Endoscopic injection sclerosis: effective treatment for bleeding peptic ulcer.

One hundred and nine patients presenting with severe haemorrhage from benign peptic ulcers were randomised to either endoscopic injection sclerotherapy using a combination of 1:100,000 adrenaline and 5% ethanolamine or to conservative treatment. Only high risk patients with active bleeding or endoscopic stigmata of recent haemorrhage and accessible ulcers were considered. The two groups were well matched for age, shock, haemoglobin concentration, endoscopic findings, and consumption of non-steroidal anti-inflammatory drugs. The group treated endoscopically had a significantly reduced rebleeding rate (12.5% v 47%, p less than 0.001). Rebleeding was successfully treated in some patients by injection sclerotherapy, other patients underwent urgent surgery. While there was a tendency towards a lower operation rate and lower transfusion requirements in the treated group, this failed to achieve statistical significance. The use of injection sclerotherapy in the conservatively treated group after rebleeding undoubtedly reduced the number of surgical operations. Endoscopic injection sclerotherapy is effective in the prevention of rebleeding in these patients.     

Endoscopic hemoclip treatment for bleeding peptic ulcer

AIM To evaluate the efficacy of endoscopic hemoclip in the treatment of bleeding peptic ulcer.METHODS Totally, 40 patients with F1a and F1b hemorrhagic activity of peptic ulcers were enrolled in this uncontrolled prospective study for endoscopic hemoclip treatment. We used a newly developed rotatable clip-device for the application of hemoclip (MD850) to stop bleeding. Endoscopy was repeated if there was any sign or suspicion of rebleeding, and reclipping was performed if necessary and feasible.RESULTS Initial hemostatic rate by clipping was 95%, and rebleeding rate was only 8%.Ultimate hemostatic rates were 87%, 96%, and 93% in the F1a and F1b subgroups, and total cases, respectively. In patients with shock on admission, hemoclipping achieved ultimate hemostasis of 71% and 83% in F1a and F1b subgroups, respectively. Hemostasis reached 100% in patients without shock regardless of hemorrhagic activity being F1a or F1b. The average number of clips used per case was 3.0 (range 2- 5). Spurting bleeders required more clips on average than did oozing bleeders (3.4 versus 2.8 ). We observed no obvious complications, no tissue injury, or impairment of ulcer healing related to hemoclipping.CONCLUSION Endoscopic hemoclip placement is an effective and safe method. With the improvement of the clip and application device,the procedure has become easier and much more efficient. Endoscopic hemoclipping deserves further study in the treatment of bleeding peptic ulcers.     

The hemostatic effect of endoscopic sodium hyaluronate injection in peptic ulcer bleeding

BACKGROUND/AIMS: Endoscopic injection therapy is a well-established method of controlling peptic ulcer bleeding but it is not clear which agent would be the best choice for injection material. In this study, we evaluated the effect of Sodium Hyaluronate for control of ulcer bleeding. METHODOLOGY: The subjects consisted of 26 patients with major peptic ulcer hemorrhage from June 2000 to August 2001. There were 17 gastric ulcers, 7 duodenal ulcers and 2 ulcers at anastomosis site. According to modified Forrest classifications, there were 7 active bleeding (spurting, 3; oozing, 4) and 19 stigmata of recent hemorrhage (visible vessel, 14; fresh blood clots, 5). Sodium Hyaluronate-saline solution was injected to control the bleeding. The initial and permanent hemostatic rate, rebleeding rate, and other complications were retrospectively evaluated. RESULTS: The initial hemostatic rate was 25/26 (96.2%) and re-bleeding rate 3/26 (11.5%). The success rate of the second trial of Sodium Hyaluronate injection was 3/3 (100%). Overall, the permanent hemostatic rate was 25/26 (96.2%) and there were no complications related to Sodium Hyaluronate injection. CONCLUSIONS: Sodium Hyaluronate is an excellent candidate agent for endoscopic injection therapy because of its convenience and safety. Further prospective randomized trials with other hemostatic methods are needed.     

