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347r: Changing Trends in Acute Upper-GI Bleeding in Greece: A Population-Based Study
Abstracts (6.3%). Active extravasation was found in 15 patients (46.9%) and post embolization extravasation was seen in 2 patients (6.3%). Embolization was attempted in 26 patients and the overall coil success rate was 88.5%. Recurrent bleeding occurred more often after TAE than surgery (42.3% vs. 12.5%, p ⬍ 0.005). In 6 patients, rebleeding after TAE was treated by surgery. Less patient in TAE group required surgery as salvage (18.8% vs. 100%). More complications were observed in surgery group (13 vs. 38, p⫽ 0.013). There was no difference in 30 day mortality (25% vs. 30.4%), mean hospital stay (17.3 vs. 21.6 days, p⫽0.088) and mean blood transfusion (15.6 vs. 14.2). ConclusionIn patients with peptic ulcer bleeding after failed endoscopic hemostasis, TAE reduces the need for surgery and overall complications without increasing the overall mortality rate.
347p Use of High-Dose Aspirin or Clopidogrel Before or After Percutaneous Endoscopic Gastrostomy Is Not Associated With Post-Procedural Bleeding James A. Richter, James T. Patrie, Robert P. Richter, Zachary Henry, George H. Pop, Kara A. Regan, David A. Peura, Robert G. Sawyer, Patrick G. Northup, Andrew Y. Wang Introduction: Percutaneous endoscopic gastrostomy (PEG) has been classified as a high-risk procedure (ASGE guidelines, GIE 2005;61:189-194) and bleeding is a potential complication following PEG. These guidelines recommend discontinuing clopidogrel for 7 to 10 days, but not withholding aspirin, prior to high-risk procedures. Aim: To determine if there is an association between aspirin or clopidogrel and post-procedural bleeding in patients following PEG. Methods: A retrospective, single-center, cohort study was conducted that included inpatients, on neurology and cardiothoracic services, who underwent PEG from January 1999 to April 2009. Patients were identified using a hospital database, and electronic medical records were reviewed. Statistical analyses were conducted using multivariate exact logistic regression with clinical indication as a concomitant (i.e., adjustment) variable. Results: A total of 990 patients (525 men) with a median age of 69.8 years (range: 18 to 95 years) underwent PEG. 16 patients (1.6%) had postprocedural bleeding during the first 48 hours after PEG. 36 patients (3.6%) were on high-dose aspirin (range: 437.5 mg to 1200 mg) during the 48 hours preceding PEG, and 27 patients (2.7%) were on high-dose aspirin (range: 600 mg to 1300 mg) during the first 48 hours after PEG. 25 patients (2.5%) were on clopidogrel (75 mg) during the 48 hours preceding PEG, and 25 patients (2.5%) were on clopidogrel (75 mg) during the first 48 after PEG. None of the patients on high-dose aspirin or clopidogrel during the 48 hours preceding PEG experienced a bleeding complication. Of the patients who received high-dose aspirin or clopidogrel during the first 48 hours after PEG, only one experienced a non-life-threatening bleed related to the PEG, and this patient was on clopidogrel alone. Table 1 illustrates that there was not a significant association between high-dose aspirin or clopidogrel use, during the 48 hours immediately before or after PEG, and post-procedural bleeding. Conclusions: Use of high-dose aspirin or clopidogrel in the 48 hours before or after PEG is not associated with a significant risk of post-procedural bleeding. Although further prospective trials are indicated, these data suggest that high-dose aspirin or clopidogrel may not need to be held prior to PEG, and these medications may be restarted during the first 48 hours following PEG, if appropriate indications exist. Table 1
Drug Aspirin Clopidogrel
Time of dosing
Conditional odds ratio [95% CI] (for post-PEG bleeding)
24-hours pre-PEG 48-hours pre-PEG 24-hours post-PEG 48-hours post-PEG 24-hours pre-PEG 48-hours pre-PEG 24-hours post-PEG 48-hours post-PEG
0.76 [0.22 to 2.70] 0.94 [0.12 to 4.57] 0.36 [0.10 to 1.38] 2.06 [0 to 12.79] 0.10 [0.10 to infinity] 3.96 [0 to 20.87] 0.30 [0.03 to 8.45] 17.27 [0 to 222.69]
P-value 0.66 0.98 0.13 0.70 0.70 0.83 0.38 0.95
347q Endoscopic Doppler Ultrasound Guided Coagulation Could Prevent Delayed Hemorrhage From Ulcer After Endoscopic Submucosal Dissection for Early Gastric Cancer: A Feasibility Study Noriya Uedo, Yoji Takeuchi, Ryu Ishihara, Koji Higashino, Richard C. Wong, Amitabh Chak, Hiroyasu Iishi BACKGROUND AND AIM: After endoscopic submucosal dissection (ESD) for early gastric cancer (EGC), all visible exposed vessels were customary coagulated even if there was no evidence of bleeding at the end of procedure, however,
