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Original Article

Efficacy of hemostasis by gastroduodenal covered metal stent placement for hemorrhagic duodenal stenosis due to pancreatobiliary cancer invasion: a retrospective study: Yasunari Sakamoto, Taku Sakamoto, Akihiro Ohba, Mitsuhito Sasaki, Shunsuke Kondo, Chigusa Morizane, Hideki Ueno, Yutaka Saito, Yasuaki Arai, Takuji Okusaka; Clin Endosc 2024;57(5):628-636. Published online June 14, 2024; DOI: https://doi.org/10.5946/ce.2023.155

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Background
/Aims: Advanced pancreatic and biliary tract cancers can invade the duodenum and cause duodenal hemorrhagic stenosis. This study aimed to evaluate the efficacy of covered self-expandable metal stents in the treatment of cancer-related duodenal hemorrhage with stenosis.
Methods
Between January 2014 and December 2016, metal stents were placed in 51 patients with duodenal stenosis. Among these patients, a self-expandable covered metal stent was endoscopically placed in 10 patients with hemorrhagic duodenal stenosis caused by pancreatobiliary cancer progression. We retrospectively analyzed the therapeutic efficacy of the stents by evaluating the technical and clinical success rates based on successful stent placement, degree of oral intake, hemostasis, stent patency, and overall survival.
Results
The technical and clinical success rates were 100%. All 10 patients achieved a gastric outlet obstruction scoring system score of three within two weeks after the procedure and had no recurrence of melena. The median stent patency duration and overall survival after stent placement were 52 days (range, 20–220 days) and 66.5 days (range, 31–220 days), respectively.
Conclusions
Endoscopic placement of a covered metal stent for hemorrhagic duodenal stenosis associated with pancreatic or biliary tract cancer resulted in duodenal hemostasis, recanalization, and improved quality of life.

Citations

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Clinical significance of peritoneal lavage cytology in duodenal cancer
Yuya Miura, Katsuhisa Ohgi, Ryo Ashida, Yoshiyasu Kato, Shimpei Otsuka, Hideyuki Dei, Katsuhiko Uesaka, Teiichi Sugiura
Surgery.2025; 181: 109256. CrossRef
Clinical effect of percutaneous hepatic puncture biliary drainage combined with metal stent implantation in the treatment of malignant obstructive jaundice
Shoulin Zhang, Shaopeng Huang, Zheng Xing, Youwen Song, Fujian Yuan
BMC Surgery.2025;[Epub] CrossRef

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Review

The role of cap-assisted endoscopy and its future implications: Sol Kim, Bo-In Lee; Clin Endosc 2024;57(3):293-301. Published online February 7, 2024; DOI: https://doi.org/10.5946/ce.2023.051

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Cap-assisted endoscopy refers to a procedure in which a short tube made of a polymer (mostly transparent) is attached to the distal tip of the endoscope to enhance its diagnostic and therapeutic capabilities. It is reported to be particularly useful in: (1) minimizing blind spots during screening colonoscopy, (2) providing a constant distance from a lesion for clear visualization during magnifying endoscopy, (3) accurately assessing the size of various gastrointestinal lesions, (4) preventing mucosal injury during foreign body removal, (5) securing adequate workspace in the submucosal space during endoscopic submucosal dissection or third space endoscopy, (6) providing an optimal approach angle to a target, and (7) suctioning mucosal and submucosal tissue with negative pressure for resection or approximation. Here, we review various applications of attachable caps in diagnostic and therapeutic endoscopy and their future implications.

Citations

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Transparent cap scope tamponade: an inexpensive, efficient, and underappreciated maneuver for bleeding visualization and hemostasis
Brandon Rodgers, Swapnil Patel, Matthew T. Moyer
VideoGIE.2025;[Epub] CrossRef
A retrospective single-center study of transnasal ileus tube insertion accompanied with cap-assisted endoscopic advancement for malignant adhesive bowel obstruction
Su-Yu Chen, Rui Huang, Yu Zhang, Zhao-Fei Xie, He Huang, Hong Shi
Scientific Reports.2024;[Epub] CrossRef

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Original Article

Diode Laser—Can It Replace the Electrical Current Used in Endoscopic Submucosal Dissection?: Yunho Jung, Gwang Ho Baik, Weon Jin Ko, Bong Min Ko, Seong Hwan Kim, Jin Seok Jang, Jae-Young Jang, Wan-Sik Lee, Young Kwan Cho, Sun Gyo Lim, Hee Seok Moon, In Kyung Yoo, Joo Young Cho; Clin Endosc 2021;54(4):555-562. Published online January 13, 2021; DOI: https://doi.org/10.5946/ce.2020.229

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Background
/Aims: A new medical fiber-guided diode laser system (FDLS) is expected to offer high-precision cutting with simultaneous hemostasis. Thus, this study aimed to evaluate the feasibility of using the 1,940-nm FDLS to perform endoscopic submucosal dissection (ESD) in the gastrointestinal tract of an animal model.
Methods
In this prospective animal pilot study, gastric and colorectal ESD using the FDLS was performed in ex vivo and in vivo porcine models. The completeness of en bloc resection, the procedure time, intraprocedural bleeding, histological injuries to the muscularis propria (MP) layer, and perforation were assessed.
Results
The en bloc resection and perforation rates in the ex vivo study were 100% (10/10) and 10% (1/10), respectively; those in the in vivo study were 100% (4/4) and 0% for gastric ESD and 100% (4/4) and 25% (1/4) for rectal ESD, respectively. Deep MP layer injuries tended to occur more frequently in the rectal than in the gastric ESD cases, and no intraprocedural bleeding occurred in either group.
Conclusions
The 1,940-nm FDLS was capable of yielding high en bloc resection rates without intraprocedural bleeding during gastric and colorectal ESD in animal models.

Citations

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Use of Diode Laser in Hysteroscopy for the Management of Intrauterine Pathology: A Systematic Review
Andrea Etrusco, Giovanni Buzzaccarini, Antonio Simone Laganà, Vito Chiantera, Salvatore Giovanni Vitale, Stefano Angioni, Maurizio Nicola D’Alterio, Luigi Nappi, Felice Sorrentino, Amerigo Vitagliano, Tommaso Difonzo, Gaetano Riemma, Liliana Mereu, Alessa
Diagnostics.2024; 14(3): 327. CrossRef
Recent advances in endoscopic management of gastric neoplasms
Hira Imad Cheema, Benjamin Tharian, Sumant Inamdar, Mauricio Garcia-Saenz-de-Sicilia, Cem Cengiz
World Journal of Gastrointestinal Endoscopy.2023; 15(5): 319. CrossRef
Safety and efficacy of dual emission endoscopic laser treatment in patients with upper or lower gastrointestinal vascular lesions causing chronic anemia: results from the first multicenter cohort study
Gian Eugenio Tontini, Lorenzo Dioscoridi, Alessandro Rimondi, Paolo Cantù, Flaminia Cavallaro, Aurora Giannetti, Luca Elli, Luca Pastorelli, Francesco Pugliese, Massimiliano Mutignani, Maurizio Vecchi
Endoscopy International Open.2022; 10(04): E386. CrossRef

