Doppler Endoscopic Probe Monitoring of Blood Flow Improves Risk Stratification and Outcomes of Patients With Severe Nonvariceal Upper Gastrointestinal Hemorrhage
Background & Aims For 4 decades, stigmata of recent hemorrhages in patients with nonvariceal lesions have been used for risk stratification and endoscopic hemostasis. The arterial blood flow that underlies the stigmata rarely is monitored, but can be used to determine risk for rebleeding. We per...
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description | Background & Aims For 4 decades, stigmata of recent hemorrhages in patients with nonvariceal lesions have been used for risk stratification and endoscopic hemostasis. The arterial blood flow that underlies the stigmata rarely is monitored, but can be used to determine risk for rebleeding. We performed a randomized controlled trial to determine whether Doppler endoscopic probe monitoring of blood flow improves risk stratification and outcomes in patients with severe nonvariceal upper gastrointestinal hemorrhage. Methods In a single-blind study performed at 2 referral centers we assigned 148 patients with severe nonvariceal upper gastrointestinal bleeding (125 with ulcers, 19 with Dieulafoy’s lesions, and 4 with Mallory Weiss tears) to groups that underwent standard, visually guided endoscopic hemostasis (control, n = 76), or endoscopic hemostasis assisted by Doppler monitoring of blood flow under the stigmata (n = 72). The primary outcome was the rate of rebleeding after 30 days; secondary outcomes were complications, death, and need for transfusions, surgery, or angiography. Results There was a significant difference in the rates of lesion rebleeding within 30 days of endoscopic hemostasis in the control group (26.3%) vs the Doppler group (11.1%) ( P = .0214). The odds ratio for rebleeding with Doppler monitoring was 0.35 (95% confidence interval, 0.143–0.8565) and the number needed to treat was 7. There also were significant differences in the rates of surgery and major complications (5.3% in the control group vs no patients in the Doppler monitoring group for each; P = .048). Conclusions In a randomized controlled trial of patients with severe upper gastrointestinal hemorrhage from ulcers or other lesions, Doppler probe–guided endoscopic hemostasis significantly reduced 30-day rates of rebleeding, surgery, and major complications compared with standard, visually guided hemostasis. Guidelines for nonvariceal gastrointestinal bleeding should incorporate these results. ClinicalTrials.gov no: NCT00732212 (CLIN-013-07F). |
doi_str_mv | 10.1053/j.gastro.2017.01.042 |
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The arterial blood flow that underlies the stigmata rarely is monitored, but can be used to determine risk for rebleeding. We performed a randomized controlled trial to determine whether Doppler endoscopic probe monitoring of blood flow improves risk stratification and outcomes in patients with severe nonvariceal upper gastrointestinal hemorrhage. Methods In a single-blind study performed at 2 referral centers we assigned 148 patients with severe nonvariceal upper gastrointestinal bleeding (125 with ulcers, 19 with Dieulafoy’s lesions, and 4 with Mallory Weiss tears) to groups that underwent standard, visually guided endoscopic hemostasis (control, n = 76), or endoscopic hemostasis assisted by Doppler monitoring of blood flow under the stigmata (n = 72). The primary outcome was the rate of rebleeding after 30 days; secondary outcomes were complications, death, and need for transfusions, surgery, or angiography. Results There was a significant difference in the rates of lesion rebleeding within 30 days of endoscopic hemostasis in the control group (26.3%) vs the Doppler group (11.1%) ( P = .0214). The odds ratio for rebleeding with Doppler monitoring was 0.35 (95% confidence interval, 0.143–0.8565) and the number needed to treat was 7. There also were significant differences in the rates of surgery and major complications (5.3% in the control group vs no patients in the Doppler monitoring group for each; P = .048). Conclusions In a randomized controlled trial of patients with severe upper gastrointestinal hemorrhage from ulcers or other lesions, Doppler probe–guided endoscopic hemostasis significantly reduced 30-day rates of rebleeding, surgery, and major complications compared with standard, visually guided hemostasis. Guidelines for nonvariceal gastrointestinal bleeding should incorporate these results. ClinicalTrials.gov no: NCT00732212 (CLIN-013-07F).