Endoscopic injection therapy in bleeding peptic ulcers ... CLINICAL GASTROENTEROLOGY Endoscopic injection
Endoscopic injection therapy in bleeding peptic ulcers ... CLINICAL GASTROENTEROLOGY Endoscopic injection
Endoscopic injection therapy in bleeding peptic ulcers ... CLINICAL GASTROENTEROLOGY Endoscopic injection
Endoscopic injection therapy in bleeding peptic ulcers ... CLINICAL GASTROENTEROLOGY Endoscopic injection
Endoscopic injection therapy in bleeding peptic ulcers ... CLINICAL GASTROENTEROLOGY Endoscopic injection

Endoscopic injection therapy in bleeding peptic ulcers ... CLINICAL GASTROENTEROLOGY Endoscopic injection

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  • CLIN ICAL GASTROENTEROLOGY

    Endoscopic injection therapy in bleeding peptic ulcers. Low

    mortality in a high risk population

    j l)A()UIM BALANi'l\ MD, CANrnn V ILLANUEV.i\, Ml\ jORt,E C ESPINt)S, ML\

    SER11h/1cauon AJml 19. I 99 2. 1\ccc/nl'd Ma)• I I . / 99 2

    BLELl)JNt; PEPTll' Ul.l'l:R Rl:;,.{AINS A rele\'ant health problem with ~ig- nifknnt nwrh1di 1y and morrnli 1y des-

    pite the intr,iduction of d iagnostic enduscnpy, impn1"ement, in technnl- ugy tor resuscitarion nf hlceding patients ,rnd in medicnl management ot ulcers wirh pharmawlogical agents ( l ). Howcver, diugnnslic endo,uipy has as- sumed an imporumt rok due tn its ac- cu rncy in detccu ng 1hc hlceding ks i1111, and in dcfining ,t igmata of rccent hemnrrh,1ge ll'h1ch nre \·aluahle prog- nosnc ind1ca1or, of the risk of an un- fo\'\lrahle outCtHne (2). Furthermore, from the rc,ul b 111 thc Clin1rolled

    stud ies rep,irtcd to date ( 1.4) and the conclusiom uf Lhc Consen,u, Con- ference at the USA National Institute · of Health (N IH) (5), therapeutic endo-

    scopy can he regarded as the fir L hemo- static procedure in patients with ulcer, ,1t high risk of funhcr bleeding.

    A recent meta-analysis abo showed that thernpcuc ic endoscopy reduces

    rcb lceding and requi rcmcnr for emer- gency surgery hy nearly Lwo-th irds and

    morta lity by nearl y o ne-third ( 4 ). Patie n ts with c linical evidence of a

    major hemorrhage and active arterial b leedi ng or a nonhlecdingvi~ihle vessel at endoscopy should he t reated ( 5 ). Thi.:

    N IL-I Cnnsen,us Conference Ji.:ter-

    265

  • R.·\l.,\Nll'l t'I ll l

    de 53±52 h eurcs. U n e dc ux ic mc injectio n d'urgcnce a e tc administ rec J uns 36 des cas ou la m anoeuvre a ech o ue er a rcussi ch cz 20 d'entre cux (55 %). U n c c hirurgie cl'urgen ce a fina le ment ere necessa ire dam 52 cas (1 5 %). Le taux d e morta lite globa le a e te de 4,9 %. De graves complica t io ns se sont produ ites ch ez 4 patien ts ( 1,2 %). (ll s'agissa it de deux cas de pe rforation c t de deux cas d e pn eumo n ic pa r inh ala tio n . ) On peut don e conclurc q ue le t raitement par injec tion est une methode efficace c t simple de traiter lcs ulcc res acrifs pour parvenir a mat'rriser rapid em cnt l'hcmo rragic clans la majo ri te J es cas, bicn q uc le taux de recurren ce d e I 'h emorragie c t des comp lications n e so it pas n cgligcablc.

