Systematic Review and Meta-Analysis of Prophylactic Transarterial Embolization for High-Risk Bleeding Peptic Ulcer Disease.

The present systematic review determined the role of transarterial embolization (TAE) as a prophylactic treatment in bleeding peptic ulcers after initial successful endoscopic hemostasis. PubMed and Ovid Medline databases were searched from inception until July 2019 for studies that included patients deemed high-risk based on Forrest Classification, Rockall score ≥ 5, or endoscopic evaluation in addition to those who underwent prophylactic TAE after initial successful endoscopic hemostasis. Meta-analysis was performed to compare patients who underwent endoscopic therapy (ET) and TAE with those who underwent ET alone. The primary outcomes measured included rates of rebleeding, reintervention, and 30-day mortality. Secondary outcome measures evaluated length of hospitalization, technical success rates, and complications associated with TAE. Of 916 publications, 5 were eligible for inclusion; 310 patients with high-risk peptic ulcer bleeding underwent prophylactic TAE, and 255 were compared against a control group of 580 patients that underwent standard treatment with ET alone. Patients who underwent ET with TAE had lower 30-day rebleeding rates (odds ratio [OR], 0.35; 95% confidence interval [CI] 0.15-0.85; P = .02; I2 = 50%). The ET with TAE group had a lower 30-day mortality rate (OR, 0.28; 95% CI, 0.10-0.83; P = .02; I2 = 58%). There was no difference in pooled reintervention rates (OR, 0.68; 95% CI, 0.43-1.08; P = .10; I2 = 0%) and length of hospitalization (mean difference, -0.32; 95% CI, -1.88 to 1.24; P = .69; I2 = 0%). Technical success rate of prophylactic TAE was 90.5% (95% CI, 83.09-97.98; I2 = 75.9%). Pooled proportion of overall complication rate was 0.18% (95% CI, 0.00-1.28; I2 = 0%). Prophylactic TAE has lower rebleeding and mortality with a good success rate and low complications. Prophylactic TAE after primary ET may be recommended for selected patients with high-risk bleeding ulcers; however, further studies should be performed to establish this as a routine tool in patients with bleeding peptic ulcer disease.

Utility of Endoscopy in Hospitalized Patients with Gastrointestinal Hemorrhage and Pulmonary Hypertension.

BACKGROUND: Gastrointestinal hemorrhage (GIH) has been reported as one of the most common GI complications in patients with pulmonary hypertension (PH). There is paucity of data on the national burden of GIH in patients with PH. We aimed to assess the prevalence, trends and outcomes of endoscopic interventions in patients with PH who were admitted with GIH. METHOD: We queried National Inpatient Sample (NIS) database from 2005 to 2014 and identified the patients hospitalized with primary or secondary discharge diagnosis of PH (ICD 9 CM Code: 416.0, 416.8, and 416.9). Using Clinical Classification Software Coding system (153) patients with concurrent diagnosis of GIH were then identified. We studied the prevalence and trends of GIH in PH, factors associated with GIH, use of endoscopy, factors associated with utilization of endoscopic interventions, endoscopy outcomes including mortality, and overall healthcare burden. RESULTS: Out of 7,586,973 PH hospitalizations 3.2% (N = 246,358) had concurrent GIH, with a rising prevalence of GIH in PH patients during the last decade. Clinical predictors for GIH in PH included older age, congestive heart failure, anticoagulation therapy and concurrent alcohol abuse. Mean length of stay (LOS) in PH patients hospitalized with GIH was significantly higher than without GIH (8.6 vs. 6.4 days, p < 0.01) along with a significant increase in hospitalization cost ($20,189 vs. $14,807, p < 0.01). Similarly, odds of in-hospital mortality increase by ~ 1.5 times in PH patients with GIH than those without it (adjusted odds ratio [aOR: 1.45, 95%CI: 1.43-1.47]). Endoscopic interventions were performed in 48.6% of patients with PH and GIH during their hospitalization. Older patients were more likely to undergo endoscopy, as well as the patients who received blood transfusion, and those with hypovolemic shock. Patients with acute respiratory failure and acute renal failure were less likely to get endoscopy. Mean LOS in patients undergoing endoscopic intervention was significantly higher than those who did not receive any intervention (8.7 vs. 8.4 days, p < 0.01), without a substantial increase in hospitalization cost ($20,344 vs. $20,041, p < 0.01). Also, there was a significant decrease in in-hospital mortality in patients undergoing endoscopic interventions. CONCLUSION: Concurrent GIH in patients with PH increases length of stay; healthcare costs and increases in-hospital mortality. Use of endoscopic interventions in these patients is associated with reduced length of stay, in-hospital mortality without significantly increasing the overall health care burden and should be considered in hospitalized patients with PH who are admitted with GIH. Future studies comparing GIH patients with and without PH should be done to assess if PH is a risk factor for worse outcomes. CLINICAL TRIAL REGISTRATION NUMBER: No IRB required due to use of national de-identified data.

