sign in sign up
<<
Home , Endoclip, Hematemesis, Melena, Therapeutic endoscopy

Clinics and Practice 2011; volume 1:e132

Upper gastrointestinal Introduction Correspondence: Vipul D. Yagnik, 77, Siddhraj : audit of a single Nagar, Station Road, Patan-384265, Gujarat, center experience in Western Upper gastrointestinal (GI) bleeding is India. Tel. +91.98795.03296. India defined as bleeding proximal to the ligament E-mail: [email protected] of Treitz. The most important aspect of man - Key words: , , endotherapy. Jignesh B. Rathod, 1 Dharmendra K. Shah, 2 agement of GI bleeding is to locate the site 1 Bhargav D. Yagnik, 3 Vipul D. Yagnik 4 and cause of bleeding. Bleeding from the Received for publication: 7 July 2011. upper GI tract is approximately five times Revision received: 2 November 2011. 1 Department of , Pramukhswami more common as compared to lower GI tract Accepted for publication: 15 November 2011. Medical College, Karamsad; 2Department bleeding, and males are affected twice as of Surgery, Govt. Medical College, much as compared to females. 2 Clinically, This work is licensed under a Creative Commons Vadodara; 3General Practitioner, upper GI bleeding often presents as Attribution NonCommercial 3.0 License (CC BY- NC 3.0). Ahmedabad; 4Ronak Endo-laparoscopy hematemesis or . Fresh per rec - Hospital, Patan, Gujarat, India tum () usually indicates lower ©Copyright J.B. Rathod et al., 2011 GI source of bleeding or massive upper GI Licensee PAGEPress, Italy bleeding in 15% of cases and is associated Clinics and Practice 2011; 1:e132 with worse prognosis. 3 About 80% of the GI doi:10.4081/cp.2011.e132 Abstract stop spontaneously; only 20% con - tinue or recur. Diagnostic accuracy of Upper gastrointestinal (GI) bleeding is endoscopy is 80-95% for upper GI bleeding. 4 defined as bleeding proximal to the ligament National Institute of Health and American Results of Treitz. The most important aspect of man - Society of Gastrointestinal and Endoscopic surgeons 4 recommend urgent endoscopy in a agement of GI bleeding is to locate the site This prospective study was conducted dur - patient who is actively bleeding or has a high and cause of bleeding. The aim of the study is ing the period August 2001-July 2003. Cases risk for re-bleeding (such as old age, , were selected randomly and included patients to find out the common etiology, presentation low hemoglobin, melena, more than 4 trans - admitted to both medical as well as surgical and management, including the role of upper fusions, etc.). The aim of the study is to find wards. The total number of cases of upper GI GI endoscopy. Recent advances have meant out the common etiology, presentation and that endoscopic hemostatic methods are now management, including role of upper GI bleeding studied was 50, out of which 37 were associated with a reduced rate of re-bleeding, endoscopy. Recent advances have meant that males and 13 were females. Age distribution is cost, , length of hospital endoscopic hemostatic methods are now shown in Table 1. stay and mortality. A prospective study of 50 associated with a reduced rate of re-bleeding, Patients’ clinical features (symptoms) are summarized in Table 2. Clinical presentation cases was carried out between August 2001 cost, blood transfusion, length of hospital stay and signs are summarized in Table 3. The most and July 2003. Patients with signs and symp - and mortality. 5 We present here the results of common symptom was hematemesis (100%) toms suggestive of upper GI bleeding (UGIB) a prospective study of 50 patients withupper followed by (84%) and melena such as hematemesis, melena, aspirated GI bleeding (UGIB) during the period of 2001- 2003. (28%). The most common sign observed was blood from nasogastric tubes, profuse hema - (18%) followed by shock (14%), and tochezia, etc., were included in the study. hepatosplenomegaly (6%) or splenomegaly The patients were selected randomly. The (6%). Of these, all (100%) patients had most common cause of UGIB in the present Materials and Methods hematemesis while 28% had melena. study was acute erosive (34%) fol - Out of 50 patients, 10 patients had a history lowed by (24%) and pep - A prospective study of 50 cases was carried of alcoholism while 14 (28%) were smokers. tic ulcer (22%). All 50 patients underwent out between August 2001 and July 2003. This Four patients had a history of upper gastroin - upper GI endoscopy, of whom 39 patients study was conducted in a tertiary care center testinal surgery and 3 patients had a pul - were treated conservatively and 11 patients and medical college in Vadodara (India). This monary tuberculosis with while one underwent endotherapy to control bleeding. study was approved by the university authori - had only pulmonary tuberculosis. Three Out of 39 patients treated non-endoscopical - ties. Written and informed consent was patients were on non-steroidal anti-inflamma - ly, 6 cases required to control obtained from the patients /relatives of the tory drugs (NSAIDs). Twelve patients had a UGIB. 8 of 50 cases had past history of UGIB, patients. All patients were selected on the past history of hematemesis (n=8) and 5 of whom had a previous history of basis of a detailed history and physical exami - abdominal pain (n=4). Radiological investigations such as ultra - endotherapy. One case was treated with de- nation. Patients with sug - sonography (all cases), CT scan (n=6), barium vascularization as routine hemostatic meth - gestive of upper GI bleeding such as hematemesis, melena, blood in the nasogas - study (n=8) and splenoportogram (n=2) were ods failed. So, initial method of choice to con - tric tubes, profuse hematochezia, were includ - carried out in addition to upper GI endoscopy trol the bleeding was endotherapy and sur - ed in the study. The patients were selected ran - to help diagnosis. gery was undertaken if an endoscopic domly. Endoscopy was performed in all patients The etiological distribution is summarized method failed. The most common cause of within 24 h of admission depending upon the in Table 4. In this study, we found that the hematemesis in our setting was acute ero - urgency of the condition by using an Olympus commonest cause of upper GI bleeding was sive gastritis followed by portal hypertension. forward viewing flexible video endoscope. acute erosive gastritis (34%), followed by por - Endoscopy is a valuable minimal invasive Endoscopy was performed by placing the tal hypertension with method to diagnose and treat upper GI bleed - patients in a left lateral position by standard (24%) and peptic ulcer (22%). A few cases had ing. technique. a dual diagnosis, so these were included