    min e,( th :it mulL ipolm e lcc trncoagula-

    tion and h eat probe were the most prn-

    m i, in g tech niq ue s and th aL injection

    therapy wammt ed further study. In th e

    past few years se vera l prospective and com rolled rri,, ls ha ve ~hmvn the effi-

    cacy of injec tion therapy (6- 12 ), irs

    simp lic ity, safel y nnd low cost ,1re great

    advan rnge, . C ompa rnt ive st ud ies h ,we

    a lso sh own th a t its efficacy seems to he

    equa l tn th at o f thenm1 l methmb such

    as YAC laser ( 12 ) or mulripo lar clcc- t rncoagu lation ( 13 ), while s imi lar m inferior resul t~ have hcen ac hieved

    compared wi th he at prohc~ ( 14, l 5 ).

    The prc~elll report descr ibe~ the

    re~Lil ts achie ved with injec t ion thernpy

    in a large se ries of ra t icn ts ad mi u ed consecuti ve ly with a h leed ing peptic ulcer at h igh ris k of furt he r h emor-

    rhage, assessed hy th e prese nce nf ac tive arte rial hlced ing, o r a nnnhleed ing v i, ihle vesse l. s ~m1e technical varia-

    tio ns suc h as the use of a second emer- gen cy injec tio n in the ma nagement of

    thernpcutic fai lures were a lsn evaluated.

    PAT IENTS AND METHODS During a 4 2-mon th period ( 19ti7-

    9 J) , 1880 p,ltien ts were adm in ed to the a utho rs' h ospital hecause n( co n fi rmed

    upper gastroimestina l hemmrhagc.

    Emergency endoscopy was pe rlnrmed

    in all within 4 h of adm ission, afte r resusc itatio n me;1s11res ,ind lavage hy rnisogast ric tuhe. Endoscopy d isc losed

    34 1 patien ts with gastr,,duodenal ul -

    cers a nd ac tive a rterial bleed ing nr ,1 non hleed ing l'is i hie vessel. J njecrinn

    th erapy was pe rformed in a ll uf t hese

    p,n ien ts. No pa Li ent wa, cxcl 11, led be- c;1usc uf technic.:;1 [ prnhlem:,, the se verity of b leeding or t he locm ion ot the ulce r. No oth er selection c rite ri a were used .

    Em ergency endoscnpy \\':l~ perfor-

    med using a n O lympus !T IO nr IT20

    fih rescope. V igomus washing of the

    u lce r floor 11·as carri ed nut when re-

    qu ired to remove c luts and de hri s. A drl•n a li nc injec tio n was pe rfo rmed

    with a Micn>vas ive l 123 need le {Mas-

    sachusetts ), during the same emergency

    p rocedure. Snme patients were a lso in-

    c luded in twn cnn t rn lled t riab to

    evaluat e whe ther addi Lion o( rh n lmhin

    ( 16 ) or 1% pnlidornn n l (1 7 ) cou ld im- pruve th e results achie ved wit h ad ren - .1li ne ,done. Adrerd ine ( l / 10,000) was

    injec ted in a liquots n f l .0 to 2.0 ml firsl a round and t he n in to th e visible vessel

    m (Wer and a round rhe bleeding a rcn,

    up to a w t al of IO LO 15 ml. A fte r therapeu tic e ndoscopy, nil pat ien ts

    were admi t ted to t he gastrointest inal

    hlecding unit.

    W h enever r oss ih lc a second clec- ti \'e endoscn py was performed be tween

    the second and the t hird day after th e

    emergency procedure. W he n a , ·isihlc

    vessel was identifi ed a t the time ,if t h b e lect ive endnscopy, ,, Sl'Cond injec t i( l!l

    was carried o ut by the sam e meth od as descri bed ahove.

