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Doppler probe reduced 30-day bleeding in non-variceal upper GI hemorrhage
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WASHINGTON — A Doppler-guided hemostasis device was associated with significant improvements in 30-day bleeding outcomes in a cohort of patients with non-variceal hemorrhage, according to findings presented in the late-breakers session.
Dennis M. Jensen, MD, of the CURE Digestive Diseases Research Center at the David Geffen School of Medicine at UCLA, and the VA Greater Los Angeles Healthcare System in California, and colleagues, aimed to compare 30-day re-bleed rates of index lesions in a cohort of 148 patients treated with standard endoscopic hemostasis or procedures guided by Doppler Endoscopic Probe (Vascular Technology).
“The aim of this randomized controlled study was to first compare the rate of re-bleed for the index lesions for patients who were treated either with standard visually-guided hemostasis vs. Doppler-guided hemostasis,” Jensen said.
Eligible participants had severe non-variceal upper GI hemorrhage (including clinical signs, decrease in hemoglobin and red blood cell transfusions) along with benign-appearing ulcers and some stigmata of recent hemorrhage or Dieulafoy’s lesions or Mallory Weiss tears.
Standard surgery included hemoclipping and/or multipolar electrocoagulation with or without dilute epinephrine injection. In the Doppler group, stigmata of recent hemorrhage and lesion base were interrogated for underlying blood flow, after which standard therapy was used on and out from the stigmata of recent hemorrhage, where clinicians traced the artery, according to the results. If residual blood flow occurred, the Doppler was used to recheck. At this point, clinicians performed further hemostasis until no blood flow was detected.
There were 76 patients in the standard treatment arm and 72 patients in the Doppler-assisted arm.
Endoscopic intervention was not used in patients in the standard therapy arm who had flat spots.
Treatment for ulcers and Dieulafoy’s lesions included high dose proton pump inhibitor (PPI) infusion for 72 hours and then twice a day for 30 days. Anti-emetics and PPI were used to treat Mallory Weiss tears.
Overall, 26.7% of patients receiving standard therapy and 11% of those treated with the Doppler device experienced one of these endpoints.
Jensen reported that active arterial bleeding occurred in 50% of patients in the standard arm and 28.6% of those in the Doppler arm. Non-bleeding visible vessel was reported in 25.9% of those receiving standard therapy and 15.4% of those treated with the Doppler device.
The adherent clot rate was 25%; the flat spot rate was 20%; and the oozing bleeding rate was 14.3% in the standard therapy, while rates of all three of these outcomes were 0% for the Doppler group.
“In every category, there was a lower frequency of re-bleeding [in the Doppler group],” Jensen said.
Surgery was lower in the Doppler group, and the mortality rates were similar between the two groups, according to Jensen. There was one perforation in the standard therapy group. “As far as red cells, as you would expect, there was a reduction at 30 days for the Doppler group,” he said.
“We recommend Doppler usage along with visual stigmata hemorrhage as a new guide to risk stratification and definitive hemostasis in patients with non-variceal bleeding,” Jensen concluded.
For more information:
Jensen D, et al. Abstract 901b. Presented at: Digestive Disease Week, May 16-19, 2015; Washington, D.C.
Disclosure: Jensen reports consulting for VTI and BFC. Please see the DDW faculty disclosure index for all other researchers’ relevant financial disclosures.
Perspective
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John Vargo, MD, MPH
We have classically used endoscopic stigmata of recent hemorrhage in order to stratify re-bleeding risk in our patients with acute upper GI bleeding. But following satisfactory therapy to the area of bleeding, is there any other avenue for endoscopists to verify success? The study by Jensen and colleagues utilized a novel ultrasound probe to interrogate a variety of non-variceal upper GI bleeding lesions. The hypothesis was whether there could be an underlying arterial signal beneath the treatment area that would belie the appearance of the treatment area. For example, if there was a gastric ulcer with a visible vessel and following endoscopic therapy it appears to be adequately treated, could there be a high risk artery in the ulcer bed which could evade careful endoscopic scrutiny? The answer form this study is "yes."
The authors randomized subjects with nonvariceal upper GI bleeding and high risk bleeding lesions to endoscopic therapy with or without Doppler probe examination following the therapy itself.
The investigators found was that, indeed, what we see is not always what we get. The Doppler probe detected visually unidentified vessels despite a satisfactory endoscopic appearance which led to additional therapy. The Doppler probe group exhibited a significantly lower re-bleeding rate when compared to those who received therapy to a satisfactory visual appearance.
This has the potential of being a game-changing addition to our diagnostic armamentarium for non-variceal upper GI bleeding. The data is exciting and would indicate that even though we visualize a bleeding site that appears to be endoscopically treated, the addition of this ultrasound probe could actually add to our ability to determine whether it has been adequately treated or not.
I am very excited about these results and look forward to further validation by other groups.
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