Endoscopic haemostasis for non-variceal upper gastrointestinal haemorrhage

Review

21 Br. 9-225 J. Surg. 1989, Vol. 76, March, Endoscopic haemostasis for non -variceal upper gastrointestinal haemorrhage

R. J. C . Steele Endoscopic haemostasis can be effective in non-variceal upper gastrointestinal haemorrhage, and should be regarded as potential front-line treatment. Diverse methods are available, and although no single technique has become firmly established, current evidence favours thermal coagulation and injection therapy.

Department of Surgery, University Medical Buildings, Aberdeen Royal Infirmary, Foresterhill, Aberdeen A59 2ZB, UK Correspondence to: Mr R. J. C. Steele Keywords: Endoscopy, gastrointestinal haemorrhage, haemostasis

Sclerotherapy is well established in the treatment of oesophageal varices', but in no sense can it be regarded as ~ u r a t i v e ~ . ~ . Endoscopic haemostasis for non-variceal bleeding, however, is more satisfactory as it represents only the first step in the management of a disease which is usually amenable to treatment. Thus, if haemorrhage from a peptic ulcer is controlled by non-operative means, then subsequent elective medical or surgical therapy can usually effect a cure without significant hazard. Furthermore, bleeding from lesions such as Mallory- Weiss tears, arteriovenous malformations and even cancers can be controlled by endoscopic means.

Why, then, is endoscopic haemostasis not more widely practised? Paradoxically, of all the techniques currently available that which was first introduced and which has undoubtedly received the most attention is also the most expensive, complex and difficult to learn. Since the introduction of the therapeutic laser4, there have been at least 11 controlled trials of endoscopic laser photocoagulation for upper gastrointestinal bleeding5. Despite the fact that only six of these have demonstrated any benefit at all, a tacit assumption that laser equipment represents a sine qua non may have inhibited many centres from attempting to develop therapeutic endoscopy for non-variceal bleeding. It is, however, becoming increasingly clear that simpler and cheaper techniques are probably as effective as laser therapy, and may indeed have distinct advantages.

The aim of this article is to review and compare the available methods in order to assess the efficacy and applicability of endoscopic haemostasis as it stands today.

The problem Fibreoptic endoscopy is the method of choice for ascertaining the precise diagnosis in acute upper gastrointestinal haemor- rhage6, and it is known that early investigation is more likely to be helpful than endoscopy which is delayed for 48 h or more'. Nevertheless randomized trials have failed to demonstrate any improvement in mortality resulting from routine early endos- copy6,*, leading to the suggestion that it should be abandoned. Counter to this argument is the finding from Australia that setting up a specialized unit which emphasizes prompt endoscopy has reduced mortality from acute upper gastrointestinal bleeding from 15 to 6 per cent within a few years'.

These points, although noteworthy, refer only to diagnostic endoscopy, and the emergence of therapeutic manoeuvres has added a further dimension. One of the problems in demonstrating a reduction in mortality for gastrointestinal haemorrhage is the fact that death rates should now be less than 10per cent, and it would therefore require a trial with very large numbers of patients to demonstrate a significant effect resulting from a specific treatment". Accordingly, another end point is necessary in order to interpret the value of any method, and the

most obvious is the need for emergency surgery. Elective surgery for peptic ulcer has been extremely safe for some years now, with many series reporting no mortality"-'3. Urgent operation for bleeding, however, can be associated with a mortality rate of around 20 per centI4. It is therefore reasonable to assume that any significant reduction in emergency surgery would eventually translate into a lowering of mortality rate, to say nothing of perioperative morbidity.

Even a reduction in the number of emergency operations, however, is difficult to demonstrate unless the patients studied are a t high risk of continued or further bleeding from the lesion which is to be treated endoscopically. Active haemorrhage would seem to place patients in this category but, as over 70 per cent of all acute upper gastrointestinal bleeding episodes stop spontaneously' ', fortuitous endoscopic visualization of actual bleeding cannot be regarded as an absolute indication for intervention. Moreover, it is now evident that a 'visible' or exposed vessel in an ulcer base is a powerful predictor of rebleeding16-18 and represents as clear an indication for treatment as does fresh haemorrhage.

