In Upper Gastrointestinal Bleeding, Doppler Probe Adds Value

Caroline Helwick

June 01, 2015

WASHINGTON, DC — In patients with severe nonvariceal upper gastrointestinal (GI) hemorrhage, use of a through-the-scope Doppler probe to guide endoscopic hemostasis can significantly reduce the risk of rebleeding and other complications, results from a randomized controlled trial show.

"We now recommend the Doppler endoscopic probe, along with stigmata of recent hemorrhage, as a guide for risk stratification and definitive endoscopic hemostasis in patients with severe nonvariceal upper GI hemorrhage," said Dennis Jensen, MD, from the University of California at Los Angeles.

"For decades, stigmata of recent hemorrhage in ulcers and nonvariceal upper GI hemorrhage has been used to guide endoscopic hemostasis. The arterial blood flow that underlies it is rarely monitored, yet it determines the risk of rebleeding after treatment," he explained during a late-breaking clinical abstract session here at Digestive Disease Week 2015.

Endoscopists traditionally look for signs that can be attributed to rebleeding risk, said session moderator John Vargo, MD, from the Digestive Disease Institute at the Cleveland Clinic.

"When we are done, we assume everything is fine; we have treated the visible vessel," he explained. "But with the Doppler, we can actually look underneath the tip of the iceberg and ask, 'Is there something beyond the visualization of the treatment area?' This study suggests we may have more areas to treat."

Dr Jensen and his colleagues conducted their study to determine whether using a disposable Doppler endoscopic probe (Vascular Technology, Inc.), which is approved by the US Food and Drug Administration, to guide hemostasis would reduce 30-day rebleeding rates of index lesions.

Significant Reduction in Rebleeding With Doppler

All 148 patients with nonvariceal bleeding received standard treatment, which involved hemoclipping or multipolar probe electrocoagulation, with or without dilute epinephrine injection. Visual end points were control of bleeding, flattening of visible vessels, and a footprint at the stigmata of recent hemorrhage.

Of these, 72 patients were randomized to receive endoscopic hemostasis in which a Doppler probe was used to pick up arterial signals. Before standard treatment, the stigmata of recent hemorrhage and lesion base were interrogated in these patients for underlying blood flow at settings less than 4 mm deep. After standard treatment, the probe was used to recheck for residual blood flow; if detected, further hemostasis was performed until the blood flow disappeared.

Patient and disease characteristics were well matched in the probe and standard groups. The main lesion types were duodenal ulcer (42.6%) and gastric ulcer (29.7%); 17% of patients had ulcers that were at least 20 mm.

Patients and the medical–surgical teams were blinded to the endoscopic treatment.

 
We showed a 15% absolute difference in rebleeding rates with the Doppler probe.
 

In the standard group, patients with flat spots were not treated endoscopically. However, in the probe group, if arterial blood flow was detected under the spot, patients were treated, Dr Jensen explained.

Study participants with ulcers and Dieulafoy's lesions received high-dose proton pump infusion for 72 hours and twice a day thereafter for 30 days. Patients with Mallory–Weiss tears received antiemetics and twice-daily dosing with proton pump inhibitors.

Rebleeding was defined as a decrease in hemoglobin of at least 2 g/dL accompanied by clinical signs. Repeat endoscopy was performed with hemostasis as needed for stigmata. If bleeding was not controlled after two endoscopic hemostasis sessions, surgery was performed.

Rebleeding of the same lesion within 30 days — the study's primary outcome — was less common in the probe group than in the standard group (11.1% vs 26.3%; P = .0214).

"We showed a 15% absolute difference in rebleeding rates with the Doppler probe," Dr Jensen reported.

Table. 30-Day Same-Lesion Rebleeds

Outcome Probe Group, % Standard Group, %
Active arterial bleed 28.6 50.0
Nonbleeding visible vessel 15.4 25.9
Adherent clot 0.0 25.0
Flat spots 0.0 18.8
Oozing bleeding 0.0 14.3

 

Surgery was required by no patients in the probe group, but in four patients in the standard group (0.0% vs 5.3%). Death was less common in the probe group than in the standard group (1.4% vs 4.0%; P = .337), as were perforations and other complications (0.0% vs 1.3%; P = .143). However, other GI bleeds were more common the probe group (6.4% vs 4.0%; P = .42).

There were more red blood cell transfusions in the standard group than in the probe group, but the number of hospital days was not significantly different.

The Doppler endoscopic probe "was safe, quick, and easy for the skilled endoscopist investigators to learn and to use," Dr Jensen said.

This is a "provocative study," said Dr Vargo. "I look for further prospective validation of the results. This could potentially become a standard of care for patients with nonvariceal upper GI bleeding."

Dr Jensen is a consultant for Vascular Technology, Inc. and Boston Scientific Corporation. Dr Vargo has disclosed no relevant financial relationships.

Digestive Disease Week (DDW) 2015. Abstract 901b. Presented May 19, 2015.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....