[page 292 ] [Clinics and Practice 2011; 1:e132] Article under both categories. Table 2. Clinical features. In our study, all patients with portal hyper - Symptom N. patients with symptom (%) tension with esophageal varices were in the 20-50 year age group, while all patients with Hematemesis 50 100 peptic ulcer were in the 20-60 year age group. Pain in abdomen 42 84 Gastric and esophageal were seen in 5 10 patients over 40 years of age. In this study, few patients had a dual diagnosis and both Abnormal behavior or altered sensorium 12 diagnoses were kept in the table. Cause of Melena 14 28 bleeding was decided by recent sign of bleed - Abdominal distension 7 14 ing in such cases. In this study, Hiatus Miscellaneous 16 32 was associated with reflux in all The most common presentation was hematemesis followed by abdominal pain, and melena. cases. We were not able to confirm etiology in 2 patients. Among the 50 cases, 44 cases were treated Table 3. Presentation and clinical features. conservatively either by medical therapy (n=33) or by endotherapy (n=11). Six patients Sign N patients (%) underwent surgical treatment. Definite surgi - Shock cal treatment was offered to the patients either Mild 12 to stop persistent bleeding or in case of recur - Moderate 36 rent bleeding (Table 5). Eleven had to undergo Severe (after Wilkinson 1969 )36 immediate endoscopy due to severe and per - 12 sistent bleeding from the upper GI tract, while Encephalopathy 12 39 patients underwent endoscopy within 24 h Hepatomegaly 24 (Table 6). All patients were followed for one year. Splenomegaly 36 Endoscopic finding was completely healed in 39 Hepatosplenomegaly 36 patients on subsequent follow up. Three Ascites 9 18 patients of portal hypertension with esophageal varices developed repeat episodes of hematemesis. All 3 patients were treated by Table 4. Endoscopic finding. one more session of endotherapy; no recurrent bleeding was observed in subsequent follow up. S. N. Diagnosis N. (%) During the one year follow up, the operated 1. Acute erosive gastritis 17(34%) case of resected gastric had recurrent upper GI bleeding due to a disease recurrence 2. Portal hypertension with esophageal varices 12(24%) and one patient with died 3. Peptic ulcer 11(22%) from metastatic disease. 4. Reflux esophagitis 9(18%) 5. Stomal ulceration 4(8%) 6. Hiatus hernia 3(6%) Discussion 7. Esophageal cancer 2(4%) 8. Gastric cancer 2(4%) This prospective study of upper GI bleeding 9. Ulcerated leiomyoma 1(2%) during the period of 2001-2003 was performed 10. Portal hypertension with gastropathy 1(2%) in the SSG Hospital and Medical College, 11. Normal endoscopy 2(4%) Baroda, India. All patients were selected ran - domly.