Endoscopic management of acute oesophageal variceal bleeding within 12 hours of admission is superior to 12-24 hours.

Background: Acute oesophageal variceal haemorrhage (AOVH) is a medical emergency. The American Association for the Study of Liver Diseases recommends endoscopy management as soon as possible and not more than 12 hours after presentation. The United Kingdom guidelines recommended endoscopy for unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation and within 24 hours of admission. We aimed to evaluate the outcome of endoscopic management of AOVH in less than 12 hours compared to 12-24 hours post admission.Methods: 297 patients with AOVH were divided into groups depending on the timing of the endoscopic management: 180 within 12 h of admission and 117 patients at 12-24 hours of admission. Routine clinical and laboratory data were collected.Results: Compared to patients with endoscopic management at 12-24 hours (mean 16 hours), patients with endoscopic management within 12 hours (mean 8.3 hours) of admission had fewer hospital stay days (P = 0.001), significant reduction of ammonia levels (P < 0.0001) and significant improvement in associated hepatic encephalopathy grade 25 (p = 0.048). There were no major clinical events in the 12-hour group, but 8 events in the 12-24 hour group (p < 0.01).Conclusion: Endoscopic management of acute variceal bleeding within 12 hours of admission is superior to endoscopic management at 12-24 hours of admission regarding reduction of hospital stay, ammonia levels, correction of hepatic encephalopathy, re-bleeding and mortality rate, hence, reducing the cost of treatment benefiting patient satisfaction and improving hospital bed availability.

Predictors of endoscopic intervention in upper gastrointestinal bleeding patients hospitalized for another illness: a multi-center retrospective study.

BACKGROUND: To characterize variables that may predict the need for endoscopic intervention in inpatients admitted for several causes who during the hospitalization developed acute non-variceal upper gastrointestinal bleeding (NVUGIB). METHODS: A retrospective analysis of inpatients who underwent upper gastro-intestinal endoscopy for acute NVUGIB while hospitalized for other causes from 1 January 2016 to 1 December 2017, was performed. In the primary outcome analysis, patients (N.=14) who underwent endoscopic intervention (group A) were compared to those (N.=87) who did not need for endoscopic intervention (group B). Secondary outcome analysis included patients who had significant endoscopic findings compared to those who did not have them. RESULTS: Multivariate regression analysis showed that in the primary outcome analysis, two parameters were significant: the number of packed red blood cells (PRBC) units transfused (odds ratio [OR]: 1.5, P=0.01) and Rockall Score (RS) (OR: 1.4, P=0.06) with receiver operator characteristic (ROC) curve of 0.7844. In the secondary outcome analysis, only the use of proton pump inhibitor drugs at admission was associated with protective effect for the development of significant endoscopic findings (odds ratio [OR]: 0.42, P=0.05) with ROC curve of 0.7342. CONCLUSIONS: In hospitalized patients, in case of de novo NVUGIB, the number of PRBC units transfused and RS are predictive of significant endoscopic findings.

Ulcer bleeding after band ligation of esophageal varices: Risk factors and prognosis.

BACKGROUND: Post-banding ulcer bleeding is a rare complication of endoscopic band ligation of esophageal varices with high morbidity and mortality. There exist no management guidelines for this complication. AIMS: To determine the incidence, outcome and risk factors of post-banding ulcer bleeding. METHODS: Data for cirrhotic patients with acute variceal bleeding during a six-year period were prospectively collected, and all band ligation sessions performed were retrospectively analyzed. Demographic, analytic and endoscopic data were recorded, as well as complications, outcome and management of each episode of post-banding ulcer bleeding. RESULTS: The study includes 521 band ligation sessions performed on 175 patients. There were 24 cases of post-banding ulcer bleeding in 21 patients (incidence 4.6%). Independent risk factors for post-banding ulcer bleeding were MELD score, hepatocellular carcinoma and total beta-blocker dose. Mortality during the bleeding episode was 23.8%. Active bleeding or adherent clots at the time of endoscopy was associated with treatment failure or death. CONCLUSIONS: Post-banding ulcer bleeding is an uncommon but severe complication of esophageal banding. Patients with hepatocellular carcinoma, poor liver function and a low beta-blocker dose have higher risk of post-banding ulcer bleeding. An aggressive treatment should be considered in case of active bleeding at endoscopy.

