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• W4246818382 abstract "There were a number of interesting abstracts presented at the 2012 Digestive Disease Week (DDW; 19-22 May, San Diego, California, USA) that covered gastrointestinal bleeding and endoscopy. The following abstracts are those that were found to have particular high clinical importance and the potential for direct impact on the endoscopic care of patients. Emerging endoscopic hemostasis therapies for acute nonvariceal upper gastrointestinal hemorrhage (NVUGIH) that do not involve using injection, thermal methods, or mechanical techniques have been developed and are now being evaluated in clinical studies. Sung et al.1Sung J.J. Luo D. Wu J.C. et al.Early clinical experience of the safety and effectiveness of Hemospray in achieving hemostasis in patients with acute peptic ulcer bleeding.Endoscopy. 2011; 43: 291-295Crossref PubMed Scopus (187) Google Scholar from the Hong Kong group recently reported pilot data on the use of Hemospray (Cook Medical, Winston-Salem, North Carolina, USA) in acute peptic ulcer bleeding. At DDW 2012, Morris et al.2Morris A.J. Smith L.A. Stanley A. et al.Hemospray for non-variceal upper gastrointestinal bleeding: results of the SEAL Dataset (survey to evaluate the application of hemospray in the luminal tract).Gastrointest Endosc. 2012; 75: AB133Abstract Full Text Full Text PDF Google Scholar reported the initial prospective, multicenter European study (the SEAL Study) evaluating the use of Hemospray as monotherapy or in combination with another endoscopic hemostasis modality in NVUGIH. Over a 3-month period (June to September 2011) at nine separate European centers, 71 patients (49 males; median age 70 years) were treated using Hemospray as monotherapy (n = 39), adjuvant endotherapy (n = 8), or as rescue therapy following failed primary hemostasis using an alternative technique (n = 24). In the monotherapy group, there was a 97% primary hemostasis rate, 16% rebleeding rate, and 8% associated mortality. In the adjuvant group, there was 75% primary hemostasis, 17% rebleeding, and no associated mortality. In the rescue therapy group, there was 67% primary hemostasis, 38% rebleeding, and 8% mortality. Overall, five deaths were reported (7.0%), none of which was directly due to gastrointestinal bleeding, and eight technical complications (11.3%) with the use of Hemospray. These are provocative data, but large-scale prospective randomized trial data are now needed to more rigorously evaluate this interesting and new hemostasis modality. The role of scheduled second-look endoscopy in NVUGIH remains controversial.3Gralnek I.M. Barkun A.N. Bardou M. Current concepts: management of acute bleeding from a peptic ulcer.N Engl J Med. 2008; 359: 928-937Crossref PubMed Scopus (301) Google Scholar, 4El Ouali S, Barkun AN, Wyse J, et al. Is routine second look endoscopy effective after endoscopic hemostasis in acute peptic ulcer bleeding? A meta-analysis. Gastrointest Endosc. Epub 2012 June 11.Google Scholar Park et al.5Park S.J. Park H. Lee Y.C. et al.Effect of scheduled second look endoscopy on peptic ulcer bleeding: interim analysis of randomized controlled trial.Gastrointest Endosc. 2012; 75: AB235Abstract Full Text Full Text PDF Google Scholar reported on a prospective randomized trial comparing scheduled second-look endoscopy (n = 113) performed at 24–36 hours after index endoscopy versus clinical observation (n = 110) with upper endoscopy performed only if there was evidence of rebleeding in patients. All patients had peptic ulcer hemorrhage and high risk stigmata (Forrest Ia-IIb) and all received endotherapy at the time of index endoscopy. Baseline patient characteristics in both groups were reported to be equal, and there was no observed difference between groups in rebleeding, transfusions, surgery, radiological intervention, duration of hospitalization or mortality. Multivariate analysis showed that a Rockall Score ≥6 and unsatisfactory endotherapy reported by the endoscopist at index endoscopy were independent risk factors for ulcer rebleeding. The authors recommended a scheduled second-look endoscopy only in those patients with a Rockall Score ≥6 or in cases where endotherapy at the time of index endoscopy was thought to be suboptimal. This was an interim analysis, and therefore the noninferiority reported may be due to low patient numbers recruited at this time and a statistical beta error; thus, data from the fully completed trial are awaited. Finally, Sung et al.6Sung J.J. Suen R. Ching J. et al.Effects of intravenous and oral esomeprazole in prevention of recurrent bleeding from peptic ulcers after endoscopic therapy.Gastroenterology. 