It is therefore important that any method of endoscopic haemostasis be subjected to randomized trials in which the control patients are treated conservatively until they fulfil criteria which are not based on endoscopic appearances. Indeed, when adequately documented studies of this type are combined, it would appear that untreated patients with arterial bleeding, non-arterial bleeding and visible vessels come to emergency surgery in only 59, 24 and 38 per cent of cases respectively (Table I). It should also be stressed, however, that the endoscopic appearance of an ulcer is not the only predictive factor. Two recent studies have highlighted the unfavourable prognostic significance of hypovolaemic s h o ~ k ' ~ . ~ ~ , and ulcer position is similarly relevant, with rebleeding being more common from lesions situated in the posteroinferior duodenum or high in the lesser curve of the stomach".

Endoscopic haemostasis, then, is most appropriate for actively bleeding lesions or visible vessels, and the presence of shock and ulcer position may also help in the selection of patients for treatment. In the following section each technique will be described, and its efficacy will be critically assessed with the emphasis on controlled trials. An attempt will then be made to compare the different approaches using those reports which contain adequate data.

The methods Different methods of endoscopic haemostasis are legion but the most firmly established are those employing thermal coagulation and injection. The commonly used thermal methods consist of laser photocoagulation, monopolar or bipolar electrocoagulation and the direct application of heat using a 'heater'

21 9

Endoscopy in gastrointestinal haemorrhage: R. J. C . Steele

Table 1 Rates of emergency surgery and overall mortality in untreated patienzs with stigmata of recent haemorrhage

Type of SRH _ _ _ _ _ _ ~ _ _ _ ~ _ _ ~ . _ _ _ _ _ _ ~

Arterial bleeding Non-arterial bleeding Non-bleeding visible vessel ____________. ~ _ _ _ ~ _ _ _ ~ Emergency Emergency Emergency

Mortality surgery Study surgery Mortality surgery Mortality

- ~ 12/24 5/24 Swain et 214 214

Papps2 ~ - 7/16 1/16

Rutgeerls et al.42 ~ 5/40 6/40 6/26 4/26 - ~ 11/29 5/29 Swain et a1.44,4s 619 219

Panes et a1.76 5/13 0113 1/24 3/24 8/21 1/21

Vallon et 9/13 3/13 - __ 5/16 3/16 ~

~

~

Freitas et a1.s6 112 112 418 1 /8 8/17 3/17

Chung et 7/10 O j l O 7/24 2/24

Total 3015 1 815 1 23/96 12/96 571149 221 149 (59%) (16%) (24%) (12%) (38%) (15%)

- SRH, stigmata of recent haemorrhage

probe. Injection therapy has focused mainly on ethanol, the sclerosant polidocanol and adrenaline, the last two being used alone or in combination. Before concentrating on these approaches, however, there are other, less well known techniques which require a brief mention.

Clotting factors in the form of cryoprecipitate or thrombin can be delivered endoscopically to bleeding lesions by spray- ing22,23, injectionz4~’’ or ferromagnetic t a m p ~ n a d e ’ ~ , ’ ~ . Sim- ilarly, topical application of microcrystalline collagen can be used to initiate ~ l o t t i n g ’ ~ , ~ ~ , and tissue adhesive in the form of trifluoroisopropyl cyanoacrylate has been given a trial3’. Mech- anical methods of endoscopic haemostasis have also been described, utilizing balloon tamponade of the duodenal bulb3‘ and direct placement of clips on to exposed vessels3’. These techniques have met with varying degrees of success, however, and have not been widely investigated or employed.

Laser photocoagulation Details of the mechanism of laser photocoagulation are available Suflice it to say that on contact with tissue, laser light is converted to heat which causes coagulation and vaporization. Two types oflaser have been used in the treatment of bleeding ulcers ~ the argon ion and the neodymium yttrium aluminium garnet (Nd YAG). The former produces a blue-green light which is largely absorbed by haemoglobin so that tissue penetration is low, especially in the presence of blood. The NdYAG laser on the other hand, has greater tissue penetra- t i ~ n ~ ~ and therefore has a theoretical advantage over the argon laser where active bleeding and large vessels are concerned.