Balloon Retrograde Transvenous Obliteration Versus Endoscopic Cyanoacrylate in Bleeding Gastric Varices: Comparison of Rebleeding and Mortality with Extended Follow-up.

PURPOSE: To assess short- and long-term mortality and rebleeding with endoscopic cyanoacrylate (EC) versus balloon-occluded retrograde transvenous obliteration (BRTO). MATERIALS AND METHODS: A retrospective cohort comparison was conducted of 90 EC patients and 71 BRTO patients from 1997 through 2015 with portal hypertension who presented due to endoscopically confirmed bleeding cardiofundal gastric varices. Patients underwent either endoscopic intra-varix injection of 4-carbon-n-butyl-2-cyanoacrylate or sclerosis with sodium tetradecyl sulfate with balloon occlusion for primary variceal treatment. RESULTS: Seventy-one BRTO patients and 90 EC patients, of whom 89% had cirrhosis and 35% were women, were included, with a respective average Model for End-Stage Liver Disease (MELD) score of 13.4 and 14.4, respectively. Mortality at 6 weeks was 14.4% for EC patients and 13.1% for BRTO patients (Kaplan-Meier/Wilcoxon, P = .85). No long-term mortality difference was observed (Cox hazard ratio [HR] = 0.89, P = .64). Also, 5.1% of EC patients and 3.5% of BRTO patients (Kaplan-Meier/Wilcoxon, P = .62) rebled at 6 weeks, but at 1 year, 22.0% of EC patients and 3.5% of BRTO patients had rebled (Kaplan-Meier/Wilcoxon, P < .01). Lower rates of long-term rebleeding were found with BRTO (Cox HR = 0.25, P = .03). No difference was seen in the rate of new portal hypertensive complications (Cox HR = 1.21, P = .464). However, 16/71 patients who underwent BRTO had simultaneous transjugular intrahepatic portosystemic shunt. Age, sex, MELD score, and presence of cirrhosis were the primary predictors of mortality. One death in the EC group and 5 deaths in the BRTO group were deemed to be procedurally related (chi-square, P = .088). CONCLUSIONS: BRTO is associated with a lower rate of rebleeding but no change in mortality.

Prognosis of patients with gastric variceal bleeding after endoscopic variceal obturation according to the type of varices.

BACKGROUND AND AIMS: This study was performed to evaluate the treatment efficacy of endoscopic variceal obturation (EVO) in patients with gastric variceal bleeding (GVB) according to the type of varices. PATIENTS AND METHODS: All patients who were treated with EVO for bleeding from gastric varices (GVs) were included. Patients with a previous history of endoscopic treatment for GVB and those with accompanying portal vein invasion by hepatocellular carcinoma or other malignancy were excluded. RESULTS: Ninety-one patients with GVB were included. Mean age was 59.4±12.4 years and 72 (79.1%) patients were men. The types of varices were gastroesophageal varices (GOV) type 1 (GOV1), GOV2, and isolated gastric varices type 1 (IGV1) in 30 (33.3%), 35 (38.5%), and 26 (28.6%) patients, respectively. Hemostasis and GV obliteration were achieved in 88 (96.7%) and 81 (89.0%) patients, respectively. Among 81 patients with GV obliteration, GV recurred in 26 (32.1%) patients. The GV recurrence rate was significantly lower in patients with GOV1 than in those with GOV2 (P=0.007), while it was comparable between patients with GOV1 and IGV1 (P=0.111) and between patients with GOV2 and IGV1 (P=0.278). Variceal rebleeding occurred in 11 (13.6%) patients. GVB recurrence rate was significantly higher in patients with GOV2 than in those with GOV1 (P=0.034) and IGV1 (P=0.018), while it was comparable between patients with GOV1 and IGV1 (P=0.623). Mortality rate was comparable among the three groups. CONCLUSIONS: EVO was very effective in patients with GVB. GV recurrence and GV rebleeding were significantly lower in patients with GOV1 than in those with GOV2.