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Case Report

Practical Experiences of Unsuccessful Hemostasis with Covered Self-Expandable Metal Stent Placement for Post-Endoscopic Sphincterotomy Bleeding: Michihiro Yoshida, Tadahisa Inoue, Itaru Naitoh, Kazuki Hayashi, Yasuki Hori, Makoto Natsume, Naoki Atsuta, Hiromi Kataoka; Clin Endosc 2022;55(1):150-155. Published online November 19, 2020; DOI: https://doi.org/10.5946/ce.2020.217

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We reviewed 7 patients with unsuccessful endoscopic hemostasis using covered self-expandable metal stent (CSEMS) placement for post-endoscopic sphincterotomy (ES) bleeding. ES with a medium incision was performed in 6 and with a large incision in 1 patient. All but 1 of them (86%) showed delayed bleeding, warranting second endoscopic therapies followed by CSEMS placement 1–5 days after the initial ES. Subsequent CSEMS placement did not achieve complete hemostasis in any of the patients. Lateral-side incision lines (3 or 9 o’clock) had more frequent bleeding points (71%) than oral-side incision lines (11–12 o’clock; 29%). Additional endoscopic hemostatic procedures with hemostatic forceps, hypertonic saline epinephrine, or hemoclip achieved excellent hemostasis, resulting in complete hemostasis in all patients. These experiences provide an alert: CSEMS placement is not an ultimate treatment for post-ES bleeding, despite its effectiveness. The lateral-side of the incision line, as well as the oral-most side, should be carefully examined for bleeding points, even after the CSEMS placement.

Citations

Citations to this article as recorded by

Application of a New Hemostatic Clip to Prevent Delayed Bleeding After Endoscopic Sphincterotomy
Jinpei Dong, Qiushi Feng, Guigen Teng, Haixia Niu, Dapeng Bian
Journal of Clinical Gastroenterology.2024; 58(6): 614. CrossRef
Effectiveness and safety of a new clip for delivery using a duodenoscope for bleeding after endoscopic sphincterotomy
Atsushi Yamaguchi, Hiroki Kamada, Shigeaki Semba, Naohiro Kato, Yasuhiro Okuda, Yuji Teraoka, Takeshi Mizumoto, Yuzuru Tamaru, Tsuyoshi Hatakeyama, Hirotaka Kouno, Shigeto Yoshida
Endoscopy International Open.2024; 12(10): E1190. CrossRef
Multiple drugs

Reactions Weekly.2022; 1907(1): 314. CrossRef

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Original Article

Clinical Usefulness of Dual Red Imaging in Gastric Endoscopic Submucosal Dissection: A Pilot Study: Naoki Yorita, Shiro Oka, Shinji Tanaka, Takahiro Kotachi, Naoko Nagasaki, Kosaku Hata, Kazutaka Kuroki, Kazuhiko Masuda, Mio Kurihara, Mariko Kiso, Tomoyuki Boda, Masanori Ito, Kazuaki Chayama; Clin Endosc 2020;53(1):54-59. Published online September 3, 2019; DOI: https://doi.org/10.5946/ce.2019.065

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Background
/Aims: Dual red imaging (DRI) is a new, image-enhanced endoscopy technique. There are few reports about the usefulness of DRI during gastric endoscopic submucosal dissection (ESD). We aimed to examine the usefulness of DRI in endoscopic hemostasis during gastric ESD.
Methods
We enrolled a total of 20 consecutive patients who underwent gastric ESD. Five endoscopists compared DRI with white light imaging (WLI) for the visibility of blood vessels and bleeding points while performing endoscopic hemostasis.
Results
The visibility of blood vessels was increased in 56% (19/34) of the cases, and the visibility of bleeding points was improved in 55% (11/20) of the cases with the use of DRI compared with the use of WLI.
Conclusions
DRI improved the visibility of blood vessels and bleeding points in cases with oozing bleeding, blood pooling around the bleeding points, and multiple bleeding points.

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Meng-Huang Wu, Jason C. Hsu, Jin-Sung Kim, Tsung-Jen Huang, Yi-Hung Huang, Hon Pan Yiu, Ching-Yu Lee, Jowy Tani, Cheng-Chun Chang
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Red dichromatic imaging reduces endoscopic treatment time of esophageal varices by increasing bleeding point visibility (with video)
Yoshihiro Furuichi, Masakazu Abe, Hirohito Takeuchi, Yuu Yoshimasu, Takao Itoi
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Clinical usefulness of red dichromatic imaging in hemostatic treatment during endoscopic submucosal dissection: First report from a multicenter, open‐label, randomized controlled trial
Ai Fujimoto, Yutaka Saito, Seiichiro Abe, Syu Hoteya, Kosuke Nomura, Hiroshi Yasuda, Yasumasa Matsuo, Toshio Uraoka, Shiko Kuribayashi, Yosuke Tsuji, Daisuke Ohki, Tadateru Maehata, Motohiko Kato, Naohisa Yahagi
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Evaluation of the visibility of bleeding points using red dichromatic imaging in endoscopic hemostasis for acute GI bleeding (with video)
Yuichiro Hirai, Ai Fujimoto, Naomi Matsutani, Soichiro Murakami, Yuki Nakajima, Ryoichi Miyanaga, Yoshihiro Nakazato, Kazuyo Watanabe, Masahiro Kikuchi, Naohisa Yahagi
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Utility of red dichromatic imaging for identifying the bleeding point in endoscopic hemostasis of colonic diverticular bleeding
Soma Fukuda, Taku Sakamoto, Hideo Suzuki, Toshiaki Narasaka, Kiichiro Tsuchiya
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Red dichromatic imaging reduces bleeding and hematoma during submucosal injection in esophageal endoscopic submucosal dissection
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Endoscopic treatment for early gastric cancer
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Novel image enhancement technology that helps find bleeding points during endoscopic submucosal dissection of gastric neoplasms
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Feasibility of red dichromatic imaging in hemostasis for postendoscopic sphincterotomy bleeding
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Endoscopic submucosal dissection of early-stage rectal cancer using full-time red dichromatic imaging to minimize and avoid significant bleeding
Aoi Kita, Hirohito Tanaka, Hemchand Ramberan, Shiko Kuribayashi, Toshio Uraoka
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The Role of Dual Red Imaging in Gastric Endoscopic Submucosal Dissection
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Focused Review Series: Endoscopic Hemostasis: An Overviews of Principles and Recent Applications

Endoscopic Therapy for Acute Diverticular Bleeding: Masayuki Kato; Clin Endosc 2019;52(5):419-425. Published online August 20, 2019; DOI: https://doi.org/10.5946/ce.2019.078

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Diverticular bleeding accounts for approximately 26%–40% of the cases of lower gastrointestinal bleeding. Rupture of the vasa recta at the neck or dome of the diverticula can be the cause of this bleeding. Colonoscopy aids in not only the diagnosis but also the treatment of diverticular bleeding after a steady bowel preparation. Endoscopic hemostasis involves several methods, such as injection/thermal contact therapy, clipping, endoscopic band ligation (EBL), hemostatic powder, and over-the-scope clips. Each endoscopic method can provide a secure initial hemostasis. With regard to the clinical outcomes after an endoscopic treatment, the methods reportedly have no significant differences in the initial hemostasis and early recurring bleeding; however, EBL might prevent the need for transcatheter arterial embolization or surgery. In contrast, the long-term outcomes of the endoscopic treatments, such as a late bleeding and recurrent bleeding at 1 and 2 years, are not well known for diverticular bleeding. With regard to a cure for diverticular bleeding, there should be an improvement in both the endoscopic methods and the multilateral perspectives, such as diet, medicines, interventional approaches, and surgery.

