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Using a systematic literature search of original articles published during 2023 in Gastrointestinal Endoscopy (GIE) and other high-impact medical and gastroenterology journals, the GIE Editorial Board of the American Society for Gastrointestinal Endoscopy compiled a list of the top 10 most significant topic areas in general and advanced GI endoscopy during the year. Each GIE Editorial Board member was directed to consider 3 criteria in generating candidate topics—significance, novelty, and impact on global clinical practice—and subject matter consensus was facilitated by the Chair through electronic voting and a meeting of the entire GIE Editorial Board. The 10 identified areas collectively represent advances in the following endoscopic spheres: GI bleeding, endohepatology, endoscopic palliation, artificial intelligence and polyp detection, artificial intelligence beyond the colon, better polypectomy and EMR, how to make endoscopy units greener, high-quality upper endoscopy, endoscopic tissue apposition and closure devices, and endoscopic submucosal dissection. Each board member was assigned a topic area around which to summarize relevant important articles, thereby generating this overview of the "top 10" endoscopic advances of 2023. [ABSTRACT FROM AUTHOR]

Nonvariceal upper gastrointestinal (UGI) hemorrhage remains a significant health and economic burden. As the use of urgent endoscopy for UGI hemorrhage has increased, there has been a decline in associated mortality. Endoscopic hemostasis is based on risk stratification of stigmata of recent hemorrhage. A Doppler endoscopic probe can provide further risk stratification by detecting arterial blood flow under the lesion and as a guide to successful endoscopic treatment. Standard treatment options for endoscopic hemostasis include submucosal injection therapy usually in combination with either thermal coagulation or through-the-scope clips. A large over-the-scope clip, which has been used to close fistulas and perforations, has been shown to be effective in cases of refractory nonvariceal UGI hemorrhage, and might also be useful in other types of gastrointestinal bleeding. [ABSTRACT FROM AUTHOR]

Background and Aims Few prospective reports describe the short-term natural history of colon diverticular hemorrhage based on stigmata of recent hemorrhage, and none include blood flow detection for risk stratification or as a guide to definitive hemostasis. Our purposes were to report the 30-day natural history of definitive diverticular hemorrhage based on stigmata and to describe Doppler probe blood flow detection as a guide to definitive hemostasis. Methods Different cohorts of patients with severe diverticular bleeding and stigmata on urgent colonoscopy are reported. For 30-day natural history, patients were treated medically. If severe rebleeding occurred, they had surgical or angiographic treatment. We report natural history with major stigmata (active bleeding, visible vessel, or adherent clot) and no stigmata or flat spots after clots were washed away. We also report Doppler probe detection of arterial blood flow underneath stigmata before and after hemostasis in a recent cohort. Results For natural history, patients with major stigmata treated medically had 65.8% (25/38) rebleeding rates, and 44.7% (17/38) had intervention for hemostasis. Patients with spots or clean bases had no rebleeding. A Doppler probe detected arterial blood flow in 92% of major stigmata—none after hemostasis—and there was no rebleeding. Conclusions (1) Patients with major stigmata treated medically had high rates of rebleeding and intervention for hemostasis. (2) Patients with clean diverticula or only flat spots had no rebleeding. (3) High rates of arterial blood flow were detected under major stigmata with a Doppler probe, but with obliteration by hemostasis no rebleeding occurred. [ABSTRACT FROM AUTHOR]