Endoscopy Is Relatively Safe in Patients with Acute Ischemic Stroke and Gastrointestinal Hemorrhage.

BACKGROUND: Gastrointestinal hemorrhage (GIH) is reported to occur in 1-8% of patients admitted with acute ischemic stroke (AIS). AIS is considered to be a relative contraindication to GIE. AIMS: Evaluate the outcomes of gastrointestinal endoscopy (GIE) in patients hospitalized with AIS and GIH. METHODS: Patients hospitalized with AIS and GIH were included from the National Inpatient Sample 2005-2014. Primary outcome measure was in-hospital mortality in patients with AIS and GIH who underwent gastrointestinal endoscopy. Secondary outcomes were (1) resource utilization as measured by length of stay (LOS) and total hospitalization costs and (2) to identify independent predictors of undergoing GIE in patients with AIS and GIH. Confounders were adjusted for by using multivariable regression analysis. RESULTS: A total of 75,756 hospitalizations were included in the analysis. Using a multivariate analysis, the in-hospital mortality was significantly lower in patients who underwent GIE as compared to those who did not [aOR: 0.4, P < 0.001]. Patients who underwent GIE also had significantly shorter adjusted mean LOS [adjusted mean difference in LOS: 0.587 days, P < 0.001]. Patients with AIS and GIH who did not undergo GIE had significantly higher adjusted total hospitalization costs. [Mean adjusted difference in total hospitalization costs was $5801 (P < 0.001).] Independent predictors of undergoing GIE in this population were male gender, age > 65 years, Asian or Pacific race, hypovolemic shock, need for blood transfusion and admission to urban non-teaching hospital. CONCLUSIONS: Gastrointestinal endoscopy can be safely performed in a substantial number of patients with AIS and GIH.

Endoscopic Cyanoacrylate Injection with Post-injection Audible Doppler Assessment of Gastric Varices: A Single-Institution Experience.

BACKGROUND AND AIMS: Gastric varices (GV) have higher rates of morbidity and mortality from hemorrhage than esophageal varices. Several studies have shown the safety and efficacy of cyanoacrylate (CA) injection for acute gastric variceal hemorrhage. We report data from our experience with CA injection for GV before and after routine use of post-injection audible Doppler assessment (ADA) for GV obturation and describe long-term outcomes after this therapy. METHODS: We retrospectively identified patients who had documented GV, underwent CA injection, and had at least 2 weeks of follow-up. We recorded and analyzed the survival and rebleeding rates with patient demographics, clinical data, and endoscopy findings between two groups of patients who were categorized by CA injection prior to and after inception of the ADA technique. RESULTS: Seventy-one patients were identified with 16 patients analyzed in a group where ADA was not used (Pre-ADA) and 55 analyzed where ADA was used (Post-ADA). No rebleeding events were observed within 1 week of initial CA injection. No embolic events were reported after any initial CA injection within 4 weeks. The rate of bleed-free survival at 1 year was 69.6% in the Pre-ADA group and 85.8% in the Post-ADA without statistical significance. The all-cause 1-year mortality was 13.8% in the Pre-ADA group and 10.7% in the Post-ADA group without statistical significance. CONCLUSIONS: ADA of CA-injected GV does not appear to significantly affect adverse events or clinical outcomes; however, our findings are limited by small sample size and cohort proportions allowing for significant type II statistical error. Further prospective investigation is required to determine the impact of ADA on clinical outcomes after GV obturation.

First-line endoscopic treatment with over-the-scope clips significantly improves the primary failure and rebleeding rates in high-risk gastrointestinal bleeding: A single-center experience with 100 cases.

