Endoscopic Cyanoacrylate Injection Treatment for Refractory High-risk Peptic Ulcer Bleeding by Conventional Endoscopic Therapy

Bleeding is a major and potentially life-threatening complication of peptic ulcer. Despite endoscopic hemostatic therapy advance, conventional endoscopic hemostatic modalities remain refractory for peptic ulcer bleeding with big size, fibrous base or in difficult-to-access anatomical locations. In this study, we attempted to evaluate the efficacy and safety of endoscopic cyanoacrylate injection treatment (ECIT) for refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy. The patients with refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy were carried out ECIT. The data were retrospectively collected. A total of 119 patients accepted ECIT. 74 patients (62.18%) obtained successful intravascular injection and perivascular injection was performed in 45 patients (37.82%). Immediate hemostatic rate for active bleeding achieved 90.91%. Rebleeding rate within 30 days was 12.07%. Overall successful hemostasis rate achieved 87.93%. Immediate hemostatic rate and overall successful hemostasis rate in intravascular injection patients were markedly superior over perivascular injection. Rebleeding rate in intravascular injection patients was markedly lower than that in perivascular injection patients. 11 patients complicated abdominal pain and no other complication occurred. In conclusion, ECIT, especial intravascular injection, was effective and safe, with high successful hemostasis rate for refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy.

Development and Validation of a Model to Predict Rebleeding Within Three Days After Endoscopic Hemostasis for Peptic Ulcer Bleeding

Background: Peptic ulcer bleeding remains a typical medical emergency with significant morbidity and mortality. Peptic ulcer rebleeding often occurs within three days after emergency endoscopic hemostasis. Our study aims to develop a nomogram to predict rebleeding within three days after emergency endoscopic hemostasis for peptic ulcer bleedingMethods: We retrospectively reviewed the data of 386 patients with bleeding ulcers who underwent emergency endoscopic hemostasis between March 2014 and October 2018. The least absolute shrinkage and selection operator method were used to identified predictors. The model was displayed as a nomogram. Internal validation was carried out using bootstrapping. The model was evaluated using the calibration plot, decision-curve analyses and clinical impact curve. Results: Overall, 386 patients meeting the inclusion criteria were enrolled, with 48 patients developed rebleeding within three days after initial endoscopic hemostasis. Predictors contained in the nomogram included albumin, prothrombin time, shock, haematemesis/melena and Forrest classification. The model showed good discrimination and good calibration with a C-index of 0.854 (C-index: 0.830 via bootstrapping validation). Decision-curve analyses and clinical impact curve also demonstrated that it was clinically valuable.Conclusion: This study presents a nomogram that incorporates clinical, laboratory, and endoscopic features, effectively predicting rebleeding within three days after emergency endoscopic hemostasis and identifying high-risk rebleeding patients with peptic ulcer bleeding.Trial registration: This clinical trial has been registered in the ClinicalTrials.gov (ID: NCT04895904) approved by the International Committee of Medical Journal Editors (ICMJE).

Clinical Guideline Highlights for the Hospitalist: Management of Upper Gastrointestinal and Ulcer Bleeding

GUIDELINE TITLE: American College of Gastroenterology: Upper Gastrointestinal and Ulcer Bleeding RELEASE DATE: May 1, 2021 PRIOR VERSION(S): March 1, 2012 DEVELOPER: American College of Gastroenterology Practice Parameters Committee FUNDING SOURCE: American College of Gastroenterology TARGET POPULATION: Adult patients with overt upper gastrointestinal bleeding

Choledochoduodenal fistula: a rare complication of acute peptic ulcer bleeding

A 75-year-old man presented with a 3-week history of melaena and right upper quadrant pain. This was on a background of significant alcohol intake and a complex medical history. He was haemodynamically unstable with investigations indicating a new iron-deficiency anaemia. After resuscitation, urgent intervention was required under general anaesthesia. This involved a triple phase abdominal CT, followed by emergency oesophagogastroduodenoscopy. This revealed deep ulceration with extension to the pancreatic head and common bile duct. There was also evidence of pneumobilia on CT, secondary to a choledochoduodenal fistula. Treatment encompassed an invasive and medical approach. Following treatment, the patient was stable, with follow-up endoscopy exhibiting good duodenal mucosal healing.

Clinical profile of patients presenting to emergency with upper gastrointestinal bleeding in a tertiary hospital of Nepal

Introduction: Upper gastrointestinal bleeding is an acute emergency condition. It is an important cause for the hospital admission. This study descriptively analyses the clinical profile of upper gastrointestinal bleeding presenting to a tertiary hospital in Nepal. Method: This is a cross-sectional study of patients presenting with upper gastrointestinal bleeding from 01 Oct 2018 to 30 Sep 2019 at Patan Hospital Emergency Department, Patan Academy of Health Sciences, Nepal. Patient’s demographics, clinical presentation, duration of illness before presenting to Emergency, vitals, and laboratory parameters were descriptively analyzed. Ethical approval was obtained. Result: There were 121 patients, male 82(67.8%) and female 38(31.4%) aging 14 to 90 years. Fifty-three patients (43.8 %) presented with hematemesis, 38(31.4%) with melena, and 27(22.3%) with both hematemesis and melena. Variceal bleeding was the main cause of upper gastrointestinal bleeding found in 73(60.33%) followed by ulcer bleeding in 48(39.66%). Conclusion: Variceal bleeding was the main cause of upper gastrointestinal bleeding and hematemesis was the most common clinical presentation in patients presenting to the Emergency Department.

Long-Term Outcomes in Patients with Post-Bulbar Ulcer Bleeding Compared to Bulbar Ulcer Bleeding in the Duodenum

<b><i>Background:</i></b> Duodenal ulcers are classified into bulbar and post-bulbar ulcers. The aim of this study is to compare the long-term outcomes of patients with post-bulbar ulcer bleeding and those with bulbar ulcer bleeding. <b><i>Methods:</i></b> A total of 272 patients with hemorrhagic duodenal ulcers requiring hospitalization were included. Their medical records were retrospectively reviewed. <b><i>Results:</i></b> All patients were categorized as bulbar or post-bulbar bleeding ulcer groups. The post-bulbar ulcer group had more patients of advanced age, concurrent malignancy, diabetes mellitus, hypertension, cirrhosis, and chronic kidney disease undergoing hemodialysis. We performed long-term follow-up for an average of 2.6 years. The mortality rate during the follow-up period in the post-bulbar ulcer group was significantly higher than that in the bulbar ulcer group (<i>p</i> &#x3c; 0.001). The PNED score was a better predictor of 30-day mortality compared to the complete Rockall score and the Glasgow-Blatchford Score. Predictors of mortality were evaluated using a Cox proportional hazards regression model. In multivariate analysis, post-bulbar ulcer, concurrent malignancy, cirrhosis, antiplatelet/anticoagulant use, and transfusion were significant predictors of mortality. <b><i>Conclusions:</i></b> Patients with post-bulbar ulcers have a poorer prognosis than those with bulbar ulcers. After the diagnosis of hemorrhagic post-bulbar duodenal ulcer, close follow-up is necessary.