In recent years, considerable clinical experience with laser photocoagulation has accumulated, and the most instructive way in which to assess its impact is to examine the 11 controlled trials which have been published. In a study of 136 patients with arterial bleeding, non-bleeding visible vessels or other stigmata of recent haemorrhage (SRH), Vallon and others could not demonstrate an overall significant reduction in the need for emergency surgery or mortality using the argon laser. However, if patients with ulcers inaccessible to laser treatment were excluded from the analysis, a significant improvement was seen in the group with arterial bleeding3’. In apparent contrast, the study conducted by Swain and his colleagues showed a clear advantage for the argon laser in terms of emergency surgery and mortality in patients with arterial bleeding or visible vessels. However, of 108 patients eligible to enter this trial, 32 were excluded before randomization, largely because the lesion was not accessible to the laser beam36. The third argon laser trial was much smaller, but of seven treated patients with arterial bleeding

or a visible vessel, none required surgery, compared with five out of nine similar controls3’.

Turning now to the N d YAG laser, there have been eight trials to date, but four of these were poorly designed or failed to give adequate definitions of the bleeding lesions t ~ a t e d ~ * - ~ l . The remaining studies, however, were more carefully con- structed and executed, and therefore deserve closer consider- ation. Rutgeerts and his colleagues randomized 129 patients with non-arterial bleeding, visible vessels or clot, and achieved 100 per cent initial haemostasis in the laser-treated group4’. They observed no differences in mortality rate or the need for emergency surgery, but laser therapy did produce a significant reduction in clinical rebleeding among the patients with active bleeding. It should be noted that 20 subjects were excluded from this study because of equipment failure and eight because of inability to gain adequate access to the lesion. In a smaller trial from Glasgow, 20 patients with visible vessels were randomized, but of 12 allocated to laser therapy, only eight actually received treatment43. Emergency surgery was required in one of the treated patients compared with all eight of the controls, and this constituted a significant advantage for laser photocoagulation even when the untreated patients in the laser group were included.

The largest favourable study of the Nd YAG laser has been that of Swain and his c o - w o r k e r ~ ~ ~ . This trial recruited 138 patients with arterial bleeding, visible vessels or other stigmata of recent haemorrhage and demonstrated a significant reduction in rebleeding rate, the need for surgery and mortality rate44.45. Unfortunately, a large number of eligible patients were excluded from this trial, mainly because of technical difficulty in aiming the laser beam. In the most recently reported trial, Krejs and others randomized 174 patients but did not find any significant benefit from the laser treatment46. Before entry into this study 281 potential subjects were excluded, 221 because they were too unstable to be moved to the laser unit, 26 because the laser was not functioning and 34 because the lesion was inaccessible. It is also important to note that only two of the trial patients had active arterial bleeding, and that laser treatment was carried out by, or under the supervision of, five different operators. The poor results of this trial may therefore have been influenced by a tendency to select low-risk patients and to have treatment delivered by multiple operators of variable experience.

In summary, there have been eleven controlled trials of laser therapy for non-variceal upper gastrointestinal haemorrhage, but not all are of similar quality. In six of these reports a significant benefit has been ~ l a i m e d ~ ~ . ~ ’ , ~ ’ 44, but in fact only four trials have shown a reduction in the need for emergency sUrgery36,37.43.44 and only two have demonstrated a significant

220 Br. J. Surg., Vol. 76, No. 3, March 1989

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~ I c e r s ~ ~ - ~ ~ . In two of these reports, particular difficulty was encountered in controlling bleeding from duodenal u l ~ e r s ~ ~ , ~ ~ , but this was not the experience of Johnston and others who achieved 100 per cent initial haemostasis in 20 patients, 11 of whom had duodenal u l c e r P .

To date, only one controlled trial of the heater probe has been reported. In this study 43 patients with active bleeding or major SRH were randomized and a significant reduction ir, rebleeding was demonstrated in the treated group6’. There was, however, no difference in terms of surgery or mortality rates and there were eight exclusions from the trial for technical reasons69.

Injection therapy Injection treatment for non-variceal bleeding has only com- manded attention relatively recently. The substances which have been used fall into two categories - sclerosants and vasoconstric- tors used alone or in combination. The main sclerosant materials in current use are ethanol and polidocanol, both of which act by thrombosing the bleeding vessel and causing necrosis with subsequent fibrosis of the surrounding tissue’. Adrenaline is the only vasoconstrictor which has been formally evaluated, and is presumed to operate via temporary vasocon- striction and platelet aggregation which combine to encourage thrombosis in the bleeding vessel7’.

