Our experience with the therapy of bleeding peptic ulcers.

Authors present their clinical experience gained in the therapy of bleeding peptic ulcers. The modified Baylor Bleeding Score has proved to be a reliable tool for assessing the risk of recurrent hemorrhage. Early introduction of H2-receptor blocker therapy is justified both in conservative as well as in surgical management of bleeding peptic ulcers.     

Laparoscopic transgastric suturing for bleeding peptic ulcers

Background: Peptic ulcers are a frequent cause of upper G.I. bleeding. Since endoscopic methods may be unsuccessful, we have studied the feasibility of a new laparoscopic approach on a porcine model to control the bleeding of these ulcers with transgastric suturing. Methods: After approval of the Animal Ethics Committee, 20 pigs (20 kg) were anticoagulated with intravenous sodium heparin (400 U/kg), and anesthetized. A nasogastric tube was inserted and a 15 mmHg pneumoperitoneum was created. Two 10-mm trocars and one 5-mm trocar were inserted through the abdominal cavity for laparoscopic guidance of three 7-mm endoluminal trocars inside the stomach through the anterior wall. Two posterior gastric ulcers were mechanically made on each pig by a lift and cut technique. Ulcers were observed for at least 1 min for evidence of continued bleeding. First, bleeding ulcers were treated with sclerosing agents (epinephrine and ethanolmine oleate 5%); following sclerotherapy, ulcers were sutured intraluminaly with 2-0 silk, with intracorporeal knots. Results: Ulcers created extended into the vascular submucosa and averaged 7 mm in diameter. Bleeding rate was variable, but significant (2 cm³/min) in 40%. It was technically possible to suture these ulcers in 80%. Bleeding was controlled in 95% of cases with sclerotherapy and intraluminal sutures. One perforation of the posterior gastric wall occurred and four endoluminal trocars had to be reinserted after dislodgement. Conclusions: It is possible to technically control bleeding ulcers in most cases with a laparoscopic transgastric technique using sclerosing agent and intraluminal sutures. This approach is promising for future human application; also, the intragastric suturing skills developed may be useful for other surgical interventions.Poster presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, Florida, USA, 11–14 March 1995     

Heater-probe treatment of bleeding peptic ulcers

Fifty-six patients with actively bleeding peptic ulcers were treated with the heater-probe unit. Initial haemostasis was achieved in 48 patients (85.7%). The mean number of heater-probe applications was 6.7 pulses at a setting of 25-30 J. Rebleeding occurred in 11 patients (19.6%). Five were successfully treated with repeat heater-probe treatment, 5 required emergency surgery, and 1 rebleeding was stopped by adrenaline injection. The complications included one perforation in a patient with duodenal ulcer. The overall mortality was 2/56 (3.6%). Heater-probe treatment is an effective and safe haemostatic method for controlling actively bleeding ulcers.     

Endoscopic treatment of bleeding peptic ulcers

Since June, 1979, patients with upper gastrointestinal bleeding, other than of the varices, have been subjected to the procedure of endoscopic hemostasis with injection of absolute ethanol. This method is based on the principle of tissue dehydration and fixation with absolute ethanol. In this procedure, the bleeding vessels are dehydrated and fixed with consequent vasoconstriction and necrosis of the vascular wall, including its endothelial lining, thereby facilitating thrombogenesis and hemostasis. We have applied this method in 147 cases of upper gastrointestinal bleeding, obtaining a successful temporary hemostasis in all cases. Rebleeding from the same site occurred in 5 cases and new bleeding from another site occurred in 6 cases; however, in these cases, hemostasis was successfully obtained by reinjecting ethanol. After hemostasis, 6 patients received elective surgery and another 2 were operated on due to perforation of the stomach. Of the patients treated by this method, 11 died due to causes unrelated to gastrointestinal bleeding. After the hemostatic procedure, cure of the ulcer by conservative treatment was attained in the remaining 136 cases. Therefore, the local injection of absolute ethanol is an effective hemostatic method for upper gastrointestinal bleeding.

