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Endoscopic Doppler examination and hemostasis in nonvariceal upper gastrointestinal hemorrhage: paradigm shift, or old wine in new bottles?

Oliver Pech, Regensburg

Gastroenterology 2017; 152:1310-1318

CLINICAL – ALIMENTARY TRACT
Doppler Endoscopic Probe Monitoring of Blood Flow Improves Risk Stratification and Outcomes of Patients With Severe Nonvariceal Upper Gastrointestinal Hemorrhage
Dennis M. Jensen1,2,3, Thomas O. G. Kovacs1,2,3, Gordon V. Ohning1,2,3, Kevin Ghassemi1,2, Gustavo A. Machicado1,2,3, Gareth S. Dulai1,2,3, Alireza Sedarat1,2,3, Rome Jutabha1,2and Jeffrey Gornbein4
11Center for Ulcer Research and Education Digestive Diseases Research Center, Gastrointestinal
Hemostasis Unit, Los Angeles, California; 4Department of Biomathematics, 2Geffen School of Medicine, University of California Los Angeles, Los Angeles, California;3Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, California

Background and Aims

For 4 decades, stigmata of recent hemorrhage 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 ¼ 76), or endoscopic hemostasis assisted by Doppler monitoring of blood flow under the stigmata (n ¼ 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 ¼ .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.

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 compared with standard, visually guided hemostasis. Guidelines for nonvariceal gastrointestinal bleeding should incorporate these results. ClinicalTrials.gov no: NCT00732212 (CLIN-013-07F).

What you need to know about this paper

During hemostasis in patients with nonvariceal upper gastrointestinal hemorrhage, the Forrest classification is recommended for risk stratification, as it correlates best with the risk of rebleeding and mortality. The recently published European Society of Gastrointestinal Endoscopy (ESGE) guidelines on the management of upper GI bleeding explicitly do not recommend routine use of Doppler examinations before or after therapy to evaluate blood flow under the bleeding lesion.1 The main reason for this negative recommendation was that the data on the method are inconsistent and out of date. For acute hemorrhage (Forrest Ia, Ib), the ESGE recommends a combination of injection and another method of hemostasis (clipping, coagulation, sclerotherapy). When there is a visible vessel stump (Forrest IIa), these methods can be combined, and the injection should be done secondarily.1

In this prospective and randomized double-blind study, 163 patients with acute upper gastrointestinal bleeding from ulcers > 5 mm, Mallory–Weiss lesions, and Dieulafoy lesions underwent hemostasis either conventionally during endoscopy or with Doppler ultrasound guidance.2 Conventional endoscopic hemostasis was carried out with clips (11 mm span) or with multipolar electrocoagulation (MPEC), with or without injection. In Doppler-guided hemostasis, the course of the underlying artery was assessed first and targeted hemostasis was then carried out. The ulcer and its immediate surroundings were also examined with disposable Doppler probes after hemostasis. If there was residual arterial blood flow, further treatment with clips or MPEC was carried out. The rate of rebleeding after 30 days was significantly lower in the group with Doppler probe–guided hemostasis than in the control group with standard hemostasis (11.1% vs. 26.3%). Important secondary end points such as the need for emergency surgery and the rate of severe complications were also significantly higher in the control group. Interestingly, an arterial Doppler signal was detected in 87.4% of patients with Forrest Ia, IIa, and IIb ulcers. An arterial signal was only noted in 42.3% of patients with Forrest Ib and IIc lesions.

The results of this well-conducted study raise the question of whether every department now needs to obtain a Doppler device to evaluate bleeding ulcers, so that hemostasis can be guided by the course of the vessel. I don’t think so (yet).

