Overlooked lesions at emergency endoscopy for acute nonvariceal upper gastrointestinal bleeding

BACKGROUND AND STUDY AIMS: Excessive blood covering the examination field is a frequent cause of diagnostic failure in emergency endoscopy for acute upper gastrointestinal bleeding. The implications and outcome in these patients have not been well described. PATIENTS AND METHODS: The records for 1459 consecutive patients who presented at our medical center with acute nonvariceal upper gastrointestinal bleeding during a 15-month period were reviewed. All of the patients underwent emergency endoscopy within 24 h of initial presentation. Patients in whom an identifiable bleeding source was not found in spite of an overtly bloody lumen were designated as having a failure of diagnosis, and these cases were analyzed further. RESULTS: Diagnosis failed in 25 patients (1.7 %), 16 of whom underwent repeat endoscopy or surgical intervention. Bleeding vessels were identified in 13 of these patients. Gastric and duodenal ulcers were the most commonly overlooked lesions, with locations in the cardia (n = 3), fundus (n = 2), posterior wall of the antrum (n = 1), duodenal bulb (n = 3), second part of the duodenum (n = 2), and in the stoma of a Billroth II gastrectomy (n = 2). The rates for endoscopic complications, recurrent bleeding, surgery, and mortality were significantly higher in the group with diagnostic failure than in patients with acute upper gastrointestinal bleeding in whom diagnosis did not fail (8 % vs. 0.4 %; 20 % vs. 3.1 %; 16 % vs. 2.9 %; and 20 % vs. 3.6 %, respectively). CONCLUSIONS: In acute nonvariceal upper gastrointestinal bleeding, diagnostic failure is associated with higher morbidity and mortality. The data from this study emphasize the importance of good preparation before the procedure and adequate removal of blood during emergency endoscopy procedures.     

急诊内镜检查在上消化道出血中的应用

目的探讨急诊内镜检查在上消化道出血患者中的临床应用价值。方法回顾性分析2003年10月至2007年5月因上消化道出血于48h内行急诊内镜检查159例患者的临床资料，对比分析不同时间内镜检查的差异以及检查前冰盐水洗胃与否对检查结果的影响。结果急诊内镜检查确诊率为94．97％，不同时间内镜检查确诊率不同，发生出血后24h内行内镜检查其确诊率明显提高，与24～48h相比差异有显著性（P〈0．01）。内镜检查前洗胃与否两组对比分析无明显差异（P〉0．05），所有患者均未发生严重并发症。结论急诊内镜检查是安全有效的，尽早行内镜检查可提高诊断准确率，内镜检查前无需冰盐水洗胃。     

Complications of endoscopy of the upper gastrointestinal tract: a single-center experience

OBJECTIVE: To evaluate prospectively the complications that occurred during consecutive endoscopies of the upper gastrointestinal tract. PATIENTS AND METHODS: We evaluated all endoscopies of the upper gastrointestinal tract (except endoscopic retrograde cholangiopancreatography and endosonography) performed at the Ambulatory Surgical Center at the Mayo Clinic in Jacksonville, Fla, between January 1999 and June 2002. A staff gastroenterologist with or without a trainee performed these procedures. Therapeutic procedures included esophageal band ligation, injection sclerotherapy, botulinum toxin injection, extended upper endoscopy, pneumatic balloon dilation, endoscopic mucosal resection, and endoscopic ablation using thermal laser, argon beam coagulator, or photodynamic therapy. All complications were tabulated prospectively as per mandatory state licensure reporting. RESULTS: Complications after diagnostic endoscopy of the upper gastrointestinal tract were related to anesthesia in 2 of the 12,841 patients. Perforations in 5 patients were associated with esophageal dilation (2), resection of duodenal lesions (2), or passage of a side-viewing instrument into the duodenum (1). No deaths occurred. CONCLUSIONS: Diagnostic endoscopy of the upper gastrointestinal tract is safe, with a complication rate of less than 1 per 5000 cases. Therapeutic endoscopy increases the risk of complications. Compared with complication rates published previously, our results from a single center indicate a favorable reduction in complications related to endoscopy of the upper gastrointestinal tract.     