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delayed bleeding occur in some portions of patients (1.2-11.6%). Endoscopic Doppler ultrasound system (DOP-US, Vascular Technology Inc.) can predict risk of recurrent bleeding of non-bleeding visible vessel (NBVV) in patients with acute peptic ulcer. Aims of this study were to establish suitable method of DOPUS for post ESD ulcer and to evaluate whether it is feasible for investigating it could reduce delayed bleeding.METHODS: 30 ulcers in 30 patients underwent ESD for mucosal EGC that was larger than 2 cm without ulcer or scar or less than 3 cm with scar, were examined and treated by following protocol: A double channel endoscope (EVIS-2TQ260M, Olympus) that fitted with transparent attachment (D-201-13404, Olympus) was used. A DOP-US probe was inserted through accessory channel and was contacted on an ulcer base to search for a positive Doppler signal (DOP (⫹)) that is defined as pulsatile sound at shallow (1.5 mm) depth. The endoscopic appearance of areas with DOP (⫹) and any stigmata of bleeding and their presence or absence of Doppler signal were documented in a schematic map. Electrical coagulation (Soft coagulation 80W, ICC200, ERBE) by hemostatic forceps (FD-410LR, Olympus) was performed for areas with active bleeding and with DOP (⫹). NBVV that were negative for Doppler signal were left untreated. The coagulated areas were re-inspected for a persistent signal and coagulation or clip was added until the signal disappeared. Oral PPI was administered for eight weeks.RESULTS: 17 oozing hemorrhage were observed and four had DOP (⫹). After coagulation for all sites, hemorrhage was stopped and the DOP (⫹) became silent. 49 of 387 NBVV (12.7%) were DOP (⫹) and were coagulated (once in 39, twice in 6, and more than three times in 4 site including one clipping) until they became silent. The reminder of 338 NBVV and 13 adherent clots that were negative for Doppler signal were not treated. A total of 24 areas without any visible endoscopic stigmata were found to be DOP (⫹), and were coagulated until the signal turn to be silent. No delayed bleeding occurred in the 31 patients within 30 days. Long procedure time (mean 32 min) was a limitation of this procedure.CONCLUSION: Our settings and maneuver could detect blood flow signal on post ESD ulcer. This protocol warrants further studies to investigate whether use of DOP-US could reduce delayed bleeding and could avoid unnecessary coagulation for NBVV in post ESD ulcer for EGC.
347r Changing Trends in Acute Upper-GI Bleeding in Greece: A Population-Based Study Konstantinos Konstantinidis, Ioannis Chalkiadakis, Georgios Tribonias, Gregorios Chlouverakis, Maria Rousomoustakaki, Gregorios A. Paspatis Introduction: Acute upper gastrointestinal bleeding (AUGIB) is a common major medical emergency. In recent days, there is increasing evidence that the incidence of AUGIB has declined. However, more data prospectively collected regarding this issue are needed. The aim of this study was to examine recent trends in the incidence and outcome of upper GI bleeding in the prefecture of Heraklion-Crete, Greece. Material and Methods: Prospective data collection on all adult patients presenting with AUGIB from the prefecture of Heraklion-Crete in the periods 1998/1999 (period A) and 2008/2009 (period B). The data for period A have been published[1]. The same protocol was used in both periods. Results: During period A, 353 cases of AUGIB were included into the study and 225 cases during period B. Incidence decreased from 160/100.000 in period A to 95/ 100.000 persons annually in period B, corresponding to a 41% decrease in the incidence. The incidence was higher among patients with more advanced age in both periods. Mortality also decreased from 9/100.000 in period A to 6.3/100.000 persons annually in period B. Among patients with ulcer bleeding, rebleeding also decreased from 12% in period A to 4.4% in period B. However, surgical intervention rate (3.3% vs 2.2%) did not differ significantly between the two time periods. Ulcer bleeding was the most frequent cause of bleeding in both periods (48.6% in period A - 44.8% in period B). Increasing age, presence of severe and life-threatening comorbidity, and rebleeding were associated with higher mortality. Almost one half of all patients were using NSAIDs or aspirin in both periods. Conclusions: Between periods A and B, the incidence and mortality rates of AUGIB significantly decreased. References[1] Paspatis GA, Matrella E, Kapsoritakis A et al. An epidemiological study of acute upper gastrointestinal bleeding in Crete, Greece. Eur J Gastroenterol Hepatol 2000; 12(11):1215-20.