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A Review of Colonoscopy in Intestinal Diseases
Seung Hong, Dong Baek
Diagnostics.2023; 13(7): 1262. CrossRef
Short Peptide Nanofiber Biomaterials Ameliorate Local Hemostatic Capacity of Surgical Materials and Intraoperative Hemostatic Applications in Clinics
Zehong Yang, Lihong Chen, Ji Liu, Hua Zhuang, Wei Lin, Changlong Li, Xiaojun Zhao
Advanced Materials.2023;[Epub] CrossRef
A new band ligation device to treat colonic diverticular bleeding
Yunho Jung
Clinical Endoscopy.2022; 55(3): 367. CrossRef
Diagnosis and Treatment of Colonic Diverticular Disease
You Sun Kim
The Korean Journal of Gastroenterology.2022; 79(6): 233. CrossRef
Efficacy of Combination Therapy with Epinephrine Local Injection and Hemostatic Clips on Active Diverticular Bleeding
Seiji Hamada, Akira Teramoto, Ryuta Zukeyama, Shinobu Matsukawa, Tomofumi Fukuhara, Ryo Takaki, Takahiro Utsumi, Masamoto Nakamura, Kasen Kobashikawa, Nobufumi Uchima, Tomokuni Nakayoshi, Fukunori Kinjo
Journal of Clinical Medicine.2022; 11(17): 5195. CrossRef
Diverticular Bleeding: A Clinical Image
Christopher F Brewer, Yayha Al Abed
Cureus.2021;[Epub] CrossRef

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Endoscopic Hemostasis for Non-Variceal Upper Gastrointestinal Bleeding: New Frontiers: Adam Kichler, Sunguk Jang; Clin Endosc 2019;52(5):401-406. Published online July 16, 2019; DOI: https://doi.org/10.5946/ce.2018.103

Abstract PDF PubReader ePub

Non-variceal upper gastrointestinal bleeding (NVUGIB) refers to blood loss from the gastrointestinal tract proximal to the ligament of Treitz due to lesions that are non-variceal in origin. The distinction of the bleeding source as non-variceal is important in numerous aspects, but none more so than endoscopic approaches for successful hemostasis. When a patient presents with acute overt blood loss, NVUGIB is a medical emergency, which requires immediate intervention. There have been major strides in pharmacologic and endoscopic interventions for successful induction and remission of hemostasis in the last two decades. Despite achieving tangible improvements, the burden of the disease and the consequent mortality remain high. To address endoscopic outcomes better, several new technologies have emerged and have been subsequently incorporated to the armamentarium of hemostatic tools. This study aims to provide a succinct review on novel technologies for endoscopic hemostasis.

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Novel hemostatic gel and powder as rescue agents for arterial bleeding related to lumen-apposing metal stent placement
Butros Fakhoury, Mohanad Awadalla, Michael Talanian, Tanya Zeina, Erika Tsuchiyose, Nikola Natov, Erik Holzwanger
Endoscopy.2025; 57(S 01): E58. CrossRef
Utility of endoscopy in paediatric gastroenterology and hepatology–Review and updates
Mohana Sathiaseelan, Tassos Grammatikopoulos
Digestive and Liver Disease.2025;[Epub] CrossRef
Clinical characteristics of acute non-varicose upper gastrointestinal bleeding and the effect of endoscopic hemostasis
Xiao-Juan Wang, Yu-Peng Shi, Li Wang, Ya-Ni Li, Li-Juan Xu, Yue Zhang, Shuang Han
World Journal of Clinical Cases.2024; 12(9): 1597. CrossRef
MODERN TRENDS IN ENDOSCOPIC HEMOSTASIS IN PATIENTS WITH EROSIVE-ULCERATIVE GASTROINTESTINAL BLEEDING WITH PREROGATIVE USE OF ARGON PLASMA COAGULATION AND TAKING INTO ACCOUNT THE SPECIAL CONDITIONS OF THE ENDOSCOPY DEPARTMENT IN WARTIME
V. V. Boiko, V. H. Hroma, I. A. Taraban, Y. V. Hroma
Kharkiv Surgical School.2024; (1): 62. CrossRef
Neutrophil-lymphocyte ratio predict outcome of upper gastrointestinal bleeding in emergency
Xinyi Chen, Xinqun Li, Guangju Zhao, Wen Xu
Frontiers in Medicine.2024;[Epub] CrossRef
Progress in Diagnosis and Treatment of Acute Upper Gastrointestinal Bleeding
泗云李
Advances in Clinical Medicine.2024; 14(08): 1674. CrossRef
Endoscopic Hemostasis and Antithrombotic Management
Jamie Bering, Mashal J. Batheja, Neena S. Abraham
Gastroenterology Clinics of North America.2024; 53(4): 573. CrossRef
UI-EWD hemostatic powder in the management of refractory lower gastrointestinal bleeding: a multicenter study
Gyeol Seong, Boram Cha, Jongbeom Shin, Sung Min Kong, Ji Taek Hong, Kye Sook Kwon
Scandinavian Journal of Gastroenterology.2024; 59(10): 1172. CrossRef
Short Peptide Nanofiber Biomaterials Ameliorate Local Hemostatic Capacity of Surgical Materials and Intraoperative Hemostatic Applications in Clinics
Zehong Yang, Lihong Chen, Ji Liu, Hua Zhuang, Wei Lin, Changlong Li, Xiaojun Zhao
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Accessory Splenic Artery Causing Massive Gastrointestinal Bleed
Priyesh Patel, Pravallika Chadalavada, Amandeep Singh, Ram Kishore Gurajala, Jean-Paul Achkar
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Diode Laser—Can It Replace the Electrical Current Used in Endoscopic Submucosal Dissection? (with Video)
Yunho Jung, Gwang Ho Baik, Weon Jin Ko, Bong Min Ko, Seong Hwan Kim, Jin Seok Jang, Jae-Young Jang, Wan-Sik Lee, Young Kwan Cho, Sun Gyo Lim, Hee Seok Moon, In Kyung Yoo, Joo Young Cho
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Endoscopic Ultrasound-Guided Treatments for Non-Variceal Upper GI Bleeding: A Review of the Literature
Claudio Giovanni De Angelis, Pablo Cortegoso Valdivia, Stefano Rizza, Ludovica Venezia, Felice Rizzi, Marcantonio Gesualdo, Giorgio Maria Saracco, Rinaldo Pellicano
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Original Article

Endoscopy Timing in Patients with Acute Upper Gastrointestinal Bleeding: Gonçalo Alexandrino, Tiago Dias Domingues, Rita Carvalho, Mariana Nuno Costa, Luís Carvalho Lourenço, Jorge Reis; Clin Endosc 2019;52(1):47-52. Published online October 5, 2018; DOI: https://doi.org/10.5946/ce.2018.093

Abstract PDF PubReader ePub

Background
/Aims: The role of very early (≤12 hours) endoscopy in nonvariceal upper gastrointestinal bleeding is controversial. We aimed to compare results of very early and early (12–24 hours) endoscopy in patients with upper gastrointestinal bleeding demonstrating low-risk versus high-risk features and nonvariceal versus variceal bleeding.
Methods
This retrospective study included patients with nonvariceal and variceal upper gastrointestinal bleeding. The primary outcome was a composite of inpatient death, rebleeding, or need for surgery or intensive care unit admission. Endoscopy timing was defined as very early and early. We performed the analysis in two subgroups: (1) high-risk vs. low-risk patients and (2) variceal vs. nonvariceal bleeding.
Results
A total of 102 patients were included, of whom 59.8% underwent urgent endoscopy. Patients who underwent very early endoscopy received endoscopic therapy more frequently (p=0.001), but there was no improvement in other clinical outcomes. Furthermore, patients at low risk and with nonvariceal bleeding who underwent very early endoscopy had a higher risk of the composite outcome.
Conclusions
Very early endoscopy does not seem to be associated with improved clinical outcomes and may lead to poorer outcomes in specific populations with upper gastrointestinal bleeding. The actual benefit of very early endoscopy remains controversial and should be further clarified.

