Somatostatin in the treatment of severe upper gastrointestinal bleeding: a multicentre controlled trial

To evaluate the effectiveness of somatostatin versus combined cimetidine and pirenzepine in the treatment of upper gastrointestinal (GI) bleeding of peptic origin, a multicentre controlled, prospective, randomized and double blind trial has been undertaken in 60 subjects. Strict selection criteria were followed. All subjects were diagnosed by endoscopy during the first 18 h after admission. Endoscopic stigmata of recent haemorrhage were also evaluated. Sixty-five per cent of the subjects presented with severe upper GI bleeding (blood pressure less than or equal to 100 mmHg, pulse rate greater than or equal to 110, haematocrit less than or equal to 30 per cent), and in 71.6 per cent stigmata were found. Thirty patients (Group 1) received a somatostatin infusion (250 micrograms/h continuously during 120 h) and 30 patients (Group 2) received cimetidine (200 mg IV every 4 h for 5 days) and pirenzepine (10 mg IV every 8 h for 5 days). Both groups were homogeneous for sex, age, backgrounds, bleeding source, grade of bleeding (moderate or severe) and presence or not of stigmata. Bleeding stopped in 27 subjects of Group 1 (90 per cent and in 20 subjects of Group 2 (66.67 per cent) (P less than 0.05, chi 2 test). The time until the bleeding stopped was significantly shorter in patients of group 1 (3.44 +/- 0.53 h) than in patients of group 2 (8.12 +/- 1.94 h) (P less than 0.05, Mann-Whitney U test). The number of blood units required for Group 1 (2.26 +/- 0.35) was significantly lower than the one required for Group 2 (3.90 +/- 0.51) (P less than 0.005, Wilcoxon test). Significant differences were not observed between the two groups regarding cross-over subjects, re-bleeding, surgery (P = 0.0635, Fisher's exact test) and hospital stay. The mortality of the trial was 5 per cent. There was no toxicity during somatostatin, cimetidine or pirenzepine infusion. In conclusion, somatostatin was more effective than cimetidine plus pirenzepine in the control of severe upper GI bleeding of peptic origin, with a lower interval time to stop bleeding and reduced transfusion requirements.     

Angiography in poor-risk patients with massive nonvariceal upper gastrointestinal bleeding

The purpose of this retrospective study was to determine the diagnostic and therapeutic usefulness of gut angiography in patients with massive upper gastrointestinal bleeding from a nonvariceal source. All patients (n = 64) in this category who underwent a gut angiogram between 1980 and 1986 were studied. Pre-angiogram endoscopy was attempted in all patients and was nondiagnostic in 14 (22%). Contrast extravasation at angiography was seen in 25 of 64 patients (39%), and in over half of these patients endoscopy was nondiagnostic (n = 11) or wrong (n = 3). Attempts to control bleeding in this group by selective arterial embolization (n = 14) or intra-arterial vasopressin (n = 11) successfully averted operation in 13 of 25 patients (52%) and was associated with a 50% reduction in mortality (83% versus 38%). Selective embolization of vessels thought to be bleeding on clinical grounds without evidence of contrast extravasation (i.e., "blind" embolization) was not helpful in controlling hemorrhage. Urgent gut angiography in patients with massive upper gastrointestinal bleeding of arteriocapillary source is a useful diagnostic and therapeutic maneuver and warrants continued application in this group of poor-risk patients.     

Limited value of early endoscopy in the management of acute upper gastrointestinal bleeding: Prospective controlled trial

In an 11 month period, 95 patients with acute upper gastrointestinal hemorrhage underwent early fiberoptic endoscopy. Patients were randomized into two groups before endoscopy depending on whether the results of the procedure were revealed immediately or after 4 days. No attempt was made to influence the treatment or diagnostic plan. The groups were comparable with respect to historical features surrounding the bleeding episode and the anatomic site of hemorrhage. There were no significant differences in any aspect of patient management or outcome between groups. Important changes in diagnostic or treatment plan were made after learning the results of endoscopy in only 12 percent of the patients, half of whom were bleeding briskly at the time of endoscopy. It is concluded that the natural history of acute upper gastrointestinal hemorrhage (for example, the spontaneous cessation of bleeding) precludes endoscopy from having a significant effect on patient management.     