老年人上消化道出血的急诊胃镜治疗分析

目的探讨对老年上消化道出血患者行急诊胃镜的疗效。方法以老年上消化道出血患者42例为治疗组,在胃镜下根据出血情况采用套扎止血、药物喷洒、金属钛夹等方法止血。以同期收治的不愿接受胃镜治疗的老年上消化道出血患者40例为对照组,采用内科传统治疗方法。结果治疗组中37例止血成功,5例止血失败而行手术治疗,胃镜下止血成功率88.10%;对照组27例止血成功,13例行手术治疗,内科止血成功率67.50%。治疗组止血成功率较对照组高,经χ2检验,差异具有统计学意义(P<0.05)。结论针对老年人上消化道出血患者,急诊胃镜下止血效果好。     

Efficacy and safety of nurse-administered propofol sedation during emergency upper endoscopy for gastrointestinal bleeding: a prospective study

BACKGROUND AND STUDY AIMS: Recent studies have documented the safety of propofol sedation for endoscopic procedures, but many endoscopists are reluctant to use propofol for high-risk patients because of adverse effects. The aim of this study was to demonstrate the safety and efficacy of nurse-administered propofol sedation during emergency upper endoscopy for patients with gastrointestinal bleeding. PATIENTS AND METHODS: Over a period of 18 months, 120 patients suffering from acute upper gastrointestinal bleeding received propofol sedation administered by a registered nurse. Among these, 15 patients were classified into American Society of Anesthesiologists (ASA) class IV, 84 were ASA class III, and 21 were ASA class II. Patients without gastrointestinal bleeding, who also received propofol during the same period and were matched for age, gender, and ASA class, served as controls. RESULTS: Endoscopic hemostasis was achieved in 98.3 % of patients, and 97.5 % were satisfied with the procedure. In patients with gastrointestinal bleeding, the rates of hypotension (systolic blood pressure < 90 mmHg) and hypoxemia (peripheral oxygen saturation < 90 %) were 8.3 % and 6.7 % respectively, values higher than those in the control group. However, neither mask ventilation nor endotracheal intubation was necessary. Although two patients with gastrointestinal bleeding developed pneumonia, most likely due to aspiration during the procedure, they recovered within 5 days of treatment. There were no sedation-associated severe complications or mortalities. CONCLUSION: Using a strict protocol designed to protect the patient's airway and cardiovascular function, nurse-administered propofol sedation during emergency upper gastrointestinal endoscopy is safe and appropriate in cases of acute gastrointestinal bleeding.     

急诊上消化道出血186例临床分析

目的:探讨急诊科上消化道出血的病因构成及特点.方法:回顾性分析我科2010年1月至2012年1月诊治的186例上消化道出血患者的临床资料.结果:(1)上消化道出血主要病因为消化性溃疡46.9％、急性胃黏膜病变12.7％、肝硬化9.0％、胃癌7.2％,贲门撕裂症6.0％.(2)急诊内镜诊断明确的阳性率(95.6％)显著高于非急诊内镜(81.3％),P＜0.01.(3)服用非甾体消炎药(NSAIDs)患者急性胃黏膜病变发生率(39.5％)明显高于未服用者(4.1％),P＜ 0.01;服用NSAIDs患者消化性溃疡发生率(52.6％)虽高于未服用者(39.2％),但差异无统计学意义,P＞ 0.05.结论:服用NSAIDs是上消化道出血的重要原因,急性胃黏膜病变发生率较前有所增加,急诊内镜检查有助于上消化道出血的诊断.     

The outcome of suspected upper gastrointestinal bleeding with 24-hour access to upper gastrointestinal endoscopy: a prospective cohort study

BACKGROUND AND STUDY AIM: The aim was to evaluate the 30-day mortality after endoscopy for suspected upper gastrointestinal bleed, following the implementation of national audit guidelines at our hospital. PATIENTS AND METHODS: All patients with suspected upper gastrointestinal bleeding, referred for endoscopy to our teaching hospital between October 2001 and December 2003, were included in a prospective cohort study. RESULTS: A total of 716 patients with suspected upper gastrointestinal tract haemorrhage were referred for urgent endoscopy. The median age was 69 years (interquartile range 51 - 80 years). Bleeding from peptic ulcer remained the single most common endoscopic diagnosis (40 %). The overall re-bleeding rate for all patients with a gastrointestinal haemorrhage was 10 %. The overall 30-day mortality rate was 14.6 %. This was not significantly different from the mortality rate in 1995 of 10.5 % ( P = 0.11). Patients who died were significantly older (78 vs. 67 years, 95 %CI of the difference 5 to 12, P < 0.001). However, in only 29 % (30/105) was gastrointestinal haemorrhage stated in the death certificate as a factor which contributed to their death. CONCLUSIONS: Our results show that implementing the good practice guideline has a limited impact on overall mortality because of contributing factors that are beyond the control of clinicians.     