Using 98 per cent ethanol, Asaki and his colleagues have accumulated the largest series of patients treated by injection therapy. In a multicentre study involving 332 patients with active bleeding or adherent clot, only two continued to bleed, 20 rebled and 10 required emergency surgery7’. In a much smaller study, Sugawa and others achieved permanent haemostasis in 34 out of 40 patients with actively bleeding lesions using the same method7’. Polidocanol has also emerged as a clinically useful sclerosant and three uncontrolled studies, one using the substance alone73 and two employing pre-injection with adren- aline74.75, have demonstrated its efficacy in both actively bleeding and non-bleeding vessels. To date, there has been one controlled trial of polidocanol in which 11 3 patients with ulcers exhibiting active bleeding, visible vessels or adherent clot were randomized. The treated group received an initial injection of 1 : 10 000 adrenaline into and around the bleeding point, followed by 1 per cent polidocanol administered in the same way. Overall, there were significant reductions in the need for emergency surgery, amount of blood transfused and duration of hospital stay76. Six patients were excluded from this study because their ulcers were inaccessible owing to duodenal deformity.

The use of adrenaline as the sole injectable agent has received scanty attention until recently, but there is now evidence that it may be of value. After an encouraging pilot a group from Hong Kong has reported on a randomized trial of 1 : 10 000 adrenaline injection which involved 68 patients with actively bleeding ulcers78. Strict criteria for selecting patients for emergency surgery were employed, and adrenaline injection was found to produce a significant decrease in the need for such Treatment, as well as reductions in the amount of blood transfused and time in hospital. Hirao and co-workers have also reported success with adrenaline, although their technique also involved the injection of hypertonic saline79. In this context it is of interest that two groups have produced a marked improvement in the efficacy of Nd YAG laser therapy by prior injection of adrenaline80.8 ’ . This has been ascribed to good visualization of the bleeding point and elimination of the arterial heat sinks2, but it is equally possible that the vasoconstrictor exerted the major therapeutic effect. The same argument can be applied to combinations of adrenaline and sclerosant

reduction in mortality rate36i44. Furthermore, these benefits must be set against the relatively large number of patients excluded from randomization in at least three of the stu- dies36,42,44 . There is little doubt, however, that laser photocoagulation can be effective in producing permanent haemostasis, but it is highly operator-dependent, and can only be used for lesions which are favourably situated within the gastrointestinal tract.

Electrocoagulation Electrocoagulation is an extremely useful haemostatic technique in surgery and can be applied to endoscopic haemostasis. Monopolar electrodes are effective in this respect, but carry the disadvantages of unpredictable depth of thermal injury, adher- ence to tissue and clot dislodgement5. These may be overcome by irrigating the tip of the probe so that it is covered by a film of water (the liquid monopolar e le~t rode)~’ or by employing the bipolar principle. As a conventional bipolar electrode would be difficult to position endoscopically, a multipolar probe (BICAP’”’, ACMI, Stamford, Connecticut, USA) has been developed, the tip of which carries three equally spaced pairs of bipolar microe lec t r~des~~.

Despite the problems associated with ‘dry’ monopolar electrodes they have been reasonably successful in controlling non-variceal bleeding, and four uncontrolled studies have produced impressive rates of initial and permanent haemostasis in actively bleeding lesions using this approach49 52. There have been two controlled trials, and in the first Papp reported a significant reduction in rebleeding and need for surgery in patients with non-bleeding visible vessels52. In the second trial 37 patients with gastric ulcers exhibiting visible vessels were randomized, and a significant reduction in rebleeding was achieved by therapy, especially among those with active bleed- ing53. Although no complications were reported in these studies, it is important to heed the early experience of Koch and others who produced three perforations with one death after the successful control of bleeding in 15 patients54. Clearly, the dry monopolar electrode can be dangerous and must be used with extreme skill and care. There has been less clinical experience with the liquid monopolar electrode, but in one study permanent haemostasis was achieved in 11 out of 15 patients with actively bleeding lesions55, and in a randomized trial a significant reduction in rebleeding and the number of emergency operations was produced in those patients with non-bleeding visible vessels56.

