Nonvariceal Upper Gastrointestinal Bleeding

Abstract

Gastroduodenal ulcerations still account for the majority of nonvariceal gastrointestinal hemorrhage. The causative roles of Helicobacter pylori and nonsteroidal anti-inflammatory drugs (NSAIDs) are still being discussed, but the role of H. pylori appears less significant in the complicated ulcers, while NSAIDs are increasingly implicated. The two factors do not appear to potentiate each other, and some data suggest that H. pylori should not be eradicated in the context of an NSAID-related ulcer hemorrhage. The role of triage and risk assessment was highlighted in several of last year's publications, and increasing attention has been given to the cost aspects of peptic ulcer bleeding. There have been few comparative therapeutic trials, but several reports from Japan make a case for ethanol injection as an alternative to other injection agents. However, a randomized comparative trial is needed to further define the role of this technique. Radiological embolization techniques and minimally invasive surgery are increasingly becoming viable options in patients with complex cases, and a multidisciplinary approach is perhaps even more crucial today than ever before.

Nonvariceal upper gastrointestinal bleeding

“…Recent recommendations for medical and early endoscopic treatment show a 90% clinical success rate of controlling NUGB in many series [2][3][4][5]. Similarly, angiography shows an 80% clinical success rate of controlling bleeding (8% of the total) [3,10,[42][43][44]. Patients who fail both endoscopic and angiographic treatment would be potential candidates for surgical intervention.…”

“…Active bleeding is visualized in 40-60% of patients with NUGB, but treatment remains very successful with empiric therapy directed by clinical or radiographic findings. Angiographic interventions are successful at controlling bleeding detectable by angiography in 89-90% of cases, with an overall clinical success rate of 52-90% [10,29,44]. Less than 2% of patients with NUGB would fail both endoscopic and angiographic intervention.…”

“…Transcatheter embolization quickly became a safe and effective treatment for many cases of NUGB. These methods are associated with a control rate of initial bleeding of 89-98% and clinical success rates ranging from 52-90% with most reports showing clinical successes of 70-80% [10,44,54]. Carreira et al reported a large series over 10 years utilizing transcatheter embolization and showed a procedural success rate of 89% and clinical success rate of 80% [59].…”

“…These lesions are important because they are often difficult to recognize at endoscopy and often require four-quadrant coagulation therapy around the lesion for optimal control of bleeding. Dieulafoy's lesions account for more than 40% of missed lesions identified on re-endoscopy [10,11]. Eighty percent of Dieulafoy's lesions occur in the stomach and are less common in the duodenum (17%) [11].…”

Endoscopic Treatment of Gastrointestinal Bleedings

“…Multiple other non-endoscopic treatments of angiodysplasia were tested with variable results: hormonal medication, administration of octreotide, antiangiogenic agents used in oncology and (thalidomide, lenalidomide bevacizumab, etc. ), the management of acid aminocaproic [61][62][63]. Endoscopic treatment reduces the rebleeding and transfusion needs.…”