Emergency endoscopy in acute upper gastrointestinal bleeding (author's transl)]

A report is given of 135 panendoscopic examinations in acute upper gastrointestinal bleeding. The importance of endoscopy is underlined by the high incidence of erosions and potential bleeding sources, since these lesions are not detected by radiological examination. Nor is it possible by means of X-rays to distinguish actual sources of haemorrhage from potential sources. The case history is only of limited value in pin-pointing the source of the haemorrhage. Endoscopy yields the best results in the diagnosis of the cause of gastrointestinal bleeding.     

A new and effective technique of Yag laser photocoagulation for severe upper gastrointestinal bleeding

A new technique of treating acute severe upper gastrointestinal haemorrhage was evaluated. The technique consisted of epinephrine injections in the bleeding lesion combined with YAG laser radiation in short pulses, applied until the bleeding vessel was completely closed. This new treatment modality was tried in 54 consecutive patients with severe upper gastrointestinal bleeding from a spurting artery, or an ulcer with a non-bleeding visible vessel in the floor of the ulcer crater at endoscopy. Permanent haemostasis was achieved in 87% of the 54 patients. Emergency surgery was needed in 13%. The mortality rate was only 10%. No complications occurred. It is concluded that this new technique of treating severe upper gastrointestinal bleeding from a spurting artery, or an ulcer with a visible vessel results in a significant improvement of the success rate (permanent haemostasis) and a marked reduction in the mortality rate.     

The diagnosis of the site of upper gastrointestinal haemorrhage in patients with established portal hypertension.

Seventy-five endoscopies were performed in 60 patients known to have oesophageal varices presenting with further upper gastrointestinal haemorrhage during the previous 72 hours. A site of active bleeding was found at 50 of 75 examinations (67 percent) including all 21 patients endoscoped within three hours of the last haemorrhage. Variceal bleeding alone was seen in 40 of these 50 examinations (80%) and both varices and mucosal lesions were bleeding in 4 patients; mucosal lesions were an uncommon cause of haemorrhage and only 6 patients were bleeding from these alone. The adult GIF-D2 endoscope was used for 45 examinations. Variceal bleeding was restarted on three occasions and prolonged unconsciousness induced by intravenous diazepam in one patient. In contrast, the paediatric GIF-P endoscope (30 examinations) was easily tolerated with little or no sedation, did not impair diagnostic accuracy and was not associated with any complications.     

术中内镜检查对上消化道大出血的诊断意义

该文报告对上消化道大出血病人术中施行内镜检查28例，其中经口腔插镜10例，经胃肠切口置镜18例。发现出血病灶26例（92.9％）。经手术治愈25例，死亡3例。其中2例镜检时分不清真正出血原因，水后再度出血死亡，1例镜检时出现心跳骤停，水后昏迷死亡。文中就水中镜检的指征、方法、镜检与手术探查的关系及临床应用应注意的问题进行了讨论。     

Esophageal visible vessel as a cause of massive upper gastrointestinal hemorrhage

Besides peptic ulcers, erosions, esophageal varices, tumors and non-variceal esophageal lesions, vascular abnormalities lead to an upper gastrointestinal hemorrhage in 1-5% of cases. Among 581 emergency esophagogastro-duodenoscopies for acute gastrointestinal bleeding performed in our institution between 1987 and 1989, an esophageal visible vessel was found to be the source of massive hemorrhage in five patients. All patients were males with ages ranging from 37 to 84 years. Esophageal visible vessel was localized in one patient in the middle third and in four patients in the distal portion of the esophagus. Using the Forrest classification, endoscopy revealed an oozing hemorrhage (Ib) in two patients and a protruding vessel (IIa) in three patients. Definitive hemostasis could be achieved in all patients by local injection of adrenaline combined with heater probe thermocoagulation. In some patients with recurrent upper gastrointestinal bleeding, visible esophageal vessel is a rare source of bleeding that has not yet been described.     