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Resumen A partir de junio de 1979, los pacientes con sangrado gastrointestinal por causas diferentes de varices han sido sometidos al procedimiento de hemostasia endoscópica por inyección de etanol absoluto. El método se fundamenta en la deshidratación y la fijación tisulares por el alcohol absoluto; los vasos sangrantes son deshidratados y fijados con la consiguiente vasoconstricción y necrosis de la pared vascular, incluyendo el endotelio, lo cual facilita la trombogénesis y hemostasis. Hemos utilizado este método en 147 casos de sangrado gastrointestinal alto, habiendo logrado hemostasis temporal en la totalidad. Hemorragia recurrente a partir de la misma fuente se presentó en 5, y a partir de un lugar diferente en 6 casos. Sin embargo, en todos los casos la hemostasia fue exitosa al reinyectar etanol. Lograda la hemostasia, 6 pacientes fueron sometidos a cirugía electiva y otros 2 fueron operados por perforación del estómago. De los pacientes tratados con este método, 11 murieron por causas no relacionadas con el sangrado gastrointestinal. Todos los 136 pacientes restantes obtuvieron curación de la úlcera con tratamiento conservador. Por consiguiente, la inyección local de etanol absoluto es un método hemostásico efectivo en la hemorragia gastrointestinal alta.

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Résumé Depuis juin 1979, toute hémorragie du tube digestif supérieur autre que celles provenant de varices, a été traitée par injection d'éthanol absolu. Cette méthode d'hémostase est basée sur les principes de déshydratation et de fixation tissulaires par l'éthanol absolu: les vaisseaux qui saignent sont déshydratés et fixés par vasoconstriction et nécrose de la paroi vasculaire, y compris la couche endothéliale ce qui détermine thrombogénie et hémostase. Nous avons appliqué cette méthode chez 147 patients présentant une hémorragie du tube digestif supérieur et nous avons obtenu l'hémostase temporaire dans tous les cas. Il y a eu récidive hémorragique au même endroit dans 5 cas et dans un nouveau dans 6 cas. Mais dans tous les cas, l'hémostase a été obtenue par une nouvelle injection d'éthanol. Après l'hémostase, 6 patients ont été opérés de façon élective et 2 ont nécessité une intervention à cause d'une perforation gastrique. Onze patients traités par cette méthode sont morts d'une cause non en rapport avec l'hémorragie. L'hémostase une fois obtenue, l'ulcère a guéri aussitôt dans les 136 autres cas. Ainsi, l'injection locale d'éthanol est une méthode d'hémostase efficace dans l'hémorragie du tube digestif supérieur.

     

Surgical perspectives in treatment of bleeding peptic ulcers

Peptic ulcer bleeding has overall incidence of 50 to 150 on 100.000 grown-ups per year and represents cause for over 1% of all urgent hospitalization today. Despite of the evolution of the endoscopic diagnostics and haemostasis, improved intensive care and surgical treatment, overall mortality is still over 10% (operative treatment over 20%), and it almost hasn't changed over past 40 years. For more than 100 years surgery had major role in treatment of peptic bleeding ulcers, whereas nowadays it is limited to treatment of its complications. Adequate surgical treatment demands properly timed operation, safest but appropriate operation and trained surgeon. Early surgery is much better compared to the last minute surgery. At high risk rebleeding ulcer, early delayed surgery appears to be adequate, since the complications and lethal outcome are more frequent in this group.     

Surgical therapy for peptic ulcer and nonvariceal bleeding

Wider use of endoscopic hemostasis in upper gastrointestinal bleeding (UGIB) has reduced significantly the need for operation. Nevertheless, surgery still plays a pivotal role. Failure to control bleeding endoscopically should not delay surgery when necessary, and a close cooperation between endoscopists and surgeons is essential. Initial endoscopy stops the bleeding in approximately 94% of patients and helps to identify those patients with a high or low risk of rebleeding. High-risk patients should be examined for rebleeding by clinical and endoscopic assessment within at least the first 2-3 days. Large ulcers are the most likely to rebleed, and in elderly patients with severe comorbidity showing little or no healing tendency, they benefit from repeated fibrin glue treatment. In cases of rebleeding despite initial endoscopic hemostasis and conservative treatment, another attempt to stop the hemorrhage endoscopically is justified in most patients. A subgroup of patients who are old, suffering from hypotension due to rebleeding, with large ulcers and several other illnesses should undergo surgery immediately because endoscopic intervention often fails, and these patients deteriorate quickly. The surgical procedure should be limited to safe hemostasis.     

