Background & Aims:
Endoscopic therapy reduces the rebleeding rate, the need for surgery, and the mortality in patients with peptic ulcer and active bleeding or visible vessel. Injection of ...epinephrine is the most popular therapeutic method. Guidelines disagree on the need for a second hemostatic procedure immediately after epinephrine; although it seems to reduce further bleeding, its effects on morbidity, surgery rates, and mortality remain unclear. The aim of this study was to perform a systematic review and meta-analysis to determine whether the addition of a second procedure improves hemostatic efficacy and/or patient outcomes after epinephrine injection.
Methods:
An extensive search for randomized trials comparing epinephrine alone vs. epinephrine plus a second method was performed in MEDLINE and EMBASE and in the abstracts of the AGA Congresses between 1990 and 2002. Selected articles were included in a meta-analysis.
Results:
Sixteen studies including 1673 patients met inclusion criteria. Adding a second procedure reduced the further bleeding rate from 18.4% to 10.6% (Peto odds ratio 0.53, 95% CI: 0.40–0.69) and emergency surgery from 11.3% to 7.6% (OR: 0.64, 95% CI: 0.46–0.90). Mortality fell from 5.1% to 2.6% (OR: 0.51, 95% CI: 0.31–0.84). Subanalysis showed that the risk of further bleeding decreased regardless of which second procedure was applied. In addition, the risk was reduced in all subgroups, although reduction was more evident in high-risk patients and when no scheduled follow-up endoscopies were performed.
Conclusions:
Additional endoscopic treatment after epinephrine injection reduces further bleeding, need for surgery, and mortality in patients with bleeding peptic ulcer.
Background and Aims
There is controversy about the length of low‐residue diet (LRD) for colonoscopy preparation. The aim of the study was to compare one‐day vs. three‐day LRD associated to standard ...laxative treatment for achieving an adequate colonoscopy preparation in average risk subjects with positive fecal immunochemical test undergoing screening colonoscopy.
Methods
A non‐inferiority, randomized, controlled, parallel‐group clinical trial was performed in the setting of average risk colorectal cancer screening program. Participants were randomized to receive 1‐day vs. 3‐day LRD in addition to standard polyethilenglicol treatment. Adequacy of preparation was evaluated using the Boston Bowel Preparation Scale (BBPS). Primary outcome was achieving a BBPS ≥ 2 in all colon segments. Analysis was performed for a non‐inferiority margin of 5%, a 95% statistical power and one‐sided 0.05 significance level.
Results
A total of 855 patients were randomized. Adequate bowel preparation was similar between groups: 97.9% of patients in the 1‐day LRD group vs 96.9% in the 3‐day LRD group achieved the primary outcome (P‐value for non‐inferiority < 0.001). The percentage of patients with BBPS scores ≥ 8 was superior in the 1‐day LRD group (254 vs 221 in the 3‐day LRD group, P = 0.032). The 1‐day regimen was better tolerated than the 3‐day diet. 47.7% (vs 28.7%, P < 0.05) of patients rated the 1‐day LRD as very easy to follow.
Conclusion
The 1‐day LRD is non‐inferior to 3‐day LRD for achieving an adequate colon cleansing before average risk screening colonoscopy and it is better tolerated.
Immunochromatographic tests need to be improved in order to enhance their reliability. Recently, several new kits have appeared on the market. The objective was to evaluate the diagnostic accuracy of ...three monoclonal rapid stool tests – the new Uni-Gold™ H.pylori Antigen (Trinity Biotech, Ireland), the RAPID Hp StAR (Oxoid Ltd., UK) and the ImmunoCard STAT! HpSA (Meridian Diagnostics, USA) – for detecting H. pylori infection prior to eradication treatment.
Diagnostic accuracy (sensitivity and specificity) and reliability (concordance between observers) were evaluated in 250 untreated consecutive dyspeptic patients. The gold standard for diagnosing H. pylori infection was defined as the concordance of two or more of rapid urease test (RUT), histopathology and urease breath test (UBT) or positive culture in isolation. Readings of immunochromatographic tests were performed by two different observers. Sensitivity, specificity, positive and negative predictive values and 95% confidence intervals were calculated. Sensitivity and specificity were compared using the McNemar test.
