The natural history (fading time) of stigmata of recent hemorrhage in peptic ulcer disease

doi:10.1016/S0016-5107(94)70253-5

Gastrointestinal Endoscopy

Volume 40, Issue 5, September–October 1994, Pages 562-566

https://doi.org/10.1016/S0016-5107(94)70253-5 Get rights and content

Abstract

From October 1991 to December 1992, 144 patients with bleeding peptic ulcer and stigmata of recent hemorrhage were included in a study designed to investigate, by means of endoscopic examinations repeated at 2-day intervals, the evolutionary development of stigmata of recent hemorrhage, such as visible vessels, and to determine the time required for each type of stigma to fade. Eighty-five patients underwent endoscopic follow-up until the stigmata had disappeared. A visible vessel takes about 4.1 ± 2.1 days to disappear, requiring significantly more time than an adherent clot or an old stigma, which take 2.4 ± 0.8 days and 2.4 ± 1.3 days, respectively ( p < .05). Bleeding does not recur after stigmata disappear. Time required for stigmata to fade is not affected by age, sex, smoking, history of peptic ulcer, ulcer location, severe bleeding, underlying systemic disease, or endoscopic local therapy. While healing, stigmata of recent hemorrhage evolve through a sequence of phases: a visible vessel may or may not appear as an adherent clot and then as a red or black flat spot before disappearing. (Gastrointest Endosc 1994;40:562-6.)

Section snippets

MATERIALS AND METHODS

Patients with peptic ulcer bleeding admitted to the National Cheng Kung University Hospital emergency department from October 1991 to December 1992 were included in the study. Subjects with an established diagnosis of peptic ulcer with SRH as determined by panendoscopy performed within 24 hours of admission were entered in a series of follow-up endoscopic observations at 2-day intervals until SRH disappeared. All patients gave informed consent. Olympus endoscopes CV200 GIF, XQ200, CV-1, and GIF

RESULTS

One hundred forty-four patients were included in the study, and 85 patients completed the series of follow-up endoscopic examinations until SRH had disappeared. Fifty-nine patients were excluded for the following reasons: 45 patients refused further endoscopy; 5 patients had other potential sources of bleeding (esophageal varices); 1 patient had an angina attack and was unsuitable for repeated endoscopy; 8 patients rebled later. Four of the 8 patients who rebled presented with a visible vessel

DISCUSSION

Peptic ulcer, a common disease with a prevalence of about 10% in the general population, is characterized by a high incidence of recurrence and complications of bleeding.⁸ Approximately 25% of patients with peptic ulcer experience bleeding in 10 years, and a mortality rate of 5% to 14% accompanies every episode of bleeding.9, 10, 11, 12, 13, 14 The problem of bleeding is particularly serious when it occurs in elderly patients or if it is continuous or recurrent.

Peptic ulcer bleeding can be

Acknowledgements

The authors thank Dr. Ming-Ho Wu, Dr. Ginger H.F. Shu, and Miss Wan-Chi Chang for their assistance.