Controlled trial of heater probe treatment in bleeding peptic ulcers

A prospective randomized controlled trial of endoscopic heater probe therapy in bleeding peptic ulcers was performed to determine whether probe therapy can reduce rebleeding rates. Of 630 patients endoscoped for suspected upper gastrointestinal haemorrhage over a 16-month period, 166 (26 per cent) were found to have a peptic ulcer. Either minor or no stigmata of recent haemorrhage were found in 115 patients at the time of endoscopy. A single peptic ulcer with either active haemorrhage or a visible vessel was found in 51 patients, 43 of whom were entered into the trial. There were eight exclusions: four were inaccessible, one was a torrential haemorrhage and three were excluded for non-technical reasons. Patients were randomized to receive either heater probe (n = 20) or sham (n = 23) therapy. In actively bleeding ulcers, immediate haemostasis was achieved following probe therapy in 14 of 18 patients (78 per cent) compared with none of 21 having sham treatment (P less than 0.002). No rebleeding occurred in the probe therapy group (n = 20) compared with rebleeding in five of 23 sham treated patients (P = 0.05). Urgent surgery for haemostasis was required in three of the five sham treated patients who rebled. It is concluded that heater probe therapy may be effective in reducing rebleeding rates in peptic ulcers accessible to the endoscope.     

Endoscopic management of bleeding peptic ulcers in Singapore: a multimodality approach.

Endoscopic haemostasis is becoming increasingly important in the management of bleeding peptic ulcers. In this study, rather than being confined to one modality of treatment, the endoscopist was allowed to customize the treatment according to the configuration of the ulcer, accessibility, and rate of bleeding in any particular patient. Fifty patients with actively bleeding peptic ulcers or stigmata of recent haemorrhage were treated endoscopically. Initial haemostasis was achieved in 48 (96%) patients. Eleven patients rebled of whom eight underwent repeat endoscopic treatment. Of these eight patients, three rebled of whom two required surgery. Permanent haemostasis was achieved in 43 of 50 patients (86%). The rate of surgery in the endoscopically treated group was 10%. There was one death due to causes not related to bleeding. The multimodality approach is a useful method of treatment in bleeding peptic ulcers, giving flexibility to the endoscopist in deciding on the best way to deal with the problem.     

Use of recombinant factor VIIa as a rescue treatment for intractable bleeding following repeat aortic arch repair

Hemorrhage, refractory to aggressive conventional therapy, at a rate of 16 L/hr following separation from cardiopulmonary bypass for aortic arch repair, was controlled with a dose of 90 μg/kg of recombinant factor VIIa, repeated once after 2 hours.     

Effects of intravenous pantoprazole in gastric PH and recurrent bleeding for peptic ulcers

