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This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. Hemodynamic status should be initially assessed with intravascular volume resuscitation started as needed. Risk stratification based on clinical parameters should be performed to help distinguish patients at high- and low-risk of adverse outcomes. Hematochezia associated with hemodynamic instability may be indicative of an upper gastrointestinal (GI) bleeding source and thus warrants an upper endoscopy. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 h of patient presentation after adequate colon preparation. Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. The endoscopic hemostasis modality used (mechanical, thermal, injection, or combination) is most often guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience with the various hemostasis modalities. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy. Strategies to prevent recurrent bleeding should be considered. Nonsteroidal anti-inflammatory drug use should be avoided in patients with a history of acute lower GI bleeding, particularly if secondary to diverticulosis or angioectasia. Patients with established high-risk cardiovascular disease should not stop aspirin therapy (secondary prophylaxis) in the setting of lower GI bleeding. [corrected]. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection., Competing Interests: Specific Author Contributions: L Strate: planning and conducting review; analysis/interpretation of data; drafting and revision of the manuscript. She approved final draft submitted. L Strate has no conflicts of interest to disclose. I Gralnek: planning and conducting review; analysis/interpretation of data; drafting and revision of the manuscript. He approved final draft submitted. I Gralnek has served as a consultant for EndoChoice, Motus GI, EndoAid GI View and is a member of the Data Safety Monitoring Board for Intec Pharma more...

Objectives: Gastrointestinal angiodysplastic lesions (GIADs) are defined as pathologically dilated communications between veins and capillaries. The objective of this systematic review and meta-analysis was to determine the efficacy of available treatment modalities for GIADs., Methods: We identified eligible studies by searching through PubMed, SCOPUS, and Cochrane central register of controlled trials. We searched for clinical trials examining the efficacy of endoscopic, pharmacologic, or surgical therapy for GIADs. Data were pooled using a random-effects model, and the effect of response to medical or surgical therapy was reported as odds ratios with 95% confidence intervals (CIs). Data and quality indicators were extracted by two authors from 22 studies, including 831 individuals with GIADs. The analysis included 623 patients treated with endoscopic therapy, 63 with hormonal therapy, 72 patients with octreotide, and 73 status post aortic valve replacement surgery., Results: Hormonal therapy, based on two case-control studies, was not effective for bleeding cessation (odds ratio: 1.0, 95% CI: 0.5-1.96). On the basis of 14 studies including patients with gastric, colonic, and small-bowel GIADs, endoscopic therapy was effective as initial therapy, but the pooled recurrence bleeding rate was 36% (95% CI: 28-44%) over a mean (±s.d.) of 22±13 months. The event rate for re-bleeding increased to 45% (95% CI: 37-52%) when studies including only small-bowel GIADs were included (N=341). In four studies assessing the efficacy of somatostatin analogs, the pooled odds ratio was 14.5 (95% CI: 5.9-36) for bleeding cessation. In two studies assessing the role of aortic valve replacement (AVR) in 73 patients with Heyde's syndrome, the event rate for re-bleeding was 0.19 (95% CI: 0.11-0.30) over a mean follow-up period of 4 years postoperatively., Conclusions: Over one-third of patients with GIADs experienced re-bleeding after endoscopic therapy. Somatostatin analogs and AVR for Heyde's syndrome appeared to be effective therapy for GIADs. more...