Background and Aims For more than 4 decades endoscopists have relied on ulcer stigmata for risk stratification and as a guide to hemostasis. None used arterial blood flow underneath stigmata to predict outcomes. For patients with severe peptic ulcer bleeding (PUB), we used a Doppler endoscopic probe (DEP) for (1) detection of blood flow underlying stigmata of recent hemorrhage (SRH), (2) quantitating rates of residual arterial blood flow under SRH after visually directed standard endoscopic treatment, and (3) comparing risks of rebleeding and actual 30-day rebleed rates for spurting arterial bleeding (Forrest [F] IA) and oozing bleeding (F IB). Methods Prospective cohort study of 163 consecutive patients with severe PUB and different SRH. Results All blood flow detected by the DEP was arterial. Detection rates were 87.4% in major SRH—spurting arterial bleeding (F IA), non-bleeding visible vessel (F IIA), clot (F IIB)—and were significantly lower at 42.3% ( P < .0001) for an intermediate group of oozing bleeding (F IB) or flat spot (F IIC). For spurting bleeding (F IA) versus oozing (F IB), baseline DEP arterial flow was 100% versus 46.7%, residual blood flow detected after endoscopic hemostasis was 35.7% versus 0%, and 30-day rebleed rates were 28.6% versus 0% (all P < .05). Conclusions (1) For major SRH versus oozing or spot, the arterial blood flow detection rate by the DEP was significantly higher, indicating a higher rebleed risk. (2) Before and after endoscopic treatment, spurting (F IA) PUB had significantly higher rates of blood flow detection than oozing (F IB) PUB and a significantly higher 30-day rebleed rate. (3) The DEP is recommended as a new endoscopic guide with SRH to improve risk stratification and potentially definitive hemostasis for PUB. [ABSTRACT FROM AUTHOR]

Highlights • Possibly first documented pseudo-transmission from endobronchial ultrasound scope. • Transmission may exist in endoscopes that do not have an elevator channel. • Endoscopes can harbor bacteria despite adherence to reprocessing steps. • Scopes without a leak may have internal damage leading to buildup of biofilm. • Scope culturing protocols may provide a false sense of security. During an investigation of positive environmental cultures with Enterobacter cloacae from an endobronchial ultrasound scope, possible pseudotransmission was discovered between 2 patients. All reprocessing steps were adhered to and the original equipment manufacture's quality control assessment of the scope could not determine the root cause. Our findings appear to be the first documented case of pseudotransmission from an endobronchial ultrasound scope and suggest bacterial transmission may exist in endoscopes without an elevator channel. [ABSTRACT FROM AUTHOR]

Abstract: Context: Activity limitation and dyspnea are the dominant symptoms of chronic obstructive pulmonary disease (COPD). Traditionally, efforts to alleviate these symptoms have focused on improving ventilatory mechanics, reducing ventilatory demand, or both of these in combination. Nevertheless, many patients with COPD remain incapacitated by dyspnea and exercise intolerance despite optimal therapy. Objectives: To determine the effect of single-dose inhalation of nebulized fentanyl citrate (a μ-opioid agonist drug) on exercise tolerance and dyspnea in COPD. Methods: In a randomized, double-blind, placebo-controlled, crossover study, 12 stable patients with COPD (mean±standard error of the mean post-β2-agonist forced expiratory volume in one second [FEV1] and FEV1 to forced vital capacity ratio of 69%±4% predicted and 49%±3%, respectively) received either nebulized fentanyl citrate (50mcg) or placebo on two separate days. After each treatment, patients performed pulmonary function tests and a symptom-limited constant work rate cycle exercise test at 75% of their maximum incremental work rate. Results: There were no significant postdose differences in spirometric parameters or plethysmographic lung volumes. Neither the intensity nor the unpleasantness of perceived dyspnea was, on average, significantly different at isotime (5.0±0.6 minutes) or at peak exercise after treatment with fentanyl citrate vs. placebo. Compared with placebo, fentanyl citrate was associated with 1) increased exercise endurance time by 1.30±0.43 minutes or 25%±8% (P =0.01); 2) small but consistent increases in dynamic inspiratory capacity by ∼0.10L at isotime and at peak exercise (both P ≤0.03); and 3) no concomitant change in ventilatory demand, breathing pattern, pulmonary gas exchange, and/or cardiometabolic function during exercise. The mean rate of increase in dyspnea intensity (1.2±0.3 vs. 2.9±0.8 Borg units/minute, P =0.03) and unpleasantness ratings (0.5±0.2 vs. 2.9±1.3 Borg units/minute, P =0.06) between isotime and peak exercise was less after treatment with fentanyl citrate vs. placebo. Conclusion: Single-dose inhalation of fentanyl citrate was associated with significant and potentially clinically important improvements in exercise tolerance in COPD. These improvements were accompanied by a delay in the onset of intolerable dyspnea during exercise near the limits of tolerance. [Copyright &y& Elsevier]

