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Endosc Int Open 2016; 04(03): E255-E262
DOI: 10.1055/s-0041-111499
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Risk factors determining the need for second-look endoscopy for peptic ulcer bleeding after endoscopic hemostasis and proton pump inhibitor infusion

Hsiu-Chi Cheng
1   Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung Univeristy, Tainan, Taiwan
2   Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
,
Chung-Tai Wu
1   Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung Univeristy, Tainan, Taiwan
2   Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
,
Wei-Ying Chen
1   Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung Univeristy, Tainan, Taiwan
2   Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
,
Er-Hsiang Yang
1   Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung Univeristy, Tainan, Taiwan
2   Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
,
Po-Jun Chen
1   Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung Univeristy, Tainan, Taiwan
2   Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
,
Bor-Shyang Sheu
1   Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung Univeristy, Tainan, Taiwan
2   Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
› Author Affiliations
Further Information

Publication History

submitted 11 May 2015

accepted after revision 14 December 2015

Publication Date:
08 February 2016 (online)

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Background and study aims: The need for routine second-look endoscopy in cases of peptic ulcer bleeding remains uncertain. We investigated risk factors related to the need for second-look endoscopy after endoscopic hemostasis and proton pump inhibitor (PPI) infusion.

Patients and methods: We prospectively enrolled 316 patients with peptic ulcer bleeding after endoscopic hemostasis. Second-look endoscopy was scheduled after 72-hour PPI infusion (Day-3 subgroup) or one day early (Day-2 subgroup). If early rebleeding developed within 3 days, emergent second-look endoscopy was conducted. Risk factors for early rebleeding (use of E2nd score to predict the need for early second-look endoscopy) and persistent major stigmata in the Day-3 subgroup (use of R2nd score to predict the need for routine second-look endoscopy) were analyzed using univariable and multivariable regression.

Results: Excluding 10 of 316 patients with early rebleeding, the rate of persistent major stigmata was lower in the Day-3 subgroup than in the Day-2 subgroup (4.8 % vs. 15.4 %, P  = 0.002). Endoscopic epinephrine-injection monotherapy and hypoalbuminemia < 3.0 g/dL were two independent risk factors for early rebleeding (P  ≤ 0.05). The Forrest Ia-Ib type and hypoalbuminemia < 3.5 g/dL were two independent risk factors for persistent major stigmata on the day-3 second-look endoscopy (P  < 0.05). The E2nd score was highly accurate for prediction of early rebleeding (AUROC 0.86; 95 % CI, 0.73~0.99), and the R2nd score could predict persistent major stigmata at second-look endoscopy (AUROC 0.84; 95 % CI, 0.69~0.99).

Conclusions: For patients with peptic ulcer bleeding, E2nd and R2nd scores can indicate the need for early and routine second-look endoscopy, respectively

(Trial registration identifier: NCT02197039).

 