The three tests showed a good correlation, with Kappa values>0.9. RAPID Hp StAR had a sensitivity of 91%–92% and a specificity ranging from 77% to 85%. Its sensitivity was higher than that of Uni-Gold™ H.pylori Antigen and ImmunoCard STAT! HpSA (p<0.01). Uni-Gold™ H.pylori Antigen kit showed a sensitivity of 83%, similar to ImmunoCard STAT! HpSA. Specificity of Uni-Gold™ H.pylori Antigen approached 90% (87–89%) and was superior to that of RAPID Hp StAR (p<0.01).
Uni-Gold™ H.pylori Antigen and ImmunoCard STAT! HpSA present similar levels of diagnostic accuracy. RAPID Hp StAR was the most sensitive but less reliable of the three immunochromatographic stool tests. None are as accurate and reliable as UBT, RUT and histology.
Guidelines recommend using prognostic scales for risk stratification in patients with non-variceal upper gastrointestinal bleeding. It remains unclear whether risk scores offer greater accuracy than ...clinical evaluation.
Compare the diagnostic accuracy of the endoscopist's judgment against different risk-scoring systems (Rockall, Glasgow-Blatchford, Baylor and the Cedars-Sinai scores) for predicting outcomes in peptic ulcer bleeding (PUB).
Between February 2006 and April 2010 we prospectively recruited 401 patients with peptic ulcer bleeding; 225 received endoscopic treatment. The endoscopist recorded his/her subjective assessment ("endoscopist judgment") of the risk of rebleeding and death immediately after endoscopy for each patient. Independent evaluators calculated the different scores. Area under the receiver-operating-characteristics (ROC) curve, sensitivity, specificity, positive and negative predictive values were calculated for rebleeding and mortality.
: The areas under ROC curve of the endoscopist's clinical judgment for rebleeding (0.67-0.75) and mortality (0.84-0.9) were similar or even superior to the different risk scores in both the whole group and in patients receiving endoscopic therapy.
The accuracy of the currently available risk scores for predicting rebleeding and mortality in PUB patients was moderate and not superior to the endoscopist's judgment. More precise prognostic scales are needed.
Background Therapy of gastric varices (GV) is still challenging. Cyanoacrylate (CYA) injection is the recommended treatment for bleeding GV, but has a known adverse event rate, which could be reduced ...if EUS is used for guidance. Otherwise, EUS-guided coil application (ECA) may be an alternative. Objectives To compare CYA and ECA embolization of feeding GV for feasibility, safety, and applicability. Design Retrospective analysis of a prospectively maintained database. Setting Multicenter study, tertiary referral centers. Patients and Interventions Thirty consecutive patients with localized GV who received either CYA injection or ECA were included with follow-up for 6 months after treatment. Results There were 11 patients in the coil group and 19 patients in the CYA group. The GV obliteration rate was 94.7% CYA versus 90.9% ECA; mean number of endoscopy sessions was 1.4 ± 0.1 (range 1-3). Adverse events occurred in 12 of 30 patients (40%) (CYA, 11/19 57.9%; ECA, 1/11 9.1%; P < .01); only 3 were symptomatic, and an additional 9 (CYA group) had glue embolism on a CT scan but was asymptomatic. No further adverse events occurred during follow-up. Six patients (20%) died unrelated to the procedures or bleeding. Limitations Nonrandomized; EUS expertise necessary. Conclusions EUS-guided therapy for GV by using CYA or ECA is effective in localized GV. ECA required fewer endoscopies and tended to have fewer adverse events compared with CYA injection. Larger comparative studies are needed to prove these data.
RESUMEN Introducción: en la actualidad no existe una clasificación endoscópica totalmente aceptada para evaluar el grado de gastropatía de la hipertensión portal (GHP). Hay pocos estudios que evalúen ...la concordancia inter e intraobservador o el grado de concordancia entre las distintas clasificaciones endoscópicas. Objetivos: evaluar la concordancia inter e intraobservador respecto a la presencia de gastro y enteropatía portal utilizando distintas clasificaciones endoscópicas. Métodos: fueron incluidos pacientes con cirrosis hepática a los que se realizó una enteroscopia bajo sedación. Se describió la localización de las lesiones y el grado de las mismas. Las imágenes se registraron mediante grabación en vídeo que posteriormente fue valorada por tres endoscopistas diferentes de manera independiente, uno de ellos el endoscopista inicial. La concordancia entre observaciones se evaluó utilizando el índice kappa. Resultados: se incluyeron un total de 74 pacientes (edad media de 63,2 años, con una proporción de 53/21 hombre/mujer). La concordancia entre los tres endoscopistas, para la presencia o ausencia de GHP según las clasificaciones de Tanoue y McCormack, fue muy baja: kappa = 0,16 y 0,27 respectivamente. Conclusiones: las actuales clasificaciones de la gastropatía portal presentan un grado de acuerdo intra e interobservador muy bajo tanto para el diagnóstico como para la evaluación de la gravedad de la gastropatía.