Citations

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Impact of duration to endoscopy in patients with non-variceal upper gastrointestinal bleeding: propensity score matching analysis of real-world data from Thailand
Arunchai Chang, Natthawat Sitthinamsuwan, Nuttanit Pungpipattrakul, Kittiphan Chienwichai, Keerati Akarapatima, Sorawat Sangkaew, Manus Rugivarodom, Attapon Rattanasupar, Bancha Ovartlarnporn, Varayu Prachayakul
BMC Gastroenterology.2025;[Epub] CrossRef
Acute Nonvariceal Upper Gastrointestinal Bleeding in Patients Using Anticoagulants: Does the Timing of Endoscopy Affect Outcomes?
Tiago Lima Capela, Vítor Macedo Silva, Marta Freitas, Tiago Cúrdia Gonçalves, José Cotter
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Reviews

Recent Developments in the Endoscopic Treatment of Patients with Peptic Ulcer Bleeding: Jae-Young Jang; Clin Endosc 2016;49(5):417-420. Published online September 30, 2016; DOI: https://doi.org/10.5946/ce.2016.135

Abstract PDF PubReader ePub

Peptic ulcer bleeding is an internal medical emergency. Endoscopic hemostasis has been shown to improve the survival rate of patients with peptic ulcer bleeding. Although the established hemostatic modalities, including injection, thermal therapy, and mechanical therapy, are effective in controlling peptic ulcer bleeding, hemostasis can be difficult to achieve in some cases. As a result, recent, new endoscopic hemostatic modalities, including over-the-scope clips, topical hemostatic sprays, and endoscopic ultrasonography-guided angiotherapy, have been developed.

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Novel Therapeutic Strategies in the Management of Non-Variceal Upper Gastrointestinal Bleeding: Ari Garber, Sunguk Jang; Clin Endosc 2016;49(5):421-424. Published online September 30, 2016; DOI: https://doi.org/10.5946/ce.2016.110

Abstract PDF PubReader ePub

Non-variceal upper gastrointestinal bleeding, the most common etiology of which is peptic ulcer disease, remains a persistent challenge despite a reduction in both its incidence and mortality. Both pharmacologic and endoscopic techniques have been developed to achieve hemostasis, with varying degrees of success. Among the pharmacologic therapies, proton pump inhibitors remain the mainstay of treatment, as they reduce the risk of rebleeding and requirement for recurrent endoscopic evaluation. Tranexamic acid, a derivative of the amino acid lysine, is an antifibrinolytic agent whose role requires further investigation before application. Endoscopically delivered pharmacotherapy, including Hemospray (Cook Medical), EndoClot (EndoClot Plus Inc.), and Ankaferd Blood Stopper (Ankaferd Health Products), in addition to standard epinephrine, show promise in this regard, although their mechanisms of action require further investigation. Non-pharmacologic endoscopic techniques use one of the following two methods to achieve hemostasis: ablation or mechanical tamponade, which may involve using endoscopic clips, cautery, argon plasma coagulation, over-the-scope clipping devices, radiofrequency ablation, and cryotherapy. This review aimed to highlight these novel and fundamental hemostatic strategies and the research supporting their efficacy.

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Original Articles

Usefulness of the Forrest Classification to Predict Artificial Ulcer Rebleeding during Second-Look Endoscopy after Endoscopic Submucosal Dissection: Duk Su Kim, Yunho Jung, Ho Sung Rhee, Su Jin Lee, Yeong Geol Jo, Jong Hwa Kim, Jae Man Park, Il-Kwun Chung, Young Sin Cho, Tae Hoon Lee, Sang-Heum Park, Sun-Joo Kim; Clin Endosc 2016;49(3):273-281. Published online March 4, 2016; DOI: https://doi.org/10.5946/ce.2015.086

Abstract PDF PubReader ePub

Background
/Aims: Delayed post-endoscopic submucosal dissection (ESD) bleeding (DPEB) is difficult to predict and there is controversy regarding the usefulness of prophylactic hemostasis during second-look endoscopy. This study evaluated the risk factors related to DPEB, the relationship between clinical outcomes and the Forrest classification, and the results of prophylactic hemostasis during second-look endoscopy.
Methods
Second-look endoscopy was performed on the day after ESD to check for recent hemorrhage or potential bleeding and the presence of artificial ulcers in all patients.
Results
DPEB occurred in 42 of 581 patients (7.2%). Multivariate analysis determined that a specimen size ≥40 mm (odds ratio [OR], 3.03; p=0.003), and a high-risk Forrest classification (Forrest Ib+IIa+IIb; OR, 6.88; p<0.001) were risk factors for DPEB. DPEB was significantly more likely in patients classified with Forrest Ib (OR, 24.35; p<0.001), IIa (OR, 12.91; p<0.001), or IIb (OR, 8.31; p<0.001) ulcers compared with Forrest III ulcers. There was no statistically significant difference between the prophylactic hemostasis and non-hemostasis groups (Forrest Ib, p=0.938; IIa, p=0.438; IIb, p=0.397; IIc, p=0.773) during second-look endoscopy.
Conclusions
The Forrest classification of artificial gastric ulcers during second-look endoscopy seems to be a useful tool for predicting delayed bleeding. However, routine prophylactic hemostasis during second-look endoscopy seemed to not be useful for preventing DPEB.

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Predictors of Rebleeding in Upper Gastrointestinal Dieulafoy Lesions: Sang-Hun Park, Du-Hyeon Lee, Chang-Hwan Park, Jin Jeon, Ho-Jun Lee, Sung-Uk Lim, Seon-Young Park, Hyun-Soo Kim, Sung-Kyu Choi, Jong-Sun Rew; Clin Endosc 2015;48(5):385-391. Published online September 30, 2015; DOI: https://doi.org/10.5946/ce.2015.48.5.385

Abstract PDF PubReader ePub

Background/Aims

Dieulafoy lesions (DLs) are a rare but significant cause of upper gastrointestinal bleeding. We aimed to define the clinical significance of rebleeding and identify the predictors of rebleeding and mortality in upper gastrointestinal Dieulafoy lesions (UGIDLs).

Methods

Patients diagnosed with UGIDLs between January 2004 and June 2013 were retrospectively evaluated. Multivariate logistic regression analyses were performed to define the predictors of rebleeding and mortality in patients with UGIDLs.