Open hemorrhoidectomy with using the apparatus controlled bipolar electrocoagulation

Hemorrhoids are known to be a widely spread disease. The aim of this study was to compare two methods of hemorrhoidectomy. The hemorrhoidectomy was performed on 262 patients with combined III-IV degree hemorrhoids, 130 patients being operated by the conventional method--Milligan-Morgan hemorrhoidectomy, 132 patients undergoing hemorrhoidectomy using a bipolar vessel sealing system. It was noted that the operation time was significantly shorter, postoperative pain and postoperative complications less frequent due to the bipolar device-controlled electrocoagulation.     

上消化道大出血患者的输液项目管理

对62例上消化道大出血抢救患者加强输液单项管理,包括早期诊断、迅速建立静脉输液通道,密切观察血流动力学变化、合理控制输液速度,根据药物作用及时效选择合适的输液通路.结果60例经补液、输血、止血治疗,血压稳定后行急诊胃镜检查治疗,60例治愈出院,2例抢救无效死亡.提示对上消化道大出血进行输液管理,能有效补充患者血容量,赢得抢救时间,提高治疗效果.     

Comparison of hemostasis using bipolar hemostatic forceps with hemostasis by endoscopic hemoclipping for nonvariceal upper gastrointestinal bleeding in a prospective non-randomized trial

Background

We previously reported on the safety and efficacy of bipolar hemostatic forceps for treating nonvariceal upper gastrointestinal (UGI) bleeding. However, no prospective or randomized studies have evaluated the efficacy of bipolar hemostatic forceps. The aim of this study was to evaluate the hemostatic efficacy of using bipolar hemostatic forceps compared with the hemostatic efficacy of the commonly used method of endoscopic hemoclipping for treating nonvariceal UGI bleeding.

Methods

A total of 50 patients who required endoscopic hemostasis for UGI bleeding were divided into two groups: those who underwent endoscopic hemostasis using bipolar hemostatic forceps (Group I) and those who underwent endoscopic hemostasis by endoscopic hemoclipping (Group II). We compared the two groups in terms of hemostasis success rate and time required to achieve hemostasis and stop recurrent bleeding.

Results

All (100 %) of 27 patients in Group I and 18 (78.2 %) of 23 patients in Group II were successfully treated using bipolar hemostatic forceps or by endoscopic hemoclipping alone, respectively, indicating a significantly higher success rate for Group I than for Group II (p < 0.05). The time required to achieve hemostasis was 6.8 ± 13.4 min for Group I and 15.4 ± 17.0 min for Group II. One patient in Group I (3.7 %) and four patients in Group II (22.2 %) experienced recurrent bleeding.

Conclusion

Bipolar hemostatic forceps was more effective than endoscopic hemoclipping for treating nonvariceal UGI bleeding.     

Automatically controlled bipolar electrocoagulation — “COA-COMP”

Summary Modern bipolar electrocoagulation has certain limitations, especially regarding the regulation of the short coagulation course. Studies on the electrical parameters of tissues during heating led to the conclusion that impedance changes in a typical and reproducible way. Furthermore, the impedance value proved to be close to minimal at the moment of coagulation. Laboratory tests were performed to correlate the pressure strength of the sealed artery to the impedance change. The tests proved that strong seals were achieved when the coagulation was interrupted soon after minimum impedance. Good seals were also achieved with later interruption of the heating but the well-known phenomena of sticking of the forceps to tissues and charging of the tips with charred tissue became more prominent. Further electrocoagulation gives carbonisation, fulguration and risk of new haemorrhage. Based on these results, microcomputerized equipment was built which cut off the coagulation soon after minimum impedance, i.e. when good strength without sticking was achieved. This equipment was tested clinically and the trials showed that the method is practical and most reliable. The microcomputer also allows automatic start of the coagulation as needed during opening or closing of wounds, as well as providing a built-in test of the equipment. This equipment saves time and labour and increases safety.     