Endoscopic hemostasis by using the TriClip for peptic ulcer hemorrhage: a pilot study

BACKGROUND: The feasibility, efficacy, and safety of the TriClip in the management of peptic ulcer hemorrhage in human beings are scarcely reported in the literature. OBJECTIVE: A pilot study was conducted to assess the feasibility, efficacy, and safety of the TriClip endoscopic clipping device in the control of peptic ulcer hemorrhage. DESIGN: Prospective evaluation. SETTING: Regional government hospital. PATIENTS: From July 2004 to January 2005, patients older than 16 years and with Forrest type I and IIa peptic ulcer hemorrhages were included in the study. INTERVENTIONS: TriClips were used for initial hemostasis. Salvage procedures, including adrenalin injection, heat probe application, argon plasma coagulation, or surgery will be carried out appropriately if TriClip failed to control bleeding alone. An endoscopy was repeated 24 hours later for the security of the TriClip and for any endoscopic evidence of recurrent bleeding. A follow-up endoscopy was performed 8 weeks later to assess ulcer healing. MAIN OUTCOME MEASUREMENTS: Procedure time, successful hemostatic rate, number of clips used, ulcer recurrent bleeding rate, complications, and ulcer healing rate were measured. LIMITATIONS: No comparative arm; pilot study only. RESULT: A total of 27 cases (11 women, 16 men) were included in the study, with a median age of 70 years (range 18-88 years). There were 19 cases of duodenal ulcer and 8 cases of gastric ulcer, with median size of 8 mm (range 2-20 mm). The rate of successful hemostasis in the first endoscopy by TriClips alone was 81.5% (22/27), with a median procedure time of 10 minutes (range 3-30 minutes). In the second endoscopy, the endoscopic recurrent bleeding rate was 14.8% (4/27) and the TriClips were found dislodged in 11 patients (40.7%). The permanent hemostasis rate was 67% (18/27). The overall failure rate was 33% (9/27). Three patients required blood transfusion before the first endoscopy. There was no morbidity or mortality observed in all cases. All ulcers healed after 8 weeks. CONCLUSIONS: The use of the TriClip is feasible in the initial control of peptic ulcer hemorrhage. However, we could not detect any obvious advantages in arresting bleeding vessels by using this new clipping device.     

Endoscopic hemostasis of a bleeding marginal ulcer: hemoclipping or dual therapy with epinephrine injection and heater probe thermocoagulation

BACKGROUND AND AIMS: Endoscopic hemoclipping and dual therapy with epinephrine injection and heater probe thermocoagulation have been proven effective in the hemostasis of bleeding peptic ulcers. However, the hemostatic efficacy has not been investigated in bleeding marginal ulcers. The aim of this study is to investigate the hemostatic efficacy of endoscopic hemoclipping and dual therapy with epinephrine injection and heater probe thermocoagulation in bleeding marginal ulcers. METHODS: From November 1997 to July 2000, 50 patients with active marginal ulcer bleeding underwent either hemoclipping (20 patients) or dual therapy (30 patients) for hemostasis. The demographic data, clinicopathological characteristics, endoscopic findings, initial hemostatic rates, rebleeding rates, amount of blood transfusion, the need of surgery, and mortality rates were collected and analyzed. RESULTS: Marginal ulcers were located at the anastomotic site (64%), saddle portion (22%), efferent loop (10%), or at the afferent loop (4%). The bleeding stigmata were classified into spurting artery (32%), oozing vessel (38%), visible vessel (20%), and blood clot adhesion (10%). The overall therapeutic results in 50 patients were initial hemostasis (100%), rebleeding rate (22%), need for surgery (4%), and hospital mortality rate (4%). There was no significant difference in demographic data and clinicopathological characteristics between the two modes of treatments, whereas recurrent bleeding developed in 5% in the hemoclipping group and 33% in the dual therapy group. No complication related to the procedure occurred in either mode of therapy. The hospital mortality rates were 0 and 6.7%, respectively. CONCLUSION: Endoscopy is effective in achieving initial hemostasis from bleeding marginal ulcers. However, the rebleeding rate remains high and repeated endoscopy may be needed to arrest the hemorrhage.     

Limitations of endoscopic haemostasis by ethanol injection and surgical management for bleeding peptic ulcer

Abstract Two hundred and fifty-three patients with bleeding peptic ulcer underwent therapeutic endoscopy using local ethanol injection and were evaluated to determine the need for surgery and outcome. Permanent endoscopic haemostasis was achieved in 178 (70.4%) cases. Pulsatile arterial bleeding in ulcers and shock on admission (respectively, P < 0.01, P < 0.05) were significantly more frequent in patients with unsuccessful endoscopic treatment. Postoperative stay was significantly longer ( P < 0.05) for patients with bleeding peptic ulcer than for patients requiring surgery for intractable ulcer without bleeding. Surgery was recommended if three attempts at endoscopic treatment did not achieve permanent haemostasis. The need for more than three such treatment sessions and the presence of a large excavated ulcer with an exposed vessel in an elderly patient were considered to indicate the necessity for surgery. Surgical procedures to which the operator is accustomed and intensive management were recommended for emergency cases to optimize the likelihood of survival.     