Gut dysfunction and endoscopic lesions after out-of-hospital cardiac arrest

BACKGROUND: Cardiac arrest induces severe mesenteric ischaemia. The objective of this study was to assess the frequency of gut dysfunction and endoscopic lesions following resuscitation after cardiac arrest, and to evaluate the potential value of gut endoscopy performance in these circumstances. METHODS: This is a retrospective data files survey of 3617 patients from the database in a medical intensive care unit. A systematic review of medical and endoscopic files was performed within this database, using a standardised chart. PATIENTS: One-hundred and thirty consecutive patients who survived up to 48 h were admitted to our unit after out-of-hospital cardiac arrest. Seventy-eight of these patients (60%) presented with early clinical signs of gut dysfunction and/or lesions. Thirty-six patients underwent gut endoscopies (26%) and were included in the survey. RESULTS: Endoscopic lesions were observed in all cases; in 15 cases, gastrointestinal haemorrhage requiring intervention was identified. The occurrence of haemorrhagic and/or necrotic lesions was found to be associated with an initial rhythm of asystole, higher SAPS II values and epinephrine requirements, compared with cardiac arrest patients without such lesions. CONCLUSION: The frequent occurrence of endoscopic lesions in the presence of gut dysfunction following a cardiac arrest could suggest systematic gut endoscopy in such patients. However, an alternative recommendation would be to watch these patients very closely, treat all with prophylactic proton pump inhibitors, and endoscope only those with evidence of bleeding.     

79例老年上消化道出血临床分析

目的 :探讨老年上消化道出血的原因和不同制酸剂对出血的治疗效果。方法 :对我院 1998年 1月至2 0 0 4年 6月共 79例老年上消化道出血患者的临床资料进行回顾性分析。男 4 5例 ,女 34例 ,年龄 6 0～ 85岁 ,平均 6 7 6岁 ,患者被随机分为两组分别接受洛赛克和法莫替丁治疗。统计治疗 3天的总有效率和引起出血的原发疾病百分比。结果 :引起出血的原发疾病中 ,胃、十二指肠溃疡 30例 (38 0 %) ,胃黏膜病变 2 8例 (35 4 %) ,门静脉高压症并发食管静脉曲张破裂出血 14例 (17 7%) ,上消化道肿瘤 5例 (6 3%) ,其他 2例 (2 5 %)。洛赛克组总有效率 95 2 %,法莫替丁组总有效率 78 4 %(P <0 0 5 )。结论 :老年上消化道出血主要由胃、十二指肠溃疡和胃黏膜病变引起。质子泵抑制剂洛赛克治疗老年上消化道出血疗效显著。     

Upper gastrointestinal haemorrhage in Emergency Departments in France: causes and management.

OBJECTIVES: Little is known about the epidemiology of acute upper gastrointestinal haemorrhage hospitalized in Emergency Departments. Most of the studies concerning digestive bleeding have been carried out by Gastroenterology Departments. This multicentre study included consecutive patients with acute upper gastrointestinal haemorrhage hospitalized after an initial management at Emergency Departments in France, to describe the initial medical management and to determine the causes of acute upper gastrointestinal haemorrhage. We also studied the relationship between the use of non-steroidal anti-inflammatory drugs or aspirin and the occurrence of an acute upper gastrointestinal haemorrhage by a case-control comparison. RESULTS: A total of 180 patients (112 men, 59+/-18 years) were included during 23 days, and 353 controls (222 men, 57+/-13 years) were selected at the same time. The delay between the first clinical signs of acute upper gastrointestinal haemorrhage and arrival at the Emergency Department was 33+/-42 h, and endoscopy was performed 14+/-16 h after admission to the Emergency Department. Sixty-six percent of patients with cirrhosis could benefit from a specific vasoactive treatment. Endoscopy was performed in 160 patients. Bleeding was caused by ulcers and gastritis in 88 patients (49%) and portal hypertension in 59 (32%). The relationship between the use of non-steroidal anti-inflammatory drugs or aspirin and acute upper gastrointestinal haemorrhage was confirmed, odds ratio, (OR) 1.69 [95% confidence interval (CI) 1.15-2.33], but not among cirrhotic patients, odds ratio 1.12 (95% CI 0.65-1.86). CONCLUSION: Hospitalized acute upper gastrointestinal haemorrhage in Emergency Departments in France is more often caused by cirrhosis than in other countries. Decreasing the delay between the first signs of bleeding and arrival at the Emergency Department is the main challenge in the management of acute upper gastrointestinal haemorrhage.     

Efficacy of absolute ethanol injection for upper gastrointestinal massive bleedings with hemorrhagic shock

We applied the absolute ethanol injection method in 182 cases of massive bleeding with hemorrhagic shock before the performance of emergency endoscopy in 627 cases of upper gastrointestinal bleeding at our department and five related institutions since June 1979. Following results were obtained: Temporary hemostasis could not be obtained in only 2 (1.1%) out of 182 cases; in the remaining 180 cases bleeding was ceased. Rebleeding was seen in 15 cases (8.2%) and new bleeding in 17 cases (9.3%). In 21 (66%) of these cases hemostasis was obtained again by the absolute ethanol injection method. Eight patients (4.4%) underwent emergency operation and 4 patients (2.2%) died from bleeding. The complete hemostasis was obtained in 170 cases (93.4%).     