AIM: To evaluate rebleeding, primary failure (PF) and mortality of patients in whom over-the-scope clips (OTSCs) were used as first-line and second-line endoscopic treatment (FLET, SLET) of upper and lower gastrointestinal bleeding (UGIB, LGIB). METHODS: A retrospective analysis of a prospectively collected database identified all patients with UGIB and LGIB in a tertiary endoscopic referral center of the University of Freiburg, Germany, from 04-2012 to 05-2016 (n = 93) who underwent FLET and SLET with OTSCs. The complete Rockall risk scores were calculated from patients with UGIB. The scores were categorized as < or ≥ 7 and were compared with the original Rockall data. Differences between FLET and SLET were calculated. Univariate and multivariate analysis were performed to evaluate the factors that influenced rebleeding after OTSC placement. RESULTS: Primary hemostasis and clinical success of bleeding lesions (without rebleeding) was achieved in 88/100 (88%) and 78/100 (78%), respectively. PF was significantly lower when OTSCs were applied as FLET compared to SLET (4.9% vs 23%, P = 0.008). In multivariate analysis, patients who had OTSC placement as SLET had a significantly higher rebleeding risk compared to those who had FLET (OR 5.3; P = 0.008). Patients with Rockall risk scores ≥ 7 had a significantly higher in-hospital mortality compared to those with scores < 7 (35% vs 10%, P = 0.034). No significant differences were observed in patients with scores < or ≥ 7 in rebleeding and rebleeding-associated mortality. CONCLUSION: Our data show for the first time that FLET with OTSC might be the best predictor to successfully prevent rebleeding of gastrointestinal bleeding compared to SLET. The type of treatment determines the success of primary hemostasis or primary failure.

Predictors of poor outcome in gastrointestinal bleeding in emergency department.

AIM: To determine the prognostic risk factors of gastrointestinal bleeding in emergency department cases. METHODS: The trial was a retrospective single-center study involving 600 patients over 18-years-old and carried out with approval by the Institutional Ethics Committee. Patient data included demographic characteristics, symptoms at admission, past medical history, vital signs, laboratory results, endoscopy and colonoscopy results, length of hospital stay, need of intensive care unit (ICU) admission, and mortality. Mortality rate was the principal endpoint of the study, while duration of hospital stay, required interventional treatment, and admission to the ICU were secondary endpoints. RESULTS: The mean age of patients was 61.92-years-old. Among the 600 total patients, 363 (60.5%) underwent upper gastrointestinal endoscopy and the most frequent diagnoses were duodenal ulcer (19.2%) and gastric ulcer (12.8%). One-hundred-and-fifteen (19.2%) patients required endoscopic treatment, 20 (3.3%) required surgical treatment, and 5 (0.8%) required angiographic embolization. The mean length of hospital stay was 5.21 ± 5.85 d. The mortality rate was 6.3%. The ICU admission rate was 5.3%. Patients with syncope, higher blood glucose levels, and coronary artery disease had significantly higher ICU admission rates (P = 0.029, P = 0.043, and P = 0.002, respectively). Patients with low thrombocyte levels, high creatinine, high international normalized ratio, and high serum transaminase levels had significantly longer hospital stay (P = 0.02, P = 0.001, P = 0.019, and P = 0.005, respectively). Patients who died had significantly higher serum blood urea nitrogen and creatinine levels (P = 0.016 and P = 0.038), and significantly lower mean blood pressure and oxygen saturation (P = 0.004 and P = 0.049). Malignancy and low Glasgow coma scale (GCS) were independent predictive factors of mortality. CONCLUSION: Prognostic factors for gastrointestinal bleeding in emergency room cases are malignancy, hypotension on admission, low GCS, and impaired kidney function.

Predictors of re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy bleeding.

AIM: To predict the re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy (ES) bleeding. METHODS: Over a 15-year period, data from 161 patients with delayed post-ES bleeding were retrospectively collected from a single medical center. To identify risk factors for re-bleeding after initial successful endoscopic hemostasis, parameters before, during and after the procedure of endoscopic retrograde cholangiopancreatography were analyzed. These included age, gender, blood biochemistry, co-morbidities, endoscopic diagnosis, presence of peri-ampullary diverticulum, occurrence of immediate post-ES bleeding, use of needle knife precut sphincterotomy, severity of delayed bleeding, endoscopic features on delayed bleeding, and type of endoscopic therapy. RESULTS: A total of 35 patients (21.7%) had re-bleeding after initial successful endoscopic hemostasis for delayed post-ES bleeding. Univariate analysis revealed that malignant biliary stricture, serum bilirubin level of greater than 10 mg/dL, initial bleeding severity, and bleeding diathesis were significant predictors of re-bleeding. By multivariate analysis, serum bilirubin level of greater than 10 mg/dL and initial bleeding severity remained significant predictors. Re-bleeding was controlled by endoscopic therapy in a single (n = 23) or multiple (range, 2-7; n = 6) sessions in 29 of the 35 patients (82.9%). Four patients required transarterial embolization and one went for surgery. These five patients had severe bleeding when delayed post-ES bleeding occurred. One patient with decompensated liver cirrhosis died from re-bleeding. CONCLUSION: Re-bleeding occurs in approximately one-fifth of patients after initial successful endoscopic hemostasis for delayed post-ES bleeding. Severity of initial bleeding and serum bilirubin level of greater than 10 mg/dL are predictors of re-bleeding.

