Clin Endosc.  2011 Dec;44(2):93-100. 10.5946/ce.2011.44.2.93.

Clinical Outcomes and Risk Factors of Rebleeding Following Endoscopic Therapy for Nonvariceal Upper Gastrointestinal Hemorrhage

• Suk KT
• Kim HS
• Lee CS
• Lee IY
• Kim MY
• Kim JW
• Baik SK
• Kwon SO
• Lee DK
• Ham YL

• KMID: 1805255
• DOI: http://doi.org/10.5946/ce.2011.44.2.93

Abstract

BACKGROUND/AIMS
Rebleeding after endoscopic therapy for non-variceal upper gastrointestinal hemorrhage (NGIH) is the most important predictive factor of mortality. We evaluated the risk factors of rebleeding in patients undergoing endoscopic therapy for the NGIH.
METHODS
Between January 2003 and January 2007, 554 bleeding events in 487 patients who underwent endoscopic therapy for NGIH were retrospectively enrolled. We reviewed the clinicoendoscopical characteristics of patients with rebleeding and compared them with those of patients without rebleeding.
RESULTS
The incidence of rebleeding was 21.7% (n=120). In the multivariate analysis, initial hemoglobin level < or =9 g/dL (p=0.002; odds ratio [OR], 2.433), inexperienced endoscopist with less than 2 years of experience in therapeutic endoscopy (p=0.001; OR, 2.418), the need for more 15 cc of epinephrine (p=0.001; OR, 2.570), injection therapy compared to thermal and injection therapy (p=0.001; OR, 2.840), and comorbidity with chronic renal disease (p=0.004; OR, 2.908) or liver cirrhosis (p=0.010; OR, 2.870) were risk factors for rebleeding following endoscopic therapy.
CONCLUSIONS
Together with patients with low hemoglobin level at presentation, chronic renal disease, liver cirrhosis, the need for more 15 cc of epinephrine, or therapy done by inexperienced endoscopist were risk factors for the development of rebleeding.

Keyword

Gastrointestinal hemorrhage; Risk factors; Endoscopy; Therapy

MeSH Terms

Comorbidity
Endoscopy
Epinephrine
Gastrointestinal Hemorrhage
Hemoglobins
Hemorrhage
Humans
Incidence
Liver Cirrhosis
Multivariate Analysis
Odds Ratio
Renal Insufficiency, Chronic
Retrospective Studies
Risk Factors
Epinephrine
Hemoglobins

Figure

• 

  Fig. 1 Bleeding status. (A) Active pumping. (B) Active oozing. (C) Vessel exposure. (D) Red or black clot.

• 

  Fig. 2 Serial endoscopic findings show rebleeding after the initial endoscopic therapy. (A) Initial endoscopic finding. (B) Post state of epinephrine injection+argon plasma coagulation. (C) Rebleeding occurred 2 days after the initial endoscopic treatment. (D) Second endoscopic therapy with epinephrine injection+argon plasma coagulation. (E) Post state of second endoscopic therapy.

Reference

1. Barkun A, Bardou M, Marshall JK. Nonvariceal Upper GI Bleeding Consensus Conference Group. Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2003; 139:843–857. PMID: 14623622.

2. Laine L, Peterson WL. Bleeding peptic ulcer. N Engl J Med. 1994; 331:717–727. PMID: 8058080.

3. Müller T, Barkun AN, Martel M. Non-variceal upper GI bleeding in patients already hospitalized for another condition. Am J Gastroenterol. 2009; 104:330–339. PMID: 19174801.

4. Chiu PW, Joeng HK, Choi CL, Kwong KH, Ng EK, Lam SH. Predictors of peptic ulcer rebleeding after scheduled second endoscopy: clinical or endoscopic factors? Endoscopy. 2006; 38:726–729. PMID: 16810597.