Table 5. Diagnostic versus therapeutic endoscopy.

Table 1. Age distribution of patients. Procedure N. cases (%) Age (years) N. of patients Diagnostic endoscopy 39 78% (%) Therapeutic endotherapy 11 22% 21-30 15 30 Total 50 100% 31-40 12 24 41-50 10 20 51-60 10 20 Table 6. Immediate versus within 24 h of endoscopy. 61-70 12Procedure N. cases (%) 71-80 24Immediate 11 22% Total 50 100 Within 24 h 39 78% The youngest patient was of 22 years of age; the oldest patient was of 76 years old. Total 50 100%

[Clinics and Practice 2011; 1:e132] [page 293 ] Article

Age and sex distribution patients treated conservatively, 6 cases treated conservatively. All patients of varices Out of 50 cases, 37 were males and 13 were required laparotomy to control UGIB. Eight of treated with endotherapy showed a good females, which suggests a preponderance of 50 cases had past history of UGIB, 5 of whom response with no episode of recurrence of UGIB in males. It is common in the 20-60 year had a previous history of endotherapy. One bleeding. Follow-up endoscopy showed good age group and may be associated with alcohol case was treated with de-vascularization as results of endotherapy. Patients with active consumption and smoking. In female patients, routine hemostatic methods failed. So, initial bleeding from peptic ulcer, who were treated by UGIB was commonly associated with use of method of choice to control the bleeding was endotherapy, showed good response except in non-steroid anti-inflammatory drugs endotherapy and surgery was undertaken if an 2 cases who had a recurrence of bleeding. One (NSAIDs). Out of 13 female patients, 6 endoscopic method failed. of these was managed with one more session (46.15%) were taking NSAIDs. According to a A study by Gasim and Fedail et al. 9 in 2002 of endotherapy, while the other underwent study conducted by Saowaros V et al. ,6 the showed that endoscopic injection sclerothera - definitive surgical management because of male:female ratio was 3.3:1 and the majority of py is an essential component in the manage - high risk of developing recurrent bleeding. the patients belonged to the 20-60 year age ment of acute variceal bleeding. In a study by Considerable progress has been made in the group. Sugawa and Steffes in 1990 at the Wayne State endoscopic hemostatic methods nowadays and University, Detroit, of etiology, recurrence and endotherapy in the form of endovariceal liga - Symptoms prognosis of UGIB, it was found that out of 562 tion (EVL) is the procedure of choice. This has patients, conservative management was suffi - almost replaced sclerotherapy as a first line of Hematemesis was present in all patients cient in 89.5% cases, endotherapy in 144 cases, management of variceal bleeding. For endo - (100%) followed by abdominal pain (84%) and while surgery was required in 58 cases. It indi - scopic management of non-variceal bleeding, melena (28%). Fourteen percent of patients cated that most patients with UGIB can be non-erosive contact probes (heater probe and presented with abdominal distension due to treated with conservative treatment. These BICAP) and adrenalin injection or sclerothera - ascites. Miscellaneous symptoms such as results are consistent with the present study. py are preferred. weakness, loss of weight and chest pain were In our study, 4 cases who had undergone New techniques have been recently intro - present in 32% cases. One patient presented surgery in the past presented with recurrent duced to control acute non-variceal bleeding, with grade II that UGIB due to stomal ulceration. All patients e.g. fibrin glue and hemoclip application to vis - responded well to conservative management. were diagnosed by endoscopy and treated con - ible vessels. Treatment failure rate with glue UGIB was associated with alcohol consump - servatively. As seen in Table 4, the most com - was found to be less than that with injection; 11 tion in 20 cases, smoking in 14 cases, and mon cause of UGIB in the present study was another study found that endoclip or hemoclip NSAID use in 3 cases. Daily NSAID use caused acute erosive gastritis (34%), followed by por - to be superior to heater probe in preventing re- a 40-fold increase in gastric ulcer and an 8-fold tal hypertension (24%) and peptic ulcer (22%). bleeding. 