</description><identifier>ISSN: 0016-5085</identifier><identifier>EISSN: 1528-0012</identifier><identifier>DOI: 10.1053/j.gastro.2017.01.042</identifier><identifier>PMID: 28167214</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject>Aged ; Aged, 80 and over ; Clinical Trial ; Endoscopy ; Endosonography ; Female ; Gastroenterology and Hepatology ; Hemostasis, Endoscopic - methods ; Humans ; Male ; Mallory-Weiss Syndrome - diagnostic imaging ; Mallory-Weiss Syndrome - therapy ; Middle Aged ; Peptic Ulcer Hemorrhage - diagnostic imaging ; Peptic Ulcer Hemorrhage - therapy ; Recurrence ; Regional Blood Flow ; Risk Assessment - methods ; Severity of Illness Index ; Single-Blind Method ; Stigmata of Hemorrhage ; Treatment Outcome ; UGI Bleeding ; Ultrasonography, Doppler ; Vascular Malformations - diagnostic imaging ; Vascular Malformations - therapy</subject><ispartof>Gastroenterology (New York, N.Y. 1943), 2017-05, Vol.152 (6), p.1310-1318.e1</ispartof><rights>AGA Institute</rights><rights>2017 AGA Institute</rights><rights>Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c463t-951c6db85216314b567f8b39a10362b2866f3ab4f6e38d91c3d84ac634b749953</citedby><cites>FETCH-LOGICAL-c463t-951c6db85216314b567f8b39a10362b2866f3ab4f6e38d91c3d84ac634b749953</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://www.sciencedirect.com/science/article/pii/S0016508517301312$$EHTML$$P50$$Gelsevier$$H</linktohtml><link.rule.ids>314,776,780,3537,27901,27902,65306</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/28167214$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Jensen, Dennis M</creatorcontrib><creatorcontrib>Kovacs, Thomas O.G</creatorcontrib><creatorcontrib>Ohning, Gordon V</creatorcontrib><creatorcontrib>Ghassemi, Kevin</creatorcontrib><creatorcontrib>Machicado, Gustavo A</creatorcontrib><creatorcontrib>Dulai, Gareth S</creatorcontrib><creatorcontrib>Sedarat, Alireza</creatorcontrib><creatorcontrib>Jutabha, Rome</creatorcontrib><creatorcontrib>Gornbein, Jeffrey</creatorcontrib><title>Doppler Endoscopic Probe Monitoring of Blood Flow Improves Risk Stratification and Outcomes of Patients With Severe Nonvariceal Upper Gastrointestinal Hemorrhage</title><title>Gastroenterology (New York, N.Y. 1943)</title><addtitle>Gastroenterology</addtitle><description>Background & Aims For 4 decades, stigmata of recent hemorrhages in patients with nonvariceal lesions have been used for risk stratification and endoscopic hemostasis. The arterial blood flow that underlies the stigmata rarely is monitored, but can be used to determine risk for rebleeding. We performed a randomized controlled trial to determine whether Doppler endoscopic probe monitoring of blood flow improves risk stratification and outcomes in patients with severe nonvariceal upper gastrointestinal hemorrhage. Methods In a single-blind study performed at 2 referral centers we assigned 148 patients with severe nonvariceal upper gastrointestinal bleeding (125 with ulcers, 19 with Dieulafoy’s lesions, and 4 with Mallory Weiss tears) to groups that underwent standard, visually guided endoscopic hemostasis (control, n = 76), or endoscopic hemostasis assisted by Doppler monitoring of blood flow under the stigmata (n = 72). The primary outcome was the rate of rebleeding after 30 days; secondary outcomes were complications, death, and need for transfusions, surgery, or angiography. Results There was a significant difference in the rates of lesion rebleeding within 30 days of endoscopic hemostasis in the control group (26.3%) vs the Doppler group (11.1%) ( P = .0214). The odds ratio for rebleeding with Doppler monitoring was 0.35 (95% confidence interval, 0.143–0.8565) and the number needed to treat was 7. There also were significant differences in the rates of surgery and major complications (5.3% in the control group vs no patients in the Doppler monitoring group for each; P = .048). Conclusions In a randomized controlled trial of patients with severe upper gastrointestinal hemorrhage from ulcers or other lesions, Doppler probe–guided endoscopic hemostasis significantly reduced 30-day rates of rebleeding, surgery, and major complications compared with standard, visually guided hemostasis. Guidelines for nonvariceal gastrointestinal bleeding should incorporate these results. ClinicalTrials.gov no: NCT00732212 (CLIN-013-07F).