Shock Index, Duodenal Ulcer Among Factors Associated With Unsuccessful Endoscopic Hemostasis in Severe Peptic Ulcer Bleeding

Artwork based on an endoscopic image of a stomach ulcer.
Investigators assessed factors associated with unsuccessful endoscopic hemostasis in patients with severe peptic ulcer bleeding.

In patients with severe peptic ulcer bleeding who have a shock index >1.53, an exposed blood vessel diameter >1.9 mm, duodenal ulcer bleeding, and Forrest classification Ia, nonendoscopic hemostasis such as interventional radiology (IVR) and surgery should be considered, according to a study in the Scandinavian Journal of Gastroenterology.

Researchers conducted a retrospective study on the factors associated with unsuccessful endoscopic hemostasis for severe peptic ulcer bleeding, which was the primary outcome. The secondary outcome was the cutoff value for the identified factors.

The cohort included 150 patients who underwent endoscopic hemostasis for shock-presenting upper gastrointestinal bleeding at a critical care center in Japan from April 1, 2007, to March 31, 2021. Participants had a median age of 68.5 (range, 31-92) years, and 107 (71.3%) were men. Lesions were located in the stomach in 124 (82.7%) cases and in the duodenum in 26 (17.3%) cases.

Successful endoscopic hemostasis occurred in 123 cases (82.0%). In the 27 cases involving unsuccessful endoscopic hemostasis, 26 patients had IVR and 1 had surgery.

Factors associated with unsuccessful endoscopic hemostasis were shock index (successful endoscopic hemostasis/unsuccessful endoscopic hemostasis, median: 1.46 [range, 0.39-5.00]/1.60 [range, 0.84-3.24]; P <.001), exposed blood vessel diameter determined via contrast-enhanced computed tomography findings (CE-CT) (successful endoscopic hemostasis/unsuccessful endoscopic hemostasis, median: 1.4 [range, 0.0-5.0]/3.1 [range, 1.4-7.3]; P <.001), lesion site (successful endoscopic hemostasis stomach/duodenum: 110/13; endoscopic failure stomach/duodenum: 14/13; P <.001), and Forrest classification (successful endoscopic hemostasis, 1a/others: 23/100; unsuccessful endoscopic hemostasis, 1a/others: 22/5; P <.001).

Regarding factors associated with unsuccessful endoscopic hemostasis, the receiver operating curve (ROC) calculated from the shock index had an area under the curve (AUC) of 0.68 (95% CI, 0.59-0.79; P <.001) with a cutoff value of 1.53, which resulted in a sensitivity and specificity of 70.4% and 63.4%, respectively. The ROC calculated from the exposed blood vessel diameter (via CE-CT findings) had an AUC of 0.92 (95% CI, 0.87-0.98; P <.001) with a cutoff value of 1.9 mm, resulting in a sensitivity and specificity of 88.9% and 83.7%, respectively.

Study limitations include the single-center retrospective design and small sample size.

“[I]n centers with IVR or surgery options, it is important to consider an early transition to IVR or surgery because prolonged endoscopy or unreasonable endoscopic hemostasis may promote bleeding,” stated the investigators. “We believe that the results of this study may be useful as a criterion for selecting the best treatment.”

Reference

Kubota Y, Yamauchi H, Nakatani K, et al. Factors for unsuccessful endoscopic hemostasis in patients with severe peptic ulcer bleeding. Scand J Gastroenterol. 2021;56(12):1396-1405. doi: 10.1080/00365521.2021.1969593