Abstract: We examined the effects of dead space loading (DSL) on ventilation , neural respiratory drive (EMGdi%max, diaphragm EMG expressed as a % of maximal EMGdi), contractile respiratory muscle effort (Pes,tidal%PImax, tidal esophageal pressure swing expressed as a % of maximal inspiratory Pes) and exertional dyspnea intensity ratings in 11 healthy adults with normal spirometry. Subjects completed, in random order, symptom-limited incremental cycle exercise tests under control (CTRL) and DSL (500ml) conditions. Compared with CTRL, DSL decreased exercise tolerance by 20–25%; increased exertional dyspnea intensity ratings in direct proportion to concurrent increases in EMGdi%max, Pes,tidal%PImax and ; and had little/no effect on the inter-relationships between EMGdi%max, Pes,tidal%PImax and during exercise. In conclusion, DSL was associated with an earlier onset of intolerable dyspnea; however, neuro-muscular and neuro-ventilatory coupling of the respiratory system remained relatively preserved during exercise in the presence of an increased external dead space. Under these circumstances, DSL-induced increases in exertional dyspnea intensity ratings reflected, at least in part, the awareness of increased neural respiratory drive, contractile respiratory muscle effort and ventilatory output. [Copyright &y& Elsevier]

Background: Risk factors and outcomes of severe hematochezia from ischemic colitis compared with other colonic diagnoses have not been well studied. Objective: Our purposes were (1) to compare demographics and outcomes of patients hospitalized with severe hematochezia from ischemic colitis compared with other colonic diagnoses, (2) to compare inpatient and outpatient start of bleeding from ischemic colitis, and (3) to describe potential risk factors. Design: Prospective cohort study. Setting: Tertiary referral academic centers. Patients: Patients referred for gastroenterology consultation for severe hematochezia. Interventions: Colonoscopic therapy was provided as indicated. Main Outcome Measurements: Rebleeding, surgery, and length of hospital stay after colonoscopy. Results: Of 550 patients in the past 12 years with severe hematochezia from colonic sources, the cause in 65 patients (11.8%) was ischemia. Ischemic colitis was found more often in females, in patients taking anticoagulant agents, in patients with severe lung disease, those with higher creatinine levels, those with higher glucose levels, and those with more fresh frozen plasma transfusions. Five patients with focal lesions had colonoscopic hemostasis. Major 30-day outcomes of ischemic colitis patients were significantly worse than patients with other colonic diagnoses. Patients with inpatient (vs outpatient) ischemic colitis had significantly more and more severe comorbidities at baseline and significantly higher rates of rebleeding, surgery, and more days spent in hospital and in the intensive care unit. Limitations: Two-center study. Conclusions: Major 30-day outcomes in ischemic colitis patients were significantly worse than in patients with other colonic diagnoses. Comparing outpatient and inpatient start of ischemic colitis, inpatients had significantly worse outcomes. [Copyright &y& Elsevier]

Abstract: The purpose of this study was to evaluate the physiological basis for sex-differences in exercise-induced dyspnea in patients with mild COPD. We compared operating lung volumes, breathing pattern and dyspnea during incremental cycling in 32 men (FEV1 =86±10% predicted) and women (FEV1 =86±12% predicted) with mild COPD and 32 age-matched controls. There were no sex differences in dyspnea in the control group at any work-rate or ventilation (). Women with COPD had significantly greater dyspnea than men at 60 and 80W. At 80W, dyspnea ratings were 5.7±2.3 and 3.3±2.5Borg units (P <0.05) and the to maximal ventilatory capacity ratio was 72% and 55% in women and men, respectively (P <0.05). Comparable increases in dynamic hyperinflation were seen in both male and female COPD groups at symptom limitation but women reached tidal volume constraints at a lower work rate and than men. Superimposing mild COPD on the normal aging effects had greater sensory consequences in women because of their naturally reduced ventilatory reserve. [Copyright &y& Elsevier]

