Predictors of Rebleeding and Mortality in Patients with High-Risk Bleeding Peptic Ulcers

Cheng, Ching‐Yi; Lin, Cheng Hui; Kuo, Chia Jung; Sung, Kai Feng; Lee, Ching Song; Liu, Nai Jen; Tang, Jui Hsiang; Ho, Cheng; Chu, Yin Yi; Tsou, Yung Kuan

doi:10.1007/s10620-009-1093-9

Cited by 21 publications

(16 citation statements)

References 26 publications

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“…We found that patients aged ≥70 years and hemoglobin <8.0 mg/dL were also independent risk factors for intractability to endoscopic hemostasis. These findings are broadly compatible with those of three other studies 16,17,18. Previous evaluations of risk factors among patients with nonvariceal UGI bleeding, by using multivariate analysis, included age >65 years16 and low initial hemoglobin values among the clinical predictors of increased risk for persistent or recurrent bleeding 17,18.…”

Section: Discussionsupporting

confidence: 89%

“…These findings are broadly compatible with those of three other studies 16,17,18. Previous evaluations of risk factors among patients with nonvariceal UGI bleeding, by using multivariate analysis, included age >65 years16 and low initial hemoglobin values among the clinical predictors of increased risk for persistent or recurrent bleeding 17,18. Many patients are administered with LDA as an antithrombotic therapy for the secondary prevention of cerebral and/or myocardial vascular events.…”

Section: Discussionsupporting

confidence: 86%

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Predictive Factors for Intractability to Endoscopic Hemostasis in the Treatment of Bleeding Gastroduodenal Peptic Ulcers in Japanese Patients

et al. 2014

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Background/AimsDespite improvements in endoscopic hemostasis and pharmacological therapies, upper gastrointestinal (UGI) ulcers repeatedly bleed in 10% to 20% of patients, and those without early endoscopic reintervention or definitive surgery might be at a high risk for mortality. This study aimed to identify the risk factors for intractability to initial endoscopic hemostasis.MethodsWe analyzed intractability among 428 patients who underwent emergency endoscopy for bleeding UGI ulcers within 24 hours of arrival at the hospital.ResultsDurable hemostasis was achieved in 354 patients by using initial endoscopic procedures. Sixty-nine patients with Forrest types Ia, Ib, IIa, and IIb at the second-look endoscopy were considered intractable to the initial endoscopic hemostasis. Multivariate analysis indicated that age ≥70 years (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.07 to 4.03), shock on admission (OR, 5.26; 95% CI, 2.43 to 11.6), hemoglobin <8.0 mg/dL (OR, 2.80; 95% CI, 1.39 to 5.91), serum albumin <3.3 g/dL (OR, 2.23; 95% CI, 1.07 to 4.89), exposed vessels with a diameter of ≥2 mm on the bottom of ulcers (OR, 4.38; 95% CI, 1.25 to 7.01), and Forrest type Ia and Ib (OR, 2.21; 95% CI, 1.33 to 3.00) predicted intractable endoscopic hemostasis.ConclusionsVarious factors contribute to intractable endoscopic hemostasis. Careful observation after endoscopic hemostasis is important for patients at a high risk for incomplete hemostasis.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionsupporting

confidence: 86%

Predictive Factors for Intractability to Endoscopic Hemostasis in the Treatment of Bleeding Gastroduodenal Peptic Ulcers in Japanese Patients

et al. 2014

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“…Risk factors for early rebleeding include unstable hemodynamic status, severe anemia (Hb <8 g/dL), active bleeding (Forrest Ia/Ib), large‐sized ulcer >2 cm, hematemesis, and exposed blood vessels >2 mm in diameter. Patients with a white, protruded and peripheral non‐bleeding visible vessel (Forrest IIA) also have a high risk of rebleeding . From the above, second‐look endoscopy should be carried out in patients with a high risk of rebleeding when PPI therapy is given after initial hemostasis (evidence level IVb, recommendation C1).…”

Section: Management Of Patients With Acute Peptic Gastroduodenal Ulcementioning

confidence: 99%

Guidelines for endoscopic management of non‐variceal upper gastrointestinal bleeding