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Silencing the Erupter: Over-the-Scope Clip in the Management of Nonvariceal Upper Gastrointestinal Bleeding
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Improved characterization of visible vessels in bleeding ulcers by using magnification endoscopy: Results of a pilot study
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Citation Excerpt :
Therefore, the presence of an NBVV may not be in itself a sufficiently reliable indicator with which to select patients for invasive therapy. Evolution of the stigmata over time is another important factor: visible vessels take significantly more time to disappear than adherent clots.20 In this study, endoscopy was always performed early, within 24 hours from the onset of bleeding, to avoid time-biased observation of the lesion.
Not all exposed vessels carry the same risk of recurrent bleeding, and sometimes endoscopic therapy may not be warranted in the setting of profound acid inhibition therapy.
To investigate the role of magnification endoscopy (ME) in improving the characterization of exposed vessels in ulcer hemorrhage.
Prospective study.
Single-center teaching hospital.
Diagnostic accuracy and safety of ME in patients with bleeding peptic ulcers.
A total of 43 patients were studied. Exposed vessels were initially categorized as high risk (protuberant, translucent, or pale) in 25 and low risk (nonprotruding through the ulcer floor, pigmented, or dark red) in 18 cases. ME was subsequently performed, and the operator was asked to reclassify the vessel into 1 of these 2 categories. A magnified view provided a clear image of the vessel and allowed visualization of the artery, the site of rupture, and the presence of a clot plugging the hole. In 6 cases previously categorized as low risk, ME clearly showed the 2 ends of the vessel, the longitudinal tear in the vessel wall, and a protuberant aspect that was not seen with standard view. The lesion was then reclassified as high risk (diagnostic gain 33%). The mean procedure time for ME inspection was 7 ± 4 minutes. No complications occurred.
Absence of controls.
In patients with peptic ulcer bleeding and exposed vessels, ME allows clear visualization of the vessel wall and provides detailed clues to further characterize the lesion.
Gastrointestinal Bleeding
2010, Sleisenger and Fordtran’s Gastrointestinal and Liver Disease- 2 Volume Set: Pathophysiology, Diagnosis, Management, Expert Consult Premium Edition - Enhanced Online Features and Print
Seven-day intravenous low-dose omeprazole infusion reduces peptic ulcer rebleeding for patients with comorbidities
2009, Gastrointestinal Endoscopy
Citation Excerpt :
From April 2004 to April 2008, a total of 147 patients with one or more comorbidities, who were undergoing upper gastroscopy because of peptic ulcer bleeding with stigmata of recent hemorrhage (SRH), and proven to have good hemostasis by endoscopic therapy, were consecutively enrolled in this study. The SRH was defined as either major or minor in our previous report.14 All of the major SRHs were treated by either local injection of diluted epinephrine 1:10,000, with or without combined therapy with heat probe, argon plasma coagulation, band ligation, or hemoclip therapy to eradicate the vessel.
Patients with comorbidities have an increased risk of ulcer rebleeding, especially within the 28 days after endoscopic therapy. Omeprazole infusion can prevent rebleeding after endoscopic therapy in patients with peptic ulcer bleeding. However, the optimal duration is uncertain, especially for those patients with comorbidities.
To determine whether prolonged low-dose intravenous omeprazole could reduce rebleeding for patients with comorbidities.
A prospective randomized control study.
National Cheng Kung University, Tainan, Taiwan.
A total of 147 patients with comorbidities and peptic ulcer bleeding controlled by endoscopic hemostasis were enrolled.
The enrolled patients were randomized into either the 7-day low-dose group or the 3-day high-dose group, who received 3.3 mg/h or 8 mg/h continuous omeprazole infusion, respectively. After omeprazole infusion, oral esomeprazole 40 mg every day was given.
To compare the rebleeding rates within 28 days after gastroscopy between the 2 study groups.
The 7-day cumulative rebleeding rate was similar between the 2 groups (9.5% vs 9.7%, P > .05), but the 7-day low-dose group had a lower risk of rebleeding between the 8th and 28th day compared with the 3-day high-dose group (0% vs 10.7%, P = .03; relative risk, 0.52 [95% CI, 0.43-0.63]). The Kaplan-Meier curves confirmed that the 7-day low-dose group had a significantly higher cumulative rebleeding-free proportion between the 8th and 28th day than the 3-day high-dose group (P = .02, log-rank test).
In Asian patients, prolonged low-dose omeprazole infusion for 7 days may reduce peptic ulcer rebleeding during the first 28 days in patients with comorbidities.
A randomized study of the safety of outpatient care for patients with bleeding peptic ulcer treated by endoscopic injection
2004, Gastrointestinal Endoscopy