Objective: To study the effects of pantoprazole in gastric pH and recurrent bleeding after endoscopic treatment for bleeding peptic ulcers. Methods: After endoscopic treatment for bleeding gastric or duodenal ulcers, patients were randomly assigned to: group 1 (infusion group): 80 mg pantoprazole intravenous bolus, followed by continuous infusion 8 mg per hour for 72 h, group 2 (bolus group): 80 mg pantoprazole intraveneous bolus, followed by 40 mg intravenous bolus every 12 h for 72 h and group 3 (no treatment group). A pH probe was placed in stomach for 24 h during the first 72 h for pH monitoring. On day 4, they were given oral famotidine for 8 weeks. Suspected recurrent bleeding will be confirmed with endoscopy. The primary end‐point is the rate of rebleeding within 30 days. The secondary end‐points are operative rate, transfusion requirement, total hospital stay, mortality rate and gastric pH analysis. Results: 86 patients were recruited for analysis (group 1: n=22, group 2: n=30, group 3: n=34). In the first part of our analysis, group 1 and 2 (those receiving pantoprazole) were combined for comparison with Group 3. There was less rebleeding in those with pantoprazole (3.8 vs 17.6%, P=0.031). The transfusion requirement was also less (1.59 vs 3.01 units, P=0.007). There was no difference in need for operation and total hospital stay. Regarding gastric pH, those receiving pantoprazole had significantly higher mean pH (5.43 vs 1.87, P=0.001), median pH (5.58 vs 1.77, P=0.001) and percentage of time with Ph >*Τ*6 (52.97 vs 7.45%, P=0.001). In the second part of our analysis, the results between group 1 and 2 were compared. There was a tendency to favour pantoprazole infusion regarding rebleeding rate (0 vs 6.7%), operation rate (0 vs 3.3%), mean pH (5.73 vs 5.22), median pH (5.78 vs 5.43) and percentage of time with pH >*Τ*6 (54.71 vs 51.84%). However, they did not reach statistical significance. There was no mortality among the studied patients. Conclusion: After endoscopic treatment for bleeding peptic ulcer, patients receiving pantoprazole had significantly higher gastric pH and lower chance of rebleeding. Further data is needed to identify the better regime for administration of pantoprazole.     

Use of a massive transfusion protocol with hemostatic resuscitation for severe intraoperative bleeding in a child

Use of a defined massive transfusion (MT) protocol for severe intraoperative bleeding in a pediatric patient has never been described. Herein we present a case whereby use of hemostatic resuscitation delineated in an MT protocol optimally treated hemorrhage resulting from a large tumor during right hepatectomy. The MT protocol principles, benefits, and postoperative course of the patient are described.     

Mechanism of action of injection therapy for bleeding peptic ulcer.

The effects of intramucosal injection of 1:100,000 adrenaline, 5 per cent ethanolamine and normal saline were determined in experimentally created, acutely bleeding gastric mucosal wounds in rabbits. The mean(s.d.) bleeding rate was decreased from 2.3(0.4) to 0.2(0.02) ml/min by adrenaline (P < 0.01), but increased by 1 ml 5 per cent ethanolamine to 4.0(0.6) ml/min (P < 0.05). Normal saline had no haemostatic effect, suggesting that local tamponade is not important. In separate experiments endoscopic injections of 5 per cent ethanolamine, 1:100,000 adrenaline and normal saline were made in the gastric antrum of rabbits. After 48 h the degree of inflammation was greatest with ethanolamine but, despite tissue necrosis and venous thrombosis, neither endarteritis nor arterial thrombosis occurred. Injections of 5 per cent ethanolamine and 80 per cent ethanol placed next to the ear arteries of rabbits caused local ulceration and necrosis, but endarteritis and arterial thrombosis were again absent.     

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.     

Use of mycophenolate mofetil as rescue therapy after pediatric liver transplantation

BACKGROUND: Mycophenolate mofetil (MMF) has been increasingly used after liver transplantation (LT) in adults. We report our preliminary experience with MMF as rescue therapy after pediatric LT. METHODS: A total of 19 children received MMF for 21 indications. Median age at LT was 30 months (range 7-149). The median initial oral dose of MMF was 23 mg/kg/day (range 12-43) orally. Median follow-up after initiation of MMF therapy was 642 days (range 229-1606). RESULTS: 1) Efficacy: MMF was indicated for rejection or insufficient immunosuppression in 16 cases, with normalization of both liver function tests and liver histology in 10 (62%). MMF was successfully used in one patient with post-LT immmune hepatitis and one patient with corticodependence. In three patients with renal function impairment, MMF allowed reduction of cyclosporine A or tacrolimus blood levels, without subsequent rejection. 2) Tolerance: Six patients (32%) experienced eight side effects, mainly gastrointestinal and hematological, which resolved after cessation of MMF in five cases and dose reduction in three. One case of posttransplant lymphoproliferative disease (PTLD) occurred under MMF therapy (5.2%). Four patients had EBV primary infection, while under MMF therapy, without subsequent PTLD. Three patients had CMV primary infection, and five CMV reactivation, under MMF therapy. Seven remained asymptomatic, and one presented with CMV enteritis. CONCLUSIONS: These preliminary results suggest that MMF is an effective and safe immunosuppressant in pediatric LT recipients. Its use is hampered by frequent gastrointestinal and hematological side-effects. MMF does not seem to increase the risk of PTLD nor CMV disease.     