2012; 142: S-192-3Google Scholar reported on a prospective, double-blind, double-dummy, randomized trial comparing the efficacy and safety of intravenous (IV) and oral esomeprazole in patients with peptic ulcer bleeding (Forrest I or IIab). After receiving endoscopic hemostasis, patients were randomly assigned to receive either IV esomeprazole 80 mg bolus followed by 8 mg/hour continuous infusion for 72 hours plus oral placebo (n = 95) or oral esomeprazole 40 mg twice daily for 72 hours plus IV placebo infusion (n = 105). The authors reported no statistically significant difference in rates of recurrent bleeding at 3, 7, or 56 days postendoscopic hemostasis. Not explicitly mentioned by the authors was the important issue of whether there was adequate power to detect a statistical difference between IV and oral esomeprazole post-hemostasis, and thus we anxiously await further information on this important study. The endoscopic use of “glue” for hemostasis of acute gastric variceal hemorrhage is commonly practiced in many parts of the world.7Seewald S. Sriram P.V. Naga M. et al.Cyanoacrylate glue in gastric variceal bleeding.Endoscopy. 2002; 34: 926-932Crossref PubMed Scopus (116) Google Scholar Chantarojanasiri et al.8Chantarojanasiri T. Prachayakul V. Aswakul P. Clinical outcomes and complications of histoacryl injection for gastric variceal hemorrhage: what are the determining factors?.Gastrointest Endosc. 2012; 75: AB363Abstract Full Text Full Text PDF Google Scholar reported on clinical outcomes and complications associated with histoacryl injection for gastric variceal hemorrhage. The investigators from Thailand retrospectively reviewed their data on 88 procedures for patients (mean age 55 years; 73% male) with acute gastric variceal hemorrhage who were treated with histoacryl from April 2008 to October 2011. Primary hemostasis using histoacryl was 96.6% and rebleeding over the ensuing 5 days was 10.1%. Early complications (14.6%) were mainly from nonfatal systemic embolization (41.6%). Factors associated with early complications were poor underlying liver status, emergency endoscopy, concurrent hepatocellular carcinoma, and higher requirements for blood transfusions. Overall mortality for this cohort was 21.3%, reported to be due primarily to infectious causes. Data on the use of glue are even more limited in the United States due to this hemostasis modality not being approved for use in gastric variceal bleeding by the US Food and Drug Administration. Abu Rajab et al.9Abu Rajab M. Holm A.N. El-Abiad R. et al.Endosocpic cyanoacrylate injection for the treatment of gastric varices: experience of a single US center.Gastroenterology. 2012; 142: S-575Google Scholar reported on a single United States tertiary care center experience using cyanoacrylate glue for gastric variceal hemorrhage. In total, 46 patients with gastric varices (32 male; mean age 60.6 years) were included, 44 of whom had acute gastric variceal bleeding. Active gastric variceal bleeding at the time of endoscopy was found in seven patients (15%), with primary hemostasis being achieved in 100%. Early rebleeding occurred in one patient (2%), which was controlled with repeat cyanoacrylate glue injection. Adverse events included ischemic stroke in two patients (4%) and portal vein emboli in one (2%). In 30/33 (91%) patients with long term follow-up (median 14 months), there was no recurrent gastric variceal bleeding. Three patients (9%) had rebleeding that was successfully retreated with glue injection. The authors concluded that cyanoacrylate glue injection for gastric variceal bleeding was effective and had few complications. There were a number of abstracts presented on the topic of upper gastrointestinal bleeding associated with endoscopic submucosal dissection (ESD). Uedo et al.10Uedo N. Ohta T. Ishihara R. et al.Endoscopic Doppler US for prediction of delayed bleeding after ESD for early gastric cancer.Gastrointest Endosc. 2012; 75: AB142Abstract Full Text Full Text PDF Google Scholar reported on the feasibility of using Doppler ultrasound for predicting post-ESD bleeding in 80 patients with early gastric cancer. Upon completion of ESD, a Doppler ultrasound probe was placed in contact with the ulcer base to search for a positive Doppler signal. Soft coagulation was performed for areas or vessels with Doppler-positive signals. Areas without a Doppler signal were left untreated. The incidence of delayed bleeding was evaluated. Delayed bleeding occurred in six patients (7.5%). Delayed bleeding occurred in 4/252 (1.6%) Doppler-positive vessels or areas, despite being prophylactically treated with soft coagulation. In one patient, the source of bleeding was not identified. Delayed bleeding arose from only 1/744 (0.13%) Doppler-negative vessels or areas. Thus, it appears that the post-ESD use of Doppler ultrasound may have a role in the prevention of post-ESD bleeding episodes. Two retrospective Japanese studies appeared to demonstrate the synergistic effect of anti-platelet agents and anti-coagulants (defined together as anti-thrombotic drugs, ATDs) on the risk of post-ESD ulcer bleeding in patients with early gastric cancer.11Kawai N. Tsumano E.R.I. Urabe M. et al.Synergistic effects of anti-thrombotic drugs on secondary hemorrhage following endoscopic submucosal dissection in patients with early gastric tumors.Gastrointest Endosc. 