Objectives: Data are scarce on the head-to-head efficacy of terlipressin and octreotide as an adjuvant therapy to endoscopic management of variceal bleed. The aim of this study was to compare the efficacy and safety of terlipressin with octreotide as an adjuvant therapy to endoscopic variceal band ligation in patients with esophageal variceal bleeding., Methods: Cirrhotic patients with esophageal variceal bleed were randomized on admission to receive terlipressin (group A) or octreotide (group B) along with the placebo in the other arm in a double-blind fashion. The two groups were compared for efficacy, safety, overall survival, and length of hospital stay. "Control of variceal bleed" was the measure of efficacy of terlipressin and octreotide. Factors predicting length of stay were also assessed., Results: A total of 324 patients were enrolled; 163 in the terlipressin group (group A) and 161 in the octreotide group (group B). The baseline characteristics of the two groups were comparable for age, gender, etiology of cirrhosis, hemoglobin at presentation, and Child-Pugh class, except that active bleed was seen during upper gastrointestinal endoscopy at the time of enrollment in 26 (16%) and 41 (25.5%) patients in groups A and B, respectively (P=0.034). Overall sixteen patients died (three failure to control bleed and thirteen from causes other than variceal bleed); nine in group A (5.5%) and seven (4.3%) in group B (P=0.626). In the intention to treat analysis, "control of variceal bleed" was noted in 305 patients (94.13%); 151 (92.63%) patients in group A and 154 (95.6%) patients in group B (confidence interval: 0.219-1.492). Packed cell transfusions in group A were 3.7+/-2.3 units, whereas in group B there were 3.9+/-2.5 units (P=0.273). Length of hospital stay in groups A and B was 108.40+/-34.81 and 126.39+/-47.45 h, respectively (P< or =0.001). No cardiovascular side effects were observed in either group. High pulse, low hemoglobin, prothrombin time, blood in nasogastric aspirate, and portosystemic encephalopathy (PSE) were predictors of prolonged hospital stay., Conclusions: The efficacy of terlipressin was not inferior to octreotide as an adjuvant therapy for the control of esophageal variceal bleed and in-hospital survival. The length of hospital stay in the terlipressin group was significantly shorter but not of any clinical importance. The predictors of prolonged hospital stay were low hemoglobin, high pulse, prolonged prothrombin time, blood at nasogastric aspirate, and PSE. more...

Background: The most effective schedule of proton pump inhibitor (PPI) administration following endoscopic hemostasis of bleeding ulcers remains uncertain., Methods: Patients with actively bleeding ulcers and those with nonbleeding visible vessel or adherent clot were treated with epinephrine injection and/or thermal coagulation, and randomized to receive intravenous PPIs according to an intensive regimen (80 mg bolus followed by 8 mg/h as continuous infusion for 72 h) or a standard regimen (40 mg bolus daily followed by saline infusion for 72 h). After the infusion, all patients were given 20 mg PPI twice daily orally. The primary end point was the in-hospital rebleeding rate, as ascertained at the repeat endoscopy., Results: Bleeding recurred in 28 of 238 patients (11.8%) receiving the intensive regimen, and in 19 of 236 (8.1%) patients receiving the standard regimen (P= 0.18). Most rebleeding episodes occurred during the initial 72-h infusion: 18 (7.6%) and 19 events (8.1%) in the intensive and standard groups, respectively (P= 0.32). Mean units of blood transfused were 1.7 +/- 2.1 in the intensive and 1.5 +/- 2.1 in the standard regimen group (P= 0.34). The duration of hospital stay was <5 days for 88 (37.0%) and 111 patients (47.0%) in the intensive and standard groups (P= 0.03). There were fewer surgical interventions in the standard versus intensive regimen (1 vs 3). Five patients in each treatment group died., Conclusions: Following endoscopic hemostasis of bleeding ulcers, standard-dose PPIs infusion was as effective as a high-dose regimen in reducing the risk of recurrent bleeding. (ClinicalTrials.gov number, NCT00374101). more...

Background: The best antisecretory treatment after endoscopic hemostasis in patients with ulcer bleeding is still in quest., Objectives: To compare pantoprazole and somatostatin continuous infusion after endoscopic hemostasis in patients with bleeding peptic ulcers., Patients and Methods: A total of 164 consecutive patients with a bleeding peptic ulcer, after successful endoscopic hemostasis, were randomly assigned to receive, double blindly, continuous IV infusion of pantoprazole 8 mg/h for 48 h after a bolus of 40 mg (group P) or somatostatin 250 microg/h for 48 h after a bolus of 250 microg (group-S). Twenty-four-hour pH-metry was performed in the last 30 patients in each group. Endoscopy was performed, in case of bleeding nonrecurrence, every 48 h until disappearance of stigmata., Results: Bleeding recurrence: group S 14 patients (17%) versus group P 4 (5%) (P=0.046). In multivariate analysis, bleeding recurrence was 4.57 (CI 1.31-15.91) times more frequent in group S (P=0.02). There was no difference in the need for surgery and mortality. Acid suppression over pH 6: group S 82.9% of the time versus group P 81.5% (P=0.97). Acid suppression over pH 6 for >85% of the time: group S 14 (47%) patients versus group P 17 (57%) (P=0.44). Disappearance of endoscopic stigmata after 48 h: group S 25/68 patients (37%) versus group P 72/78 (92%) (P<0.0001). No major side effects identified in either study group., Conclusions: In patients with a bleeding ulcer, after successful endoscopic hemostasis, despite equipotent acid suppression, pantoprazole continuous infusion was superior to somatostatin to prevent bleeding recurrence and quick disappearance of the endoscopic stigmata. Nevertheless, no differences were seen in the need for surgery and mortality. more...