Results

The study group consisted of 81 male and 36 female patients. Primary hemostasis was achieved in 115 out of 117 patients (98.3%) with various endoscopic therapies. Rebleeding occurred in 10 patients (8.5%). The mortality rate was significantly higher in patients with rebleeding than in those without rebleeding (30.0% vs. 4.7%, p=0.020). Multivariate logistic regression analysis revealed that kidney disease (p=0.006) and infection (p=0.005) were significant predictors of rebleeding in UGIDLs and that kidney disease (p=0.004) and platelet count (p=0.013) were significant predictors of mortality.

Conclusions

Rebleeding has an important prognostic significance in patients with UGIDLs. Kidney disease and infection are major predictors of rebleeding and mortality in patients with UGIDLs.

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Review

Endoscopic Management of Nonvariceal Upper Gastrointestinal Bleeding: State of the Art: Naoki Muguruma, Shinji Kitamura, Tetsuo Kimura, Hiroshi Miyamoto, Tetsuji Takayama; Clin Endosc 2015;48(2):96-101. Published online March 27, 2015; DOI: https://doi.org/10.5946/ce.2015.48.2.96

Abstract PDF PubReader ePub

Nonvariceal upper gastrointestinal (GI) bleeding is one of the most common reasons for hospitalization and a major cause of morbidity and mortality worldwide. Recently developed endoscopic devices and supporting apparatuses can achieve endoscopic hemostasis with greater safety and efficiency. With these advancements in technology and technique, gastroenterologists should have no concerns regarding the management of acute upper GI bleeding, provided that they are well prepared and trained. However, when endoscopic hemostasis fails, endoscopy should not be continued. Rather, endoscopists should refer patients to radiologists and surgeons without any delay for evaluation regarding the appropriateness of emergency interventional radiology or surgery.

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Case Report

Endoscopic Management of Rectal Dieulafoy's Lesion: A Case Series and Optimal Treatment: Jung Gil Park, Jung Chul Park, Yong Hwan Kwon, Sun Young Ahn, Seong Woo Jeon; Clin Endosc 2014;47(4):362-366. Published online July 28, 2014; DOI: https://doi.org/10.5946/ce.2014.47.4.362

Abstract PDF Supplementary Material PubReader ePub

Rectal Dieulafoy's lesion (DL) is rare cause of lower gastrointestinal bleeding. Because of its rarity, there is no consensus on the optimal endoscopic hemostasis technique for rectal DL. We analyzed six patients who underwent endoscopic management for rectal DL after presenting with hematochezia at a single institute over 10 years. Of the six patients, three underwent endoscopic band ligation (EBL) and three underwent endoscopic hemoclip placement (EHP). Only one patient was treated with thermocoagulation. There were no immediate complications in any of the patients. None of the patients required a procedure or surgery for the treatment of rebleeding. Mean procedure times of EBL and EHP were 5.25 minutes and 7 minutes, respectively. Both EHP and EBL are shown to be effective in the treatment of bleeding rectal DL. We suggest that EBL may have potential as the preferred therapy owing to its superiority in technical and economic aspects, especially in elderly and high-risk patients.

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Georges-Paul Dieulafoy (1839–1911) de l’ulcération…
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Lower gastrointestinal bleeding due to rectal Dieulafoy’s lesion
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Reviews

Endoscopy for Nonvariceal Upper Gastrointestinal Bleeding: Ki Bae Kim, Soon Man Yoon, Sei Jin Youn; Clin Endosc 2014;47(4):315-319. Published online July 28, 2014; DOI: https://doi.org/10.5946/ce.2014.47.4.315

Abstract PDF PubReader ePub

Endoscopy for acute nonvariceal upper gastrointestinal bleeding plays an important role in primary diagnosis and management, particularly with respect to identification of high-risk stigmata lesions and to providing endoscopic hemostasis to reduce the risk of rebleeding and mortality. Early endoscopy, defined as endoscopy within the first 24 hours after presentation, improves patient outcome and reduces the length of hospitalization when compared with delayed endoscopy. Various endoscopic hemostatic methods are available, including injection therapy, mechanical therapy, and thermal coagulation. Either single treatment with mechanical or thermal therapy or a treatment that combines more than one type of therapy are effective and safe for peptic ulcer bleeding. Newly developed methods, such as Hemospray powder and over-the-scope clips, may provide additional options. Appropriate decisions and specific treatment are needed depending upon the conditions.

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Management of Acute Variceal Bleeding: Young Dae Kim; Clin Endosc 2014;47(4):308-314. Published online July 28, 2014; DOI: https://doi.org/10.5946/ce.2014.47.4.308

Abstract PDF PubReader ePub

Acute variceal bleeding could be a fatal complication in patients with liver cirrhosis. In patients with decompensated liver cirrhosis accompanied by ascites or hepatic encephalopathy, acute variceal bleeding is associated with a high mortality rate. Therefore, timely endoscopic hemostasis and prevention of relapse of bleeding are most important. The treatment goals for acute variceal bleeding are to correct hypovolemia; achieve rapid hemostasis; and prevent early rebleeding, complications related to bleeding, and deterioration of liver function. If variceal bleeding is suspected, treatment with vasopressors and antibiotics should be initiated immediately on arrival to the hospital. Furthermore, to obtain hemodynamic stability, the hemoglobin level should be maintained at >8 g/dL, systolic blood pressure >90 to 100 mm Hg, heart rate <100/min, and the central venous pressure from 1 to 5 mm Hg. When the patient becomes hemodynamically stable, hemostasis should be achieved by performing endoscopy as soon as possible. For esophageal variceal bleeding, endoscopic variceal ligation is usually performed, and for gastric variceal bleeding, endoscopic variceal obturation is performed primarily. If it is considered difficult to achieve hemostasis through endoscopy, salvage therapy may be carried out while keeping the patient hemodynamically stable.

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Special Issue Article of IDEN 2013

Preventing and Controlling Bleeding in Gastric Endoscopic Submucosal Dissection: Chan Hyuk Park, Sang Kil Lee; Clin Endosc 2013;46(5):456-462. Published online September 30, 2013; DOI: https://doi.org/10.5946/ce.2013.46.5.456

Abstract PDF PubReader ePub

Although techniques and instruments for endoscopic submucosal dissection (ESD) have improved, bleeding is still the most common complication. Minimizing the occurrence of bleeding is important because blood can interfere with subsequent procedures. Generally, ESD-related bleeding can be divided into intraprocedural and postprocedural bleedings. Postprocedural bleeding can be further classified into early post-ESD bleeding which occurs within 48 hours after ESD and late post-ESD bleeding which occurs later than 48 hours after ESD. A basic principle for avoiding intraprocedural bleeding is to watch for vessels and coagulate them before cutting. Several countertraction devices have been designed to minimize intraprocedural bleeding. Methods for reducing postprocedural bleeding include administration of proton-pump inhibitors or prophylactic coagulation after ESD. Medical adhesive spray such as n-butyl-2-cyanoacrylate is also an option for preventing postprocedural bleeding. Various endoscopic treatment modalities are used for both intraprocedural and postprocedural bleeding. However, hemoclipping is infrequently used during ESD because the clips interfere with subsequent resection. Bleeding that occurs as a result of ESD can usually be managed easily. Nonetheless, more effective ways to prevent bleeding, including reliable ESD techniques, must be developed.