</description><subject>Aged</subject><subject>Aged, 80 and over</subject><subject>Clinical Trial</subject><subject>Endoscopy</subject><subject>Endosonography</subject><subject>Female</subject><subject>Gastroenterology and Hepatology</subject><subject>Hemostasis, Endoscopic - methods</subject><subject>Humans</subject><subject>Male</subject><subject>Mallory-Weiss Syndrome - diagnostic imaging</subject><subject>Mallory-Weiss Syndrome - therapy</subject><subject>Middle Aged</subject><subject>Peptic Ulcer Hemorrhage - diagnostic imaging</subject><subject>Peptic Ulcer Hemorrhage - therapy</subject><subject>Recurrence</subject><subject>Regional Blood Flow</subject><subject>Risk Assessment - methods</subject><subject>Severity of Illness Index</subject><subject>Single-Blind Method</subject><subject>Stigmata of Hemorrhage</subject><subject>Treatment Outcome</subject><subject>UGI Bleeding</subject><subject>Ultrasonography, Doppler</subject><subject>Vascular Malformations - diagnostic imaging</subject><subject>Vascular Malformations - therapy</subject><issn>0016-5085</issn><issn>1528-0012</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2017</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNqFUk1v1DAQtRCILoV_gJCPXJL6I_E6FyQo_ZIKrVgqjpbjTLbeJnZqO4v6c_in9bKFAxcuHmn03jy_eYPQW0pKSmp-tCnXOqbgS0bosiS0JBV7hha0ZrIghLLnaJGLKGoi6wP0KsYNIaThkr5EB0xSsWS0WqBfn_00DRDwiet8NH6yBl8H3wL-4p1NPli3xr7HnwbvO3w6-J_4YpyC30LE32y8w6sUdLK9Nfn1DmvX4as5GT9mQOZd5za4FPEPm27xCrYQAH_1bquDNaAHfDNNWf3stxXrEsRkXW6fw-hDuNVreI1e9HqI8OapHqKb05Pvx-fF5dXZxfHHy8JUgqeiqakRXStrRgWnVVuLZS9b3mhKuGAtk0L0XLdVL4DLrqGGd7LSRvCqXVZNU_ND9H4_N7u7n_M_1GijgWHQDvwcFZWilow0Fc_Qag81wccYoFdTsKMOD4oStQtHbdQ-HLULRxGqcjiZ9u5JYW5H6P6S_qSRAR_2AMg-txaCiiZvz0BnA5ikOm__p_DvADNYl7MZ7uAB4sbPIS83e1GRKaJWuwPZ3QddckI5ZfwRQ6q5oA</recordid><startdate>20170501</startdate><enddate>20170501</enddate><creator>Jensen, Dennis M</creator><creator>Kovacs, Thomas O.G</creator><creator>Ohning, Gordon V</creator><creator>Ghassemi, Kevin</creator><creator>Machicado, Gustavo A</creator><creator>Dulai, Gareth S</creator><creator>Sedarat, Alireza</creator><creator>Jutabha, Rome</creator><creator>Gornbein, Jeffrey</creator><general>Elsevier Inc</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope></search><sort><creationdate>20170501</creationdate><title>Doppler Endoscopic Probe Monitoring of Blood Flow Improves Risk Stratification and Outcomes of Patients With Severe Nonvariceal Upper Gastrointestinal Hemorrhage</title><author>Jensen, Dennis M ; Kovacs, Thomas O.G ; Ohning, Gordon V ; Ghassemi, Kevin ; Machicado, Gustavo A ; Dulai, Gareth S ; Sedarat, Alireza ; Jutabha, Rome ; Gornbein, Jeffrey</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c463t-951c6db85216314b567f8b39a10362b2866f3ab4f6e38d91c3d84ac634b749953</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2017</creationdate><topic>Aged</topic><topic>Aged, 80 and over</topic><topic>Clinical Trial</topic><topic>Endoscopy</topic><topic>Endosonography</topic><topic>Female</topic><topic>Gastroenterology and Hepatology</topic><topic>Hemostasis, Endoscopic - methods</topic><topic>Humans</topic><topic>Male</topic><topic>Mallory-Weiss Syndrome - diagnostic imaging</topic><topic>Mallory-Weiss Syndrome - therapy</topic><topic>Middle Aged</topic><topic>Peptic Ulcer Hemorrhage - diagnostic imaging</topic><topic>Peptic Ulcer Hemorrhage - therapy</topic><topic>Recurrence</topic><topic>Regional Blood Flow</topic><topic>Risk Assessment - methods</topic><topic>Severity of Illness Index</topic><topic>Single-Blind Method</topic><topic>Stigmata of Hemorrhage</topic><topic>Treatment Outcome</topic><topic>UGI Bleeding</topic><topic>Ultrasonography, Doppler</topic><topic>Vascular Malformations - diagnostic imaging</topic><topic>Vascular Malformations - therapy</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Jensen, Dennis M</creatorcontrib><creatorcontrib>Kovacs, Thomas O.G</creatorcontrib><creatorcontrib>Ohning, Gordon