the-scope clips, hemostatic sprays and stents are helpful in specific situations. Biopsies are also possible during index endoscopy. For variceal bleeding in high-risk patients, the early insertion of a coated transjugular intrahepatic portosystemic shunt (TIPS) should be discussed. In refractory or recurrent esophageal variceal bleeding, a coated self-expanding metal stent can be inserted as a bridge to further management options. Hematochezia is caused by upper gastrointestinal bleeding in a significant percentage of patients. In lower gastrointestinal bleeding, early colonoscopy after intensified lavage ameliorates the detection of the source of bleeding.     

内镜下微波治疗非门脉高压上消化道出血

目的 :探讨内镜下微波治疗非门脉高压上消化道出血的疗效。方法 :将 6 2例有活动性出血的非门脉高压上消化道出血病例分 2组 ,比较内镜下微波治疗与过去传统治疗的效果。结果 :止血效果内镜下微波治疗优于传统治疗 ,近期再出血率、近期急诊手术率、平均住院时间及病死率均有显著性差异 (P <0 .0 5 )。本组治疗未见并发症。结论 :内镜下微波治疗非门脉高压上消化道出血疗效肯定 ,方法简便 ,经济 ,使用安全     

Massive gastric antral vascular ectasia successfully treated by endoscopic band ligation as the initial therapy

Gastric antral vascular ectasia(GAVE) accounted for 4% of non-variceal gastrointestinal hemorrhage.Even though unclear pathogenesis,GAVE often associated with chronic renal failure,autoimmune diseases and cirrhosis.Asymptomatic lesions were reasonably not to treated.The treatment options for GAVE are nonendoscopic and endoscopic treatments.For the pharmacological treatment,some success were reported for the use of octreotide,thalidomide and tranexamic acid.While the endoscopic treatment is the mainstay for treatment of symptomatic lesions.The endoscopic ablative therapies such as argon plasma coagulation was reported with good clinical outcomes.However,these treatment options had some limitation due to the need of special equipment and multiple sessions needed to control the bleeding.We reported another treatment option using the routine-achievable instrument such as endoscopic band ligation as an initial treatment which also provided a good treatment outcome and less sessions.     

Endoscopic hemostasis state of the art-Nonvariceal bleeding

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 clipping for the management of gastrointestinal bleeding

Endoscopic clipping is a safe and effective technique for the treatment of various bleeding gastrointestinal lesions. Randomized controlled trials and a meta-analysis have shown comparable efficacy between clipping and conventional contact thermal therapy for definitive hemostasis of nonvariceal upper gastrointestinal hemorrhage. Clipping also seems to be efficacious for selected lower gastrointestinal bleeding lesions, such as diverticular bleeding and postpolypectomy bleeding. Proficiency in clip application and endoscopic identification of lesions that are amenable to clipping are key determinants of a successful outcome.     

CLINICAL EVALUATION OF EMERGENCY ENDOSCOPIC HEMOSTASIS WITH BIPOLAR FORCEPS IN NON‐VARICEAL UPPER GASTROINTESTINAL BLEEDING

The present study was designed to evaluate the usefulness and safety of bipolar hemostatic forceps, known as a less invasive and highly safe means of thermal coagulation used for hemostasis in cases of non‐variceal upper gastrointestinal bleeding. This technique of bipolar forceps is simple, safe and unlikely to induce complications, and is therefore promising as a new technique of endoscopic hemostasis. The study involved 39 cases where hemostasis was attempted with bipolar forceps to deal with non‐variceal upper gastrointestinal bleeding, including 28 cases of gastric ulcer, six cases of duodenal ulcer, three cases of bleeding after endoscopic submucosal dissection (ESD), one case of Mallory‐Weiss syndrome and one case of postoperative bleeding from the anastomosed area. There were 34 males and five females, with a mean age of 63.6 years. Bipolar forceps were the first‐line means of hemostasis in cases of oozing bleeding (venous bleeding), pulsatile or spurting bleeding (arterial bleeding) and exposed vessels without active bleeding. The primary hemostasis success rate was 92.3%, and the re‐bleeding rate was 0%. In cases where the bleeding site was located along the tangential line or in cases where large respiration‐caused motions hampered identification of the bleeding site, hemostasis by means of coagulation was easily effected by application of electricity while the forceps were kept open and compressed the bleeding area. In addition, there were no complications. This technique of bipolar forceps is simple, safe and unlikely to induce complications, and is therefore promising as a new technique of endoscopic hemostasis.     

New and emerging technologies to endoscopically manage nonvariceal upper gastrointestinal bleeding

A subset of patients with nonvariceal upper gastrointestinal bleeding either fails or is deemed unsuitable for standard endoscopic hemostatic therapy. Newer endoscopic and endosonographic techniques have been developed to offer an alternative treatment and potentially improve patient outcome for the difficult-to-treat lesions. These alternative therapies include over-the-scope clip devices, radiofrequency ablation, cryotherapy, hemostatic sprays, endoscopic suturing, and endoscopic ultrasound-guided angiotherapy. This article serves to review these novel techniques that can be incorporated in the armamentarium to treat nonvariceal upper gastrointestinal bleeding.     