Objective: To perform meta-analyses of studies on outcome of bleeding ulcers of different proton-pump inhibitors (PPIs) regimens, after stratification of patients by endoscopic stigmata, and analysis of studies with and without endotherapy., Methods: A total of 35 randomized trials comparing PPIs to placebo and/or H2-receptor antagonists (H2RAs) in 4,843 patients with high-risk endoscopic stigmata were retrieved. Outcomes were rebleeding, surgery, and mortality., Results: Monotherapy with oral or bolus PPIs was superior to placebo and H2RAs in reducing rebleeding in both bleeders and nonbleeders at index endoscopy; the need for surgery was reduced only when compared to H2RAs. In nonbleeders, PPI monotherapy was as effective as a combination of endotherapy with H2RAs. A combination of endotherapy with PPIs was superior to monotherapy in reducing bleeding and surgery, and superior to endotherapy alone in minimizing rebleeding, but not surgery; the benefit was lost when confronted to endotherapy plus H2RAs, whether PPIs were given as infusion or bolus. By pooling data from studies comparing high doses of PPIs as continuous infusion versus regular doses as intermittent bolus, rebleeding, surgery, and mortality were not significantly different., Conclusions: Combination of endotherapy with either PPIs or H2RAs is indicated for nonbleeding ulcers at endoscopy with the intent to reduce rebleeding and surgery. Its value may extend to bleeding lesions, but current data are scanty. The benefit appears to be independent from route and doses of PPIs, as oral, bolus, or infusional methods are all effective. more...

Objectives: From the Canadian Registry of patients with Upper Gastrointestinal Bleeding and Endoscopy (RUGBE), we determined clinical outcomes and explored the roles of endoscopic and pharmacologic therapies in a contemporary real-life setting., Methods: Analysis of randomly selected patients endoscoped for nonvariceal upper gastrointestinal bleeding at 18 community and tertiary care institutions between 1999 and 2002. Covariates and outcomes were defined a priori and 30-day follow-up obtained. Logistic regression models identified predictors of outcomes., Results: One thousand eight-hundred and sixty-nine patients were included (66 +/- 17 yr, 38% female, 2.5 +/- 1.6 comorbid conditions, hemoglobin, 96 +/- 27 g/L, 54% received a mean of 2.9 +/- 1.7 units of blood). Endoscopy was performed within 24 h in 76%, with ulcers (55%) most commonly noted. High-risk endoscopic stigmata and endoscopic therapy were reported in 37%. Rebleeding, surgery, and mortality rates were 14.1%, 6.5%, and 5.4%, respectively. Decreased rebleeding was significantly and independently associated with PPI use (85% of patients, mean daily dose 56 +/- 53 mg) in all patients regardless of endoscopic stigmata, (odds ratio (OR):0.53, 95% confidence interval, 95% CI:0.37-0.77) and endoscopic hemostasis in patients with high-risk stigmata (OR:0.39, 95% CI:0.25-0.61). PPI use (OR:0.18, 95% CI:0.04-0.80) and endoscopic therapy (OR:0.31, 95% CI:0.11-0.91) were also each independently associated with decreased mortality in patients with high-risk stigmata., Conclusions: These results appear to confirm the protective role of endoscopic therapy in patients with high-risk stigmata, and suggest that acute use of PPIs may be associated with a reduction of rebleeding in all patients, and lower mortality in patients with high-risk stigmata. Independent prospective validation of these observational findings is now required. more...