Use of everolimus as a rescue immunosuppressive therapy in liver transplant patients with neoplasms

Everolimus is a new immunosuppressant with antitumoral properties and few side effects, but limited use in liver transplantation. The aim of the present study was to evaluate the effect on survival and safety of everolimus in post liver transplantation neoplasms in a single center. Ten liver transplant recipients with a posttransplant diagnosis of neoplasm received everolimus during a median of 12.7 (5.5-27.5) months; median survival was 21.3 (7.5-40.5) months. The probability of survival of everolimus group was significantly greater than the observed in a historical cohort of 14 liver recipients with comparable tumors who did not receive everolimus (100%, 90%, 72% vs. 50%, 29%, 14%) at 6, 12, and 24 months, respectively (HR=4.6, 95% confidence interval: 1.3-16.4; P=0.008). During everolimus therapy no patients showed rejection. Renal function improved in three patients. Furthermore, severe adverse effects and infections were infrequent. In summary, everolimus seems safe for liver transplant recipients with cancer and may improve short-term survival, but further studies are needed to determine long-term benefits and safety.     

Complications of peptic ulcers

Peptic ulcer disease, defined as the breakdown of the epithelial mucosal barrier of the stomach and/or duodenum, remains a cause of significant morbidity and mortality. Major aetiological factors include Helicobacter pylori infection and non-steroidal anti-inflammatory drug use. Epigastric pain, heartburn, reflux symptoms and nausea are common in patients with peptic ulceration. The diagnosis is most often established following upper gastrointestinal endoscopy. The introduction of acid-reducing pharmacological agents and H. pylori eradication regimes are the mainstay of current treatment. Surgical management is generally reserved for the management of the complications of peptic ulcer disease, such as acute haemorrhage, intestinal perforation and gastric outflow obstruction. Surgery in these circumstances is often challenging and may require a high level in expertise. This review will discuss the main aetiological agents involved in the development of peptic ulcer disease and describe the underlying pathogenesis. The diagnosis and management of uncomplicated peptic ulcer disease will then be outlined. Finally, the management of peptic ulcer complications will be detailed, with particular reference to the surgical aspects of care.     

Use of a preoperative bleeding questionnaire in pediatric patients who undergo adenotonsillectomy

OBJECTIVE: To determine the efficacy of a preoperative bleeding questionnaire (POBQ) and coagulation screening in predicting hemorrhage associated with adenotonsillectomy. STUDY DESIGN: Retrospective study. SUBJECTS AND METHODS: Between January 1998 and December 2003, 7730 tonsillectomy and adenotonsillectomy patients were administered the POBQ preoperatively. Further coagulation screening was based on POBQ responses. RESULTS: A total of 232 (3.0%) of 7730 had postoperative bleeding; 184 (3.2%) of 5782 patients who had negative questionnaires bled postoperatively compared with 48 (2.5%) of 1948 patients with positive questionnaires (P = 0.126). Of 1948 patients with positive questionnaires, 141 (7.2%) had abnormal preoperative coagulation screens and 9 (6.4%) of 141 bled; of the 1807 (92.8%) with negative coagulation screens, 39 (2.2%) bled (P = 0.005). CONCLUSION: The POBQ is an effective tool for identifying patients who are at potential risk for post-tonsillectomy bleeding. Patients with both a positive POBQ and coagulation screen had a statistically higher likelihood of postoperative bleeding than other patients. The POBQ allowed the identification of individuals with bleeding disorders to be treated before surgery, likely decreasing the risk of bleeding in these patients.