348 A Comparison of Patients’ Satisfaction With Two Different Sedation Regimens for Endoscopy: Propofol, Midazolam and Fentanyl Versus Midazolam and Fentanyl Jesse Lachter, Yaniv Elzam, Ian M. Gralnek, Irit Chermesh, Rami Eliakim Background: Utilization of gastroenterologist-administered propofol (GAP) for sedation in endoscopy is increasing worldwide. Patient satisfaction is one major issue essential for determining criteria for optimizing use of propofol. Better satisfaction may improve the perceptions of the public regarding endoscopy and increase willingness to undergo endoscopies. While safety has been extensively assessed, prospective data on satisfaction as a potential benefit is scarce and
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347p Use of High-Dose Aspirin or Clopidogrel Before or After Percutaneous Endoscopic Gastrostomy Is Not Associated With Post-Procedural Bleeding James A. Richter, James T. Patrie, Robert P. Richter, Zachary Henry, George H. Pop, Kara A. Regan, David A. Peura, Robert G. Sawyer, Patrick G. Northup, Andrew Y. Wang Introduction: Percutaneous endoscopic gastrostomy (PEG) has been classified as a high-risk procedure (ASGE guidelines, GIE 2005;61:189-194) and bleeding is a potential complication following PEG. These guidelines recommend discontinuing clopidogrel for 7 to 10 days, but not withholding aspirin, prior to high-risk procedures. Aim: To determine if there is an association between aspirin or clopidogrel and post-procedural bleeding in patients following PEG. Methods: A retrospective, single-center, cohort study was conducted that included inpatients, on neurology and cardiothoracic services, who underwent PEG from January 1999 to April 2009. Patients were identified using a hospital database, and electronic medical records were reviewed. Statistical analyses were conducted using multivariate exact logistic regression with clinical indication as a concomitant (i.e., adjustment) variable. Results: A total of 990 patients (525 men) with a median age of 69.8 years (range: 18 to 95 years) underwent PEG. 16 patients (1.6%) had postprocedural bleeding during the first 48 hours after PEG. 36 patients (3.6%) were on high-dose aspirin (range: 437.5 mg to 1200 mg) during the 48 hours preceding PEG, and 27 patients (2.7%) were on high-dose aspirin (range: 600 mg to 1300 mg) during the first 48 hours after PEG. 25 patients (2.5%) were on clopidogrel (75 mg) during the 48 hours preceding PEG, and 25 patients (2.5%) were on clopidogrel (75 mg) during the first 48 after PEG. None of the patients on high-dose aspirin or clopidogrel during the 48 hours preceding PEG experienced a bleeding complication. Of the patients who received high-dose aspirin or clopidogrel during the first 48 hours after PEG, only one experienced a non-life-threatening bleed related to the PEG, and this patient was on clopidogrel alone. Table 1 illustrates that there was not a significant association between high-dose aspirin or clopidogrel use, during the 48 hours immediately before or after PEG, and post-procedural bleeding. Conclusions: Use of high-dose aspirin or clopidogrel in the 48 hours before or after PEG is not associated with a significant risk of post-procedural bleeding. Although further prospective trials are indicated, these data suggest that high-dose aspirin or clopidogrel may not need to be held prior to PEG, and these medications may be restarted during the first 48 hours following PEG, if appropriate indications exist. Table 1
Drug Aspirin Clopidogrel
Time of dosing
Conditional odds ratio [95% CI] (for post-PEG bleeding)
24-hours pre-PEG 48-hours pre-PEG 24-hours post-PEG 48-hours post-PEG 24-hours pre-PEG 48-hours pre-PEG 24-hours post-PEG 48-hours post-PEG
0.76 [0.22 to 2.70] 0.94 [0.12 to 4.57] 0.36 [0.10 to 1.38] 2.06 [0 to 12.79] 0.10 [0.10 to infinity] 3.96 [0 to 20.87] 0.30 [0.03 to 8.45] 17.27 [0 to 222.69]
P-value 0.66 0.98 0.13 0.70 0.70 0.83 0.38 0.95
347q Endoscopic Doppler Ultrasound Guided Coagulation Could Prevent Delayed Hemorrhage From Ulcer After Endoscopic Submucosal Dissection for Early Gastric Cancer: A Feasibility Study Noriya Uedo, Yoji Takeuchi, Ryu Ishihara, Koji Higashino, Richard C. Wong, Amitabh Chak, Hiroyasu Iishi BACKGROUND AND AIM: After endoscopic submucosal dissection (ESD) for early gastric cancer (EGC), all visible exposed vessels were customary coagulated even if there was no evidence of bleeding at the end of procedure, however,
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Volume 71, No. 5 : 2010
