 |
|
Therapeutic Endoscopy and Bleeding Ulcers
JAMA. 1989;262(10):1369-1372.
Abstract
| |
Peptic ulcer disease is a major health problem in the United States that affects more than 4 million people each year. Bleeding is one of the most dread complications of peptic ulcer. Upper gastrointestinal bleeding is a common cause of emergency hospitalization in the United States. It has been estimated that more than 100 000 patients with peptic ulcer disease bleed each year. Morbidity and mortality from ulcer bleeding remain significant despite major improvements in the accurate diagnosis of peptic ulcer disease and the use of H2-receptor antagonist drugs and other pharmacologic agents. The mortality rate from bleeding ulcers has averaged between 6% and 10% during the past 30 years despite advances in diagnosis and treatment.
During the past decade, there has been a remarkable transition of the application of the endoscope from solely a diagnostic tool to a therapeutic modality. With the advent of this therapeutic role, there has been much enthusiasm about using endoscopie techniques in managing high-risk patients. A variety of approaches for endoscopie management of bleeding have evolved and there has been continuing improvement over the past decade, resulting in considerable interest in evaluating the various treatment options for managing patients with bleeding ulcers. Unfortunately, there have been limited and conflicting clinical studies on the efficacy and safety of the various hemostatic modalities available for treating these ulcers. In an effort to define the role of these methods, the National Institute of Diabetes and Digestive and Kidney Diseases and the Office of Medical Applications of Research of the National Institutes of Health sponsored a Consensus Development Conference on therapeutic endoscopy and bleeding ulcers. The conference brought together research clinicians and other health professionals and representatives of the public on March 6 through 8, 1989. Following 2 days of presentations and discussion by the invited experts and the audience, members of a consensus panel drawn from the health care and medical communities weighed the scientific evidence in formulating a statement in response to several questions:
- Which patients with bleeding ulcers are at risk for rebleeding and thus emergency surgery?
- How effective is endoscopie hemostatic therapy?
- How safe is endoscopie hemostatic therapy?
- Which bleeding patients should be treated?
- What further research is required?
It is important that certain limitations be considered when applying the findings of this conference to a particular bleeding patient. The conference was charged to address specifically the question of therapeutic endoscopy for the treatment of bleeding peptic ulcer. Other causes of upper gastrointestinal bleeding, including gastric and esophageal varices, diffuse erosive gastritis, and Mallory-Weiss tears, were necessarily excluded from consideration. It should be noted that the conclusions reached should not be extrapolated to those diseases excluded from consideration. Moreover, a striking finding from the review of available clinical trials of therapeutic endoscopy was the selective inclusion of only a small proportion (10% to 25%) of the total population of patients who presented with upper gastrointestinal bleeding. In addition to patients with the above diagnoses, many other patients were also excluded, quite appropriately, owing to hemorrhage too massive or too little to justify prudent therapeutic endoscopy.
In this conference, the need for emergency surgery was taken as one indicator of inadequately controlled bleeding. Although many patients treated with surgery do well, they are subjected to additional discomfort and cost and to approximately a 10% risk of mortality when the surgery must be performed under such emergency conditions. On the other hand, when temporary hemostasis achieved by endoscopie therapy allows resuscitation and hemodynamic control of a patient whose condition is unstable, considerable benefit may be realized even if surgery must be performed ultimately. Fora variety of reasons, a surgeon should be involved from the outset in the team caring for the patient with bleeding peptic ulcer.
Footnotes
NIH Consensus Development Conferences are convened to evaluate available scientific information and to resolve safety and efficacy issues related to a biomedical technology. The resultant NIH Consensus Statements are intended to advance understanding of the technology or issue in question and to be useful to health professionals and the public.
NIH Consensus Statements are prepared by a nonadvocacy, nonfederal panel of experts based on (1) presentations by investigators working in areas relevant to the consensus question during a 1 1/2-day public session; (2) questions and statements from conference attendees during open discussion periods that are part of the public session; and (3) closed deliberations by the panel during the remainder of the second day and the morning of the third day. This statement is an independent report of the panel and is not a policy statement of the NIH or the federal government.
From the Office of Medical Applications of Research, National Institutes of Health, Bethesda, Md.
Reprint requests to Office of Medical Applications of Research, Bldg 1, Room 260, National Institutes of Health, Bethesda, MD 20892 (William H, Hall). Bibliography, prepared by the National Library of Medicine, is available from the same address.
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Management of Acute Bleeding from a Peptic Ulcer
Gralnek et al.
NEJM 2008;359:928-937.
FULL TEXT
The Effect of Endoscopic Therapy in Patients Receiving Omeprazole for Bleeding Ulcers with Nonbleeding Visible Vessels or Adherent Clots: A Randomized Comparison
Sung et al.
ANN INTERN MED 2003;139:237-243.
ABSTRACT
| FULL TEXT
Treatment of Patients at High Risk for Recurrent Bleeding from a Peptic Ulcer
Jensen
ANN INTERN MED 2003;139:294-295.
FULL TEXT
Endoscopy for Acute Nonvariceal Upper Gastrointestinal Tract Hemorrhage: Is Sooner Better?: A Systematic Review
Spiegel et al.
Arch Intern Med 2001;161:1393-1404.
ABSTRACT
| FULL TEXT
The Role of Endoscopy in Managing Acute Lower Gastrointestinal Bleeding
Gostout
NEJM 2000;342:125-127.
FULL TEXT
Prospective Evaluation of a Clinical Guideline Recommending Hospital Length of Stay in Upper Gastrointestinal Tract Hemorrhage
Hay et al.
JAMA 1997;278:2151-2156.
ABSTRACT
A Comparison of Omeprazole and Placebo for Bleeding Peptic Ulcer
Khuroo et al.
NEJM 1997;336:1054-1058.
ABSTRACT
| FULL TEXT
Therapy for Bleeding Peptic Ulcers
Saltzman and Zawacki
NEJM 1997;336:1091-1093.
FULL TEXT
Bleeding Peptic Ulcer
Laine and Peterson
NEJM 1994;331:717-727.
FULL TEXT
Endoscopic Hemostasis: An Effective Therapy for Bleeding Peptic Ulcers
Sacks et al.
JAMA 1990;264:494-499.
ABSTRACT
Gastric Lavage in Patients With Gastrointestinal Hemorrhage: Yea or Nay?
BASUK and ISENBERG
Arch Intern Med 1990;150:1379-1380.
ABSTRACT
|