Objectives: Endoscopic heater probe thermocoagulation and hemoclip are considered to be safe and very effective in the treatment of bleeding peptic ulcer. So far, there are only few reports concerning hemostasis with endoscopic hemoclip. The aims of this study were to compare the hemostatic effects of both therapeutic modalities in patients with peptic ulcer bleeding., Methods: A total of 80 patients with active bleeding or nonbleeding visible vessels were randomized to receive endoscopic hemoclip (n = 40) or heater probe thermocoagulation (n = 40)., Results: Initial hemostasis was achieved in 34 patients (85%) in the hemoclip group and 40 patients (100%) in the heater probe group (p = 0.01277). Rebleeding occurred in three patients (8.8%) in the hemoclip group and two patients (5%) in the heater probe group (p > 0.1). Among patients with difficult-to-approach bleeding, we obtained a better hemostatic rate in the heater probe group (nine of 11 patients vs three of 10, p = 0.02417). The volume of blood transfused after entry into the study, duration of hospital stay, number of patients requiring urgent surgery, and the mortality rate were not statistically significantly different between the two groups., Conclusions: For patients with peptic ulcer bleeding, heater probe thermocoagulation offers an advantage in achieving hemostasis than hemoclip. In difficult-to-approach bleeders, heater probe is a more suitable therapeutic modality. more...

Dieulafoy lesions are uncommon sources of GI hemorrhage and predominantly occur in the proximal stomach. At one time a pathological diagnosis made postoperatively, Dieulafoy lesions are now routinely diagnosed and treated endoscopically. Their true incidence is unclear as quiescent Dieulafoy lesions are easily overlooked on endoscopy and bleeding lesions are occasionally misidentified. Over 6 yr (June 1993-November 1999), 40 Dieulafoy lesions were identified on upper endoscopy at our institution, of which seven were located in the duodenum and one in the right colon. Forty-seven percent of patients were hospitalized for other causes before onset of bleeding, and 17 of 40 were found to have other abnormal findings at endoscopy. In 90% of the cases, endoscopic treatment was successful. Seven patients died, but none as a result of hemorrhage. In 24 endoscopically-treated patients in whom follow-up data are available, Dieulafoy bleeding recurred in one patient. Dieulafoy lesions are rare and often difficult to diagnose, but must be considered in the evaluation of upper and lower GI tract hemorrhage, as they can usually be managed endoscopically. more...

The authors retrospectively compared endoscopic injection therapy with endoscopic hemoclipping by examining 113 patients over a 10-yr period between 1985 and 1995 who had gastrointestinal bleeding and who received one or the other procedure. Endoscopic injection using ethanol alone, epinephrine plus ethanol, or aethoxysclelol plus ethanol was performed in 87 cases. Endoscopic hemoclipping was performed in 26 cases from 1993 to 1995. The permanent hemostasis rate of endoscopic injection was 84% and that of endoscopic hemoclipping was 100%. Complications associated with endoscopic injection included enlargement of the ulcer bed, bleeding caused by exposed vessels within the expanded ulcer and one case of perforation. No complications were noted among patients treated with endoscopic hemoclipping. more...

Objective: Endoscopic injection sclerotherapy and variceal ligation are two popular endoscopic methods used to treat esophageal variceal hemorrhage. These two methods have not been compared with regard to esophageal dysfunction after treatment. This is a prospective investigation of esophageal dysmotility after endoscopic injection sclerotherapy and variceal ligation., Methods: Sequential changes of esophageal motility after endoscopic injection sclerotherapy (n = 25) and variceal ligation (n = 25) were investigated in 50 cirrhotic patients with recent variceal bleeding. Another 22 cirrhotics without esophageal varices were included as controls. Radionuclide esophageal transit tests were performed before initial endoscopic treatment, and 1 and 3 months after variceal eradication., Results: The baseline esophageal transit time was longer in both the sclerotherapy (n = 25, 7.8 +/- 1.4 s) and ligation groups (n = 25, 8.2 +/- 1.8 s) than in controls (n = 22, 6.7 +/- 0.7 s, p < 0.005). The transit time was longer in patients with large varices than in those with small varices (8.3 +/- 1.7 vs. 7.2 +/- 0.7 s, p < 0.05). In the sclerotherapy group, the transit time was prolonged 1 month after variceal eradication, compared with its pretreatment state (n = 20, 7.6 +/- 1.5 vs. 10.0 +/- 2.2 s, p < 0.0001) but was shortened at 3 months compared with 1 month after variceal eradication (n = 12, 10.7 +/- 1.5 vs. 8.6 +/- 2.2 s, p < 0.05). Multiple regression analysis showed that the number of treatment sessions required to eradicate varices was the only significant factor associated with prolonged transit time (p < 0.05). In the ligation group, the transit time changed little at 1 month or 3 months after variceal eradication., Conclusions: Impairment of esophageal motility can be significant with endoscopic injection sclerotherapy but is reversible. However, endoscopic variceal ligation exerts no significant impact on esophageal motility. more...