delayed bleeding occur in some portions of patients (1.2-11.6%). Endoscopic Doppler ultrasound system (DOP-US, Vascular Technology Inc.) can predict risk of recurrent bleeding of non-bleeding visible vessel (NBVV) in patients with acute peptic ulcer. Aims of this study were to establish suitable method of DOPUS for post ESD ulcer and to evaluate whether it is feasible for investigating it could reduce delayed bleeding.METHODS: 30 ulcers in 30 patients underwent ESD for mucosal EGC that was larger than 2 cm without ulcer or scar or less than 3 cm with scar, were examined and treated by following protocol: A double channel endoscope (EVIS-2TQ260M, Olympus) that fitted with transparent attachment (D-201-13404, Olympus) was used. A DOP-US probe was inserted through accessory channel and was contacted on an ulcer base to search for a positive Doppler signal (DOP (⫹)) that is defined as pulsatile sound at shallow (1.5 mm) depth. The endoscopic appearance of areas with DOP (⫹) and any stigmata of bleeding and their presence or absence of Doppler signal were documented in a schematic map. Electrical coagulation (Soft coagulation 80W, ICC200, ERBE) by hemostatic forceps (FD-410LR, Olympus) was performed for areas with active bleeding and with DOP (⫹). NBVV that were negative for Doppler signal were left untreated. The coagulated areas were re-inspected for a persistent signal and coagulation or clip was added until the signal disappeared. Oral PPI was administered for eight weeks.RESULTS: 17 oozing hemorrhage were observed and four had DOP (⫹). After coagulation for all sites, hemorrhage was stopped and the DOP (⫹) became silent. 49 of 387 NBVV (12.7%) were DOP (⫹) and were coagulated (once in 39, twice in 6, and more than three times in 4 site including one clipping) until they became silent. The reminder of 338 NBVV and 13 adherent clots that were negative for Doppler signal were not treated. A total of 24 areas without any visible endoscopic stigmata were found to be DOP (⫹), and were coagulated until the signal turn to be silent. No delayed bleeding occurred in the 31 patients within 30 days. Long procedure time (mean 32 min) was a limitation of this procedure.CONCLUSION: Our settings and maneuver could detect blood flow signal on post ESD ulcer. This protocol warrants further studies to investigate whether use of DOP-US could reduce delayed bleeding and could avoid unnecessary coagulation for NBVV in post ESD ulcer for EGC.
347r Changing Trends in Acute Upper-GI Bleeding in Greece: A Population-Based Study Konstantinos Konstantinidis, Ioannis Chalkiadakis, Georgios Tribonias, Gregorios Chlouverakis, Maria Rousomoustakaki, Gregorios A. Paspatis Introduction: Acute upper gastrointestinal bleeding (AUGIB) is a common major medical emergency. In recent days, there is increasing evidence that the incidence of AUGIB has declined. However, more data prospectively collected regarding this issue are needed. The aim of this study was to examine recent trends in the incidence and outcome of upper GI bleeding in the prefecture of Heraklion-Crete, Greece. Material and Methods: Prospective data collection on all adult patients presenting with AUGIB from the prefecture of Heraklion-Crete in the periods 1998/1999 (period A) and 2008/2009 (period B). The data for period A have been published[1]. The same protocol was used in both periods. Results: During period A, 353 cases of AUGIB were included into the study and 225 cases during period B. Incidence decreased from 160/100.000 in period A to 95/ 100.000 persons annually in period B, corresponding to a 41% decrease in the incidence. The incidence was higher among patients with more advanced age in both periods. Mortality also decreased from 9/100.000 in period A to 6.3/100.000 persons annually in period B. Among patients with ulcer bleeding, rebleeding also decreased from 12% in period A to 4.4% in period B. However, surgical intervention rate (3.3% vs 2.2%) did not differ significantly between the two time periods. Ulcer bleeding was the most frequent cause of bleeding in both periods (48.6% in period A - 44.8% in period B). Increasing age, presence of severe and life-threatening comorbidity, and rebleeding were associated with higher mortality. Almost one half of all patients were using NSAIDs or aspirin in both periods. Conclusions: Between periods A and B, the incidence and mortality rates of AUGIB significantly decreased. References[1] Paspatis GA, Matrella E, Kapsoritakis A et al. An epidemiological study of acute upper gastrointestinal bleeding in Crete, Greece. Eur J Gastroenterol Hepatol 2000; 12(11):1215-20.
348 A Comparison of Patients’ Satisfaction With Two Different Sedation Regimens for Endoscopy: Propofol, Midazolam and Fentanyl Versus Midazolam and Fentanyl Jesse Lachter, Yaniv Elzam, Ian M. Gralnek, Irit Chermesh, Rami Eliakim Background: Utilization of gastroenterologist-administered propofol (GAP) for sedation in endoscopy is increasing worldwide. Patient satisfaction is one major issue essential for determining criteria for optimizing use of propofol. Better satisfaction may improve the perceptions of the public regarding endoscopy and increase willingness to undergo endoscopies. While safety has been extensively assessed, prospective data on satisfaction as a potential benefit is scarce and
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