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Background and Aims Recommendations for the treatment of lower GI bleeding do not include bleeding from venous malformations (VMs). The aim of this study was to delineate the usefulness of a novel hybrid intervention (fluoroscopy-guided endoscopic sclerotherapy) for the treatment of symptomatic VMs in the rectosigmoidal colon with bleeding. Methods The magnetic resonance images of 421 patients with VM, referred to multicenter vascular anomaly centers from 2009 to 2017, were analyzed retrospectively. Treatment was performed for all patients who experienced bleeding from rectosigmoidal VMs using fluoroscopy-guided endoscopic sclerotherapy with polidocanol foam as a novel approach. Results A total of 27 patients displayed VM in the rectosigmoidal area. Eleven of these presented with acute or previous bleeding and received treatment. Active bleeding was observed in 8 patients (72.7%), whereas 3 patients (27.3%) had signs of previous bleeding. Six of the 11 patients had anemia (54.5%). There were no adverse events within 24 hours of the intervention. In a 2-year follow-up period, only 1 patient (9.1%) presented with recurrent bleeding after 13 months and was successfully treated again with fluoroscopy-guided endoscopic sclerotherapy. Conclusions Fluoroscopy-guided endoscopic sclerotherapy was shown to be a safe and effective treatment of symptomatic VMs of the rectosigmoidal area. Thus, fluoroscopy-guided endoscopic sclerotherapy should be considered for patients with bleeding from VMs of the rectosigmoid after a comprehensive workup and interdisciplinary case discussion.

Background and Aims Small-bowel hemangioma is a rare disease that often causes active bleeding. The standard therapeutic method for small-bowel hemangioma is surgical resection. The aim of this study was to evaluate the usefulness of polidocanol injection (PDI) for small-bowel hemangiomas. Methods This study included 12 patients with obscure GI bleeding (6 male; mean age 62 years) with 39 small-bowel hemangiomas; patients were treated with PDI by using double-balloon endoscopy (DBE). EUS with DBE was performed before PDI. The lesions were divided into 2 groups according to tumor size: Group A (size Results There was no difference in the location of lesions and treatment times between the 2 groups. Group B had a significantly higher injection time per lesion ( P P r = 0.77). The optimal amount of polidocanol for small-bowel hemangioma was determined to be 0.2 mL/mm. Conclusions PDI is an easy, safe, and effective method to treat small-bowel hemangiomas.

Background and Aims With the development of imaging techniques, the detection rate of pancreatic cystic neoplasms (PCNs) has increased. The surgical morbidity and mortality rates of PCNs are quite high. This study is intended to evaluate the safety and effectiveness of a minimally invasive treatment, EUS-guided PCN ablation with lauromacrogol. Methods From April 2015 to May 2016, 120 patients with PCNs were enrolled to undergo EUS. We prospectively studied 29 of the 120 patients who underwent EUS-guided ablation with lauromacrogol. The follow-up contrast-enhanced CT or magnetic resonance image was conducted at 3 months and then 6 months after ablation. We determined the effectiveness of ablation by the changes in the volume of the cysts. Results Twenty-nine patients were enrolled in the study, and 7 of them underwent a second ablation; therefore, there were 36 treatments. The mean tumor diameter was 28.6 ± 14.5 mm preoperation, whereas the diameter postoperation was 13.4 ± 10.5 mm. Mild pancreatitis occurred in 2 patients and moderate fever in 1; they occurred in the cysts located in the head/uncinate. Among the 29 treatments with complete follow-up of 9 months (range, 3-15), 11 had complete response and 9 had partial response. The resolution rate was 37.9% (11/29) with 36.4% (8/22) in the cysts of the head/uncinate and 42.9% (3/7) in the body/tail ( P > .05). Conclusions EUS-guided PCN ablation with lauromacrogol is safe and efficient. Adverse event rates seem to be higher in the head/uncinate than in the body/tail, but their resolution rates are similar. Further studies involving larger populations and longer follow-ups are warranted.