V</creatorcontrib><creatorcontrib>Ghassemi, Kevin</creatorcontrib><creatorcontrib>Machicado, Gustavo A</creatorcontrib><creatorcontrib>Dulai, Gareth S</creatorcontrib><creatorcontrib>Sedarat, Alireza</creatorcontrib><creatorcontrib>Jutabha, Rome</creatorcontrib><creatorcontrib>Gornbein, Jeffrey</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>Gastroenterology (New York, N.Y. 1943)</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Jensen, Dennis M</au><au>Kovacs, Thomas O.G</au><au>Ohning, Gordon V</au><au>Ghassemi, Kevin</au><au>Machicado, Gustavo A</au><au>Dulai, Gareth S</au><au>Sedarat, Alireza</au><au>Jutabha, Rome</au><au>Gornbein, Jeffrey</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Doppler Endoscopic Probe Monitoring of Blood Flow Improves Risk Stratification and Outcomes of Patients With Severe Nonvariceal Upper Gastrointestinal Hemorrhage</atitle><jtitle>Gastroenterology (New York, N.Y. 1943)</jtitle><addtitle>Gastroenterology</addtitle><date>2017-05-01</date><risdate>2017</risdate><volume>152</volume><issue>6</issue><spage>1310</spage><epage>1318.e1</epage><pages>1310-1318.e1</pages><issn>0016-5085</issn><eissn>1528-0012</eissn><abstract>Background & Aims For 4 decades, stigmata of recent hemorrhages in patients with nonvariceal lesions have been used for risk stratification and endoscopic hemostasis. The arterial blood flow that underlies the stigmata rarely is monitored, but can be used to determine risk for rebleeding. We performed a randomized controlled trial to determine whether Doppler endoscopic probe monitoring of blood flow improves risk stratification and outcomes in patients with severe nonvariceal upper gastrointestinal hemorrhage. Methods In a single-blind study performed at 2 referral centers we assigned 148 patients with severe nonvariceal upper gastrointestinal bleeding (125 with ulcers, 19 with Dieulafoy’s lesions, and 4 with Mallory Weiss tears) to groups that underwent standard, visually guided endoscopic hemostasis (control, n = 76), or endoscopic hemostasis assisted by Doppler monitoring of blood flow under the stigmata (n = 72). The primary outcome was the rate of rebleeding after 30 days; secondary outcomes were complications, death, and need for transfusions, surgery, or angiography. Results There was a significant difference in the rates of lesion rebleeding within 30 days of endoscopic hemostasis in the control group (26.3%) vs the Doppler group (11.1%) ( P = .0214). The odds ratio for rebleeding with Doppler monitoring was 0.35 (95% confidence interval, 0.143–0.8565) and the number needed to treat was 7. There also were significant differences in the rates of surgery and major complications (5.3% in the control group vs no patients in the Doppler monitoring group for each; P = .048). Conclusions In a randomized controlled trial of patients with severe upper gastrointestinal hemorrhage from ulcers or other lesions, Doppler probe–guided endoscopic hemostasis significantly reduced 30-day rates of rebleeding, surgery, and major complications compared with standard, visually guided hemostasis. Guidelines for nonvariceal gastrointestinal bleeding should incorporate these results. ClinicalTrials.gov no: NCT00732212 (CLIN-013-07F).</abstract><cop>United States</cop><pub>Elsevier Inc</pub><pmid>28167214</pmid><doi>10.1053/j.gastro.2017.01.042</doi><oa>free_for_read</oa></addata></record> |
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subjects | Aged Aged, 80 and over Clinical Trial Endoscopy Endosonography Female Gastroenterology and Hepatology Hemostasis, Endoscopic - methods Humans Male Mallory-Weiss Syndrome - diagnostic imaging Mallory-Weiss Syndrome - therapy Middle Aged Peptic Ulcer Hemorrhage - diagnostic imaging Peptic Ulcer Hemorrhage - therapy Recurrence Regional Blood Flow Risk Assessment - methods Severity of Illness Index Single-Blind Method Stigmata of Hemorrhage Treatment Outcome UGI Bleeding Ultrasonography, Doppler Vascular Malformations - diagnostic imaging Vascular Malformations - therapy |
title | Doppler Endoscopic Probe Monitoring of Blood Flow Improves Risk Stratification and Outcomes of Patients With Severe Nonvariceal Upper Gastrointestinal Hemorrhage |
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