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Special Issue Articles of IDEN 2012

How Can We Maximize Skills for Non-Variceal Upper Gastrointestinal Bleeding: Injection, Clipping, Burning, or Others?: Il Kwun Chung; Clin Endosc 2012;45(3):230-234. Published online August 22, 2012; DOI: https://doi.org/10.5946/ce.2012.45.3.230

Abstract PDF PubReader ePub

Endoscopy has its role in the primary diagnosis and management of acute non-variceal upper gastrointestinal bleeding. Main roles of endoscopy are identifying high risk stigmata lesion, and performing endoscopic hemostasis to lower the rebleeding and mortality risks. Early endoscopy within the first 24 hours enables risk classification according to clinical and endoscopic criteria, which guide safe and prompt discharge of low risk patients, and improve outcomes of high risk patients. Techniques including injection therapy, ablative therapy and mechanical therapy have been studied over the recent decades. Combined treatment is more effective than injection treatment, and single treatment with mechanical or thermal method is safe and effective in peptic ulcer bleeding. Specific treatment and correct decisions are needed in various situations depending on the site, location, specific characteristics of lesion and patient's clinical conditions.

Citations

Citations to this article as recorded by

Endoscopic thermocoagulation hemostasis for acute non-varicose upper gastrointestinal hemorrhage: a randomized controlled study
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Comparison on Endoscopic Hemoclip and Hemoclip Combination Therapy in Non-variceal Upper Gastrointestinal Bleeding Patients Based on Clinical Practice Data: Is There Difference between Prospective Cohort Study and Randomized Study?
Su Hyun Lee, Jin Tae Jung, Dong Wook Lee, Chang Yoon Ha, Kyung Sik Park, Si Hyung Lee, Chang Heon Yang, Youn Sun Park, Seong Woo Jeon
The Korean Journal of Gastroenterology.2015; 66(2): 85. CrossRef
Predictive Factors for Endoscopic Hemostasis in Patients with Upper Gastrointestinal Bleeding
Il Kwun Chung
Clinical Endoscopy.2014; 47(2): 121. CrossRef
Endoscopy for Nonvariceal Upper Gastrointestinal Bleeding
Ki Bae Kim, Soon Man Yoon, Sei Jin Youn
Clinical Endoscopy.2014; 47(4): 315. CrossRef
Preparation and Patient Evaluation for Safe Gastrointestinal Endoscopy
Seong Hee Kang, Jong Jin Hyun
Clinical Endoscopy.2013; 46(3): 212. CrossRef
Upper Endoscopy in International Digestive Endoscopy Network 2012: Towards Upper End of Quality
Il Ju Choi
Clinical Endoscopy.2012; 45(3): 217. CrossRef

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A Case of Gastric Intramural Hematoma after an Epinephrine Injection for Gastric Ulcer Bleeding in a Patient Medicated with Aspirin: Hyung Min Noh, M.D., Young Ho Seo, M.D., Nam Hun Lee, M.D., Bong Kyu Lee, M.D., Sang Hyun Park, M.D., Yeon Hwa Kim, M.D., Chur Hoan Lim, M.D. and Sung Hwan Song, M.D.^*; Korean J Gastrointest Endosc 2011;43(1):13-16. Published online July 28, 2011

Abstract PDF: An intramural hematoma of the stomach usually results from trauma. Gastric intramural hematomas may also occur in patients with bleeding disorders who are receiving anticoagulation therapy or after an endoscopic procedure. Here, we describe a case of a gastric intramural hematoma after endoscopic hemostasis for gastric ulcer bleeding in a patient medicated with aspirin. (Korean J Gastrointest Endosc 2011;43:13-16)

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An Intramural Gastric Hematoma after Epinephrine Injection for Gastric Ulcer Bleeding in Patient with Liver Cirrhosis: Hyeong Cheol Cheong, M.D., Tae Hyeon Kim, M.D., Jin Soo Chung, M.D., Tae Hyun Kim, M.D., Bong Jun Yang, M.D., Hyo Jung Oh, M.D. and Yong Woo Sohn, M.D.; Korean J Gastrointest Endosc 2010;40(6):366-369. Published online June 30, 2010

Abstract PDF: Intramural hematoma of the gastrointestinal tract is an uncommon occurrence with the majority being localized to the esophagus or duodenum. Hematoma of the gastric wall is very rare, and has been reported most commonly in association with coagulopathy, trauma, hematologic disease, and therapeutic endoscopy. Here we describe a case of intramural gastric hematoma after epinephrine injection therapy for a gastric ulcer with underlying liver cirrhosis that was successfully managed with conservative therapy. (Korean J Gastrointest Endosc 2010;40:366-369)

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Intramural Duodenal Hematoma following Endoscopic Epinephrine and Thrombin Injection for Bleeding Duodenal Ulcer in a Geriatric Patient with a History of Anticoagulant Drug Use: Jung Bok Park, M.D., Won Ki Bae, M.D., Hyoung Don Lee, M.D., Jung Hoon Kim, M.D., Nam-Hoon Kim, M.D., Kyung-Ah Kim, M.D., June Sung Lee, M.D. and Young Soo Moon, M.D.; Korean J Gastrointest Endosc 2009;39(4):240-243. Published online October 30, 2009

Abstract PDF: Intramural duodenal hematoma is a rare injury of the duodenum due mainly to blunt abdominal trauma and, less commonly, a hematologic disorder, anticoagulant drug use and post-therapeutic endoscopy. Intramural duodenal hematoma following endoscopic intervention is even rarer. Patients usually present with gradual onset of vomiting and abdominal pain approximately 48 h post-injury. The hematoma usually resolves in 1∼2 weeks with conservative therapy. Surgery is usually reserved for patients with suspected duodenal perforation, bile or pancreatic duct compression and inadequate resolution of the hematoma after 1∼2 weeks of conservative therapy. We describe a patient with a history of anticoagulant drug use who developed intramural duodenal hematoma after endoscopic hemostasis of a bleeding duodenal ulcer. Conservative therapy produced a successful outcome. (Korean J Gastrointest Endosc 2009;39:240-243)

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A Case of a Bleeding Dieulafoy's Lesion in a Duodenal Diverticulum Treated by Endoscopic Hemoclipping: Nang Hee Kim, M.D., Kyu-Jong Kim, M.D., Seo Ryong Han, M.D., Ji Eun Park, M.D., Ji Hyeon Nam, M.D., Sung Hoon Kim, M.D., Eun Kyung Shin, M.D., Do Hyun Kim, M.D., Jun Young Song, M.D., Sung Eun Kim, M.D., Won Moon, M.D., Moo In Park, M.D. and Seun Ja Park,; Korean J Gastrointest Endosc 2007;35(4):258-261. Published online October 30, 2007

Abstract PDF: A duodenal diverticulum is common and usually originates in the second portion of the duodenum. The majority of diverticula are asymptomatic; however, they may sometimes present with symptoms such as obstruction, hemorrhage, perforation, jaundice and pancreatitis. Active bleeding from a duodenal diverticulum is rare, and moreover, Dieulafoy's lesion as a cause is quite rare with very few cases reported so far. The use of endoscopic methods instead of surgery in achieving hemostasis has been on the increase with the widespread use and improvement in endoscope instrumentation and accessories. Of these methods, the use of endoscopic hemoclipping for Dieulafoy's lesion is considered more effective and safe than the use of other methods, such as injection and thermal methods. We report here a case of a bleeding Dieulafoy's lesion in a duodenal diverticulum treated by endoscopic hemoclipping. (Korean J Gastrointest Endosc 2007;35:258-261)