Objectives: Patients who present to the emergency department with upper gastrointestinal bleeding can have persistent or recurrent (further) bleeding or self-limited bleeding. We performed a study to determine the frequency, risks factors, and impact on outcome of further bleeding., Methods: Clinical predictors of further bleeding were retrospectively identified in 137 consecutive patients presenting to our institution with upper gastrointestinal bleeding in 1994-1995., Results: Persistent or recurrent bleeding occurred in 30.7% of the cases, bleeding intractable to endoscopic therapy occurred in 15.3%. Hematemesis (odds ratio [OR] 5.7; 95% confidence interval [CI], 2.4-13.1, p = 0.0001) and a initial hemoglobin (OR, 0.8; 95% CI, 0.7-0.96; p = 0.01) were independent risk factors for persistent or recurrent bleeding, whereas liver disease (OR, 6.0; 95% CI, 2.0-18.4; p = 0.002) and hematemesis were independent risk factors for intractable bleeding. The mortality rate was 14.3 and 1%, respectively, in patients with and without further bleeding. In patients who did not present with hematemesis, liver disease, coagulopathy, hypotension, and initial hemoglobin < 11 g/dl, the frequency of further bleeding and mortality was 0%., Conclusions: Persistent, recurrent, and intractable bleeding occurs in a substantial proportion of patients admitted with upper gastrointestinal bleeding. The risk of further bleeding can be estimated on the basis of clinical presentation. Further bleeding is associated with a worse outcome. more...

Objectives: The aim of the present study was to compare the safety of endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS) in terms of liver and kidney functions in patients with liver cirrhosis., Methods: Forty-four patients admitted to Takatsuki General Hospital between February 1991 and March 1993 with esophageal varices due to liver cirrhosis were randomly assigned to receive either EVL or EIS. Serum levels of AST, ALT, total bilirubin (T-bil), direct bilirubin (D-bil), prothrombin time (PT), hepaplastin test (HPT), antithrombin III (ATIII), creatinine (Cr), and blood urea nitrogen (BUN) were measured before and 24 h, 3 days, 7 days, and 14 days after both forms of therapy., Results: Significant elevations of serum T-bil, serum D-bil, and serum ALT and AST levels were observed in the EIS group but not in the EVL group. No significant increases of serum PT, HPT, ATIII, BUN, or Cr levels were observed after treatment in either group., Conclusion: EVL should be considered a first choice therapy for eradicating esophageal varices. more...

Objectives: Transjugular intrahepatic portosystemic stent-shunts (TIPSS) have been shown to reduce portal hypertension consistently and have recently been reported to arrest active variceal hemorrhage. This retrospective and nonrandomized study compares the results of TIPSS with esophageal transection (ET) and devascularization in patients with uncontrolled variceal hemorrhage admitted to a single center with an interest in variceal bleeding., Patients and Methods: Two hundred and sixty cirrhotic patients have been referred with variceal bleeding over the past 7 yr. In 41 patients (15.8%), hemorrhage was uncontrolled despite two treatments with sclerotherapy. Thirty-eight patients were eligible for analysis. Nineteen were considered for ET and 19 for TIPSS. Patients in the two groups were well matched for age, sex, etiology of liver disease, and its severity and complications. They have been followed for 13 patient years (TIPSS-7, longest 20 months; ET-6, longest 23 months). Data for survival and rebleeding were analyzed by the Kaplan-Meier method on an intention-to-treat basis., Results: Seven of the 19 were considered unfit for surgery, and 12 underwent esophageal transection and devascularization. TIPSS was undertaken successfully in 17 patients, the Palmaz stent being used in 4 and the Wallstent in 13. Successful TIPSS reduced the mean portal pressure gradient from 22.2 (SE 1.2) to 9.7 (SE 0.7) mm Hg (p < 0.001). Mortality within 30 days of the initial bleed was 42% in the TIPSS group compared with 79% in the ET group (p < 0.05). Rebleeding occurred in 15.6% patients with TIPSS, compared with 26.2% in the ET group. Encephalopathy in the two groups of patients was not significantly different (TIPSS 25% and ET 22%). TIPSS was followed by active infection in 20% compared with 36% after ET., Conclusions: This study shows that the overall mortality in this group of patients is high whatever the type of treatment used. TIPSS can be performed successfully on these patients who are often not suitable for surgery. Mortality rates were significantly lower in patients treated by TIPSS. Compared with ET, TIPSS should be regarded as the preferred mode of treatment for uncontrolled variceal hemorrhage in patients with cirrhosis. more...