One hundred and one over-the-scope-clip applications for severe gastrointestinal bleeding, leaks and fistulas.

AIM: To investigate the efficacy and clinical outcome of patients treated with an over-the-scope-clip (OTSC) system for severe gastrointestinal hemorrhage, perforations and fistulas. METHODS: From 02-2009 to 10-2012, 84 patients were treated with 101 OTSC clips. 41 patients (48.8%) presented with severe upper-gastrointestinal (GI) bleeding, 3 (3.6%) patients with lower-GI bleeding, 7 patients (8.3%) underwent perforation closure, 18 patients (21.4%) had prevention of secondary perforation, 12 patients (14.3%) had control of secondary bleeding after endoscopic mucosal resection or endoscopic submucosal dissection (ESD) and 3 patients (3.6%) had an intervention on a chronic fistula. RESULTS: In 78/84 patients (92.8%), primary treatment with the OTSC was technically successful. Clinical primary success was achieved in 75/84 patients (89.28%). The overall mortality in the study patients was 11/84 (13.1%) and was seen in patients with life-threatening upper GI hemorrhage. There was no mortality in any other treatment group. In detail OTSC application lead to a clinical success in 35/41 (85.36%) patients with upper GI bleeding and in 3/3 patients with lower GI bleeding. Technical success of perforation closure was 100% while clinical success was seen in 4/7 cases (57.14%) due to attendant circumstances unrelated to the OTSC. Technical and clinic success was achieved in 18/18 (100%) patients for the prevention of bleeding or perforation after endoscopic mucosal resection and ESD and in 3/3 cases of fistula closure. Two application-related complications were seen (2%). CONCLUSION: This largest single center experience published so far confirms the value of the OTSC for GI emergencies and complications. Further clinical experience will help to identify optimal indications for its targeted and prophylactic use.

Clinical Backgrounds and Outcomes of Elderly Japanese Patients with Gastrointestinal Bleeding.

OBJECTIVE: Elderly gastrointestinal bleeding (GIB) patients sometimes cannot be discharged home. In some cases, they die after hemostasis, even following appropriate treatment. This study investigates the clinical backgrounds and outcomes of elderly Japanese GIB patients. METHODS: The medical records of 185 patients (123 men, 62 women; mean age 68.2 years; range 10-99 years) with GIB symptoms who underwent esophagogastroduodenoscopy or colonoscopy to detect or treat the source of GIB were retrospectively reviewed. We compared the outcomes between patients ≤70 (n=85) and >70 (n=100) years. The clinical backgrounds of the patients who died or changed hospitals to undergo rehabilitation or receive palliative care were evaluated, as were the association of four factors with these poor outcomes: GIB (re-bleeding or uncontrolled bleeding), endoscopic procedure-related complications, exacerbation of the pre-existing comorbidity, and any complications that were not directly related to GIB. RESULTS: Of the patients ≤70 and >70 years of age, three (3.5%) and 17 (17.0%), respectively, were transferred to another hospital (p=0.003). One (1.2%) and five (5.0%), respectively, died (p=0.144). All three patients ≤70 years old that changed hospitals did so because their comorbidities became worse. The reasons for changing hospitals in the 17 patients >70 years of age included exacerbation of a pre-existing comorbidity (41.1%, 7/17), other complications (35.4%, 6/17), GIB itself (17.6%, 3/17), and endoscopic procedure-related complications (5.9%, 1/17). CONCLUSION: Although non-elderly and elderly GIB patients had similar mortality rates, many more elderly patients could not be discharged home for various reasons.

Evolving techniques for gastrointestinal endoscopic hemostasis treatment.