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A Case of Bleeding Due to Angiodysplasia of the Ampulla of Vater: Jong Ryul Eun, M.D. and Byung Ik Jang, M.D.; Korean J Gastrointest Endosc 2006;32(6):405-408. Published online June 30, 2006

Abstract PDF: Although angiodysplasia can be found along the whole gastrointestinal tract, it is extremely rare at the ampulla of Vater. We experienced a case of chronic bleeding due to an angiodysplasia of the major papilla. A 53-year-old man was admitted due to intermittent melena and dyspnea for approximately 4 months. Esophagogastroduodenoscopy revealed bleeding from the ampulla of Vater. A subsequent examination with side-viewing duodenoscopy revealed vascular ectasia around the orifice of the major papilla and blood oozing from this lesion. Hemostasis was successfully performed by endoscopic bipolar electrocoagulation. No further bleeding was observed and the previous vascular abnormality disappeared at the follow-up duodenoscopy. (Korean J Gastrointest Endosc 2006;32: 405⁣408)

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The Usefulness of Positional Change in Endoscopic Hemostasis for Bleeding Dieulafoy's Lesion: Jae Hak Lee, M.D., Suck Ho Lee, M.D., Won Yeop Bae, M.D., Jeong Hoon Park, M.D., Do Hyun Park, M.D., Il Kwun Chung, M.D., Sang Heum Park, M.D. and Sun Joo Kim, M.D.; Korean J Gastrointest Endosc 2006;32(3):168-172. Published online March 30, 2006

Abstract PDF: Background
/Aims: Dieulafoy's lesion is a rare cause of massive upper gastrointestinal bleeding, most commonly in the proximal stomach. Although the mechanical hemostatic method has been widely used, it is difficult to access for complete application. This study evaluated the utility of a positional change in patients with a bleeding Dieulafoy's lesion. Methods: Between January 2003 and March 2004, 15 patients with a bleeding Dieulafoy's lesion were randomly assigned to either a positional change group (right decubitus or supine, n=7) or a left decubitus group (n=8). The demographic characteristics, endoscopic variables, and clinical outcomes were analyzed. Results: The patients' characteristics at entry were similar in both groups. Initial hemostasis was achieved in all patients. Recurrent bleeding developed in only one patients in the left decubitus group. The mean procedure time was significantly shorter in the positional change group than in the left decubitus group (4.5⁑3.4 min vs. 7.4⁑5.2 min, p＜0.05). The ineffective hemoclip number (respectively, 0.3⁑0.1 vs. 1.4⁑1.2, p＜0.05) was significantly different in the two groups. No major procedure-related complications occurred in the positional change group. Conclusions: Endoscopic hemostasis with a positional change is an effective and safe method for treating in a bleeding Dieulafoy's lesion. (Korean J Gastrointest Endosc 2006; 32:168⁣172)

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Results of Histoacryl-Lipiodol Sequential Injection Using Specific Gradient Difference for Bleeding Gastric Varices: Tae Oh Kim, M.D., Jeong Heo, M.D., Seong Hun Lee, M.D., Dae Sik Gwon, M.D.,Gwang Ha Kim, M.D., Dae Hwan Kang, M.D., Geun Am Song, M.D. and Mong Cho, M.D.; Korean J Gastrointest Endosc 2005;31(2):84-89. Published online August 30, 2005

Abstract PDF: Background
/Aims: Histoacryl forms hard substances in an instance after a brief exposure to polar liquid, blood or body temperature. This often causes obstruction of injector and endoscopic channel. Furthermore, splashed Histoacryl during injection can lead to accidental loss of vision. We propose a new convenient method of Histoacryl-lipiodol sequential injection and report the results. Methods: From May 2001 to August 2004, sequential injector method was performed in treating consecutive thirty gastric varices patients. Histoacryl (S.G. 1.0) 1 mL and lipiodol (S.G. 1.28) 1∼1.5 mL are filled in 2.5 mL disposable syringe with 16 gauge needle, which are separated into two compartments by specific gravity difference. The injector attached side of charged syringe is gently placed upward and the piston is pushed after the lesion site puncture. Then, normal saline is promptly infused to wash out and the needle is withdrawn. Results: There were 26 males and 4 females. 4 had active bleeding and 26 had the stigmata of bleeding. Varices types were Lg-c in 10, Lg-cf in 16 and Lg-f in 4 patients and the Child-Pugh classification were A in 17%, B in 53% and C in 30%. The average amount was 1.53 mL. Initial hemostasis rate was 97%, 3 of patients re-bled in 4 weeks and 2 patients later. One patient died after the procedure and a case of procedure related bacteremia has occurred. Conclusions: Histoacryl-lipiodol sequential injection by specific gravity difference is convenient and safe. Also, it carries less damage to the instruments. (Korean J Gastrointest Endosc 2005;31:84⁣89)

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Is Routine Second-Look Endoscopy Necessary for All Bleeding Peptic Ulcers?: Eun Ju Lee, M.D., Sang Won Lee, M.D., Tae Dong Kim, M.D., Kook Hyun Kim, M.D.,; Korean J Gastrointest Endosc 2003;26(1):1-7. Published online January 30, 2003

Abstract PDF: Background
/Aims: Second-look endoscopy is generally performed to prevent rebleeding in patients with bleeding peptic ulcers. However, considering recent technologic advances of endoscopic hemostasis and decreasing rate of rebleeding, a small benefit with second-look endoscopy is suggested. Prospective study was carried out to evaluate the efficacy of second-look endoscopic examinations. Methods and Results: One hundred thirty six patients with bleeding from peptic ulcer were included. Emergency endoscopic treatments consisting of the injection of hypertonic saline- epinephrine (HSE), band ligation and/or clipping were performed in patients with Forrest class I-IIb. They were scheduled to receive second-look endoscopy in 48 hours after initial endoscopy. Nine patients (6.6%) received endoscopic retreatment during second-look endoscopy and emergency endoscopic retreatment was required before scheduled endoscopy in six patients (4.4%) because of the evidence of rebleeding. Factors influencing retreatment were Forrest classification of initial endoscopy and methods of hemostasis. None of the patients with Forrest class IIb-III and the patients receiving endoscopic band ligation or clipping on initial endoscopy required retreatment during follow-up endoscopy. Conclusion: Routine second-look endoscopy may not be recommended after initial successful endoscopic treatment of peptic ulcer bleeding, especially in case of Forrest class IIb, IIc or III and in the patients treated with band ligation or clipping. (Korean J Gastrointest Endosc 2003;26:1⁣7)

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소화성궤양 출혈의 내시경적 지혈술 후의 조기 재출혈에 관한 우험 인자 분석 ( Risk Factors for Early Rebleeding after Initial Endoscopic Hemostasis in Patients with Bleeding Peptic Ulcers ): Korean J Gastrointest Endosc 2000;21(6):898-908. Published online November 30, 1999