联合应用内镜注射和热凝治疗消化性溃疡出血

目的观察评价内镜注射肾上腺素、热探头热凝治疗和联合上述两种方法治疗消化性溃疡出血的疗效。方法１０２例消化性溃疡出血患者分为三组,其中内镜注射组３７例,热凝治疗组３１例,内镜注射联合热凝治疗组３４例。结果４８小时止血率在三组分别为８６．５％、８７．１％和９７．１％。一周内再出血率分别为１３．５％、９．７％和８．８％,手术率为１６．２％、１６．１％和８．８％。观察期间未发生严重并发症,无一例死亡。联合治疗组的４８小时止血率高于其他二组（Ｐ＜０．０５）;一周内再出血率低于内镜注射组（Ｐ＜０．０５）,与热凝治疗组没有明显差别（Ｐ＞０．０５）;手术率低于其他二组（Ｐ＜０．０５）。结论联合应用内镜注射和热探头热凝治疗可以提高消化性溃疡出血的止血率、降低近期再出血率和外科手术率。     

内镜下注射治疗消化性溃疡并出血的临床应用评价

目的探讨内镜下注射止血的临床意义。方法2001年7月至2002年8月因呕血和(或)黑便入院，经紧急内镜检查确诊为消化性溃疡并出血患81例．分成内科保守治疗和内镜注射止血治疗二组，内镜组在内科保守治疗的基础上，内镜下于出血灶注射HLGE液。结果内镜组42例，止血成功率95．24％，对照组39例，止血成功率79．49％，二组有显性差异。结论内镜注射止血治疗简单有效，降低手术率和再出血率。     

Endoscopic Doppler ultrasound after injection therapy for peptic ulcer hemorrhage

BACKGROUND/AIMS: A positive Doppler signal in endoscopic Doppler ultrasound at index endoscopy predicts a high risk for rebleeding from peptic ulcer. The aim of this study was to evaluate if a negative Doppler status immediately after injection therapy may exclude a rebleeding from peptic ulcer in a high-risk cohort. METHODOLOGY: Twenty consecutive patients (pts) (age: 68 (33-91) yrs; 11 female) with peptic ulcer bleeding were enrolled. All patients with an actively bleeding ulcer and those with a non-actively bleeding, but Doppler-positive ulcer were treated by injection of adrenaline (1:10,000 dilution). Treatment was performed during index endoscopy until the Doppler status was negative. Patients were followed-up clinically and endoscopically (including Doppler ultrasound) for bleeding recurrence. RESULTS: Patients were treated by injection of 12 (6 to 20) mL of adrenaline solution until Doppler scan was negative. During follow-up four pts (20%) had a clinically overt rebleeding episode. At control endoscopy three ulcers were actively bleeding and another two were Doppler positive without rebleeding (total: five of eighteen (27.7%) Doppler-positive ulcers). Two of the twenty pts required surgical therapy due to rebleeding (10%). CONCLUSIONS: A negative endoscopic Doppler status immediately after injection therapy is not helpful to identify patients with no risk for rebleeding from peptic ulcer.     

A prospective, randomized trial comparing mechanical methods of hemostasis plus epinephrine injection to epinephrine injection alone for bleeding peptic ulcer

BACKGROUND: The hemostatic efficacy of mechanical methods of hemostasis, together with epinephrine injection, was compared with that of epinephrine injection alone in bleeding peptic ulcer. METHODS: Ninety patients with a peptic ulcer with active bleeding or a non-bleeding visible vessel were randomly assigned to undergo a mechanical method of hemostasis (23 hemoclip application, 22 band ligation) plus epinephrine injection, or epinephrine injection alone. RESULTS: The two groups were similar with respect to all background variables. Initial hemostasis was achieved in 44/45 (97.8%) patients in both groups. The mean number of hemoclips and elastic bands applied were 2.8: 95% CI[2.5, 3.1] and 1.1: 95% CI[1.0, 1.2], respectively, and the mean volume of epinephrine injected was 19.9 mL: 95% CI[19.3 mL, 20.5 mL]. The rate of recurrent bleeding in the combination group (2/44, 4.5%) was significantly lower in comparison with the injection group (9/44, 20.5%, p < 0.05). The mean number of therapeutic endoscopic sessions needed to achieve permanent hemostasis in the combination group (1.04: 95% CI[1.01, 1.07]) was significantly lower vs. the injection group (1.22: 95% CI[1.15, 1.30]). CONCLUSIONS: The combination of an endoscopic mechanical method of hemostasis plus epinephrine injection is more effective than epinephrine injection alone for the treatment of bleeding peptic ulcer.     