The authors of the study have been involved in the use of Doppler imaging in patients with gastrointestinal hemorrhage for several years and have the corresponding level of experience.3 The research group in Ludwigshafen was already investigating the use of endoscopic Doppler ultrasonography during hemostasis in the 1990s, but the method never came into widespread use and it was later abandoned by its proponents, not least due to the publication of a few negative studies.4,5

This study has a few limitations, and the situation in connection with hemostasis in the USA is not fully transferable to conditions in Germany. A total of 800 patients were screened in the study before 163 patients were finally included in it. A certain amount of selection bias seems not improbable here. In addition, multipolar electrocoagulation — a technique that is not used in Germany — was frequently used as a method of hemostasis in the study. In Germany, hemostasis for bleeding ulcers usually involves a combination of clipping and injection. When clips are used, occlusion of the afferent vessel is more likely to be achieved even without precise knowledge of the exact course of the artery under the ulcer. The clips used in the study only had a span of 11 mm. Nowadays, much wider clips (up to 16 mm) and even over-the-scope clips (OTSCs) are available, which are able to grasp much more tissue and can thus lead to lasting hemostasis more effectively.6,7. Particularly in patients with spurting hemorrhage or ulcers with a vascular stump, OTSCs are being used more and more often in many countries in Europe, as they allow safe and highly effective hemostasis in most cases and this markedly reduces the risk of rebleeding.

Further prospective and randomized studies in Europe will be needed before any final conclusions can be drawn regarding the value of endoscopic Doppler imaging in patients with gastrointestinal hemorrhage.

References

  1. Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, Rotondano G, Hucl T, Dinis-Ribeiro M, Marmo R, Racz I, Arezzo A, Hoffmann RT, Lesur G, de Franchis R, Aabakken L, Veitch A, Radaelli F, Salgueiro P, Cardoso R, Maia L, Zullo A, Cipolletta L, Hassan C. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2015 Oct;47(10):a1-46. doi: 10.1055/s-0034-1393172. Epub 2015 Sep 29.
  2.  Jensen DM, Kovacs TOG, Ohning GV, Ghassemi K, Machicado GA, Dulai GS, Sedarat A, Jutabha R, Gornbein J. Doppler Endoscopic Probe Monitoring of Blood Flow Improves Risk Stratification and Outcomes of Patients With Severe Nonvariceal Upper Gastrointestinal Hemorrhage. Gastroenterology. 2017 May;152(6):1310-1318.e1. doi: 10.1053/j.gastro.2017.01.042. Epub 2017 Feb 4.
  3. Jensen DM, Ohning GV, Kovacs TO, Ghassemi KA, Jutabha R, Dulai GS, Machicado GA. Doppler endoscopic probe as a guide to risk stratification and definitive hemostasis of peptic ulcer bleeding. Gastrointest Endosc. 2016 Jan;83(1):129-36. doi: 10.1016/j.gie.2015.07.012. Epub 2015 Aug 28.
  4. Kohler B, Maier M, Benz C, Riemann JF. Acute ulcer bleeding. A prospective randomized trial to compare Doppler and Forrest classifications in endoscopic diagnosis and therapy. Dig Dis Sci. 1997 Jul;42(7):1370-4.
  5. Jakobs R, Zoepf T, Schilling D, Siegel EG, Riemann JF. Endoscopic Doppler ultrasound after injection therapy for peptic ulcer hemorrhage. Hepatogastroenterology. 2004 Jul-Aug;51(58):1206-9.
  6. Richter-Schrag HJ, Glatz T, Walker C, Fischer A, Thimme R. First-line endoscopic treatment with over-the-scope clips significantly improves the primary failure and rebleeding rates in high-risk gastrointestinal bleeding: A single-center experience with 100 cases. World J Gastroenterol. 2016 Nov 7;22(41):9162-9171.
  7. Schmidt A, Goelder S, Messmann H, et al. 62 Over-The-Scope-Clips Versus Standard Endoscopic Therapy in Patients With Recurrent Peptic Ulcer Bleeding and a Prospective Randomized, Multicenter Trial (Sting). Gastrointestinal Endoscopy;85:AB50.

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