Background Esophageal varices–related GI bleeding occurs frequently and early in life in children with biliary atresia and it may be life threatening. Objective We report the results of prophylactic sclerotherapy in 13 infants with biliary atresia and large varices. Patients Mean age was 13 months, mean weight was 8.2 kg, mean total serum bilirubin was 258 μmol/L, and mean prothrombin time was 78%. Esophageal varices were grade III (11 patients) or II (2 patients), with red signs in all infants and gastric varices in 12. None had GI bleeding. Intervention Sclerotherapy was performed with the patient under continuous intravenous octreotide therapy in 7 infants. Results In 8 children a complete or almost complete eradication of varices was obtained; none of these children bled later, 4 underwent liver transplantation, 3 are alive without liver transplantation, and 1 died of sepsis after 9 months awaiting liver transplantation. In 4 children a partial eradication was obtained and liver transplantation was performed. None of these children bled. One other child bled to death after 2 sessions of sclerotherapy. Limitations Four ulcers and 2 stenoses occurred in 6 children with no octreotide versus no ulcer and 1 stenosis in 7 children receiving octreotide. Conclusion These results (1) indicate that primary prevention of GI bleeding by sclerotherapy of esophageal varices is technically feasible and fairly effective in infants with biliary atresia and large varices, even in those with end-stage liver disease, (2) suggest that decreasing the risk of bleeding may allow liver transplantation under better conditions, and (3) further suggest that octreotide associated with sclerotherapy lowers the rate of complications.

Endoscopic sclerotherapy is a well-established treatment for bleeding esophageal varices, although it has a substantial complication rate. A prospective randomized trial was conducted to determine whether endoscopic variceal ligation is safer and more effective than sclerotherapy in adults with bleeding esophageal varices because of extrahepatic portal venous obstruction.Thirty-six patients underwent sclerotherapy and 37 had band ligation.Ligation and sclerotherapy were equally effective for achieving variceal eradication (94.6% vs. 91.7%, respectively; p=0.67). However, ligation achieved eradication with fewer endoscopic sessions (3.7 [1.2] vs. 7.7 [3.3]; p0.0001) and within a shorter time interval (50.1 [17.7] days vs. 99 [54.8] days; p0.0001). In the ligation group, recurrent bleeding was less frequent (2.7% vs. 19.4%; p=0.028; however, Bonferroni correction for multiple testing removes this significance) and the rate of major complications was lower (2.7% vs. 22.2%; p=0.014). Total cost per patient was significantly higher in the sclerotherapy vs. the ligation group ($216.6 [71.8] vs. $182.6 [63.4]; p=0.035). During the follow-up period after variceal eradication, no significant differences were found between the sclerotherapy and the ligation groups with respect to recurrent bleeding (3% vs. 2.9%; p=1.0), esophageal variceal recurrence (9.1% vs. 11.4%; p=1.0), and formation of new gastric varices (9.1% vs. 14.3%; p=0.51).Variceal band ligation is superior to sclerotherapy, because it is less costly and achieves variceal eradication more quickly, with lower relative frequencies of recurrent variceal bleeding and complications.

Background: The combination treatment of band ligation plus sclerotherapy has been proposed to hasten variceal eradication. The aim of this study was to assess the efficacy of band ligation alone versus band ligation plus sclerotherapy in the prevention of recurrent variceal bleeding. Methods: Eighty cirrhotic patients were randomized to group I (band ligation) with 41 patients or to group II (band ligation plus sclerotherapy) with 39 patients in whom polidocanol (2%) was injected 1 to 2 cm proximal to each band. Results: At baseline, both groups were similar with regard to clinical, demographic and laboratory data. Mean follow-up time (standard error) for group I was 336.5 ± 43.4 days and for group II 386.1 ± 40.1 days ( p = 0.4). No statistical differences were observed between group I and group II in relation to recurrence of bleeding (31.7% vs. 23%, p = 0.38), treatment failure (24.4% vs. 12.8%, p = 0.18), death (39% vs. 30.8%, p = 0.44) and variceal eradication (65.8% vs. 74.4%, p = 0.40). Group II had a significantly higher number of complications than group I, 30.8% versus 7.3%, respectively ( p = 0.05). The number of bleeding related deaths was higher in group I than in group II (22% vs. 10.3%, respectively; p = 0.15). Conclusions: No significant difference was observed between band ligation and band ligation plus sclerotherapy in prevention of recurrent variceal bleeding. Furthermore, there was a higher incidence of complications in the latter group. (Gastrointest Endosc 2000;51:157-63.)