2012; 75: AB231Abstract Full Text Full Text PDF Google Scholar, 12Takeuchi T. Umegaki E. Kojima Y. et al.Investigation of hemorrhage from ulcer after gastric endoscopic submucosal dissection (ESD) in patients administered antithrombotic agents.Gastrointest Endosc. 2012; 75: AB232Abstract Full Text Full Text PDF Google Scholar These two studies assessed the association between the use of ATDs and the rate of secondary post-ESD ulcer hemorrhage in patients with early gastric cancer. Kawai et al.11Kawai N. Tsumano E.R.I. Urabe M. et al.Synergistic effects of anti-thrombotic drugs on secondary hemorrhage following endoscopic submucosal dissection in patients with early gastric tumors.Gastrointest Endosc. 2012; 75: AB231Abstract Full Text Full Text PDF Google Scholar reported on 552 patients, of whom 131 (23.7%) were taking ATDs and Takeuchi et al.12Takeuchi T. Umegaki E. Kojima Y. et al.Investigation of hemorrhage from ulcer after gastric endoscopic submucosal dissection (ESD) in patients administered antithrombotic agents.Gastrointest Endosc. 2012; 75: AB232Abstract Full Text Full Text PDF Google Scholar reported on 833 patients, 90 of whom (10.8%) were taking ATDs. In the study by Kawai et al., anti-coagulants or anti-platelet drugs alone did not increase the rate of secondary hemorrhage (4/104, 3.8%; P < 0.60) or blood transfusion (1/104, 1.0%; P = 0.99), but the combination of anti-coagulants and anti-platelet drugs increased the rate of secondary hemorrhage (25.9%; P < 0.01) and blood transfusions (14.8%; P < 0.01). Takeuchi et al. also showed that in patients taking both anti-platelet agents and anti-coagulants, post-ESD hemorrhage occurred in 24% (5/21) compared with 6% (4/69) in those not taking both types of ATDs (P < 0.016). Moreover, Takeuchi et al. reported that the use of post-ESD proton pump inhibitors or mucosal protective agents significantly reduced the incidence of post-ESD hemorrhage (P = 0.039). On the topic of lower gastrointestinal bleeding, there were several abstracts that related to post-polypectomy bleeding. Kishino and Oyama13Kishino T. Oyama T. Prevention of bleeding after colon polypectomy in patients with antithrombotic therapy.Gastrointest Endosc. 2012; 75: AB169Abstract Full Text Full Text PDF Google Scholar compared the incidence of post-polypectomy bleeding and thromboembolic events for patients who had their anti-thrombotic agents withheld for a period before and after polypectomy (aspirin alone withheld from 5 days before until 3 days after; dual anti-platelet therapy 7 days before and 5 days after; and warfarin 4 days before and 3 days after). A control group of patients who did not normally take anti-thrombotic agents was also included. For those taking warfarin, the international normalized ratio was checked on the day of colonoscopy and if ≥1.5 the colonoscopy procedure was cancelled. The immediate post-polypectomy bleeding rate was 11/282 (3.9%) in the drugs-withheld group and 76/1648 (4.6%) in the control group (P = 0.45). The delayed post-polypectomy bleeding rate was 4/282 (1.4%) in the drugs-withheld group and 18/1648 (1.1%) in the control group (P = 0.52). There were no thromboembolic events in either group. Logistic regression analysis showed that withholding anti-thrombotic agents did not appear to influence post-polypectomy bleeding rates (odds ratio 1.29; 95% confidence interval 0.38-4.41). In a retrospective, matched case–control study of patients who underwent elective colonoscopy at a single VA hospital between July 2008 and December 2009, Iqbal et al.14Iqbal R. Lee I. Uddin F.S. et al.The prophylactic placement of hemoclips to prevent delayed post-polypectomy bleeding: an unnecessary practice?.Gastrointest Endosc. 