Endoscopic Band Ligation Could Decrease Recurrent Bleeding in Mallory–Weiss Syndrome as Compared to Haemostasis by Hemoclips Plus Epinephrine

Endoscopic Band Ligation Versus Hemoclips Plus Epinephrine

S. Lecleire, M. Antonietti; I. Iwanicki-Caron; A. Duclos; S. Ramirez; E. Ben-Soussan; S. Hervé; P. Ducrotté

Disclosures

Aliment Pharmacol Ther. 2009;30(4):399-405. 

In This Article

Discussion

Our results suggest that endoscopic band ligation and hemoclip placement associated with epinephrine injection are both safe and efficient in primary haemostasis of bleeding MWS. However, a recurrent bleeding occurred significantly more often in patients treated by hemoclips combined with epinephrine than in patients treated by band ligation.

This is the first time that band ligation is proved to decrease the rebleeding rate as compared with hemoclip placement combined with epinephrine injection. This result was confirmed by our multivariate analysis, although the study design was retrospective. The results of several series suggested that the use of epinephrine injection alone in MWS with active bleeding could lead to an increased rate of recurrent bleeding as compared to mechanical haemostasis procedures.[5,9,10] For this reason, epinephrine injection alone should not be performed as a first-line haemostasis in MWS. Moreover, the only study available in the literature that compared band ligation and hemoclip placement in bleeding MWS did not show any difference between the two techniques as regards the primary haemostatic efficacy and the rebleeding rate.[12] Nevertheless, in that study of 20 patients in each arm, the mean haemoglobin level at admission was 12 g/dL and there were only 17% of patients who presented at admission with hemodynamic shock. These data suggest that the bleeding was not always very abundant in those patients. In our series, a shock defined by an hemodynamic instability was found in a half of admitted patients with bleeding MWS and the mean haemoglobin level was 8.7 g/dL, showing that the bleeding was very abundant and poorly tolerated. This could partly explain the higher rate of rebleeding observed in our patients. Shock at admission and haemoglobin level less than 10 g/dL are indeed two well-known risk factors of rebleeding in peptic ulcer haemorrhage treated by endoscopic haemostasis.[16,17] In our study, shock at admission was also significantly associated with a rebleeding in univariate analysis and there was a trend towards a higher risk of rebleeding after logistic regression, although it did not reach statistical significance.

The use of antiplatelets or anticoagulant drugs was a significant risk factor of rebleeding in our study in univariate analysis, but not after logistic regression. The use of antiplatelets or anticoagulant drugs is a debated risk factor of rebleeding in upper GI haemorrhage treated by endoscopic haemostasis.[18–21] Basically, the use of anticoagulants does not seem to be associated with an increased rate of rebleeding,[20] whereas the use of antiplatelet therapy could be associated with an increase in rebleeding.[21] This result raises the issue of the reintroduction time of antiplatelets or anticoagulant drugs after a successful primary endoscopic haemostasis in gastrointestinal bleeding, including in MWS. In current practice, this can be a real problem in patients with drug-eluting coronary stents, who need the continuous use of dual antiplatelet therapy for 6–12 months, because of the important risk of stent thrombosis.[22] In these patients, the early discontinuation of the antiplatelet therapy is associated with an increased risk of 26.9% of death, myocardial infarction or stroke.[23] Patients taking antiplatelets or anticoagulant drugs should have the most efficient haemostasis procedure in case of UGIB. The confirmation of our results by a prospective randomized trial would favour the primary endoscopic haemostasis by band ligation in patients with bleeding MWS.

The decreased rate of rebleeding in MWS patients treated by band ligation as compared with hemoclips plus epinephrine deserves further explanations. It can be observed that the hemoclip placement in a bleeding MW tear is challenging because of the haemorrhage location at the oesophago-gastric junction and is probably more technically demanding than band ligation at this site. It has already been suggested that the variable success rates for endoscopic hemoclip application in gastrointestinal bleeding lesions may reflect the technical difficulty of accurate placement.[24,25] This has been described in peptic ulcer bleeding, where the tangential approach of the lesions was the major cause of failure of successful hemoclip placement.[25] In contrast, band ligation is simple and easy to perform in the lower oesophagus, even with the endoscope placed tangential to the bleeding lesion, where it is widely used for oesophageal variceal bleeding. Moreover, oesophageal and cardial motility could be associated with the hemoclips detachment because of high amplitude contractions at this anatomic site. Indeed, a clip placement remains quite superficial compared to band ligation, where mucosa and submucosa are strongly sucked before banding and less exposed to an unexpected detachment after vigorous oesophageal contractions. To finish with, a prior injection of epinephrine could have led to a tissue oedema at the bleeding location, rendering the hemoclip more prone to spontaneous detachment. Moreover, conceptually, band ligation can treat large MW tears in one single band, whereas several hemoclips often are required to close a MW tear. This result is supported in our study by the mean number of required bands to achieve haemostasis, which was 1.14 for bands vs. 2.3 for hemoclips.

Band ligation has proved to be of great interest in oesophageal variceal haemorrhage with a decrease in rebleeding as compared to sclerotherapy and is now a first-line haemosatsis procedure in this indication.[26] Authors also described the use of band ligation to treat gastrointestinal bleeding from different sources, such as Dieulafoy's lesions, gastric antral vascular ectasia, gastric varices or arteriovenous malformations of upper and lower digestive tract.[27–30] The major advantage of band ligation is that it is technically easier to perform than other haemostasis methods, with the lesions well viewed under direct pressure and suction from the transparent ligation cap.

In conclusion, we suggest that the first-line treatment of bleeding MWS could be the endoscopic band ligation of the MW tear. Indeed, if the primary haemostasis can be achieved in all cases by band ligation or hemoclips plus epinephrine, we found that endoscopic treatment by hemoclips plus epinephrine was an independent risk factor of early rebleeding. An active bleeding during endoscopy was an additional independent rebleeding risk factor, whereas a shock at admission and the use of antiplatelets or anticoagulant drugs were associated with an increased rebleeding rate in univariate analysis, but not after logistic regression. Given the retrospective design of our study, these results require further prospective assessment.

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