Background: The pharmacologic response and microvascular effects associated with the endoscopic injection of sclerosing agents around vessels (paravascular injection) to stop bleeding from the digestive tract remain to be clarified. Methods: Using in vivo microscopy, we directly visualized submucosal microvessels of the rat stomach and intestine. We studied differences among sclerosing agents in thrombus formation and vascular diameter change that occur through a pharmacologic response and/or local compression after topical application or paravascular injection of the agents. Results: Except for absolute ethanol, topical application of the agents did not cause constriction or thrombi in either arterioles or venules. Polidocanol topical application and paravascular injection significantly dilated arterioles. Injecting ethanolamine oleate near venules constricted them the longest and most effectively, but vasoconstriction in arterioles was transient. Injecting absolute ethanol formed long-lasting thrombi and caused vasoconstriction in venules, but arteriole thrombi persisted no more than 3 minutes. The vascular response to thrombin did not significantly differ from that to physiologic saline. Conclusion: The paravascular injection of ethanolamine oleate, because of its long-lasting vasoconstriction, or of absolute ethanol, because of its thrombogenic effect, is a valid therapeutic approach to treating venous bleeding. The efficacy of paravascular injection of sclerosing agents for treating acute arterial bleeding, however, is not supported in this experimental model. (Gastrointest Endosc 1999;50:499-505.)

Background: We devised a new combined method of endoscopic variceal ligation and injection sclerotherapy, namely, endoscopic scleroligation, for the treatment of esophageal varices. The aim of this prospective randomized trial was to compare endoscopic scleroligation with endoscopic variceal ligation alone with regard to efficacy, complications, variceal recurrence, and survival. Methods: Fifty-one patients with cirrhosis and esophageal varices were randomly assigned to be treated by endoscopic scleroligation (n = 25) or endoscopic variceal ligation (n = 26). In the initial session in the endoscopic scleroligation group, endoscopic injection sclerotherapy was performed with injection of 5% ethanolamine oleate around the lower esophagus to obliterate the feeding veins. This was followed by endoscopic variceal ligation from the injection site to the most orad varix. In subsequent sessions, endoscopic injection sclerotherapy was performed with 1% polidocanol. In the endoscopic variceal ligation group, that procedure was performed in all treatment sessions. Results: Both methods were equally effective in achieving complete eradication of esophageal varices. Among the cases in which complete eradication was achieved, the 1- and 3-year cumulative recurrence rates in the endoscopic scleroligation group (9.5%, 22.1%) were significantly lower than those in the endoscopic variceal ligation group (61.9%, 72.2%) ( p Conclusions: Endoscopic scleroligation is superior to endoscopic variceal ligation in preventing variceal recurrence. (Gastrointest Endosc 1999;50:7-12.)

Background: Endoscopic band ligation combined with sclerotherapy has been postulated to be superior to ligation alone for the treatment of esophageal variceal bleeding. Methods: A randomized trial of ligation versus combined ligation and sclerotherapy was designed to determine whether combined therapy results in faster eradication of varices compared to ligation alone. Sixty patients were randomized to undergo band ligation or ligation combined with injection of 1 to 2 mL of polidocanol (1%) into each variceal column immediately proximal to the previously placed bands. Therapy was repeated at 1- or 2-week intervals until variceal eradication was achieved. Follow-up endoscopy was performed at 3 months and then at 6-month intervals. Results: The demographic and clinical characteristics of the 31 patients who underwent ligation were similar to those of the 29 who received combined treatment. Sixty percent of the patients had cirrhosis due to viral hepatitis. No significant differences were found between the combined and ligation alone groups in arresting active bleeding [9 of 9 (100%) vs. 6 of 7 (86%)], units of blood transfusion (3 ± 0.8 vs. 2 ± 0.6), number of sessions required to eradicate varices (3.8 ± 0.5 vs. 3.6 ± 0.4), treatment failure [2 (17%) vs. 4 (14%)], esophageal varice recurrence [6 (21.%) vs. 2 (6%)], gastric varices formation [4 (14%) vs. 1 (3%)], stricture [1 (3%) vs. 0 (0%)], recurrent bleeding [5 (17%) vs. 7 (23%)], other complications [10 (34%) vs. 9 (29%)], or death [3 (10%) vs. 7 (23%)] during a follow-up period of up to 36 months. Conclusions: Combined ligation and sclerotherapy does not reduce the number of endoscopic treatment sessions required for variceal eradication and offers no benefit over ligation alone. Because of the lack of benefit, the added procedure time, and the cost, we do not advocate combination therapy, and ligation alone remains the best endoscopic treatment. (Gastrointest Endosc 1999;50:1-6.)