术中内镜在急性消化道大出血急诊剖腹探查术中的应用价值

目的 探讨术中内镜在急性消化道大出血患者行急诊剖腹探查术中的应用价值及其安全性。方法对25例急性消化道大出血行急诊剖腹探查的患者进行术中内镜检查，评价其应用价值。结果25例术中内镜检查有24例明确了出血原因，检出率达96．0％。术中内镜平均用时13min，无一例术中内镜受检者发生术中内镜相关性并发症。所有患者均根据术中内镜诊断进行了相关手术治疗，术后无一例再出血。结论急性消化道大出血患者术中内镜的应用，不仅提高了病变的检出率，而且能对病灶进行准确定位与定性，可提高剖腹探查的成功率。     

Low utility of endoscopy for suspected upper gastrointestinal bleeding occurring in hospitalized patients

OBJECTIVES: To determine the clinical utility of upper endoscopy in patients who have upper gastrointestinal bleeding after hospitalization. METHODS: Patients were studied who underwent upper endoscopy for an indication of suspected upper gastrointestinal bleeding that developed more than 48 hours after hospitalization. Demographic, clinical, and endoscopic data were extracted by chart review. Bleeding was characterized as clinically important (defined as overt bleeding in association with hemodynamic compromise or the need for blood transfusion) or non-clinically important. RESULTS: Eighty-six patients met inclusion criteria. Clinically important bleeding occurred in 17%. Peptic ulcer disease and gastritis were the most common sources of bleeding in the clinically important and non-clinically important groups, respectively. The bleeding source was not found in 24% of patients. Endoscopic therapy was required in 11% (all of whom had clinically important bleeding). Upper endoscopy prompted no treatment changes in the non-clinically important bleeding group. CONCLUSIONS: Endoscopic therapy was needed only in the few patients with clinically important bleeding. Nonendoscopic treatment can be recommended for upper gastrointestinal bleeding developing in hospitalized patients who do not meet established criteria for a clinically important bleed.     

急诊胃镜在上消化道急症的临床应用

目的 评估急诊胃镜在上消化道急症中的临床应用。方法对587例上消化道急症分4组进行急诊胃镜检查，并用相应的器械及方法进行镜下治疗。结果上消化道异物组155例全部病例诊断明确，镜下一次去除成功148例，成功率为95．5％。食管静脉曲张出血(EVB)69例，其中并胃底静脉曲张11例，急诊止血率为loo％，2例再出血死亡。非静脉曲张性上消化道出血组(NVB)256例，诊断明确24l例(94．1％)，无结论者15例(5．9％)，镜下治疗197例，止血成功率为94．9％，术后7天内再出血14例，近期再出血率7．1％。24例胆道蛔虫，23例成功取出虫体，l例断裂。结论急诊胃镜在上消化道急症的应用安全有效。     

Glasgow-Blatchford和AIMS65评分系统在急性消化道出血患者预后评估中的价值

目的探讨Glasgow-Blatchford(GBS)和AIMS65评分对急诊内镜检查的消化道出血患者的预后价值。方法选取2009年1月-2011年1月在该院需行急诊消化道内镜检查的急性消化道出血患者作为研究对象,对其临床资料进行回顾性分析。结果 180例符合条件的患者进行了220例次内镜检查(121例食管胃十二指肠镜检查,99例结肠镜检查)。随访期间,46例(25.56%)患者出现再出血。86例患者(47.78%)为低危GBS评分(分数≤11),94例患者(52.22%)为高危GBS评分(分数≥12)。高危组与低危组患者再出血频率差异无统计学意义,而高危组死亡率(29.79%)明显高于低危组(10.47%,P0.001)。单独研究下消化道出血组时,高危组死亡率(26.93%)仍高于低危组(6.01%,P0.05)。94例患者(52.22%)为高危AIMS65评分(0分或1分),86例患者(47.78%)为低危AIMS65评分(≥3分)。高危组与低危组患者再出血频率差异无统计学意义,而高危组死亡率(32.98%)明显高于低危组(6.98%,P0.001)。单独研究下消化道出血组时,高危组死亡率(28.12%)仍高于低危组(5.93%,P0.05)。Cox多变量分析显示输血、并存肿瘤、未使用内镜止血和高AIMS65评分是低生存率的独立预后因素。结论 GBS和AIMS65两种评分中,AIMS65评分是急性胃肠道出血患者有效的预后因子。