Objective: To examine the long-term consequences of endoscopic therapy for bleeding peptic ulcers., Methods: Eighty-seven consecutive patients who underwent endoscopic treatment for bleeding gastric ulcer (GU) and/or duodenal ulcer (DU) over a 42-month period were identified. Long-term follow-up was available for 76 (mean, 495 days; SEM, 45 days). Therapy consisted of epinephrine injection, heater probe use, or both. Recurrent hemorrhage only at the primary treatment site was considered., Results: The sites of hemorrhage were GU (40 patients), DU (34 patients), and both (2 patients). Emergent surgery was required in two GU patients for whom endoscopic treatment was ineffective. Recurrent hemorrhage ultimately occurred in 33% of patients--40% of GU and 25% of DU patients. Surgical therapy was eventually required in 26% of patients after endoscopic hemostasis and was more frequent in patients with recurrent hemorrhage from DU than GU (78% vs 56%). For those patients who re-bled within 8 days of the index endoscopy, 82% required surgery, compared with 33% of patients who re-bled more than 8 days after the index endoscopy (p = 0.03)., Conclusions: The rate of recurrent hemorrhage after endoscopic hemostasis for bleeding GU and DU was 33% in our long-term follow-up. After endoscopic hemostasis, surgery was eventually required in 24% of all patients and in 64% of patients who had recurrent hemorrhage. Patients who had recurrent hemorrhage more than 1 wk after initial endoscopic hemostasis were effectively treated by repeated endoscopic therapy and were significantly less likely to require surgery than patients who re-bled within 1 wk. more...

Objectives: A number of randomized clinical trials of prophylactic sclerotherapy have been carried out with different results. The main objective of this study was to determine if the literature provides evidence that prophylactic sclerotherapy increases the survival rate of patients with esophageal varices., Methods: Meta-analysis was used to evaluate the effect of prophylactic sclerotherapy on the survival of patients with esophageal varices. Only randomized controlled trials that compared prophylactic sclerotherapy to placebo were included., Results: Fourteen fully published randomized controlled trials, as well as six trials published as abstracts, were identified in the English literature. Pooling of the 14 fully published trials yielded an odds ratio of death in the treatment group compared with the control group of 0.74 (95% confidence interval, 0.60-0.93) in favor of prophylactic sclerotherapy. There was statistically significant heterogeneity that resolved when the trials were pooled in subgroups based on the sclerosant used. Pooling of trials using polidocanol showed a highly significant benefit for prophylactic sclerotherapy in terms of overall mortality, particularly when those trials that selected subjects at high risk of bleeding were pooled, yielding an odds ratio of 0.51 (95% confidence interval, 0.36-0.73). When trials using sodium tetradecyl sulfate were pooled, a detrimental effect for prophylactic sclerotherapy was seen, with an odds ratio of 1.86 (95% confidence interval, 1.15-3.00). Subgroup analysis by Child's class showed no benefit for patients in Child's class A., Conclusion: These results suggest that prophylactic sclerotherapy with polidocanol is effective, particularly in high-risk patients. more...

We prospectively and randomly compared heat probe and ethanol injection in 80 patients with major nonvariceal upper gastrointestinal hemorrhage who were bleeding actively or had endoscopic stigmata associated with a high risk for rebleeding. We also attempted to predict which patients would rebleed within 72 h after successful endoscopic therapy, using a three-component scoring system. Heat probe and ethanol injection proved to be similar in efficacy and safety. Active bleeding was controlled with equal success with heat probe and ethanol injection (92% vs. 82%), and there was no difference in the rebleeding rate (11% vs. 13%). The scoring system was useful in predicting which patients would rebleed. Significant differences were seen in the mean values of all three scores, and specific cut-offs in the pre-endoscopy and post-endoscopy scores predicted patients who rebled. High likelihood ratios and post-test probabilities for rebleeding were found for the number and severity of concurrent illnesses, but not for endoscopic stigmata, implying that the excess risk associated with stigmata is eliminated after effective endoscopic therapy, and clinical factors become the primary determinants of rebleeding. more...

