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© Borgis - New Medicine 1/2003, s. 41-43
Olivia Alexandra Sgarbura1, Dragos Cinteza1, Cristian Viorel Poalelungi1, Dan Cristian2
The impact of endoscopy on upper gastrointestinal haemorrhage
1 University of Medicine and Pharmacy „Carol Davila”
2 Coltea University Hospital, Bucharest
Summary
Aim: Upper GI haemorrhage (UGIH) is one of the most frequent reasons for referral to gastro-enterology and surgical clinics. This provides a strong motivation for updating diagnostic procedures, and range of therapeutic methods. Oesogastroduodenoscopy is a highly reliable visualising method, classically used for diagnosis but with growing importance in therapy. Our goal is to demonstrate that there is great benefit in accepting endoscopy as a common therapeutic procedure.
Methods: We studied cases of UGIH in an important Romanian clinical hospital throughout 2 years (2001 and 2002), identifying a group of 125 patients (man:woman ratio 1.45) aged between 30 and 87 years (average 58 years, SD = 13.9) that underwent diagnostic endoscopy. We analysed their medical files and evaluated the therapeutic procedures that were applied for the whole group and for aetiologic groups.
Results: In order to evaluate the therapeutic method, we first studied the aetiology and epidemiology of UGIH within the group. We found that the average age of men referred for UGIH was significantly lower than that of women (56.6 y compared to 59.2; p-value < 0.0002) and that gastric ulcer and oesophagitis are significantly more frequent in men (p < 0.0001 and p<0.05), the other causes of UGIH being almost equally distributed. Endoscopic treatment of UGIH occured in 43.2% of cases, only 9.6% of them needing surgery, which was very significant (p = 0). Compared to the approach that Forrest I and Forrest II UGIH have had previously, we noticed the growing role of endoscopy (p < 0.05) and the diminishing role of classic surgery (p < 0.0002) in the studied pathology.
Conclusion: The recent advance that endoscopy has shown as a treatment method is due to its reduced invasivity with less intraoperatory time, less anaesthetic risks, and higher diagnostic and therapeutic efficiency. The recent tendency is to replace classical surgery with endoscopic methods as much as possible, an important step in the treatment of UGIH and obtaining agood outcome.
Upper gastrointestinal haemorrhage is an important issue for doctors at the beginning of the 21st century, especially because of our changing habits in nutrition. Doctors working in departments such as digestive/general surgery, or gastroenterology, are often confronted with patients in the emergency room because of bleeding of the digestive tract. Therefore, we considered it useful to conduct a study that aimed to prove the therapeutic impact of endoscopy, its importance under all circumstances – both emergency and ambulatory referrals – and its flexibility for all ages.
Out of a large number of cases, we chose to address only patients with bleeding of the upper gastrointestinal tract (down to the Treitz angle), so that we could select only oesogastroduodenoscopy, and ignore colonoscopy. Our decision was based on several reasons: we could focus on a lesser amount of pathologies, we could conduct a study that would carefully consider several aspects of the clinical evolution, and oesogastroduodenoscopy offered us a wide enough range of therapeutic methods as can be seen in chart 1.

Chart 1. Classification of endoscopic therapeutical proce-dures.
Endoscopic haemostasisEndoscopic surgical proceduresOther endoscopic methods
Alcohol coagulationBandingInjection with local substances
ElectrocoagulationLigation
ThermocoagulationSclerotherapyApplication of topical substances
Laser photocoagulationClipping
In order to assess the impact of endoscopy on UGIH, we worked for two years (2001, 2002) in Coltea University Hospital, an important hospital located in the centre of Bucharest. From the patients that came for diagnosis and therapy, we selected those presenting UGIH, which resulted in a group of 125 patients with a man:woman ratio similar to that found in the literature – 1.45. Their ages were from 30 to 87 years, with an average age of 58 years (SD = 13.9) also similar to the average age described in medical publications. The similarity of data indicates that our group was representative of patients visiting Romanian hospitals with these signs. At the end of their stay in the hospital we reviewed all the patients" medical records and collected the important elements: sex, age, aetiology of UGIH, Forrest degree of UGIH, emergency referral Y/N, therapy, and comorbidity.