With mortality due to gastrointestinal (GI) bleeding remaining stable, the focus on endoscopic hemostasis has been on improving other outcomes such as rebleeding rate, need for transfusions, and need for angiographic embolization or surgery. Over the past few years, a number of devices have emerged to help endoscopically assess and treat bleeding GI lesions. These include the Doppler endoscopic probe, hemostatic powder, and over-the-scope clip. Also, new applications have been described for radiofrequency ablation. In this article, we will discuss these evolving tools and techniques that have been developed, including an analysis of their efficacy and limitations.

Can proton pump inhibitors reduce rebleeding following Histoacryl sclerotherapy for gastric variceal hemorrhage?

BACKGROUND/AIMS: To evaluate the efficacy of proton pump inhibitors (PPIs) in reducing rebleeding and bleeding-related death rates after endoscopic gastric variceal obliteration (GVO) using N-butyl-2-cyanoacrylate (NBC). METHODS: This study enrolled 341 patients who were consecutively diagnosed with and treated for bleeding gastric varices. The patients were divided into PPI and non-PPI groups, and their endoscopic findings, initial hemostasis outcomes, rebleeding and bleeding-related death rates, and treatment-related complications were analyzed. RESULTS: The rate of initial hemostasis was 97.1%. rebleeding occurred in 2.2% of patients within 2 weeks, 3.9% of patients within 4 weeks, 18.9% of patients within 6 months, and 27.6% of patients within 12 months of the GVO procedure. A previous history of variceal bleeding (relative risk [RR], 1.955; 95% confidence interval [CI], 1.263 to 3.028; p = 0.003) and use of PPIs (RR, 0.554; 95% CI, 0.352 to 0.873; p = 0.011) were associated with rebleeding. Child-Pugh class C (RR, 10.914; 95% CI, 4.032 to 29.541; p < 0.001), failure of initial hemostasis (RR, 13.329; 95% CI, 2.795 to 63.556; p = 0.001), and the presence of red-colored concomitant esophageal varices (RR, 4.096; 95% CI, 1.320 to 12.713; p = 0.015) were associated with bleeding-related death. CONCLUSIONS: The prophylactic use of PPIs reduces rebleeding after GVO using NBC in patients with gastric variceal hemorrhage. However, prophylactic use of PPIs does not reduce bleeding-related death.

Risk factors for band-induced ulcer bleeding after prophylactic and therapeutic endoscopic variceal band ligation.

BACKGROUND AND AIMS: Endoscopic variceal band ligation (EVBL) aims to eradicate high-risk oesophageal varices. There is a small risk of precipitating bleeding from EVBL-induced oesophageal ulceration, which is associated with significant mortality. We explore the risk factors and outcome of EVBL-induced ulcer bleeding. METHODS: Retrospective review of our endoscopy database between 2007 and 2012 identified upper endoscopies during which EVBL was performed. Patient demographics, biochemistry and endoscopic findings were recorded as were the complications of EVBL-induced ulcer bleeding and death. RESULTS: A total of 749 episodes of EVBL were performed in 347 patients with a mean Model for End-stage Liver Disease (MELD) score of 15.8. In all, 609 procedures were performed for prophylaxis and 140 for acute haemorrhage. There were 21 episodes (2.8% of procedures) of EVBL-induced ulcer bleeding in 18 patients, five of whom subsequently died (28%). On multivariable analysis, acute variceal haemorrhage was the only significant predictor of EVBL-induced ulcer bleeding [odds ratio (OR) 6.25 (2.57-15.14), P<0.0001]. In 609 procedures performed for prophylaxis, the EVBL-induced ulcer bleeding rate was 1.5%, with 22% mortality. In this group, higher MELD score and reflux oesophagitis were associated significantly with EVBL-induced ulcer bleeding [OR 25.53 (2.14-303.26), P=0.010 and OR 1.07 (1.01-1.13), P=0.019, respectively]. CONCLUSION: Our EVBL-induced ulcer bleeding rate was low, but associated with significant mortality. Highest rates were observed following EVBL for acute variceal haemorrhage, for which EVBL is unavoidable. The incidence was lower following prophylactic EVBL, with the MELD score being the predominant risk factor. Reflux oesophagitis requires further investigation as a potentially modifiable risk factor for EVBL-induced ulcer bleeding.

Endoscopic variceal ligation compared with endoscopic injection sclerotherapy for treatment of esophageal variceal hemorrhage: a meta-analysis.

