Overlooked Lesions at Emergency Endoscopy for Acute Nonvariceal Upper Gastrointestinal Bleeding

Abstract

In acute nonvariceal upper gastrointestinal bleeding, diagnostic failure is associated with higher morbidity and mortality. The data from this study emphasize the importance of good preparation before the procedure and adequate removal of blood during emergency endoscopy procedures.

Hemorrhagic stress ulceration in a case of appendicitis

“…Upper endoscopy is the best test to determine the location and nature of the bleeding lesion. However, diagnosti c failure o wing to limit ed vision by blood and clots and the location of the ulcer in the duodenal bulb is a known problem in emergent endoscopy for management of severe nonvariceal upp er gastrointestina l bleeding [12], as evidenced by visualization of only a gastric cardia clot on the first endoscopy in our patient. Diluted epinephrine injection followed by additional endoscopic treatment is the preferred treatm ent of hi gh-risk b leeding u lcers [13].…”

Predictive Factors for Endoscopic Visibility and Strategies for Pre-endoscopic Prokinetics Use in Patients with Upper Gastrointestinal Bleeding

“…However, use of a large-bore orogastric tube is difficult and uncomfortable for patients and is not recommended for routine use [17]. The standard small-bore NGT typically used for NGL is not likely to effectively clear clots from the stomach [10]. Randomized studies to investigate the efficacy of pre-endoscopic prokinetics in patients with UGIB after baseline small-bore NGL demonstrated that 45-56 % of patients still had inadequate gastric visualization in the placebo group [12,14].…”

“…Moreover, once a bleeding lesion has been identified, endoscopic therapeutic intervention can achieve acute hemostasis and prevent recurrent bleeding in most patients [8]. Optimal endoscopic visibility is a crucial prerequisite for UGIB patients receiving endoscopy; however, a substantial number of patients show inadequate endoscopic preparation due to residual blood and clots hampering proper endoscopic diagnosis and intervention [9][10][11]. With regard to this issue, prokinetic agents including erythromycin and metoclopramide have been tested to see whether these drugs improve endoscopic visibility by clearing the stomach of blood, clots, and food residue in several randomized trials in patients with UGIB [12][13][14][15].…”

Nonvariceal Upper Gastrointestinal Bleeding

“…These patients have a significantly higher rate of complications, rebleeding, need for surgery and mortality. 19 Bolus administration of intravenous erythromycin prior to endoscopy has been shown to clear the stomach of blood, increase the likelihood of successful haemostasis and reduce the need for subsequent interventions. 20,21 Most haemostatic techniques are equally effective when used alone, although doubt has been cast on the value of "stand alone" therapy with adrenaline injection.…”