Trends in acute nonvariceal upper gastrointestinal bleeding in dialysis patients

Impaired kidney function is a risk factor for upper gastrointestinal (GI) bleeding, an event associated with poor outcomes. The burden of upper GI bleeding and its effect on patients with ESRD are not well described. Using data from the US Renal Data System, we quantified the rates of occurrence of and associated 30-day mortality from acute, nonvariceal upper GI bleeding in patients undergoing dialysis; we used medical claims and previously validated algorithms where available. Overall, 948,345 patients contributed 2,296,323 patient-years for study. The occurrence rates for upper GI bleeding were 57 and 328 episodes per 1000 person-years according to stringent and lenient definitions of acute, nonvariceal upper GI bleeding, respectively. Unadjusted occurrence rates remained flat (stringent) or increased (lenient) from 1997 to 2008; after adjustment for sociodemographic characteristics and comorbid conditions, however, we found a significant decline for both definitions (linear approximation, 2.7% and 1.5% per year, respectively; P<0.001). In more recent years, patients had higher hematocrit levels before upper GI bleeding episodes and were more likely to receive blood transfusions during an episode. Overall 30-day mortality was 11.8%, which declined significantly over time (relative declines of 2.3% or 2.8% per year for the stringent and lenient definitions, respectively). In summary, despite declining trends worldwide, crude rates of acute, nonvariceal upper GI bleeding among patients undergoing dialysis have not decreased in the past 10 years. Although 30-day mortality related to upper GI bleeding declined, perhaps reflecting improvements in medical care, the burden on the ESRD population remains substantial.     

A rare cause of acute upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding (AUGB) remains a common indication for admissions and is associated with significant morbidity and mortality. Peptic ulcer diseases and varices are the commonest lesions identified during endoscopy. However, endoscopists need to be aware of the rare causes of AUGB, as missing such lesions can potentially be fatal. Rare causes can be missed if they are not looked for systematically during endoscopy. We report a case of AUGB secondary to bullous pemphigoid involving the esophagus in an elderly gentleman presenting with significant blood loss from hematemesis. A review of the English literatures on bullous pemphigoid involvements of the esophagus was carried out and the underlying pathogenesis and management are discussed.     

营养不良的胃肠道肿瘤患者术后营养支持的随机对照研究

目的评价术后营养支持对营养不良的胃肠道肿瘤患者预后的影响。方法646例营养不良的胃肠道肿瘤患者随机分为肠外营养组(215例)和肠内营养组(215例)及对照组(216例),术后营养支持7d,采用等热卡[125.5kJ(30kcal)·kg-1·d-1]和等氮(0.25g·kg-1·d-1);对照组术后常规补液直至恢复正常饮食。观察比较术后死亡率、并发症发生率及住院时间。结果入选的3组患者资料具有可比性。术后总死亡率为1.5%,3组间差异无统计学意义。术后并发症发生率:肠外营养组33.5%(72例),肠内营养组28.4%(61例),对照组44.9%(97例);对照组与肠外营养组比较,P=0.001;与肠内营养组比较,P=0.000。肠内营养组感染性并发症发生率10.2%,明显低于肠外营养组的15.3%,P=0.002;而两组非感染性并发症发生率差异无统计学意义(21.9%vs.23.7%,P=0.06)。住院时间:肠外营养组(11.2±5.0)d,肠内营养组(9.8±3.4)d,对照组(14.5±7.1)d;肠内营养组住院时间短于肠外营养组,P=0.002;对照组与肠外营养组比较,P=0.003;与肠内营养组比较,P=0.001。结论术后营养支持可改善营养不良的胃肠道肿瘤患者的预后,术后早期肠内营养较肠外营养能降低术后感染性并发症发生率,并缩短住院时间。     