To evaluate the safety and efficiency of variceal ligation compared with endoscopic sclerotherapy, 88 patients with cirrhosis with recent variceal bleeding were randomized to undergo either treatment.Sclerotherapy was performed using ethanolamine and polidocanol injection at 1, 2, and 3 weeks and every 3 weeks thereafter. The Stiegmann-Goff device was used for variceal ligation at the same intervals.The rate of variceal eradication was the same for both groups, but eradication was accomplished sooner in patients undergoing variceal ligation (5.3+/-1.6 vs. 6.6+/-2.4 endoscopic sessions, p0.05) and with fewer complications (19 vs. 6, p0.005). The rate of recurrent bleeding was lower in patients treated by ligation (31% vs. 50%, p0.05). After eradication, variceal recurrence was more frequent in patients treated by variceal ligation at 1 and 3 years (47% and 92% vs. 23% and 55%, p0.01). Portal hypertensive gastropathy was significantly worse in the patients who had variceal ligation (17 patients vs. 6, p0.01). Survival and treatment failure were similar in both groups.Variceal ligation was superior to sclerotherapy in terms of the rate of recurrent bleeding and the occurrence of complications but worse with respect to recurrence of varices and the evolution of portal hypertensive gastropathy. Long-term follow-up studies are required to find out whether there are deleterious effects of variceal ligation.

Background: A prospective, randomized study was performed to compare the hemostatic effect of injection therapy and heater probe thermocoagulation in the treatment of peptic ulcer bleeding. Methods: This study includes 104 patients with upper gastrointestinal bleeding in whom endoscopy revealed a gastric or duodenal ulcer with nonbleeding or bleeding vessel (n = 66), oozing hemorrhage (n = 21), or adherent red clot (n = 17). Patients with other stigmata or clean ulcers were excluded. Patients were randomly assigned during endoscopy to receive injection therapy (adrenaline and polidocanol) (n = 51) or heater probe thermocoagulation (10F probe, at setting of 30 J (n = 53). Therapy was considered successful if there was no further hemorrhage or only minor rebleeding that was controlled with a second endoscopic procedure. Patients with major rebleeding or failure of retreatment underwent emergency surgery. Results: There were no significant differences in effectiveness between injection therapy and thermocoagulation in any of the assessed parameters: the percentage of patients with major recurrent hemorrhage (4% vs 6%) or minor rebleeding (16% vs 17%), need for emergency surgery (two patients from each group), transfusion requirement (0.45 ± 0.9 units vs 0.51 ± 1.1 units), the mean number of hospitalization days (7.1 ± 4.2 vs 6.9 ± 4.9), and mortality (one patient from each group died). Conclusion: Injection therapy and heater probe have similar efficacies in the treatment of bleeding peptic ulcers. (Gastrointest Endosc 1996;43:117-20.)

The purpose of this study was to compare the relative efficacy and technical ease of use of eight different agents for endoscopic hemostasis and obliteration of bleeding gastric varices in a canine model, as no comparative data are available on gastric variceal sclerotherapy. Large bleeding gastric varices in 20 heparinized dogs were randomized to endoscopic injection treatment with one of the following agents: cyanoacrylate; a 1:1:1 mixture of sodium tetra-decyl sulfate 3%, ethanol 98%, and normal saline solution; ethanolamine oleate 5%; sodium morrhuate 5%; sodium tetradecyl sulfate 1.5%; polidocanol 1%; normal saline solution with epinephrine 1:10,000; or normal saline solution (control). The number and volume of injections and the time required to achieve complete hemostasis were evaluated; follow-up endoscopy was performed at 1 month to assess gastric variceal obliteration. Cyanoacrylate was the best agent overall in terms of immediate efficacy, low volume requirement, time required for initial hemostasis, and reduction of gastric variceal size. Cyanoacrylate, tetradecyl sulfate, and polidocanol were the most effective agents for reducing gastric variceal size. Epinephrine was effective for controlling induced or secondary bleeding caused by puncture of the gastric varices with the sclerotherapy needle during intravariceal injections. Ongoing studies are evaluating combinations of agents with different mechanisms of action, such as epinephrine (for vasoconstriction to minimize secondary bleeding) plus alcohol, and/or tetradecyl sulfate (for variceal thrombosis and sclerosis). In addition, different concentrations of alcohol as a single agent or combined with epinephrine should be evaluated because of the relatively low cost and wide availability of these substances. (Gastrointest Endosc 1995; 41:206-11.)

