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The Prediction of Peptic Ulcer Rebleeding After Therapeutic Scheduled Second Endoscopy Clinical or Endoscopic Factors? Philip W. Y. Chiu, Henry K. M. Joeng, Catherine L. Y. Choi, Kwok-Hung Kwong, Siu-Ho Lam Aim Recurrent bleeding carries a significant impact in patients with bleeding peptic ulcers. From our published randomised controlled trial, we have demonstrated that by repeating a second endoscopy with appropriate therapy within 16-24 hours after endoscopic hemostasis, we could reduce the rate of recurrent bleeding from 13.8% to 5%. In this study, we would like to identify possible factors that predict the development of recurrent bleeding in patients after receiving a scheduled second endoscopy. Methods 249 patients presented to the United Christian Hospital, Hong Kong from 8.1999 to 12. 2002 with acute bleeding peptic ulcers. All these patients received a scheduled second endoscopy after initial successful endoscopic hemostasis. The data, which included clinical, endoscopic and outcome measures were collected and subjected to statistical analysis. Results There were 146 patients with bleeding duodenal ulcers (58.6%), 101 patients with gastric ulcers (40.6%) and 2 patients with anastomotic ulcers (0.8%). 17 patients developed recurrent bleeding (6.8%), 7 of themwere treated by another successful endoscopic therapy, while the remaining 10 patients required surgical intervention. The overall mortality rate was 2.8 %. Mortality rate in the recurrent bleeding group was 17.6%, compared with 1.7% in the non-rebleeding group (p=0.008). Multiple logistic regression on the possible prediction factors found that endoscopic findings of persistent stigmata of active bleeding, vessel or clots on scheduled second endoscopy (Odd ratio 6.58, 95% CI 2.23-19.4), ulcer with size > 1.0cm (Odd ratio 5.62, 95% CI 1.90-16.6), and Hb on admission less than 8 g/dl (Odd ratio 3.91, 95%CI 1.39-11.0) are associated with a significant risk of recurrent bleeding after scheduled second endoscopy. Conclusions Recurrent bleeding after scheduled second endoscopy carries a high mortality. Endoscopic factors, including the endoscopic classification of bleeding peptic ulcers on scheduled second endoscopy and ulcer size, and clinical factors like low Hb on admission are important predictors for recurrent ulcer bleeding. Those high risk patients perhaps will benefit from early surgery. **361 Long Term Outcome of Patients with Unexplained GI Bleeding Investigated by Push Enteroscopy Marie Bellecoste-Martin, Jean-Louis Gaudin, Sabine Roman, Veronique Michalet, Jean-Christophe Souquet In unexplained GI bleeding, lesions are evidenced by push enteroscopy in 50 to 70%of patients; half of them, at best, are located within the small bowell. The long term outcome of such patients has been seldomly studied and the real impact of enteroscopy is presently poorly known. The aims of this retrospective study were to determine the long term evolution of a large group of patients with unexplained GI bleeding and the impact of enteroscopy on patients’ management. Patients and methods: 138 consecutive patients with unexplained GI bleeding (normal gastroscopy and colonoscopy) were explored by enteroscopy from 07/95 to 12/ 01. Patients’status was determined inO4/03 by studying patient’s file, phone call to GP’s or the patient itself. 6 patients were lost of follow-up. For the 132 remaining patients with a mean age of 57, there were 72 male and 60 female; 83 had at least one episode of overt GI bleeding, while 49 had only occult bleeding with severe anemia. 68% of patients had received blood transfusions. A mean of 5.6 examinations had been performed before enteroscopy. Mean follow-up was 42.4 months. Results: Enteroscopy found at least one GI lesion in 78 patients (59%), located in the small intestine in 40. Following enteroscopy, specific treatment was given in 59. During follow-up, 61% of patients rebled (in mean 15 months after enteroscopy). 37 patients needed blood transfusions and 75 at least one examination in relation with bleeding. At the end of follow-up, 12 patients (9.1%) had died from bleeding, a percentage higher than in other series with shorter follow-up. 81 patients did not bleed anymore, 27 needed iron administration and 12 repeated blood transfusions. A highly probable diagnosis was made in 103 patients. The causative lesion was located in the small bowel in 40, the stomach or the colon in 54, and outside the GI tract in 9. Index enteroscopy had allowed the diagnosis in 53%of these patients, but only in 15%when only the small bowell was considered. Enteroscopy was fully useful in 14 patients (i.e. made the correct diagnosis and allowed a successfull treatment,without other examinations). Patient with normal enteroscopy had decreased mortality (2 vs 14%) and needed less transfusions (13 vs 38.5%). Conclusions:In this large series, enteroscopy was beneficial in only a low proportion of patients with unexplained GI bleeding. Other examination (videocapsule) has to be performed first, enteroscopy being performed only for treatment or biopsy purpose in case of upper jejunum abnormality. |
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