In order to structure our knowledge and our data, we chose a more elaborate study design that included four steps: the first step was to analyse the variation in UGIH depending on sex, and the second step was expected to perform a comparison between our population. and the data obtained for the general population. The third step was designed to reveal the impact of endoscopic therapeutic methods on the entire group of patients, and in the last step of our study we were to describe the impact of endoscopy on each aetiologic group. We identified significant factors by using statistical tests such as the Students" T-test, ZTest, Fisher test, chi-squared test, and relative risk calculations.
During the first step of our research, we thought it would be useful to answer one question: is there any sex variation in UGIH? Therefore, we calculated the age average for men and women referring with digestive bleeding, and we compared them. The age average for the 74 men was 56.6 years (SD = 14), while the average for women was 59.2 years (SD = 13.7). The difference between the two categories (p = 0.0002) indicates that UGIH appears significantly earlier in males than in females. We also wanted to know if the distribution of a aetiologies is the same in men and women, so that we could compare the prevalence of the different diseases leading to UGIH in the two groups.

Chart 2. Prevalence of diseases that caused UGIH in our group.
Gastric ulcerWomen 8Men 32
Gastritis87
Esophagitis314
Mallory Weiss24
Jejuno-duodenal ulcer95
Achalazia10
Gastric tumour53
Traumas01
Esophageal varices32
Varices of the fornix21
Poliposis32
Aortoenteric fistula11
Angioma20
Pharmaceutical causes32
Hemobilia10
The result of the comparison was that gastric ulcer is more frequent in men (p = 0.0002) with a relative risk of RR = 3.15 (p = 0.0006). Oesophagitis is also more frequent in males (p = 0.05) with RR = 2.14 (p = 0.05), the remaining causes being similarly distributed.
During the second step of our research we took advantage of our structured oetiologies in order to compare their prevalence in our group with the prevalence described by previous studies (Merck Manual, 17th edition). The results can be seen in chart 3.

Chart 3. Comparison between our prevalences and the published prevalences.
PathologyCase %Literature %Significance
Gastric ulcer34.2%15%P = 0
Duodenal ulcer5.6%25%P = 0.000001
Mallory Weiss4.8%7.5%P = 0.2
Varices4.8%17.5%P = 0.0002
Esophagitis14.4%7.5%P = 0.006
As can be seen, there is an increase of gastric ulcer and oesophagitis in our group as well as a decrease of duodenal ulcer. This helps us to characterize our group of patients properly, but also raises one question: what is the cause for this change in the occurence of the various pathologies? At this point, we believe it might be connected with nutrition habits, but as we do not have any proof to support this we expect further studies to consider it.
The third step of our study was aimed at a correct classification of the therapeutic methods. Although we mentioned pharmaceutical treatment distinct from endoscopic treatment, this does not mean that patients who underwent endoscopic therapy were not given medication. As has been stated in previous studies, pluritherapy is usually considered more efficient than single therapy, and therefore physiopathological treatment was considered useful for all types of patients. The patients mentioned as having therapeutic treatment did not need any other kind of intervention than medicines.

Chart 4. The elected therapeutic methods.
Classic surgeryMedicineEndoscopic haemostasisEndoscopic surgical proceduresOther endoscopic methods
12 patients60 patients22 patients13 patients18 patients
9.6%48%17.6%10.4%14.4%
We also consider important the fact that out of the 8 patients referred to Coltea University Hospital with Forrest I A bleeding, 5 were helped by endoscopic means (usually pluritherapy – electrocoagulation + local adrenaline injection), the other 3 being redirected to surgery because of recurrent bleeding following the endoscopic procedure. Patients redirected to classic surgery were suffering from gastric tumours. Out of the 8 patients referring to the hospital with varices, either oesophageal or of the fornix, only 2 came to the emergency room with Forrest IB bleedings, and both of these were treated by endoscopic clipping.