Endoscopic injection therapy for bleeding peptic ulcer; a comparison of adrenaline alone with adrenaline plus ethanolamine oleate.

One hundred and seven consecutive patients presenting with significant peptic ulcer haemorrhage were randomised to endoscopic injection with 3-10 ml of 1:100,000 adrenaline (55 patients, group 1) or to a combination of adrenaline and 5% ethanolamine (52 patients, group 2). All had major stigmata of haemorrhage and endoscopic injection was undertaken by a single endoscopist. The groups were well matched with regard to risk factors. Rebleeding occurred in eight of the group 1 patients and seven in the group 2 patients; surgical operation rates, median blood transfusion requirements, and hospital stay were similar in both groups. The efficacy of either form of injection was similar whether patients presented with active bleeding or a non-bleeding visible vessel. No complications occurred. In patients presenting with significant peptic ulcer bleeding, the addition of a sclerosant confers no advantage over injection with adrenaline alone.     

Endoscopic injection with fibrin sealant versus epinephrine for arrest of peptic ulcer bleeding: a randomized,comparative trial

BACKGROUND: endoscopic epinephrine and fibrin injection in the treatment of bleeding peptic ulcer are reported to be safe, effective, and easy to use. However, a wide range of rebleeding rates has been reported with epinephrine injection. GOALS: to compare the hemostatic effects of endoscopic injection with fibrin sealant versus epinephrine. STUDY: between December 1998 and July 2000, 51 patients with active bleeding or nonbleeding visible vessels entered this trial. The clinical parameters were comparable between both groups. In the epinephrine group, we injected 5 to 10 mL of 1:10,000 epinephrine, surrounding the bleeder. In the fibrin sealant group, we injected fibrin sealant 4 mL, surrounding the bleeder. RESULTS: initial hemostasis was obtained in all enrolled patients. Rebleeding was more in the epinephrine group than in the fibrin sealant group (4 [15%] of 26 vs. 14 [56%] of 25, = 0.003 on the intention-to-treat basis, and 4 [16.7%] of 24 vs. 14 [58.3%] of 24, = 0.003 on the per protocol basis, respectively). Volume of blood transfusion, number of surgeries, hospital stay, and number of deaths were similar between both groups. CONCLUSION: fibrin sealant injection is more effective in preventing rebleeding than epinephrine after endoscopic therapy, but this study showed no difference in outcomes with either therapy.     

Endoscopic haemoclip versus heater probe thermocoagulation plus hypertonic saline–epinephrine injection for peptic ulcer bleeding

Background. Treating patients of bleeding peptic ulcers with heater probe thermocoagulation and haemoclip is considered to be safe and very effective. Yet, there is no report comparing the haemostatic effects of endoscopic haemoclip versus heater probe thermocoagulation plus hypertonic saline–epinephrine injection in these patients.

Aim. To compare the clinical outcomes of both therapeutic modalities in patients with peptic ulcer bleeding.

Methods. A total of 93 patients with active bleeding or non-bleeding visible vessels were randomised to receive either endoscopic haemoclip (n=46) or heater probe thermocoagulation plus hypertonic saline–epinephrine injection (n=47). Five patients from the haemoclip group were excluded because of the inability to place the haemoclip.

Results. Initial haemostasis was achieved in 39 patients (95.1%) of the haemoclip group and 47 patients (100%) of the heater probe group (P>0.1). Rebleeding occurred in four patients (10.3%) of the haemoclip group and three patients (6.4%) of the heater probe group (P>0.1). The volume of blood transfused after entry into the study, duration of hospital stay, number of patients requiring urgent surgery and the mortality rates were not statistically different between the two groups.

Conclusions. If the haemoclip can be applied properly, the clinical outcomes of the haemoclip group would be similar to those of the heater probe group in patients with peptic ulcer bleeding. However, if the bleeders are located at the difficult-to-approach sites, heater probe plus hypertonic saline injection is the first choice therapy.