  • References

  • 1 Marmo R, Koch M, Cipolletta L et al. Predicting mortality in non-variceal upper gastrointestinal bleeders: validation of the Italian PNED score and prospective comparison with the Rockall score. Am J Gastroenterol 2010; 105: 1284-1291
    CrossrefPubMedGoogle Scholar
  • 2 Laine L, Peterson WL. Bleeding peptic ulcer. N Engl J Med 1994; 331: 717-727
    CrossrefPubMedGoogle Scholar
  • 3 Laine L, McQuaid KR. Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials. Clin Gastroenterol Hepatol 2009; 7: 33-47
    CrossrefPubMedGoogle Scholar
  • 4 Barkun AN, Martel M, Toubouti Y et al. Endoscopic hemostasis in peptic ulcer bleeding for patients with high-risk lesions: a series of meta-analyses. Gastrointest Endosc 2009; 69: 786-799
    CrossrefPubMedGoogle Scholar
  • 5 Villanueva C, Balanzó J, Torras X et al. Value of second-look endoscopy after injection therapy for bleeding peptic ulcer: a prospective and randomized trial. Gastrointest Endosc 1994; 40: 34-39
    CrossrefPubMedGoogle Scholar
  • 6 Saeed ZA, Cole RA, Ramirez FC et al. Endoscopic retreatment after successful initial hemostasis prevents ulcer rebleeding: a prospective randomized trial. Endoscopy 1996; 28: 288-294
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Chiu PW, Lam CY, Lee SW et al. Effect of scheduled second therapeutic endoscopy on peptic ulcer rebleeding: a prospective randomised trial. Gut 2003; 52: 1403-1407
    CrossrefPubMedGoogle Scholar
  • 8 Sung JJ, Barkun A, Kulpers EJ et al. Intravenous esomeprazole for prevention of recurrent peptic ulcer bleeding. Ann Intern Med 2009; 150: 455-464
    CrossrefPubMedGoogle Scholar
  • 9 Sung JJ, Chan FK, Chen M et al. Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding. Gut 2011; 60: 1170-1177
    CrossrefPubMedGoogle Scholar
  • 10 Marmo R, Rotondano G, Bianco MA et al. Outcome of endoscopic treatment for peptic ulcer bleeding: Is a second look necessary? A meta-analysis. Gastrointest Endosc 2003; 57: 62-67
    PubMedGoogle Scholar
  • 11 El Ouali S, Barkun AN, Wyse J et al. Is routine second-look endoscopy effective after endoscopic hemostasis in acute peptic ulcer bleeding? A meta-analysis. Gastrointest Endosc 2012; 76: 283-292
    CrossrefPubMedGoogle Scholar
  • 12 Sheu BS, Wu CY, Wu MS et al. Consensus on control of risky nonvariceal upper gastrointestinal bleeding in taiwan with national health insurance. Biomed Res Int 2014; 2014: 563707
    PubMedGoogle Scholar
  • 13 Cheng HC, Chuang SA, Kao YH et al. Increased risk of rebleeding of peptic ulcer bleeding in patients with comorbid illness receiving omeprazole infusion. Hepatogastroenterology 2003; 50: 2270-2273
    PubMedGoogle Scholar
  • 14 Cheng HC, Kao AW, Chuang CH et al. The efficacy of high and low dose intravenous omeprazole in preventing rebleeding for patients with bleeding peptic ulcers and comorbid illnesses. Dig Dis Sci 2005; 50: 1194-1201
    CrossrefPubMedGoogle Scholar
  • 15 Barkun AN, Bardou M, Kuipers EJ et al. Internal Consensus Upper Gastrointestinal Bleeding Conference Group. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010; 152: 101-113
    CrossrefPubMedGoogle Scholar
  • 16 Forrest JA, Finlayson ND, Sherman DJ. Endoscopy in gastrointestinal bleeding. Lancet 1974; 2: 394-397
    CrossrefPubMedGoogle Scholar
  • 17 Rockall TA, Logan RF, Devlin HB et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996; 38: 316-321
    CrossrefPubMedGoogle Scholar
  • 18 Cheng HC, Wu CT, Chang WL et al. Double oral esomeprazole after three-day intravenous esomeprazole infusion reduces recurrent peptic ulcer bleeding in high-risk patients-a randomized controlled study. Gut 2014; 63: 1864-1872
    CrossrefPubMedGoogle Scholar