Outpatient management is safe for patients with non-variceal upper-GI bleeding who are at low risk of recurrent bleeding and death. However, outpatient care cannot be offered to many patients because of the presence of risk factors (severe comorbid disorders, major endoscopic stigmata of bleeding, significant hemorrhage). The present study assessed the safety of outpatient management for selected high-risk patients with bleeding peptic ulcer.
Patients hospitalized with upper-GI bleeding because of peptic ulcer with a non-bleeding vessel were eligible for inclusion in the study. Inclusion criteria were the following: ulcer size less than 15 mm, absence of hypovolemia, no associated severe disease, and appropriate family support. After endoscopic therapy (injection of epinephrine and polidocanol), patients were randomized to outpatient or hospital care. Patients remained in the emergency ward for a minimum of 6 hours before discharge, during which time omeprazole was administered intravenously. Outpatients were contacted by telephone daily during the first 3 days; a 24-hour telephone hotline was provided for any queries. For both groups, outpatient visits were scheduled at 7 to 10 and 30 days after discharge.
A total of 82 patients were included: 40 were randomized to outpatient care and 42 to hospital care. Clinical and endoscopic variables were similar in both groups. The rate of recurrent bleeding was similar in both groups (4.8% outpatient, 5% hospital). There was no morbidity or mortality in either group at 30 days. Seven patients (17%) randomized to outpatient care received blood transfusion compared with 14 (38%) in the hospital care group (p = 0.06). Mean cost of care per patient was significantly lower for the outpatient vs. the hospital group ($970 vs. $1595; p < 0.001).
Selected patients with bleeding peptic ulcer can be safely managed as outpatients after endoscopic therapy. This policy conserves health care resources without compromising standards of care.
Recurrent bleeding from peptic ulcer associated with adherent clot: A randomized study comparing endoscopic treatment with medical therapy
2002, Gastrointestinal Endoscopy
Citation Excerpt :
In the present study, the participating endoscopists met and reviewed the definition, as well as endoscopic pictures of various stigmata, in an effort to reduce the effects of this variable and to conform the study to a specific definition of an adherent clot. ( 5) Timing of endoscopy is also a critical variable because there can be a stabilizing evolution of a clot over time.16,17 In many studies, the exact timing of endoscopy in relation to the onset of bleeding is not stated.
Background: Endoscopic therapy reduces the recurrence of bleeding from actively bleeding peptic ulcers and those with visible vessels. However, the use of endoscopic therapy for ulcers with adherent clots remains controversial. The purpose of this study was to determine whether removal of clot from an ulcer and endoscopic therapy reduces the frequency of recurrent bleeding. Methods: Patients with acute upper GI bleeding from peptic ulcers with adherent clots and no active bleeding were enrolled in a multicenter study. At each center patients were stratified for age, use of nonsteroidal anti-inflammatory drugs, and ulcer location, and were randomized to endoscopic or medical management. Endoscopic therapy consisted of injection of the base of the adherent clot with a solution of epinephrine and mechanical removal of the clot. The base of the ulcer and any stigmata of bleeding were then coagulated until cavitation and adequate coagulation were obtained. Patients in both groups received standard medical therapy for peptic ulcer. Patients were evaluated for recurrence of bleeding for 1 month. Results: Fifty-six patients were enrolled. Rates of recurrent bleeding were 34.3% (12/35) in the medical treatment arm versus 4.8% (1/21) in the endoscopic treatment arm (p < 0.02). Conclusions: In patients with GI bleeding caused by gastric or duodenal ulcers with an adherent clot found on endoscopy, endoscopic therapy with injection of the base of the clot, clot removal, and heat probe coagulation significantly reduces the rate of recurrent bleeding compared with medical therapy alone. (Gastrointest Endosc 2002;56:1-6.)

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^☆: From the Division of Gastroenterology, Department of Internal Medicine, Department of Emergency Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.

^☆☆: Reprint requests: Jeng-Shiann Shin, MD, Division of Gastroenterology, Department of Internal Medicine, National Cheng Kung University Hospital, 138, Sheng Li Road, Tainan 704, Taiwan.

^★: 37/1/55012

^★★: GASTROINTESTINAL ENDOSCOPY

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The natural history (fading time) of stigmata of recent hemorrhage in peptic ulcer disease☆,☆☆,★,★★

Abstract

Section snippets

MATERIALS AND METHODS

RESULTS

DISCUSSION

Acknowledgements

Gastroenterology

Gastroenterology

Gastroenterology

Anatomie pathologique du corps humain

Gastroscopy

Die Gastroskopie

Endoscopic prediction of recurrent bleeding in peptic ulcers

N Engl J Med

The visible vessel as an indicator of uncontrolled or recurrent hemorrhage

N Engl J Med

Stigmata of recent hemorrhage in diagnosis and prognosis of upper gastrointestinal bleeding

BMJ

Randomized trial of endoscopic argon laser, photocoagulation in bleeding peptic ulcer

Gut