AIM: To compare the effect of endoscopic variceal ligation (EVL) with that of endoscopic injection sclerotherapy (EIS) in the treatment of patients with esophageal variceal bleeding. METHODS: We performed a systematic literature search of multiple online electronic databases. Meta-analysis was conducted to evaluate risk ratio (RR) and 95% confidence interval (CI) of combined studies for the treatment of patients with esophageal variceal bleeding between EVL and EIS. RESULTS: Fourteen studies comprising 1236 patients were included in the meta-analysis. The rebleeding rate in actively bleeding varices patients in the EVL group was significantly lower than that in the EIS group (RR=0.68, 95%CI: 0.57-0.81). The variceal eradication rate in actively bleeding varices patients in the EVL group was significantly higher than that in the EIS group (RR=1.06, 95%CI: 1.01-1.12). There was no significant difference about mortality rate between the EVL group and EIS group (RR=0.95, 95%CI: 0.77-1.17). The rate of complications in actively bleeding varices patients in the EVL group was significantly lower than that in the EIS group (RR=0.28, 95%CI: 0.13-0.58). CONCLUSION: Our meta-analysis has found that EVL is better than EIS in terms of the lower rates of rebleeding, complications, and the higher rate of variceal eradication. Therefore, EVL is the first choice for esophageal variceal bleeding.

Endoscopic cyanoacrylate injection for the treatment of gastric varices in children.

AIM: To evaluate the efficacy and safety of N-butyl-2-cyanoacrylate in treating acute bleeding of gastric varices in children. METHODS: The retrospective study included 21 children with 47 episodes of active gastric variceal bleeding who were treated by endoscopic injection of N-butyl-2-cyanoacrylate at Asan Medical Center Children's Hospital between August 2004 and December 2011. To reduce the risk of embolism, each injection consisted of 0.1-0.5 mL of 0.5 mL N-butyl-2-cyanoacrylate diluted with 0.5 or 0.8 mL Lipiodol. The primary outcome was incidence of hemostasis after variceal obliteration and the secondary outcome was complication of the procedure. RESULTS: The 21 patients experienced 47 episodes of active gastric variceal bleeding, including rebleeding, for which they received a total of 52 cyanoacrylate injections. Following 42 bleeding episodes, hemostasis was achieved after one injection and following five bleeding episodes it was achieved after two injections. The mean volume of each single aliquot of cyanoacrylate injected was 0.3 ± 0.1 mL (range: 0.1-0.5 mL). Injection achieved hemostasis in 45 of 47 (95.7%) episodes of acute gastric variceal bleeding. Eleven patients (52.4%) developed rebleeding events, with the mean duration of hemostasis being 11.1 ± 11.6 mo (range: 1.0-39.2 mo). No treatment-related complications such as distal embolism were noted with the exception of abdominal pain in one patient (4.8%). Among four mortalities, one patient died of variceal rebleeding. CONCLUSION: Endoscopic variceal obliteration using a small volume of aliquots with repeated cyanoacrylate injection was an effective and safe option for the treatment of gastric varices in children.

Endoscopic treatment of esophageal varices in patients with liver cirrhosis.

Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Patients with medium- or large-sized varices can be treated for primary prophylaxis of variceal bleeding using two strategies: non-selective beta-blockers (NSBBs) or endoscopic variceal ligation (EVL). Both treatments are equally effective. Patients with acute variceal bleeding are critically ill patients. The available data suggest that vasoactive drugs, combined with endoscopic therapy and antibiotics, are the best treatment strategy with EVL being the endoscopic procedure of choice. In cases of uncontrolled bleeding, transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene (PTFE)-covered stents are recommended. Approximately 60% of the patients experience rebleeding, with a mortality rate of 30%. Secondary prophylaxis should start on day six following the initial bleeding episode. The combination of NSBBs and EVL is the recommended management, whereas TIPS with PTFE-covered stents are the preferred option in patients who fail endoscopic and pharmacologic treatment. Apart from injection sclerotherapy and EVL, other endoscopic procedures, including tissue adhesives, endoloops, endoscopic clipping and argon plasma coagulation, have been used in the management of esophageal varices. However, their efficacy and safety, compared to standard endoscopic treatment, remain to be further elucidated. There are safety issues accompanying endoscopic techniques with aspiration pneumonia occurring at a rate of approximately 2.5%. In conclusion, future research is needed to improve treatment strategies, including novel endoscopic techniques with better efficacy, lower cost, and fewer adverse events.