Endoscopic management of acute gastrointestinal (GI) bleeding is an advanced procedure associated with high morbidity and mortality. The traditional apprentice model of training for such events is often inadequate because of their unpredictable frequency, common occurrence off hours, and high stakes for patient outcome. Hemostasis is the cessation of active bleeding and prevention of rebleeding with an endoscopic intervention. Proficiency in endoscopic management of GI hemorrhage includes proper preparation, a systematic categorization of both the source of bleeding and the technique used to control it, the necessary knowledge base, and technical skills to perform the endoscopic intervention. Various simulation platforms, including virtual reality simulators, in vivo models, and explanted tissue, can be helpful in gaining proficiency in endoscopic hemostasis, although validated criteria for obtaining and maintaining procedural competence in this area are still lacking. [Copyright &y& Elsevier]

Abstract: We examined the impact of human pregnancy on breathlessness intensity at matched levels of ventilation during isoxic hyperoxic CO2 rebreathing and incremental cycle exercise tests in 21 healthy women in the third trimester (TM3) and again ∼5 months post-partum (PP). Pregnancy had no significant (P >0.05) effect on the slope or threshold of the breathlessness relationship during both exercise and rebreathing. By contrast, the slope of the breathlessness relationship was significantly higher, while the threshold of this relationship was consistently lower during rebreathing vs. exercise (both P <0.05), regardless of pregnancy status (P >0.05). As a result, breathlessness intensity was markedly higher at any given (e.g., by ∼4 Borg units at 40L/min) during rebreathing vs. exercise, regardless of pregnancy status. Inter-subject variation in breathlessness slopes during exercise was not associated with inter-subject variation in breathlessness slopes during rebreathing or with increased central chemoreflex responsiveness during pregnancy (both P >0.05). In conclusion, the intensity of perceived breathlessness for a given depends, at least in part, on the nature and source of increased central respiratory motor command output, independent of pregnancy status; and pregnancy-induced increases in activity-related breathlessness cannot be easily explained by increased central chemoreflex responsiveness. [Copyright &y& Elsevier]

Abstract: We tested the hypothesis that the magnitude of the pregnancy-induced increase in exercise hyperpnea is predictable based on the level at which is regulated at rest. We performed a detailed retrospective analysis of previous data from 25 healthy young women who performed exercise and rebreathing tests in the third trimester (TM3; 36.5±0.2 weeks gestation; mean±SEM) and again 20.4±1.7 weeks post-partum (PP). At rest, arterialized venous blood was obtained for the estimation of , [H+] and [HCO3 −]; and serum progesterone ([P4]) and 17β-estradiol ([E2]) concentrations. Duffin''s modified hyperoxic rebreathing procedure was used to evaluate changes in central ventilatory chemoreflex control characteristics at rest. Breath-by-breath ventilatory and gas exchange variables were measured at rest and during symptom-limited incremental cycle exercise tests. At rest in TM3 compared with PP: , [H+], [HCO3 −] and the central chemoreflex ventilatory recruitment threshold for () decreased, while ventilation (), [P4], [E2] and central chemoreflex sensitivity () increased (all p ≤0.001). The slope of the linear relation between and during exercise was significantly higher in TM3 vs. PP (31.2±0.6 vs. 27.5±0.5, p <0.001). The magnitude of this change in the slope correlated significantly with concurrent reductions in each of the (R 2 =0.619, p <0.001), (R 2 =0.203, p =0.024) and [HCO3 −] (R 2 =0.189, p =0.030); and was independent (p >0.05) of changes in [P4], [E2] and . In conclusion, the increased ventilatory response to exercise in pregnancy can be explained, in large part, by reductions in the respiratory control system''s resting equilibrium point as manifest primarily by reductions in the . [Copyright &y& Elsevier]

Abstract: We quantified the magnitude of within- and between-day, within-subject variability of the ventilatory response to Duffin''s modified rebreathing procedure in 20 healthy humans. The at which ventilation increased with progressive increases in during rebreathing was identified as the ventilatory recruitment threshold (); the ventilatory response below and above the was taken as an estimate of non-chemoreflex drives to breathe () and chemoreflex sensitivity (), respectively. Within- and between-day intraclass correlation coefficients for each of these parameters were >0.60 (range: 0.62–0.93), indicating good-to-excellent test–retest reliability. Within- and between-day, within-subject coefficients of variation for hyperoxic and hypoxic (range: 24.6–30.7%) and (range: 18.5–32.7%) were relatively high but acceptable, while those for the were very small (range: 3.0–3.8%). In conclusion, Duffin''s modified rebreathing procedure, in both its hyperoxic and hypoxic form, is a highly reliable tool for measurement of chemoreflex and non-chemoreflex ventilatory control characteristics over short and long periods of time in healthy humans. [Copyright &y& Elsevier]