  • 19 Kohavi R. A study of cross-validation and bootstrap for accuracy estimation and model selection. In: Proceedings of the 14th International Joint Conference on Artificial Intelligence. 2. Volume San Francisco: Morgan Kaufmann; IJCAI (US); 1995: 1137-1143
    Google Scholar
  • 20 Calvet X, Vergara M, Brullet E et al. Addition of a second endoscopic treatment following epinephrine injection improves outcome in high-risk bleeding ulcers. Gastroenterology 2004; 126: 441-450
    CrossrefPubMedGoogle Scholar
  • 21 Lin HJ, Perng CL, Lee FY et al. Clinical courses and predictors for rebleeding in patients with peptic ulcers and non-bleeding visible vessels: a prospective study. Gut 1994; 35: 1389-1393
    CrossrefPubMedGoogle Scholar
  • 22 Pescatore P, Jornod P, Borovicka J et al. Epinephrine versus epinephrine plus fibrin glue injection in peptic ulcer bleeding: a prospective randomized trial. Gastrointest Endosc 2002; 55: 348-353
    CrossrefPubMedGoogle Scholar
  • 23 Lau JY, Leung WK, Wu JC et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Eng J Med 2007; 356: 1631-1640
    CrossrefPubMedGoogle Scholar
  • 24 Sreedharan A, Martin J, Leontiadis GI et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review). Cochrane Database Syst Rev 2010; 7 CD005415.pub3. DOI: 10.1002/14651858.CD005415.pub3.
    PubMedGoogle Scholar
  • 25 Vergara M, Bennett C, Calvet X et al. Epinephrine injection versus epinephrine injection and a second endoscopic method in high-risk bleeding ulcers. Cochrane Database Syst Rev 2014; 10 CD005584 DOI: 10.1002/14651858.
    PubMedGoogle Scholar
  • 26 Jellinge ME, Henriksen DP, Hallas P et al. Hypoalbuminemia is a strong predictor of 30-day all-cause mortality in acutely admitted medical patients: a prospective, observational, cohort study. PloS One 2014; 9: e105983
    CrossrefPubMedGoogle Scholar
  • 27 Chojkier M. Inhibition of albumin synthesis in chronic diseases molecular mechanisms. J Clin Gastroenterol 2005; 39: 143-146
    CrossrefPubMedGoogle Scholar
  • 28 Cheng HC, Chang WL, Yeh YC et al. Seven-day intravenous low-dose omeprazole infusion reduces peptic ulcer rebleeding for patients with comorbidities. Gastrointest Endosc 2009; 70: 433-439
    CrossrefPubMedGoogle Scholar
  • 29 Hyett BH, Abougergi MS, Charpentier JP et al. The AIMS65 score compared with the Glasgow-Blatchford score in predicting outcomes in upper GI bleeding. Gastrointest Endosc 2013; 77: 551-557
    CrossrefPubMedGoogle Scholar
  • 30 Cheng HC, Chang WL, Chen WY et al. Intravenous albumin shortens the duration of hospitalization for patients with hypoalbuminemia and bleeding peptic ulcers: a pilot study. Dig Dis Sci 2013; 58: 3232-3241
    CrossrefPubMedGoogle Scholar
  • 31 Regardh CG, Gabrielsson M, Hoffman KJ et al. Pharmacokinetics and metabolism of omeprazole in animals and man-an overview. Scand J Gastroenterol 1985; 108 (Suppl) 79-94
    PubMedGoogle Scholar
  • 32 Chiu PW, Sung JJ. High risk ulcer bleeding: when is second-look endoscopy recommended?. Clin Gastroenterol Hepatol 2010; 8: 651-654
    CrossrefPubMedGoogle Scholar
  • 33 Spiegel BM, Ofman JJ, Woods K et al. Minimizing recurrent peptic ulcer hemorrhage after endoscopic hemostasis: the cost-effectiveness of competing strategies. Am J Gastroenterol 2003; 98: 86-97
    CrossrefPubMedGoogle Scholar
  • 34 Marmo R, Rotondano G, Piscopo R et al. Dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers: a meta-analysis of controlled trials. Am J Gastroenterol 2007; 102: 279-289
    CrossrefPubMedGoogle Scholar
  • 35 Elmunzer BJ, Young SD, Inadomi JM et al. Systematic review of the predictors of recurrent hemorrhage after endoscopic hemostatic therapy for bleeding peptic ulcers. Am J Gastroenterol 2008; 103: 2625-2632
    CrossrefPubMedGoogle Scholar