Background: The optimal therapy for bleeding small bowel vascular lesions is controversial. This study investigated the efficacy and safety of endoscopic band ligation in this clinical condition.
...Methods: Fourteen patients bleeding from angiodysplasia and 4 bleeding from Dieulafoy's lesions located in the small bowel were included in this pilot study. Endoscopic band ligation was performed by using less than 200 mBar negative pressure in suctioning the target lesion into the ligation cap just before band release. Mean follow-up was 18 months (range 6–31 months).
Observations: Endoscopic band ligation achieved hemostasis in a single session in all patients. No adverse events occurred except for mild abdominal pain in two patients. Mortality was null, and no patient required further blood transfusion during the 40 days after endoscopic band ligation. No patient with Dieulafoy's lesion had further bleeding, whereas bleeding recurred in 6 of 14 (43%) patients with angiodysplasia during long-term follow-up.
Conclusions: Endoscopic band ligation is safe and effective for treatment of acutely bleeding small bowel vascular lesions. Although endoscopic band ligation is definitive therapy for Dieulafoy's lesion, long-term efficacy in the treatment of Gl bleeding from angiodysplasia is limited.
Acute lower gastrointestinal bleeding (ALGIB) is a common cause of hospitalization. Recent guidelines recommend the use of prognostic scales for risk stratification. However, it remains unclear ...whether risk scores are more accurate than some simpler prognostic variables.
To compare the predictive values of haemoglobin alone and the Oakland score for predicting outcomes in ALGIB patients.
Single-centre, retrospective study at a University Hospital. Data were extracted from the hospital's clinical records. The Oakland score was calculated at admission. Study outcomes were defined according to the original article describing the Oakland score: safe discharge (the primary Oakland score outcome), transfusion, rebleeding, readmission, therapeutic intervention and death. Area under the receiver operating characteristics (AUROC) curve and accuracy using haemoglobin and the Oakland score were calculated for each outcome.
Two hundred and fifty-eight patients were included. Eighty-four (32.6%) needed transfusion, 50 (19.4%) presented rebleeding, 31 (12.1%) required therapeutic intervention, 20 (7.8%) were readmitted and six (2.3%) died. There were no differences in the AUROC curve values for haemoglobin versus the Oakland score with regard to safe discharge (0.82 (0.77–0.88) vs 0.80 (0.74–0.86), respectively) or to therapeutic intervention and death. Haemoglobin was significantly better for predicting transfusion and rebleeding, and the Oakland score was significantly better for predicting readmission.
In our study, the Oakland score did not perform better than haemoglobin alone for predicting the outcome of patients with ALGIB. The usefulness of risk scores for predicting outcomes in clinical practice remains uncertain.
La hemorragia digestiva baja (HDB) aguda es una causa frecuente de hospitalización. Guías recientes recomiendan el uso de escalas pronósticas para la estratificación del riesgo. Sin embargo, aún no está claro si los índices de riesgo son más precisos en cuanto a pronóstico que algunas variables más simples.
Comparar el valor predictivo aislado de la hemoglobina con el índice pronóstico de Oakland para predecir resultados en pacientes con HDB.
Estudio retrospectivo unicéntrico realizado en un hospital universitario. Los datos se extrajeron de las historias clínicas del hospital. La puntuación del score de Oakland se calculó en el momento del ingreso. Los resultados a valorar en el estudio se definieron igual que el artículo original que describe el índice de Oakland: alta segura (el resultado primario del score de Oakland), transfusión, resangrado, reingreso, intervención terapéutica y muerte. Para cada resultado se calcularon el área bajo la curva (AUROC) y la precisión utilizando la hemoglobina y el índice de Oakland.