Background: Several different hemoclips are marketed for endoscopic hemostasis of nonvariceal upper GI (UGI) bleeding. No previous reports have compared success rates of clip deployment onto bases of chronic gastric ulcers (GUs), clip retention rates, or their influence on ulcer healing. Objectives: For the treatment of chronic GUs, to compare 3 different hemoclips with multipolar electrocoagulation (MPEC) and control. Design: Randomized, controlled study. Subjects: Seven adult dogs with prehepatic portal hypertension had GUs created by rubber band ligation. Animals received oral proton pump inhibitors daily and underwent weekly endoscopies to quantitate clip retention and ulcer healing. Interventions: One week after banding, 10 chronic ulcers were randomized in pairs to control (no endoscopic treatment), MPEC, or different hemoclips (QuickClip2 [QC], TriClip [TC], or Resolution Clip [RC]). Main Outcome Measurements: Times and success of hemoclip deployment, clip retention rates, and ulcer healing rates on weekly endoscopies. Results: Success rates of clip deployment were 100% for the RC, 93.1% for the TC, and 83.3% for the QC. Clip retention rates were significantly higher with the RC than the QC or TC at 1 to 3 weeks. Retained clips did not delay GU healing compared with MPEC or control. Conclusions: Hemoclipping time was similar with all 3 clips; the RC was retained significantly longer than the QC or TC, hemoclips did not delay ulcer healing compared with control or MPEC, and all 3 hemoclips were safe and no complications such as bleeding and weight loss were noted. [Copyright &y& Elsevier]

Abstract: The healthy human respiratory system has impressive ventilatory reserve and can easily meet the demands placed upon it by strenuous exercise. Several acute physiological adaptations during exercise ensure harmonious neuromechanical coupling of the respiratory system, which allow healthy humans to reach high levels of ventilation without perceiving undue respiratory discomfort (breathlessness). However, in certain circumstances, such as pregnancy, obesity and natural aging, ventilatory reserve becomes diminished and exertional breathlessness is present. In this review, we focus on what is known about the mechanisms of increased activity-related breathlessness in these populations. Notwithstanding the obvious physiological differences between the three conditions, they share some common perceptual and ventilatory responses to exercise. Breathlessness intensity ratings (described as an increased “sense of effort”) are consistently higher than normal at any given submaximal power output; and central motor drive to the respiratory muscles is consistently increased, reflecting increased ventilatory stimulation. The increased contractile respiratory muscle effort required to support the increased ventilatory requirements of exercise remains the most plausible source of increased activity-related breathlessness in pregnant, obese and elderly humans. In all three conditions, static and dynamic respiratory mechanical/muscular function is, to some extent, altered or impaired. Nevertheless, breathlessness intensity ratings are not significantly increased (compared to normal) at any given exercise ventilation in any of these three conditions. This strongly suggests that respiratory mechanical/muscular factors, per se, may be less important in the genesis of breathlessness. Moreover, in pregnancy and obesity, we present evidence that effective physiological adjustments exist to counterbalance the potentially negative sensory consequences of the altered respiratory mechanical/muscular function peculiar to these conditions. [Copyright &y& Elsevier]