2012; 75: AB169Google Scholar compared the rates of delayed post-polypectomy bleeding (within 30 days) in patients with and without prophylactic placement of endoscopic hemoclips. The authors identified 102 patients (mean age 62.4 years) who had prophylactic clipping of 127 polypectomy sites (mean polyp size 13 mm). The authors then recruited 102 control patients who were matched for age, co-morbidities, and polyp characteristics, and who underwent polypectomy without clipping. There was one delayed post-polypectomy bleed in both groups (0.98%; P = 1.0). Although this is a retrospective study with a limited number of cases/controls, and confirmatory data are required, these present findings may prompt the re-evaluation of routine prophylactic hemoclipping after polypectomy. These data also point out the need for better identification of higher risk patients, in whom hemoclipping would be more appropriate and cost-efficient. In contrast to upper gastrointestinal bleeding, there are limited population-based data on acute lower gastrointestinal bleeding presenting as severe hematochezia. Moreover, data from tertiary care referral centers indicate that the use of endoscopic hemostasis during colonoscopy for severe hematochezia is reported at a frequency of between 10% and 40% of the time.15Strate L.L. Naumann C.R. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding.Clin Gastroenterol Hepatol. 2010; 4: 333-343Abstract Full Text Full Text PDF Scopus (127) Google Scholar Utilizing the United States endoscopic database, CORI, Ron-Tal Fisher et al.16Ron-Tal Fisher O. Gralnek I.M. Eisen G.M. et al.Endoscopic hemostasis is rarely used for severe hematochezia: population-based data from a large consortium of diverse endoscopy practices in the United States.Gastrointest Endosc. 2012; 75: AB178Abstract Full Text Full Text PDF Google Scholar reported on 3151 patients with severe hematochezia who underwent inpatient colonoscopy (most in a community hospital setting) with or without endoscopic hemostasis. The authors reported that only 144 (4.7%) received hemostasis during colonoscopy. The most common hemostasis modalities used included injection, bipolar coagulation, and argon plasma coagulation. These data, primarily from community practice, appear to show lower rates of hemostasis than previously reported. There were several other published abstracts on the topic of gastrointestinal bleeding, including NVUGIH, risk stratification/timing of endoscopy, variceal bleeding, and lower gastrointestinal bleeding17Koh R. Hirasawa K. Oka H. et al.Clinicopathological risk factors for delayed postoperative bleeding after ESD for gastric cancer: comparison with the factors for early bleeding.Gastrointest Endosc. 2012; 75: AB358Abstract Full Text Full Text PDF Google Scholar, 18Ang D. Teo E.K. Seng A.G.S. et al.A comparison of surgery vs. transcatheter angiographic embolization in the treatment of non-variceal upper gastrointestinal bleeding uncontrolled by endoscopy.Gastroenterology. 2012; 142: S-504Google Scholar, 19Cook M. Pickard L. Ajayi O.O. et al.A study of mesenteric angiography and embolization in the management of gastrointestinal bleeding.Gastroenterology. 2012; 142: S-508Google Scholar, 20Nguyen N.Q. Bryant R.V. Kuo P. et al.Risk stratification with Glasgow–Blatchford bleeding score for hospitalized patients with upper gastrointestinal bleeding can avoid the needs for urgent endo-therapy.Gastrointest Endosc. 2012; 75: AB289Abstract Full Text Full Text PDF Google Scholar, 21Park J.H. Cheng D.W. Lu L.W. et al.Early endoscopy for upper gastrointestinal hemorrhage is associated with increased intervention and reduced length of stay.Gastroenterology. 2012; 142: S-508Google Scholar, 22Jairath V. Hearnshaw S. Logan R.F. et al.Acute variceal bleeding in the UK: clinical characteristics, endoscopic therapy and predictors of outcomes.Gastrointest Endosc. 2012; 75: AB459Abstract Full Text Full Text PDF Google Scholar, 23Ron-Tal Fisher O. Gralnek I.M. Eisen G.M. et al.Endoscopic hemostasis for severe hematochezia in the elderly: population-based data from a large consortium of diverse endoscopy practices in the United States.Gastroenterology. 2012; 142: S-408Google Scholar, 24Jensen D.M. Ohning G.V. Kovacs T.O. et al.How to find, diagnose and treat definitive diverticular hemorrhage during urgent colonoscopy in patients with severe hematochezia: results and outcomes of a large prospective study.Gastrointest Endosc. 2012; 75: AB179Abstract Full Text Full Text PDF Google Scholar, 25Shrode C.W. Kennedy J.L. Shami V.M. et al.Colonic lesions remain frequent sources of gastrointestinal bleeds in patients with continuous-flow left ventricular assist devices.Gastrointest Endosc. 2012; 75: AB242Abstract Full Text Full Text PDF Google Scholar, 26Mekaroonkamol P. Chaput K.J. Chae Y.K. et al.When bleeding recurs, should colonoscopy be repeated?.Gastrointest Endosc. 2012; 75: AB404Abstract Full Text Full Text PDF Google Scholar; these abstracts, though not reviewed here, are also worth attention." @default.
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• W4246818382 date "2012-09-01" @default.
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• W4246818382 title "Gastrointestinal bleeding" @default.
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