Fujishiro

Iguchi

Kakushima

et al. 2016

Digestive Endoscopy

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Japan Gastroenterological Endoscopy Society (JGES) has compiled a set of guidelines for endoscopic management of non‐variceal upper gastrointestinal bleeding using evidence‐based methods. The major cause of non‐variceal upper gastrointestinal bleeding is peptic gastroduodenal ulcer bleeding. As a result, these guidelines mainly focus on peptic gastroduodenal ulcer bleeding, although bleeding from other causes is also overviewed. From the epidemiological aspect, in recent years in Japan, bleeding from drug‐related ulcers has become predominant in comparison with bleeding from Helicobacter pylori (HP)‐related ulcers, owing to an increase in the aging population and coverage of HP eradication therapy by national health insurance. As for treatment, endoscopic hemostasis, in which there are a variety of methods, is considered to be the first‐line treatment for bleeding from almost all causes. It is very important to precisely evaluate the severity of the patient's condition and stabilize the patient's vital signs with intensive care for successful endoscopic hemostasis. Additionally, use of antisecretory agents is recommended to prevent rebleeding after endoscopic hemostasis, especially for gastroduodenal ulcer bleeding. Eighteen statements with evidence and recommendation levels have been made by the JGES committee of these guidelines according to evidence obtained from clinical research studies. However, some of the statements that are supported by a low level of evidence must be confirmed by further clinical research.

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“…The second reason is more germane to this issue: the risk of rebleeding is high enough to warrant the repeat endoscopy. Risk factors for rebleeding include a large initial bleeding episode as evidenced by shock or hypotension at baseline, a large ulcer (2 cm or larger), comorbid disease, fresh blood in the stomach, active bleeding at the time of index endoscopy, and ulcers on the high lesser curve or posterior wall of the duodenal bulb, 16, 24 which are locations where therapeutic endoscopy may be technically challenging.…”

Section: Discussionmentioning

confidence: 99%

Second-look Endoscopy for Bleeding Peptic Ulcer Disease

Imperiale

Kong

2012

Journal of Clinical Gastroenterology

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BACKGROUND Second-look endoscopy after initial therapeutic endoscopy for bleeding peptic ulcer disease (PUD) may decrease the risk of rebleeding; however, it is not recommended routinely. Understanding conditions under which second-look endoscopy is beneficial might be useful for clinical decision making. METHODS Using a decision model, literature-based probabilities, and Medicare reimbursement costs, we compared routine second-look endoscopy to no second-look endoscopy. We measured rebleeding, need for surgery, hospital mortality, and costs, and calculated the cost to avoid each outcome, expressed as the number needed to treat (NNT), along with the cost per outcome prevented. RESULTS In the base case, routine second-look endoscopy reduced rebleeding from 16% to 10% (NNT=16) but had no effect on other outcomes. The cost to prevent one case of rebleeding was nearly $13,000. Threshold analysis revealed a rebleeding threshold of 31% to neutralize the cost difference between routine second-look endoscopy and no routine second-look endoscopy. If routine second-look endoscopy were 100% effective in preventing rebleeding, then the rebleeding threshold for cost neutrality would be 17.5%. When rebleeding risks after the index endoscopy and second-look endoscopy were simultaneously considered, the cost per bleed prevented ranged from a cost savings of $165 when the respective risks were 25% and 5%, to a cost of nearly $33,000 when the risks were 20% and 15%. CONCLUSION The results suggest that routine second-look endoscopy is not indicated following therapeutic endoscopy for bleeding PUD. However, if rebleeding risk is 31% or greater, then routine second-look endoscopy reduces this risk at no additional cost.

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Predictors of Rebleeding and Mortality in Patients with High-Risk Bleeding Peptic Ulcers

Abstract: The study emphasizes the role of ulcer size, anemia and in-hospital bleeding as the determining high-risk predictors for adverse outcomes for bleeding peptic ulcers.

Cited by 21 publications

References 26 publications

Predictive Factors for Intractability to Endoscopic Hemostasis in the Treatment of Bleeding Gastroduodenal Peptic Ulcers in Japanese Patients

Predictive Factors for Intractability to Endoscopic Hemostasis in the Treatment of Bleeding Gastroduodenal Peptic Ulcers in Japanese Patients

Guidelines for endoscopic management of non‐variceal upper gastrointestinal bleeding

Second-look Endoscopy for Bleeding Peptic Ulcer Disease

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