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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Veröffentlicht in:Gastroenterology (New York, N.Y. 1943) N.Y. 1943), 2017-05, Vol.152 (6), p.1310-1318.e1
Hauptverfasser: Jensen, Dennis M, Kovacs, Thomas O.G, Ohning, Gordon V, Ghassemi, Kevin, Machicado, Gustavo A, Dulai, Gareth S, Sedarat, Alireza, Jutabha, Rome, Gornbein, Jeffrey
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container_end_page 1318.e1
container_issue 6
container_start_page 1310
container_title Gastroenterology (New York, N.Y. 1943)
container_volume 152
creator Jensen, Dennis M
Kovacs, Thomas O.G
Ohning, Gordon V
Ghassemi, Kevin
Machicado, Gustavo A
Dulai, Gareth S
Sedarat, Alireza
Jutabha, Rome
Gornbein, Jeffrey
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 &amp; 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. 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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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