Abstract PDF: Backgrund/Aims: Rebleeding rate after initial endoscopic hemostasis in patients with ulcer hemorrhage has been reported in 20-30%, Identification of patients who are at high risk for rebleeding would be expected to improve the outcome of endoscopic hemostasis. The purpose of this study was to evaluate risk factors for early rebleeding after initial hemostasis in the view of clinical and endoscopic characteristics. Methods: We reviewed 99 patients who presented with bleeding peptie ulcers and were treated with endoscopic hemostasis including hypertonic saline injection, electrocautery and clipping. We compared the clinical variables (age, pulse rate, hemoglobin), endoscopic characteristics of ulcer (size, number, and location of ulcer, clots on the base, bleeding stigmata, size and color of exposed vessel) between the patients who bled early (n=22) and who didnt bleed (n=77) within 5 days. Results: The statistically significant correlates with early rebleeding after hemostasis were number of comorbid illness (≥2) (p=0.031), volume of transfusion (≥5 units) (p=0.001), size of ulcer (>1 cm) (p=0.038), multiple ulcers (p=O.O2O), presence of blood clots on ulcer base (p=0.012), stigmata (active bleeding and visible vessels) (p=0.010), size of exposed vessel (>1 mm) (p<0.0001). In multivariate analysis, volume of transfusion (odds ratio[OR] 14.4), size of ulcer (OR 11.7), multiple ulcers (OR 5.5) and size of exposed vessel (OR 13.2) were significant risk factors. Conclusions: The risk factors for early rebleeding after hemostasis in bleeding peptic ulcer can be predicted by clinical variables and endoscopic findings. Early identifieation of risk factors such as transfusion over 5 units, large-sized ulcer, multiple ulcers, bleeding stigmata and size of exposed vessei over 1 mm can predict the prognosis of peptic ulcer bleeding.

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혈관 확장증에 의한 상부위장관 출혈의 내시경적 치료 ( Endoscopic Treatment of Bleeding Angioectasia of the Upper Gastrointestinal Tract ): Korean J Gastrointest Endosc 2000;21(3):683-689. Published online November 30, 1999

Abstract PDF: Background
/Aims: Angioectasia of the gastrointestinal tract have been recognized with increasing frequency as an important cause of acute and chronic gastrointestinal bleeding. The purpose of this study is to define the response of endoscopic treatment for bleeding angioectasia of upper gastrointestinal tract and to evaluate long term efficacy of endoscopic treatment. Methods: A clinical study was done on 18 patients (20 cases) of angioectasia bleeding of upper gastrointestinal tract who admitted to Yeungnam University hospital from January 1989 to October 1998. Endoscopic therapy was done by electrocauterizaton, laser therapy, O-band ligation. In cases of failure to achieve hemostasis after endoscopic retreatment, we have done operation or used antifibrinolytic agent. Results: The mean age was 60.6±11.2 years (range 31-77 years). Bleeding control was succeeded in 19 cases and one case was failed by endoscopic therapy. This patient was operated. Recurred bleeding was observed in 4 patients during long term follow-up period. Bleeding was controlled after endoscopic re-treatment in two of four patients. The other patients (Osler-Weber-Lendu syndrome 2 patients) were periodically required of transfusion after endoscopic therapy. Tranexamic acid was given to these patients) Conclusions: Endoscopic therapy for bleeding angioectasia could reduce bleeding or make it stop, but repeated treatment was often necessary for multiple angioectasia. Tranexandc acid may be a useful treatment for refractory bleeding due to multiple angioectasia, such as Osler-Weber-Lendu syndrome.

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내시경적 유두 괄약근 절개술에 의한 출혈 ; 발생 빈도, 위험 인자 및 내시경적 지혈 효과 ( Sphincterotomy - Induced Hemorrhage ; Prevalence, Risk Factors and Endoscopic Hemostasis ): Korean J Gastrointest Endosc 2000;20(4):274-280. Published online November 30, 1999

Abstract PDF: Background
/Aims : Endoscopic biliary sphincterotomy (EST)-induced hemorrhage occurs in approximately 0.5-12% of procedures. We prospectively investigated the risk factors of EST-induced hemorrhage and evaluated its safety as well as the effectiveness of endoscopic hemostasis. Methods : One thousand three hundred and four patients, who underwent EST between July 1996 and June 1998, were enrolled. As a hemostatic treatment, epinephrine spray was initially used. If bleeding persisted, epinephrine injection was performed consecutively. In patients with exposed vessels, epinephrine injection followed by alcohol injection was given. Results : EST-induced hemorrhage occurred in 136 (10.4%) patients. Types of sphincterotome (needle-knife sphincterotome, p=0.0079) and cutting speed (so-called, zipper cut, p=0.03) were revealed as significant variables for the occurrence of bleeding. Once bleeding occurred, patients with an associated ampullary lesion (impacted stone or cancer) or with coagulopathy were more likely to bleed profusely. Initial hemostasis was achieved in all patients. However, rebleeding occurred in eight patients who were initially classified in the moderate or severe bleeding group. Finally, EST-induced hemorrhage was successfully controlled in all patients after 1-3 treatment sessions (mean: 1.1 sessions). The difference in the incidence of complications between the groups with and without endoscopic hemostasis was not statistically significant. Conclusions : The use of needle-knife sphincterotome and cutting speed were independent risk factors for bleeding occurrence. Once bleeding occurred, its severity was affected by the associated ampullary lesion (impacted stone or cancer) or coagulopathy. Endoscopic hemostasis with epinephrine and/or alcohol was effective and safe in EST-induced hemorrhage. (Korean J Gastrointest Endosc 2000;20: 274-280)

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원저 : 비식도정맥류 상부위장관 출혈에서 Hypertonic Saline Epinephring 용액의 치료요법 - 지혈성적 및 시간대별 진단율과 지혈율 비교 - ( Original Articles : Endoscopic Local Injection of Hypertionic Saline Epinephrine Solution for Arrest Hemorrhage from Upper Gastrointestinal Tract - Hemostatic and diagnostic rate according to the time interval - ): Korean J Gastrointest Endosc 1994;14(1):8-18. Published online November 30, 1993

Abstract PDF: A prospective randomised trial was performed to assess the diagnostic accuracy according to the time interval and the efficacy of endoscopic injection of hypertonic saline-epinephrine(HS- E)solution, consisting of 3.5% sodium chloride with 0.0045% epinephrine, for actively bleeding peptic ulcers, exposed vessel or blood clot on ulcer bed, or Mallory-Weiss tear. Over 24 month, emergency endoscopy in 180 patients admitted for upper gastrointestinal hemorrhage identified 51 patients with nonvariceal hemorrhage. The causes of bleeding were; gastric ulcer in 32; duodenal ulcer in 13; gastric cancer in 4; Mallory-Weiss tear in 2. With this method, the hemostatic effect was permanent in 40 cases(84.3%), temporary in 9 cases(11.8%), and failed in 2 cases(3.9%). By applying this method, the rate of emergency operation for patients with bleeding from the upper gastrointestinal tract was significantly reduced from 20.0% (8/40)to 3.9%(2/51)(p<0.05). Emergency endoscopy in acute UGI bleeding increases the accuracy of detection of actual bleeding sites(p<0.05), but if the endoscopic procedure was performed within 48 hours, the hemostatic rate was not affected(p<0.05). We concluded that hypertonic saline-epinephrine injection method could provide a simple maneuver with reasonable cost, high safety, and satisfactory hemostatic efficacy in the treatment of nonvariceal upper gastrointestinal bleeding.

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