The classic Dieulafoy lesion is a minute gastric mucosal defect that bleeds massively from an exposed artery. Similar lesions have been identified in the small intestine, colon, and rectum. In this report, we describe a patient who presented with an exsanguinating hemorrhage from a small rectal ulcer with a visible vessel. Control of the bleeding was achieved with endoscopic sclerotherapy using absolute alcohol and 1.5% sodium tetradocyl sulfate, with eventual complete healing of the site. more...

The purpose of this study was to define the risk factors linked to the rupture of esophageal varices following endoscopic injection sclerotherapy. A total of 197 patients with esophageal varices who had been treated by endoscopic injection sclerotherapy between 1985 and 1991 were observed for post-therapeutic bleeding from esophageal varices. Among 197 patients, 96 had esophageal varices and concomitant hepatocellular carcinoma. Analysis by the multivariate Cox's proportional hazard model disclosed that incomplete eradication of esophageal varices, the presence of hepatocellular carcinoma, and Child-Pugh classes were statistically significant predictors for rupture of esophageal varices after sclerotherapy. We conclude that complete eradication of esophageal varices is essential for sustained effectiveness of endoscopic injection sclerotherapy. The presence of hepatocellular carcinoma and a lack of hepatic functional reserve, as indicated by Child's classification, are also major determinants of post-therapeutic bleeding. more...

Unlabelled: Endoscopic laser coagulation effectively controls bleeding from radiation-induced rectal vascular lesions., Objective: To assess the outcome of endoscopic treatment of radiation-induced bleeding due to vascular lesions located proximal to the sigmoid colon., Methods: We identified 15 consecutive patients with such proximal radiation enteropathy treated at our Institution with Nd:YAG laser between 1984 and 1991. Ten patients (66%) had gastric and/or small bowel involvement, and five (33%) had colonic involvement with or without more proximal lesions. Bleeding first appeared at a mean of 21.2 +/- 12.5 months after completion of radiotherapy. Mean duration of gastrointestinal bleeding before laser treatment was 7.6 +/- 4.6 months., Results: After completion of laser therapy, bleeding ceased in nine (60%) patients, decreased in three (20%), and persisted in three (20%). The mean hemoglobin level increased from 8.4 +/- 0.5 g/dl to 10.4 +/- 0.6 g/dl after completion of laser treatments (p < 0.02). The mean number of transfusions per patient per year decreased from 10.5 +/- 2.8 to 0.9 +/- 0.7 (p < 0.01). No treatment-related complications or deaths occurred., Conclusions: Endoscopic laser coagulation of radiation-induced mucosal vascular lesions in the upper gastrointestinal tract and proximal colon appears to be safe and, in most cases, effective. more...

Angiodysplasia is an important vascular lesion of the gut and a source of significant morbidity from bleeding. This lesion is probably responsible for approximately 6.0% of cases of lower gastrointestinal (GI) bleeding and 1.2-8.0% of cases of hemorrhage from the upper GI tract. Small bowel angiodysplasia accounts for 30-40% of cases of GI bleeding of obscure origin and represents the single most common cause for hemorrhage in this subset of patients. Lesions in the large bowel occur most often in the right colon. Their cause is unknown but most are probably acquired and the result of a degenerative process associated with aging. The incidence of colonic angiodysplasia among strictly asymptomatic individuals has never been determined and the natural history for these lesions is incompletely understood. Angiodysplasia in the upper GI tract occurs most often in the stomach and duodenum. When affected patients have been evaluated by colonoscopy concomitant lesions have been diagnosed in one-third of instances. Angiodysplasia has been purported to occur with higher frequency in patients with renal failure, von Willebrand's disease, aortic stenosis, cirrhosis, and pulmonary disease. Not all of these associations have been subjected to critical analysis, but available evidence does not support a strong relationship in most instances. Patients with bleeding angiodysplasia are occasionally treated with hormones or, more often, by endoscopic methods. Uncontrolled case studies have reported reduction or cessation of bleeding in subjects managed with conjugated estrogens. However, prospective randomized controlled trials assessing the efficacy of hormonal therapy are limited, and results from two trials conflict. Safety profiles for the endoscopic methods are acceptable, and reported efficacies are high, although not all methods have been extensively evaluated specifically for the treatment of angiodysplasia. Perforation of the right colon is a potential problem, especially for monopolar electrocoagulation and lasers. more...