12 increase in duodenal ulcer. 7 Twenty percent of A study by Saowarso et al. ,6 in a review of 5,000 Nowadays, there is very little doubt about the patients with long-term use develop cases for upper GI bleeding, peptic ulcer was the effectiveness of endoscopic hemostatic mucosal ulceration. 8 found to be the commonest cause (51.24%), methods. These are found to be very useful in The incidence of is followed by erosive gastritis (31.61%) and controlling primary active bleeding as well as declining but it remains the biggest cause of esophageal varices (8.2%). In another study in in reducing the re-bleeding rate and reducing UGIB (35-60%). In this study, acute erosive 1991, Makela et al. 10 found that peptic ulcer the need for emergency surgery. A meta analy - gastritis was the most common cause of UGIB (43%) was the commonest cause followed by sis by Cook et al. has indicated significant followed by portal hypertension and then pep - erosive gastritis (16%) and esophageal varices reduction in mortality with endotherapy. 13 tic ulcer. A disproportionately large number of (16%). However, these results differ from The worldwide mortality of UGIB has stabi - patients (40%) have a personal history of alco - those of the present study as the most common lized at 10% (5-12%) over the last 50 years. It holism and this may be the probable reason cause here was acute erosive gastritis. The is zero in this study. This is due to good man - why portal hypertension is the leading cause of probable reason for erosive gastritis being the agement and also because the biggest cause in UGIB as compared to peptic ulcer. most common cause of GI bleeding in this this study was acute erosive gastritis, which is study may be the overuse of NSAIDs, smoking associated with a better outcome. Examination and alcohol. But overall, from previous studies The main limitation of this study is the After initial resuscitation, patients were and our own, we can conclude that the major small sample size and we have not included investigated. According to these investiga - causes of UGIB are peptic ulcer, erosive gastri - Glasgow-Blatchford scoring on admission or tions, 16 patients were found to have moderate tis or portal hypertension with varices. the Forrest classification for endoscopic triage. to severe iron deficiency as a result of Four patients were found to have cancer This study does, however, show zero mortality either acute or chronic blood loss; blood trans - (esophageal n=2, gastric n=2). All these and that erosive gastritis is the commonest fusion was carried out in these cases due to patients were over 40 years of age. All patients cause. This is in contrast to Western literature hemodynamic instability. Altered liver function were followed for at least one year. All patients in which peptic ulcer is the most common test was observed in 8 cases. Hypoproteinemia were observed for persistence of symptoms, cause. was found in 3 cases. Altered liver function and recurrence of symptoms and appearance of hypoproteinemia were because of chronic newer symptoms. In this study, no complica - alcoholism leading to poor nutritional intake tion was observed with endoscopy including due to loss of appetite. Altered liver function endotherapy. One patient died of advanced Conclusions test was corrected with vitamin K. malignancy in the successive follow-up year. Endoscopy was found to be most useful The most common cause of upper GI bleed Endoscopy and treatments method of management of UGIB; it reduced in the present study is acute erosive gastritis All 50 patients underwent upper GI the risk of mortality and morbidity of surgery. and not peptic ulcer. From the present study, it endoscopy, of whom 39 patients were treated Upper GI endoscopy was also found to be a is clear that endoscopy has a definite role in conservatively and 11 patients underwent great help in the diagnosis of lesions such as the diagnosis as well as the therapeutic man - endotherapy to control bleeding. Out of 39 gastritis, reflux esophagitis, which can be agement of UGIB. It is minimally invasive and