Culprit for recurrent acute gastrointestinal massive bleeding: &ldquo;Small bowel Dieulafoy&rsquo;s lesions&rdquo; - a case report and literature review

A Dieulafoy's lesion is a dilated, aberrant, submucosal vessel that erodes the overlying epithelium without evidence of a primary ulcer or erosion. It can be located anywhere in the gastrointestinal tract. We describe a case of massive gastrointestinal bleeding from Dieulafoy’s lesions in the duodenum. Etiology and precipitating events of a Dieulafoy’s lesion are not well known. Bleeding can range from being self-limited to massive life- threatening. Endoscopic hemostasis can be achieved with a combination of therapeutic modalities. The endoscopic management includes sclerosant injection, heater probe, laser therapy, electrocautery, cyanoacrylate glue, banding, and clipping. Endoscopic tattooing can be helpful to locate the lesion for further endoscopic re-treatment or intraoperative wedge resection. Therapeutic options for re-bleeding lesions comprise of repeated endoscopic hemostasis, angiographic embolization or surgical wedge resection of the lesions. We present a 63-year-old Caucasian male with active bleeding from the two small bowel Dieulafoy’s lesions, which was successfully controlled with epinephrine injection and clip applications.     

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.     

几种内镜下止血措施在非静脉曲张性上消化道出血中的选择应用

目的探讨内镜下不同止血措施在非静脉曲张性上消化道出血中的应用,评价其可行性、成功率及临床疗效。方法根据出血病因及内镜下改良Forrest分级,对112例非静脉曲张性上消化道出血患苦选择性使用：注射药物、氩离子凝固术（APC）、血管夹及注射联合氲离子凝固术等4种内镜下止血措施,观察其临床疗效并进行统计分析。结果112例非静脉曲张性出血患者,总的即时止血率98．2％（110／112）,再出血率12．7％（14／112）,未见明显并发症者,无死亡病例。注射组23例,即时止血率100％,有效止血率73．9％（17／23）,再出血率26．1％（6／23）;APC组29例,即时止血率100％,有效止血率86．2％（25／29）,再出血率13．8％（4／29）;血管夹组27例,即时止血率96．3％（26／27）,有效止血率92．6％（25／27）,再出血率3．8％（1／26）,明显低于注射组及APC组（P〈0．05）;联合组33例,即时止血率96．97％（32／33）,有效止血率87．9％（29／33）,再出血率9．4％（3／32）,低于单纯注射组（P〈0．05）。各组即时止血成功率差异无统计学意义（P〉0．05）。结论急诊内镜下止血起效迅速,疗效肯定,可成为非静脉曲张性出血的一线治疗方法,根据不同的出血病因选择合理的止血措施可提高止血成功率,降低再出血率。     

Vascular Malformations of the Small Intestine

Opinion statement Vascular malformations of the small bowel are uncommon, yet remain a cause of gastrointestinal bleeding in up to 5% of patients with gastrointestinal hemorrhage. The diagnosis of these lesions is suspected in patients with a gastrointestinal source of blood loss with a negative upper endoscopy and colonoscopy. Enteroscopy remains the mainstay in diagnosing these lesions. Therapeutic options include endoscopic coagulation, pharmacologic agents (hormones, octreotide, iron replacement), and occasionally surgery. Pharmacologic and endoscopic treatments are discussed.     

食管隆起病灶EMR术后创面出血内镜治疗33例

目的:探讨食管隆起病灶内镜下黏膜切除术(EMR)术后创面出血内镜不同止血方法,并分析疗效.方法:33例食管隆起病灶行EMR术合并创面出血,其中直接使用金属肽夹止血8例,余下25例首先采用内镜下喷洒药物止血,成功10例,继续出血的15例中7例采用黏膜注射止血,8例采用内镜下热凝止血,仍然有3例无效采用金属钛夹止血,术后6 wk复查内镜,观察创面愈合情况.结果:8例直接使用金属肽夹止血均成功,25例采用喷洒药物止血成功10例;15例止血无效,对其中7例采用注射药物止血,成功6例;8例采用热凝止血成功6例,剩余3例止血仍然无效加用钛夹止血均成功.术后6 wk内镜复查,创面愈合良好.结论:对于食管隆起病灶EMR术后创面出血,内镜止血方法多样,操作简单、安全、效果好,值得推广.     

Management of bleeding and artificial gastric ulcers associated with endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD), an endoscopic procedure for the treatment of gastric epithelial neoplasia without lymph node metastases, spread rapidly, primarily in Japan, starting in the late 1990s. ESD enables en bloc resection of lesions that are difficult to resect using conventional endoscopic mucosal resection (EMR). However, in comparison to EMR, ESD requires a high level of endoscopic competence and a longer resection time. Thus, ESD is associated with a higher risk of adverse events, including intraoperative and postoperative bleeding and gastrointestinal perforation. In particular, because of a higher incidence of intraoperative bleeding with mucosal incision and submucosal dissection, which are distinctive endoscopic procedures in ESD, a strategy for endoscopic hemostasis, mainly by thermo-coagulation hemostasis using hemostatic forceps, is important. In addition, because of iatrogenic artificial ulcers that always form after ESD, endoscopic hemostasis and appropriate pharma-cotherapy during the healing process are essential.