The diagnostic accuracy and practical impact of trans-endoscopic Doppler ultrasonography were prospectively investigated in an open preliminary study of patients with hemorrhage from colonic vascular malformations. From January 1, 1991, to December 31, 1992, 437 consecutive patients were seen with lower gastrointestinal bleeding. In 15 cases the source of hemorrhage proved to be colorectal angiodysplasias (3.4%). In all cases bleeding had stopped spontaneously before the endoscopic examination. Upper gastrointestinal causes of bleeding were excluded endoscopically in each patient. To detect the superficial arterial vessels responsible for the hemorrhage a total of 32 lesions were scanned by trans-endoscopic Doppler ultrasonography. Twenty-nine vascular malformations in 12 patients were Doppler-positive (91%) and 3 lesions in 3 patients were Doppler-negative without an arterial signal. All Doppler-positive lesions had injection therapy with epinephrine and polidocanol. Twenty-six of the 29 sclerosed angiodysplasias (90%) in 9 patients could not be found endoscopically 2 weeks later, confirming the success of therapy. Doppler noise was still recorded in 3 visible malformations in the remaining 3 patients, indicating insufficient treatment. Further injections were made into these lesions, and the vascular anomalies were finally eliminated. During 6 months of follow-up, one of the 12 treated patients relapsed with an actively bleeding cecal angiodysplasia. After repeated endoscopic hemostasis, no further hemorrhage was observed in this patient. No bleeding recurred in the 3 patients with Doppler-negative lesions. Endoscopic Doppler sonography may help in the identification of intestinal angiodysplasias. The technically simple method allows objective evaluation of the endoscopic findings and enables monitoring of local endoscopic therapy. (Gastrointest Endosc 1994;40:40-4.)

Background: Endoscopic injection is widely used in the therapy of bleeding gastroduodenal ulcers, but its role in the management of bleeding Mallory-Weiss tears has not been properly assessed. Methods: Sixty-three patients undergoing emergency endoscopy in whom there was a high index of suspicion that a Mallory-Weiss tear was the source of bleeding were randomly assigned to undergo endoscopic injection therapy (epinephrine and polidocanol) or no endoscopic therapy in 2 university-affiliated hospitals. Rates of recurrent bleeding, transfusion requirements, complications, mortality, and length of hospital stay were determined for both groups of patients. Results: Bleeding recurred in 8 patients in the control group versus only 2 in the endoscopic treatment group (25.8% vs. 6.2%, p < 0.05). Hospital stay was longer for the control group (5.5 ± 0.2, median 6.0, range 2.0-8.0 days vs. 3.4 ± 0.2, median 3.0, range 2.0-6.0 days; p < 0.001). There was a trend toward a higher transfusion requirement after endoscopy in the control group versus the patients treated by injection (0.9 ± 0.2, median 0.0, range 0.0-4.0 units vs. 0.2 ± 0.1, median 0.0, range 0.0-2.0 units; p = 0.09). No complications or adverse events caused by endoscopic injection were noted. Two patients in the control group died of causes unrelated to bleeding. Conclusions: Endoscopic injection therapy is a useful option in the management of patients with Mallory-Weiss syndrome at high risk for recurrent bleeding. (Gastrointest Endosc 2001;54:679-81.)

Background Early upper GI hemorrhage (UGH) is a potential complication after laparoscopic Roux-en-Y gastric bypass (RYGBP), and early reoperative intervention is the most accepted treatment. Experience with endoscopic treatment is limited. Objective Our purpose was to describe the role of endoscopy and injection therapy in the management of early UGH after laparoscopic RYGBP. Design Case series study. Setting Endoscopy Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain. Patients We describe the endoscopic treatment of 6 patients with early UGH within 24 hours after a RYGBP. Instrumentation Upper endoscopy was performed in all 6 cases. The origin of the bleeding was identified at the staple line in all cases, and epinephrine alone or combined with polidocanol was successfully injected in 5 of 6 patients. Results Endoscopic therapy arrested active bleeding without any complications in all cases without the need for further surgery or endoscopic treatments. Limitation Our experience is limited to 6 cases. Conclusion Early postoperative UGH after RYGBP may be adequately controlled with endoscopic treatment and may obviate the need for surgery. Further data are necessary to evaluate the safety and the efficacy of this approach.