Background & Aims: Nonsteroidal anti-inflammatory drugs (NSAIDs) cause lower gastrointestinal (GI) clinical events such as bleeding. Cyclo-oxygenase (COX)-2 selective inhibitors decrease upper GI events, but no prospective trial has prespecified assessment of lower GI clinical events. Methods: Patients ≥50 years old with osteoarthritis or rheumatoid arthritis were randomly assigned to etoricoxib (60 or 90 mg qd) or diclofenac (150 mg qd). Lower GI clinical events, confirmed by a blinded adjudication committee, included perforation or obstruction requiring hospitalization or bleeding (gross or occult rectal bleeding without upper GI cause associated with hypotension, orthostatic changes in heart rate [>20 beats per minute] or blood pressure [>20 mmHg systolic or >10 mmHg diastolic], hemoglobin drop ≥2 g/dl, or transfusion; or observed active bleeding or stigmata of hemorrhage). Results: We enrolled 34,701 patients with mean duration of therapy of 18 months. Rates were 0.32 and 0.38 lower GI clinical events per 100 patient-years for etoricoxib and diclofenac (hazard ratio [HR] = 0.84; 95% confidence interval [CI], 0.63–1.13). Bleeding was the most common event (rates of 0.19 and 0.23 per 100 patient-years, respectively). Multivariable analysis revealed significant risk factors to be prior lower GI event (HR = 4.06; 95% CI, 2.93–5.62) and age ≥65 years (HR = 1.98; 95% CI, 1.45–2.71). Conclusions: A statistically significant decrease in lower GI clinical events was not seen with the COX-2 selective inhibitor etoricoxib versus the traditional NSAID diclofenac. The risk of a lower GI clinical event with NSAID use seems to be constant over time, and the major risk factors are a prior lower GI event and older age. [Copyright &y& Elsevier]

Background: Mechanical closure of bleeding vessels is clinically appealing, and several types of hemoclips are now marketed for endoscopic hemostasis of nonvariceal lesions. No comparative data have been reported on ease of clip placement, hemostasis efficacy, or clip retention rates on bleeding ulcers. Objective: To compare 3 different types of hemoclips for hemostasis of bleeding ulcers. Design: Randomized controlled study. Subjects: Seven adult dogs with prehepatic portal hypertension were heparinized, and acute gastric ulcers were made with jumbo biopsy forceps. Animals had oral proton pump inhibitors daily and weekly endoscopies to quantitate clip retention and ulcer healing. Interventions: Bleeding ulcers were randomized in pairs (2 for each treatment/dog) to endoscopic hemoclip treatment or control. Main Outcome Measurements: Initial times and success of deployment, hemostasis efficacy, clip retention rates, and ulcer healing during endoscopic follow-ups. Results: There was no difference in initial hemostasis rates of hemoclips, and no major complications occurred. Ulcer healing times were faster (Resolution Clip [RC] or TriClip [TC]) or similar (QuickClip2 [QC]) to controls. Clip retention at 1 week was significantly less with TC and, at 3 to 7 weeks, was significantly higher with RC. Conclusions: (1) For the 3 hemoclip devices, initial hemostasis rates were 100%, but all devices required similar learning time to place clips successfully. (2) Short-term retention rates of TC were significantly less than QC or RC. (3) Long-term clip retention was significantly higher with RC. (4) All 3 hemoclips were safe, and none interfered with ulcer healing. [Copyright &y& Elsevier]

Background & Aims: The optimal management of bleeding peptic ulcer with adherent clot is controversial and may include endoscopic therapy or medical therapy. Methods: We searched MEDLINE, BIOSIS, EMBASE, and the Cochrane Library to identify all randomized controlled trials comparing the 2 interventions. Outcomes evaluated in the meta-analysis were recurrent bleeding, need for surgical intervention, length of hospitalization, transfusion requirement, and mortality. Results: Six studies were identified that included 240 patients from the United States, Hong Kong, South Korea, and Spain. Patients in the endoscopic therapy group underwent endoscopic clot removal and treatment of the underlying lesion with thermal energy, electrocoagulation, and/or injection of sclerosants. Rebleeding occurred in 5 of 61 (8.2%) patients in the endoscopic therapy group, compared with 21 of 85 (24.7%) in the medical therapy group (P = .01), for a pooled relative risk of 0.35 (95% confidence interval, 0.14–0.83; number needed to treat, 6.3). There was no difference between endoscopic therapy and medical therapy in length of hospital stay (mean, 6.8 vs 5.6 days; P = .27), transfusion requirement (mean, 3.0 vs 2.8 units of packed red blood cells; P = .75), or mortality (9.8% vs 7%; P = .54). Patients in the endoscopic therapy group were less likely to undergo surgery (pooled relative risk, 0.43; 95% confidence interval, 0.19–0.98; number needed to treat, 13.3); however, this outcome became nonsignificant when only peer-reviewed studies were considered. Conclusions: Endoscopic therapy is superior to medical therapy for preventing recurrent hemorrhage in patients with bleeding peptic ulcers and adherent clots. The interventions are comparable with respect to the need for surgical intervention, length of hospital stay, transfusion requirement, and mortality. [Copyright &y& Elsevier]