Se incluyeron 258 pacientes. Ochenta y cuatro (32,6%) necesitaron transfusión, 50 (19,4%) presentaron resangrado, 31 (12,1%) requirieron intervención terapéutica, 20 (7,8%) reingresaron y 6 (2,3%) fallecieron. No hubo diferencias en los valores de la curva AUROC de la hemoglobina frente al índice de Oakland con respecto al alta segura (0,82 0,77-0,88 vs a 0,80 0,74-0,86, respectivamente) ni a la intervención terapéutica y la muerte. La hemoglobina fue significativamente mejor para predecir transfusión y resangrado, y el índice de Oakland fue significativamente mejor para predecir reingreso.
En nuestro estudio, el índice de Oakland no fue mejor que la hemoglobina aislada para predecir resultados en pacientes con HDB. La utilidad de los índices de riesgo para predecir resultados en la práctica clínica sigue siendo incierta.
BACKGROUND:Hemospray TM (TC-325) is a novel hemostatic agent licensed for use in nonvariceal upper gastrointestinal bleeding (NVUGIB) in Europe.
GOALS:We present the operating characteristics and ...performance of TC-325 in the largest registry to date of patients presenting with NVUGIB in everyday clinical practice.
METHODS:Prospective anonymized data of device performance and clinical outcomes were collected from 10 European centers using the multicentre SEAL survey (Survey to Evaluate the Application of Hemospray in the Luminal tract). TC-325 was used as a monotherapy or as second-line therapy in combination with other hemostatic modalities at the endoscopists’ discretion.
RESULTS:Sixty-three patients (44 men, 19 women), median age 69 (range, 21 to 98) years with NVUGIB requiring endoscopic hemostasis were treated with TC-325. There were 30 patients with bleeding ulcers and 33 with other NVUGIB pathology. Fifty-five (87%) were treated with TC-325 as monotherapy; 47 85%; 95% confidence interval (CI), 76%-94% of them achieved primary hemostasis, and rebleeding rate at 7 days was 15% (95% CI, 5%-25%). Primary hemostasis rate for TC-325 in patients with ulcer bleeds was 76% (95% CI, 59%-93%). Eight patients, who otherwise may have required either surgery or interventional radiology, were treated with TC-325 as second-line therapy after failure of other endoscopic treatments, all of whom achieved hemostasis following the adjunct of TC-325.
CONCLUSIONS:This multicentre registry identifies potentially useful characteristics of Hemospray (TC-325) when used either as monotherapy or as a rescue therapy in a wide variety of ulcer and nonulcer NVUGIB.
TC-325 (Hemospray, Cook Medical, Winston-Salem, NC) is an inorganic hemostatic powder recently approved by the U.S. Food and Drug Administration. This study aimed to examine the effectiveness, ...safety, and predictors of TC-325 failure in a large real-life cohort.
This was a retrospective study conducted at 21 Spanish centers. All patients treated with TC-325 until September 2018 were included. The primary outcome was treatment failure, defined as failed intraprocedural hemostasis or recurrent bleeding within the first 30 postprocedural days. Secondary outcomes included safety and survival. Risk and predictors of failure were assessed via competing-risk models.
The cohort comprised 261 patients, of whom 219 (83.9%) presented with upper gastrointestinal bleeding (GIB). The most common causes were peptic ulcer (28%), malignancy (18.4%), and therapeutic endoscopy-related GIB (17.6%). TC-325 was used as rescue therapy in 191 (73.2%) patients. The rate of intraprocedural hemostasis was 93.5% (95% confidence interval CI, 90%-96%). Risks of TC-325 failure at postprocedural days 3, 7, and 30 were 21.1%, 24.6%, and 27.4%, respectively. On multivariate analysis, spurting bleeding (P = .004), use of vasoactive drugs (P = .02), and hypotension (P = .008) were independent predictors of failure. Overall 30-day survival was 81.9% (95% CI, 76%-86%) and intraprocedural hemostasis was associated with a better prognosis (adjusted hazard ratio, 0.29; P = .006). Two severe adverse events were noted.
TC-325 was safe and effective for intraprocedural hemostasis in more than 90% of patients, regardless of the cause or site of bleeding and its use as rescue therapy. In this high-risk cohort treated with TC-325, the 30-day failure rate exceeded 25% and was highest with spurting bleeding or hemodynamic instability.
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