The multipolar electrode has received more attention, but although early experience indicated that it could be u s e f ~ l ~ ~ , ~ ~ , two controlled trials have shown no b e r ~ e f i t ~ ~ , ~ ’ and a third, although demonstrating a significant reduction in rebleeding, did not show a reduction in the need for emergency surgery or mortality rate6’. One investigator, however, has achieved much better results. In a randomized study of 44 patients with actively bleeding lesions, Laine demonstrated significant reductions in emergency surgery, amount of blood transfused, duration of hospital stay and overall cost of treatment62. Further, in a separate trial involving 74 patients with non-bleeding visible vessels similar results were reported by the same author63. It is important to note that Laine used a l0Fr probe, as opposed to the small 7 Fr electrode employed by the other workers. This may go part of the way towards explaining the difference in results, although operator skill may have been a crucial factor, as no patient had to be excluded from Laine’s series owing to profuse bleeding or poor access.

Direct thermal coagulation Direct thermal coagulation can be produced by means of a heater probe consisting of an aluminium tip coated by non-stick TEFLON”’ (Du Pont de Nemour Incorporated, UK) which is heated to 250°C by an inner There is relatively little published clinical experience of the heater probe, but three non-randomized studies testify to its ability to produce initial and, in some cases, permanent haemostasis in bleeding peptic

Comparisons between different methods There have been relatively few studies comparing different techniques of endoscopic haemostasis. Goff looked at Nd YAG laser therapy and multipolar electrocoagulation in 33 patients with active bleeding or visible vesselss3 and could find no

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Endoscopy in gastrointestinal haemorrhage: R. J. C. Steele

difference. This was a small group, however, and only partly randomized. In a larger, better designed prospective trial, Rutgeerts and others similarly compared the Nd YAG laser with the multipolar electrode and found them to be equally effective*'. In this study, however, both forms of coagulation were preceded by adrenaline injection, making interpretation of the results difficult.

The Nd YAG laser has also been compared with the heater probe, and in a non-randomized retrospective study Johnston came down in favour of the heater probe. Emergency surgery was required in only 5 per cent of 20 subjects treated by the probe, whereas 17 per cent of the 35 laser-treated patients came to ~ p e r a t i o n ~ ~ . In a three-way randomized trial, however, Northfield and his colleagues have reported significantly less rebleeding with Nd YAG laser treatment when compared with controls, but not with heater probe therapys4.

Finally, in another three-pronged trial comparing multipolar electrocoagulation, heater probe and non-treated controls, Jensen and others found that both forms of therapy were effective in obtaining initial haemostasis, but that only the heater probe produced a significant reduction in rebleeding and the need for urgent surgerys5.

Although randomized trials may be seen as the ideal way of establishing the best form of endoscopic haemostasis it must be accepted that any investigator will obtain optimum results from the type of therapy with which he or she is most familiar. Until trials that overcome this obstacle are carried out, it will remain necessary to draw conclusions from separate studies. This can be awkward, as stratification of patients into various levels of risk is not always possible from the data in the available literature, but a certain amount of comparative analysis is possible. As outlined in the introduction, only patients with active bleeding at the time of endoscopy or visible vessels are a t real risk of requiring emergency surgery or of dying from bleeding. In addition, as can be seen from Table 1 , those with arterial bleeding are at greater risk than those with simple oozing haemorrhage. It is only instructive, therefore, to compare different studies within appropriate subgroups, and an attempt has been made to do this using three broad categories: laser photocoagulation, electrocoagulation and injection techniques (Table 2). Unfortunately, many published reports simply do not contain sufficiently detailed information and cannot therefore be used for comparison. In addition, the groups are clearly heterogeneous and the electrocoagulation results are heavily biased by one study, With these provisos, however, it would seem that while all three methods are roughly equivalent in the treatment of non-arterial bleeding and visible vessels, laser therapy of arterial bleeding is not as effective as electrocoagulation or injection.