[page 294 ] [Clinics and Practice 2011; 1:e132] Article the safest method of controlling the bleeding. 4. A.S.G.E. Standards of Practice Committee: Endoscopy sclerotherapy for bleeding By using endoscopic hemostatic methods it is The role of endoscopy in the management esophageal varices: experience in sudan. possible to avoid major surgery and the associ - of non-variceal acute upper gastrointesti - Trop Gastroenterol 2002;23:107-9. ated mortality and morbidity can be avoided. nal bleeding.guideline for clinical applica - 10. Makela J, Haukipuro K, Laitinen S, tion. Gastrointest Endosc 1992;38:760-4. Kairaluoma MI. Endoscopy for diagnosis of 5. Sarin SK, Lamba GS, Kumar M, et al. acute gastrointestinal bleeding. Scand J Comparisons of Endoscopic ligation and Gastroenterol 1991;26:1082-8. References propranolol for primary prevention of variceal bleeding. N Engl J Med 1999;340: 11. Lin HJ, Hseieh YH, Tseng GY, et al. 1. Cappell MS, Friedel D. Initial management 988-93. Endoscopic injection with fibrin sealant of acute upper gastrointestinal bleeding: 6. Saowaros V, Udaya Chalem W, Wee-sakul versus epinephrine in the arrest of peptic from initial evaluation up to gastrointesti - B, Tienpaitoon V. Causes of upper GI ulcer bleeding: a randomized,comparative nal endoscopy. Med Clin North Am bleeding in Thai patient: review of 5000 trial. J Clin Gastroenterol 2002;35:218-21. 2008;92:491-509. upper GI endoscopy. J Med Assoc Thai 12. Cipollete L, Bianco MA, Marmot R, et al. 2. Yavorski RT, Wong RK, Maydonovitch C, et 1994;77:561-5. Endoclips versus heater probe in prevent - al. Analysis of 3,294 cases of upper gas - 7. Corson JD, Williamson RCN, eds. Surgery. ing early recurrent bleeding from peptic London, UK: Mosby-Year Book; 2001. trointestinal bleeding in military medical ulcer: a prospective and randomized trial. facilities. Am J Gastroenterol 1995;90:568- 8. Pilotto A, Maggi S, Noale M, et al. Gastrointest Endosc 2001;53:147-51. 73. Development and validation of a new ques - 3. Wilcox CM, Alexander LN, Costonis G. A tionnaire for the evaluation of upper gas - 13. Cook DJ, Guyatt GH, Salena BJ, et al. prospective characterization of upper gas - trointestinal symptoms in the elderly pop - Endoscopic therapy for acute non-variceal trointestinal hemorrhage presenting with ulation: a multicenter study. J Gerontol A upper gastrointestinal haemorrhage: a hematochezia. Am J Gastroenterol Biol Sci Med Sci 2010;65:174-8. meta-analysis. 1992;102: 1997;92:231-5. 9. Gasim B, Fedail SS, Musaad AM, et al. 139-48.

[Clinics and Practice 2011; 1:e132] [page 295 ]