    Pe rmanen t h em nstas is was d efined

    .1s cessatio n o f b leeding ( initia l h emo- stasis ) and absence of recurrence du ring

    lh )spi La lizatio n. T rea l me nc was con - s ide red a failure if th e re were s igns of further bleed ing afLer t he emergen cy

    injec tion treatmen t. Furth e r bleeding

    was defin eJ as one of the fo llowing:

    act h'C bleeding m repe:n ed endo,copy; vomit ing of fresh h lood or bloody

    nsp irn te., a fter pre\' icius cle,, r la"ages hy

    nasogast ri c t uhe; u r th e passage of fresh

    melena , p lus: hernodyn am ic and c lini -

    ca l e\' iden ce ofhypovll lemia; lll' a fo ll of h l'llHlgl,lhin requiring transfusion. Rc-

    pe,u cd endoscopy when the rapeuti c

    fai lure occurred ll'as nrn mancla ted hv

    the prow col and \\'ils only pe rfllrmed Ill c ase nf do u ht.

    ' S tuden t \ r test and th e x.- test with the Y,1tcs' correc tio n when necessary.

    were used for swtisti cal ,u1alysis.

    P

  • TABLE l Global results of endoscopic injec- tion therapy in 341 patients

    Results Initial hemostasis

    Rebleeding Emergency surgery Major complications Mortality

    Number(%)

    333 (97%)

    75/333 (22%) 52 (15%) 4 (1.2%) 17 (4.9%)

    'Transfusion (mean ± SD) 2.7-t2.7 Hospital stay (days.

    mean± SD) 10.9±9.9

    'Units of pocked red cells

    tects in re latio n to the injected agent~

    were observed. Emergency surgery was requ ired in

    52 patients ( 15%), in 51 hecause of uncontrolled hemorrhage and in one due ma complication of t he technique.

    Injection therapy was successful in 2 58

    l'atients after one emergency injection {75 .6%) while permanent hemosrasis

    wa, fina lly achieved in 278 cases (81.5%). Transfusinnal requ in.:ment~ were 2.7±2.7 un its nf packed red h lood cells and the du rnrion o( the hospiw l scay was l0.9±9.9 days (Tahle l ).

    Overall morta lit y wa~ 17 patients (4.9%) due to the hemorrhage or re -

    lated to procedurnl complicat1om in 12 cases (3.5%). The remain ing five p.:1- nenrs died from associated diseases after

    Jefinitive control of t he hemorrhage. Re ults were also evaluated acc11rd-

    ing co the stigmata 1l hemorrhage ob- served at the time of the in it ia l emer- gency endoscopy (T,1hle 2). Pmient~

    with a non bleeding visible vesse l had a tendency towards lower rates of therapeutic fai lure, fewer nct:d~ for

    emergency surgery, luwcr trnnsfusinnal requiremenrs and ,1 shorter lengrh nf hospital stay alt hough nnne u( the rrends reached ~tatistical significance.

    The result~ were alsu analyzed ac-

    cording to the locmion of the ulcer in regard to large vcsseb. T h erapeutic lailures were signifirnntly more cnm-

    mon in ulce rs !neared in the poste rior wall of the d uoJ cna I hu I h ( 24 of 48,

    50%) than in those at other sites (P

  • BALAN7t'I i!C al

    adre naline alone Llr comhined with either thrombin ( 15) or I% polido-

    canol ( 16). Combined injections did not imprnvc outcome.

    Present results indicate that cndo- ,cnpic injection of adrenaline is a simple and effective fir,r therapeutic approach fnr bleeding peptic ulcers at risk of further hemorrhage. Major com-

    plicarions, although rnrc, arc nnt ir-

    REFERENCES I. Cilben L)A. Epidemiol,igy ,ii uppL'r

    g;i:-tromresunal hkedmg. G,1,1ro1nte,1 Enclose I 990; 16:S~- I 1.

    J Johnston J 11. Emlnscop1c ri,k foct()rs fllr hlccding peptic ulcer. Ua,trointcst Endnsc I 990; 36:S I 6-20.

    ). I knry L)A, White I. Endnscopic coagul.11 ion for g.ist ru1111c,1 in:d hlceding. N Engl J Med 1988;118:186-7.

    4. S,1cb I IS, Ch:ilmL·r, TC. Blum AL, Bcrril.!r J, Pa.l.(an,, D. En,l,"cupic he1m1,1a,1,. An cffcct1v1.! thernpy fnr bleeding peptic ukc•rs. JAMA I 99();264:494