Discussion The current profusion of techniques for endoscopic haemostasis indicates that no one method has gained supremacy. Laser photocoagulation has been in the forefront for a number of years, but careful appraisal of the literature does not inspire great confidence in this approach. Few of the controlled trials have demonstrated clear benefit from laser treatment, and the overall results for arterial bleeding are not impressive. Further- more, in several trials relatively large numbers of patients had to be excluded because their lesions were i n a c c e s ~ i b l e ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ' ~ , a problem which is less common with other forms of therapy. Equipment malfunction, absence of the laser operator and inability to transfer patients to the laser facility are also frequently cited reasons for treatment f a i l ~ r e ~ ~ . ~ ' 46 and adverse effects including perforation and reactivation of bleeding have been r e p ~ r t e d ~ ~ , ~ ~ , ~ ~ , " . Finally, laser equipment is expensive and its widespread introduction for endoscopic haemostasis cannot yet be justified.

What then, of the alternatives? Electrocoagulation offers a simpler approach, and despite its theoretical disadvantages the monopolar electrode does appear to be useful, although it still

requires careful prospective evaluation. Evidence from randomized trials indicates that the 10 Fr multipolar electrode is more likely to be effective than the 7 Fr probe, but it should be stressed that only one investigator has been able to demonstrate a significant reduction in the need for emergency surgery using this d e ~ i c e ~ ' , ~ ~ . The heater probe is also an attractive concept and shows some promise at an early stage of its clinical development. All these coagulation instruments do carry a risk of extensive tissue damage and perforation, but in practice this does not seem to be a major problem. They also involve extra cost, although not of the same order as laser units.

The final approach is injection therapy which has the attraction of demanding little extra equipment beyond an upper gastrointestinal endoscope. It is not clear, however, which of the injectable agents is most satisfactory. Spectacular results have been obtained from Japan using ethanol7', but there has been little confirmatory evidence as yet. The sclerosant polidocanol also seems effective, but most of the studies, including the only controlled trial, also utilized preinjection with a d ~ - e n a l i n e ~ ~ - ~ ~ . Adrenaline alone would seem to be effective in actively bleeding lesion^^^.^* and does not carry the risk of ulcer extension and perforation occasionally seen with sclerosants7 1 * 7 3 . Having said this, further controlled studies are needed to define the value of adrenaline more precisely, and although no adverse systemic effects have been reported, care must be exercised in its use.

Whatever method is employed it is important to be able to predict which patients will benefit from endoscopic haemostasis and in which it will be unnecessary or fail. Appraisal of the data from randomized trials would indicate that all patients with active bleeding or visible vessels should be seriously considered for therapy at the time of endoscopy, whereas those with minor stigmata of recent haemorrhage or clean ulcers are unlikely to require active treatment. The question of which lesions will not respond permanently to endoscopic intervention is still un- resolved, and represents a crucial area for future research. At present the only obvious contraindication is inability to apply the chosen therapeutic modality because of access difficulty or torrential bleeding.

Before concluding this review some technical points should be emphasized. Primarily, it must be understood that even diagnostic endoscopy requires considerable skill in the presence of bleeding, and haemostasis should not be attempted by an inexperienced operator. The endoscopist must also be prepared to carry out gastric lavage, preferably with the aid of an overtube for airway protections6, and to use vigorous washing in order to obtain a good views7. Likewise, the importance of routine repeat endoscopy within 24 h of successful initial haemostasis cannot be overstated, as this affords a valuable opportunity for further therapy should subclinical rebleeding have occur-

Endoscopic treatment for non-variceal bleeding is in a state of flux, and the way forward must be to establish the optimum technique or combination of techniques. In a recent leading article, Schuman suggested setting up a multicentre trial to establish whether 'injection therapy can become the frontline endoscopic management for upper gastrointestinal bleeding or whether it is just too good to be true"'. Preempting this proposal, Rutgeerts has initiated a trial comparing adrenaline alone, adrenaline followed by polidocanol and adrenaline followed by laser therapys9. The final result of this study will be of great interest and it may be that other combinations will prove to be of value". In the meantime we may be confident that endoscopic haemostasis will soon become recognized as the initial treatment of choice in most cases of upper gastrointestinal haemorrhage where intervention is indicated. With the present availability of simple and relatively inexpensive methods, it should be feasible to offer this service wherever standard equipment and a reasonable level of expertise exist, and conventional surgery for bleeding may become a rarity in the near future. It therefore behoves all surgical gastroenterologists to work in very close collaboration with their endoscopically trained colleagues or to be endoscopists themselves.