On the basis of the medical records, we calculated the number of cases that would previously have been directed to classic surgery. We compared this expected percentage with the actual percentage of surgery, obtaining a significance for the decrease in the role of surgery which was very high (p = 0.0002). The significance for the increase in the role of endoscopy following its recent uses was reasonably high (p = 0.05). We also compared the number of cases that were solved by classic surgery with the number of cases solved by endoscopic methods. We obtained a p-value = 0 (highly relevant, in favour of endoscopy). This was interpreted as a measure of the usefulness of endoscopy in the general population suffering from UGIH. This, considered with previous results, is actually what gave us the final proof that endoscopy can be the solution for an impressive number of patients.
We then proceeded to the fourth level of our study, considering the impact of endoscopy on aetiologic groups. However, the calculation for the general group showed a higher impact of endoscopy than that on the aetiologic group. This can be explained by the small number of patients in each aetiologic group, this has statistically produced larger confidence intervals for each calculus. A study that would focus on only one aetiologic group could estimate the real importance of the impact. However, our results showed that bleeding gastric ulcer was offered a better treatment with the help of endoscopy: the role of endoscopy increased significantly (p = 0.05), while the role of classic surgery showed an important decrease (p = 0.02). The therapies for oesophagitis and duodenal ulcer have changed slightly and, as expected, the therapy for gastric cancer suffered no change.
The conclusions follow the steps of the study. It is important for therapy and epidemiology to know that the debut of UGIH is significantly earlier in males than in females, which means that the practitioner has to cure a younger male patient who is more capable of fighting with the disease but, at the same time, the elected treatment must permit a longer life after healing. Also 3 times more men than women refer at the hospital for gastric ulcer and 2.5 times more men refer for oesophagitis. In our country gastric pathology seems to occur more often than intestinal pathology, and the risk factors that or lead to this situation should be examined. With this clinical basis, the practitioner may have a wider view on the choice of therapy. The use of endoscopy as a therapeutic mean proves its efficiency on various pathologies at any age, in emergency as well as regular conditions, and decreases the risks undergone by the patient. It is a reliable alternative to classic surgery, and the introduction of endoscopic therapy significantly changed the approach to ulcerative lesions. It has shown good chances to change the outcome of UGIH produced by many other conditions. It is important to state once again that endoscopy is a very modern, efficient and easy to use method for treating UGIH, and these qualities remain fundamental reasons for its massive impact on medical practice.
Piśmiennictwo
1. Corley D.: Accute bleeds: Gaining control in emergency setting. Gastroenterology 2001; 120:946- 954. 2. Oelschlager B.K. et al.: Advancement in the use of Endoscopy for GERD. Medscape Gastroenterology eJournal, 2002. 3. Ziegler D. et al.: Comparison of endoscopic sclerotherapy versus endoscopic ligation of esophageal varices. SAGES, 2002. 4. Shahrier M. et al.: Endoluminal gastroplication (ELGP) improves acid-related pulmonary symptoms in GERD patients. Gastroenterology, 2002; 122:27. 5. Yol S. et al.: Endoscopic clipping versus band ligation in the management of bleeding esophageal varices. Kanya, Turkey, 2002. 6. Ponchon T. et al.: Endoscopic mucosal resection. J. Clini. Gastroenterol. 2001; 32:6-10. 7. Fennerty M.B.: Endoscopic therapies for GERD. Medscape Gastroenterol. eJ. 2002. 8. Waxman E.: Endoscopic treatment of early gastroesophageal malignacy. Current Opinion in Gastroenterology 2002; 18(5):587-594. 9. Merck Manual, 17th edition***,1999. 10. Vettoretto N. et al.: Surgical treatment of bleeding gastroduodenal ulcer: a retrospective analysis of 47 cases (1984-1999). Brescia, Italy, 1999. 11.Mantynen T. et al.: The impact of upper gi endoscopy referral volume on the diagnosis of gastroesophageal reflux disease and its complications: a 1-year cross-sectional study in a referral area with 260,000 inhabitants. Am. J. Gastroenterol. 2002; 97:2524-2529. 12. Krivchenya D.U. et al.: Treatment and prevention of bleeding in portal hypertension in children. Kiew, 1999.
New Medicine 1/2003
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