A rare case of Bouveret's syndrome presenting with upper gastrointestinal bleeding

We report a case of duodenal obstruction caused by a large gallstone wedged in the duodenal bulb (Bouveret's syndrome), presenting with acute upper gastrointestinal bleeding and successfully treated by surgery following a failed attempt at endoscopic retrieval of the stone. Haemorrhage is a very rare form of presentation. After an extensive review of the literature, the therapeutic options and surgical strategies (one-stage and two-stage procedure) are critically discussed.     

Evaluation of the effectiveness of controlled pH in management of massive upper gastrointestinal bleeding

Twenty-five patients with massive upper gastrointestinal hemorrhage have been treated by control of the intragastric pH at 7.0 with antacids. In twenty-three of the twenty-five patients, bleeding stopped. The two treatment failures included one patient in whom the pH could not be raised above 4.5 despite massive instillations of antacid; the other failure occurred in a patient who had had thrombolytic therapy and extensive small bowel resection for gangrene.     

Cimetidine and antacid prophylaxis of acute upper gastrointestinal bleeding in high risk patients: Controlled,randomized trial

A randomized, controlled clinical trial was performed to compare the efficacy of prophylactic cimetidine treatment, antacid treatment and no treatment in high risk patients. Sixty patients received cimetidine (200 mg every 6 hours), 52 patients received antacids (Maalox^®, 10 ml/hour), and 56 patients received no treatment. One hundred thirty-five patients completed the study. Eight patients in the control group and one patient in the antacid-treated group presented with upper gastrointestinal bleeding. No bleeding occurred in the cimetidine-treated group. Patients considered at low risk had no bleeding. Cimetidine or antacid prophylaxis significantly decreased the incidence of upper gastrointestinal bleeding in the high risk patients.     

Choriocarcinoma presenting with upper gastrointestinal bleeding and intussusception

Choriocarcinomas are rare genital tract tumours, which can present with extragenital symptoms and signs. We report on an 18-year-old nulliparous woman presenting with jejunal choriocarcinoma. An outline of the diagnostic difficulties and different manifestations of extragenital choriocarcinoma is given. A high index of suspicion should be maintained and a multi-disciplinary approach is mandatory.     

Effects of acute kidney injury on clinical outcomes in patients with upper gastrointestinal bleeding

Aim Upper gastrointestinal bleeding (UGIB) is a very frequently encountered condition that has a high morbidity and which increases treatment costs. Duration of hospital stay and mortality increases in patients with UGIB complicated by acute kidney injury (AKI). The aim of this study was to reveal risk factors in patients with UGIB developing AKI and to compare clinical outcomes and hospital costs between patients with UGIB developing AKI and those with UGIB not developing AKI.

Material and methods This retrospective study included 245 patients admitted to the emergency unit and the intensive care unit for internal diseases at Ankara Numune Education and Research Hospital, Turkey. Results The difference in mortality rates between the patients with AKI and those without AKI was significant (p?0.001). The mean duration of intensive care unit stay was 0.2?±?1.1 days in the patients without AKI (n?=?143) and 2.5?±?5.6 days in the patients with AKI. It was significantly higher in the patients with AKI (p?0.001). Hospital stay was significantly longer in the patients with AKI than those without AKI, and as severity of AKI increased, hospital stay became considerably longer (p?0.001). Hospital costs were significantly higher in the patients with AKI than those without AKI, and as severity of AKI increased, hospital costs considerably rose (p?0.001). Conclusion AKI is a condition that lengthens hospital stay, increases hospital costs and creates a burden on health care systems. Detect kidney injury earlier and administering an appropriate treatment can improve clinical outcomes in patients with UGIB developing AKI.