Endoscopy by well-trained and skilled endoscopists yields a definitive diagnosis in over 95% of patients with upper gastrointestinal (UGI) bleeding, and endoscopic hemostasis can be applied in most patients with major stigmata of hemorrhage: active bleeding, nonbleeding visible vessels, or adherent clots. Based on these high rebleeding rates on medical therapy alone, we now recommend endoscopic treatment of all patients with active arterial bleeding, NBVV, and adherent clots. Persistent oozing without other stigmata is also included in this group, although rebleeding rates on medical therapy are substantially lower. In the last 15 years, ulcer hemorrhage has decreased in prevalence, whereas the prevalences of esophagogastric varices and erosive esophagitis have both increased. Heat energy applied through endoscopic probes coagulates tissue proteins, causes edema and vasoconstriction, activates intrinsic arterial (platelet) coagulation, and thereby obliterates the arterial lumen. These contact devices can be applied directly on the ulcer stigmata or the bleeding site to compress the underlying vessel with moderate appositional pressure before coagulation. The pressure on the stigmata interrupts blood flow through the underlying vessel and reduces the heat sink effect. Subsequent applications of low energy, long coagulation with MPEC or heater probe can weld the walls of mesenteric arteries up to 2.0 mm in diameter together for effective “coaptive coagulation” in the laboratory. Combination therapy combines the mechanisms of action for arterial hemostasis of two or more treatment methods. Both epinephrine injection and thermal coagulation activate platelet coagulation and cause tamponade of the vessel. In addition, epinephrine causes vessel constriction, and thermal coagulation probes result in secondary edema and coaptive coagulation. In two recent randomized trials, investigators reported that combination endoscopic treatment with epinephrine injection near the pedicle of the clot in the ulcer base, followed by mechanical shaving down of the clot to expose the underlying stigmata, and subsequent thermal coagulation with MPEC or heater probes, dramatically reduced rebleeding rates compared with medical therapy alone from about 34% to less than about 5%. Combination therapy with epinephrine injection followed by thermal therapies (eg, MPEC or heater probe) has reduced these ulcer rebleeding rates to 15% to 20% for active arterial bleeding and to about 10% for NBVV. In two recent randomized controlled trials, combination epinephrine and thermal therapy (multipolar probe) was also reported to have similar rebleeding rates to hemoclipping for hemostasis of active ulcer bleeding or NBVV. Combination therapy was better than hemoclipping for the subgroup of patients with tangential ulcers. [Copyright &y& Elsevier]

Background & Aims: Standard care for prevention of first esophageal variceal hemorrhage is β-blockade, but this may be ineffective or unsafe. Our purpose was to compare endoscopic banding with propranolol for prevention of first variceal hemorrhage. Methods: In a multicenter, prospective trial, 62 patients with cirrhosis with high-risk esophageal varices were randomized to propranolol (titrated to reducing resting pulse by ≥25%) or banding (performed monthly until varices were eradicated) and were followed up on the same schedule for a mean duration of 15 months. The primary end point was treatment failure, defined as the development of endoscopically documented variceal hemorrhage or a severe medical complication requiring discontinuation of therapy. Direct costs were estimated from Medicare reimbursements and fixed or variable charges for services up to treatment failure. Results: Background variables of the treatment groups were similar. The trial was stopped early after an interim analysis showed that the failure rate of propranolol was significantly higher than that of banding (6/31 vs. 0/31; difference, 19.4%; P = .0098; 95% confidence interval for true difference, 6.4%–37.2%). Significantly more propranolol than banding patients had esophageal variceal hemorrhage (4/31 vs. 0/31; difference, 12.9%; P = .0443; 95% confidence interval for true difference, 0.8%–29%), and the cumulative mortality rate was significantly higher in the propranolol than in the banding group (4/31 vs. 0/31; difference, 12.9%; P = .0443; 95% confidence interval for true difference, 0.8%–29%). Direct costs of care were not significantly different. Conclusions: For patients with cirrhosis with high-risk esophageal varices and no history of variceal hemorrhage, propranolol-treated patients had significantly higher failure rates of failure, first esophageal varix hemorrhage, and cumulative mortality than banding patients. Direct costs of medical care were not significantly different. [Copyright &y& Elsevier]