red78,82

222 Br. J. Surg., Vol. 76, No. 3, March 1989

Endoscopy in gastrointestinal haemorrhage: I?. J . C. Steele

Table 2 Rates of emergency surgery and overall mortality rate for different forms of endoscopic haemostasis. Omission of figures indicates that the subgroup was not studied or that the data were inadequate

Study

Arterial bleeding -_

Emergency surgery

Non-arterial bleeding

Mortality Erne r g e n c y surgery

Laser:

Laurence et ~ 1 . ~ ’ (argon) Vallon et a / . 35 (argon) Swain et a/.36 (argon) Rutgeerts et u I . ~ ~ (Nd YAG)

Swain et u/.44,45 (Nd YAG)

Heldwein et a/.8’ (Nd YAG)

Rutgeerts et a/.*’ (adrenaline + Nd YAG)

Rutgeerts et a/.82 (adrenaline + Nd YAG)

Heldwein et a/ .81 (adrenaline + Nd YAG)

Total

Electrocoagulation :

Papp” (monopolar)

Freitas et ~ 1 . ~ ~ (monopolar)

Moreto et a / . 53 (monopolar)

Rutgeerts et a / .82 (adrenaline +multipolar)

Laine6’ (multipolar)

Total

Injection:

Soehendra et a/.74 (adrenaline +polidocanol)

Sugawa et ~ 1 . ~ ~ (ethanol)

Panes et ~ 1 . ~ ~ (adrenaline + polidocanol)

Kortan et a/.75 (adrenaline + polidocanol)

Leung and C h ~ n g ~ ~ (adrenaline)

Chung et (adrenaline)

Steele et a/.92* (adrenaline)

Total

12/36

7/15

417

14/23

2/10

19/30

4/26

5/12

316

70/165 (42%)

13/86

314

016

3/15

~

19/111 (17%)

0122

4/10

1/15

4/32

1/12

319

2/15

15/115 (13%)

4/36

2/15

017

7/23

1/10

11/30

4/26

~

216

311153 (20%)

9/86

114

1 16

-

~

11/96 (11%)

0122

~~

0115

~~

~

019

1/15

1/61 (2%)

1/24

-_

-

1/46

-

--

-_

019

--

2/79 (2 yo )

-

117

1/10

116

~-

3/23 (13%)

1/27

2/27

0122

0124

2/25

2/25

-

7/150 (5%)

Non-bleeding visible vessel

Mortality

1/24

~

~

6/46

~

~

~

-

~

7/70 (10%)

--

017

O j l O

~

.~

0117

0127

~

1/22

~

~

3/25

4/74 (5%)

Emergency surgery

-

6/19

4/17

2/17

2/25

912 1

3/28

1/29

4/26

311182 (17%)

1/16

2/14

~

3/29

3/37

9/96 (9%)

0/8

016

2/18

~

~

~

-~

2/32 (6%)

Mortality

-

3/19

0117

211 7

0125

412 1

1/28

~

0126

10/153 (6%)

011 6

1/14

~

~

1/37

2/67 (3%)

1

~

1/18

~

~

~

~

2/26 (8%)

3. References 1 , Fleischer D. Endoscopic therapy of upper gastrointestinal bleed-

ing in humans. Gastroenterology 1986; 90: 217-34. Terblanche J . The long-term management of patients after an 2. oesophageal variceal bleed: the role of sclerotherapy. Br J Surg 4. 1985; 72: 88-90.

Cello JP , Grendell JH, Crass RA, Weber TE, Trunkey DD. Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and acute variceal haemorrhage. N Engl J Med 1987; 316: 11-5. Nath G , Gorisch W, Kiefhaber P. First laser endoscopy via fibreoptic transmission system. Endoscopy 1973; 5 : 208-10.

Br . J. Surg., Vol. 76, No. 3, March 1989 223

Endoscopy in gastrointestinal haemorrhage: I?. J. C. Steele

5 .

6.

7.

8.

9.

10.

1 I .

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

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Paper accepted 3 November 1988

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Endoscopic haemostasis for non-variceal upper gastrointestinal haemorrhage