5. Lin HJ, Lo WC, Lee FY, Perng CL, Tseng GY. A prospective randomized comparative trial showing that omeprazole prevents rebleeding in patients with bleeding peptic ulcer after successful endoscopic therapy. Arch Intern Med. 1998; 158:54–58. PMID: 9437379.

6. Wong SK, Yu LM, Lau JY, et al. Prediction of therapeutic failure after adrenaline injection plus heater probe treatment in patients with bleeding peptic ulcer. Gut. 2002; 50:322–325. PMID: 11839708.

7. Kaviani MJ, Hashemi MR, Kazemifar AR, et al. Effect of oral omeprazole in reducing re-bleeding in bleeding peptic ulcers: a prospective, double-blind, randomized, clinical trial. Aliment Pharmacol Ther. 2003; 17:211–216. PMID: 12534405.

8. Chan FK, Ching JY, Hung LC, et al. Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding. N Engl J Med. 2005; 352:238–244. PMID: 15659723.

9. Chiu PW, Ng EK, Cheung FK, et al. Predicting mortality in patients with bleeding peptic ulcers after therapeutic endoscopy. Clin Gastroenterol Hepatol. 2009; 7:311–316. PMID: 18955161.

10. Wolf AT, Wasan SK, Saltzman JR. Impact of anticoagulation on rebleeding following endoscopic therapy for nonvariceal upper gastrointestinal hemorrhage. Am J Gastroenterol. 2007; 102:290–296. PMID: 17100959.

11. Tajima A, Koizumi K, Suzuki K, et al. Proton pump inhibitors and recurrent bleeding in peptic ulcer disease. J Gastroenterol Hepatol. 2008; 23(Suppl 2):S237–S241. PMID: 19120905.

12. Andriulli A, Annese V, Caruso N, et al. Proton-pump inhibitors and outcome of endoscopic hemostasis in bleeding peptic ulcers: a series of meta-analyses. Am J Gastroenterol. 2005; 100:207–219. PMID: 15654802.

13. Lau JY, Sung JJ, Lee KK, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Engl J Med. 2000; 343:310–316. PMID: 10922420.

14. Ng FH, Wong SY, Lam KF, et al. Gastrointestinal bleeding in patients receiving a combination of aspirin, clopidogrel, and enoxaparin in acute coronary syndrome. Am J Gastroenterol. 2008; 103:865–871. PMID: 18177451.

15. Marmo R, Koch M, Cipolletta L, et al. Predictive factors of mortality from nonvariceal upper gastrointestinal hemorrhage: a multicenter study. Am J Gastroenterol. 2008; 103:1639–1647. PMID: 18564127.

16. Sung JJ, Barkun A, Kuipers EJ, et al. Intravenous esomeprazole for prevention of recurrent peptic ulcer bleeding: a randomized trial. Ann Intern Med. 2009; 150:455–464. PMID: 19221370.

17. Cheung J, Yu A, LaBossiere J, Zhu Q, Fedorak RN. Peptic ulcer bleeding outcomes adversely affected by end-stage renal disease. Gastrointest Endosc. 2010; 71:44–49. PMID: 19595311.

18. Dinoso VP Jr, Murthy SN, Saris AL, et al. Gastric and pancreatic function in patients with end-stage renal disease. J Clin Gastroenterol. 1982; 4:321–324. PMID: 7119408.

19. Hu ML, Wu KL, Chiu KW, et al. Predictors of rebleeding after initial hemostasis with epinephrine injection in high-risk ulcers. World J Gastroenterol. 2010; 16:5490–5495. PMID: 21086569.

20. Vallurupalli NG, Goldhaber SZ. Gastrointestinal complications of dual antiplatelet therapy. Circulation. 2006; 113:e655–e658. PMID: 16567572.

21. Peters RJ, Mehta SR, Fox KA, et al. Effects of aspirin dose when used alone or in combination with clopidogrel in patients with acute coronary syndromes: observations from the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) study. Circulation. 2003; 108:1682–1687. PMID: 14504182.

22. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010; 152:101–113. PMID: 20083829.