Portal hypertensive gastropathy (PHG) is an extremely common endoscopic finding in patients with portal hypertension. This article examines the various endoscopic grading systems that have been developed for PHG with further discussion on the risk of bleeding with PHG and if endoscopic grading can predict the risk of bleeding. Finally, both the nonendoscopic and endoscopic treatment modalities for acute and chronic bleeding secondary to PHG are discussed. [Copyright &y& Elsevier]

No prior randomized controlled trial (RCT) has reported patient outcomes of large over-the-scope clip (OTSC) compared to standard hemostasis as initial endoscopic treatment of severe NVUGIB. This was our study aim. Patients with bleeding ulcers or Dieulafoy's lesions and major stigmata of hemorrhage - SRH (active spurting bleeding, visible vessel, or clot) - or lesser SRH (oozing bleeding or flat spots – with arterial blood flow by Doppler probe) were randomized to OTSC or standard endoscopic hemostasis (with hemoclips or multipolar electrocoagulation – MPEC). Patients and their healthcare providers were blinded to treatments and made all post-randomization management decisions. Ulcer patients received high dose intravenous infusions of proton pump inhibitors (PPI) for 3 days, then 27 days of oral PPI. 30 day outcomes were prospectively recorded; data management was with SAS; and data analysis was by a statistician. 53 patients (25 OTSC, 28 Standard) were randomized, with similar baseline risk factors. However, there were significant differences in OTSC vs. Standard groups in rates of rebleeding (4% vs. 28.6%; p =.017; relative risk 0.10, 95% confidence intervals 0.01, 0.91; number needed to treat 4); severe complications (0 % vs. 14.3%); and post-randomization units of red cell transfusions (0.04 vs. 0.68). All rebleeds occurred in patients with major SRH and none with lesser SRH. 1. OTSC significantly reduced rates of rebleeding, severe complications, and post-randomization red cell transfusions. 2. Patients with major stigmata benefited significantly from hemostasis with OTSC, but those with lesser stigmata did not. (ClinicalTrials.gov , Number: NCT03065465). [ABSTRACT FROM AUTHOR]

Background & Aims For 4 decades, stigmata of recent hemorrhage in patients with nonvariceal lesions have been used for risk stratification and endoscopic hemostasis. The arterial blood flow that underlies the stigmata rarely is monitored, but can be used to determine risk for rebleeding. We performed a randomized controlled trial to determine whether Doppler endoscopic probe monitoring of blood flow improves risk stratification and outcomes in patients with severe nonvariceal upper gastrointestinal hemorrhage. Methods In a single-blind study performed at 2 referral centers we assigned 148 patients with severe nonvariceal upper gastrointestinal bleeding (125 with ulcers, 19 with Dieulafoy’s lesions, and 4 with Mallory Weiss tears) to groups that underwent standard, visually guided endoscopic hemostasis (control, n = 76), or endoscopic hemostasis assisted by Doppler monitoring of blood flow under the stigmata (n = 72). The primary outcome was the rate of rebleeding after 30 days; secondary outcomes were complications, death, and need for transfusions, surgery, or angiography. Results There was a significant difference in the rates of lesion rebleeding within 30 days of endoscopic hemostasis in the control group (26.3%) vs the Doppler group (11.1%) ( P = .0214). The odds ratio for rebleeding with Doppler monitoring was 0.35 (95% confidence interval, 0.143–0.8565) and the number needed to treat was 7. Conclusions In a randomized controlled trial of patients with severe upper gastrointestinal hemorrhage from ulcers or other lesions, Doppler probe guided endoscopic hemostasis significantly reduced 30-day rates of rebleeding compared with standard, visually guided hemostasis. Guidelines for nonvariceal gastrointestinal bleeding should incorporate these results. ClinicalTrials.gov no: NCT00732212 (CLIN-013-07F). [ABSTRACT FROM AUTHOR]