Emergency endoscopy: A basis for therapeutic decisions in the treatment of severe gastroduodenal bleeding

Abstract

This prospective study compares 3 different consecutive treatment protocols of gastroduodenal hemorrhage. Three hundred sixty-one patients underwent emergency endoscopy as the basis for further treatment. Clinical and endoscopic findings, such as site and type of the bleeding source, bleeding activity and intensity, age, and concomitant diseases of the patient were scored between 0 and 6 points, the higher number indicating a higher risk. The mean values of the total score of the 7 risk factors were comparable in the 3 treatment protocols. In period I (n = 77), a total of 16 patients (20.8%) underwent emergency operations because of severe bleeding, 27 (35%) were operated on after cessation of the bleeding, and 34 (44.2%) were treated conservatively. The mortality was 16.9%. In period II (n = 116), patients with actively bleeding lesions (n = 38) underwent endoscopic sclerotherapy, with a primary rate of hemostasis in 95%. As a result, the rate of emergency surgery could be reduced to 12.9% and the mortality for the entire group was reduced to 9.5%. The problem in this protocol was the rate of recurrent bleeding after primary endoscopic hemostasis: 13/116 (11.2%). Eleven of the 13 rebleeders presented with a lesion either on the back wall of the duodenum or with a visible vessel. In period III (n = 168), a total of 83 patients (50%) underwent endoscopic injection therapy with a primary success in 93%. Sixteen patients (9.5%) with lesions of high rebleeding risk (duodenal ulcer on the posterior wall or visible vessel) were scheduled for urgent elective operation after volume resuscitation within 24 hours of emergency endoscopy (mortality, 6.3%).(ABSTRACT TRUNCATED AT 250 WORDS)

A Review on Treatment of Bleeding Peptic Ulcer: A Collaborative Task of Gastroenterologist and Surgeon

“…With rebleeding the success of endoscopic haemostatic treatment drops from 90% with the initial bleeding to 50% (16). Most of the ulcers that rebled were localized in the posterior duodenal bulb or high in the lesser curvature of the stomach (32,(64)(65)(66). The failure to achieve permanent haemostasis in these ulcers can be partly explained from technical problems in positioning the endoscope for optimal injection or thermal therapy in these regions (65,66).…”

Ulcer surgery – what remains?

“…Tab. 2; [20,33,38,41,42,43,46,55] ne konservative Therapie versucht werden kann [11,28]. Wird später als 12 h nach dem Eintritt und der Persistenz klinischer Symptome operiert, so verschlechtern sich die Resultate deutlich [10, 11,15,50,54].…”

Current perspectives in the management of non‐variceal upper gastrointestinal bleeding

“…Early elective surgery in patients considered to be at high risk after initial endoscopic hemostasis was shown by Pimpl et al to reduce the overall mortality rate from 11.2 to 7.1%. 42 A recent prospective randomized trial from a group in Hong Kong compared the outcome after endoscopic retreatment with that of surgery for patients who rebled after initial endoscopic hemostasis. 43 Of 92 patients with rebleeding after endoscopic hemostasis, 48 were randomized to receive endoscopic retreatment and 44 to surgery.…”