Background EMR is the standard of care for the resection of large polyps. Objective To compare the efficacy and safety profile of submucosal polidocanol injection with epinephrine–saline solution injection for colon polypectomy with a diathermic snare. Design After 1-to-1 propensity score caliper matching, comparison of submucosal epinephrine injection was performed with polidocanol injection. Setting Endoscopic suite at the University of Foggia between 2005 and 2014. Patients Of 711 patients who underwent endoscopic resection of colon sessile polyps 20 mm or larger, 612 were analyzed after matching. Interventions Submucosal epinephrine injection in 306 patients and polidocanol injection in 306 patients. Main Outcome Measurements Univariate and multivariate logistic regression models aimed at identifying independent predictors of postpolypectomy bleeding (PPB). Results The 2 groups presented similar baseline clinical parameters and lesion characteristics. All patients had a single polyp 20 mm or larger; the median size was 32 mm (interquartile range [IQR], 25-38) in the polidocanol group and 32 (IQR, 24-38) in the epinephrine group ( P = .7). Polidocanol was more effective in preventing both immediate and delayed PPB ( P P = .003, respectively), and its efficacy was confirmed in almost all of the subgroups, regardless of polyp size and histology. Postprocedure perforation was observed in 2 patients (0.3%), both in the epinephrine group ( P = .49). The 2 groups did not differ in the number of snare resections of lesions or the procedure duration ( P = .24 and .6, respectively). Limitations Absence of randomization. Conclusion The submucosal injection of polidocanol for colon EMR is effective and significantly lowers the PPB rate.

Background Outpatient management is safe for patients with non-variceal upper-GI bleeding who are at low risk of recurrent bleeding and death. However, outpatient care cannot be offered to many patients because of the presence of risk factors (severe comorbid disorders, major endoscopic stigmata of bleeding, significant hemorrhage). The present study assessed the safety of outpatient management for selected high-risk patients with bleeding peptic ulcer. Methods Patients hospitalized with upper-GI bleeding because of peptic ulcer with a non-bleeding vessel were eligible for inclusion in the study. Inclusion criteria were the following: ulcer size less than 15 mm, absence of hypovolemia, no associated severe disease, and appropriate family support. After endoscopic therapy (injection of epinephrine and polidocanol), patients were randomized to outpatient or hospital care. Patients remained in the emergency ward for a minimum of 6 hours before discharge, during which time omeprazole was administered intravenously. Outpatients were contacted by telephone daily during the first 3 days; a 24-hour telephone hotline was provided for any queries. For both groups, outpatient visits were scheduled at 7 to 10 and 30 days after discharge. Results A total of 82 patients were included: 40 were randomized to outpatient care and 42 to hospital care. Clinical and endoscopic variables were similar in both groups. The rate of recurrent bleeding was similar in both groups (4.8% outpatient, 5% hospital). There was no morbidity or mortality in either group at 30 days. Seven patients (17%) randomized to outpatient care received blood transfusion compared with 14 (38%) in the hospital care group ( p =0.06). Mean cost of care per patient was significantly lower for the outpatient vs. the hospital group ($970 vs. $1595; p Conclusions Selected patients with bleeding peptic ulcer can be safely managed as outpatients after endoscopic therapy. This policy conserves health care resources without compromising standards of care.

Background: A randomized comparative study was conducted of injection therapy with epinephrine-polidocanol (1%) versus hemoclip application, versus injection combined with hemoclip for bleeding peptic ulcers. Methods: One hundred five patients were randomized and 101 could be evaluated (46 had active spurting or oozing of blood; 55 a visible vessel). Patients were randomized to 1 of the 3 treatment modalities during endoscopy performed within 12 hours of admission. Endoscopy was repeated after 1 day or at recurrence of bleeding and before discharge. In case of recurrent bleeding, patients were retreated with the same modality. Results: Initial failure or the rate of early recurrence of bleeding was highest (but not statistically significant) in the hemoclip group (13/35; 37%), versus the injection (5/34; 15%) and combination (8/32; 25%) groups. Overall failure was significantly ( p = 0.01) different among the 3 groups with the highest rate in the hemoclip group (12/35; 34%), versus the injection (2/34; 6%) and combination therapy (8/32; 25%) groups. The use of hemoclips alone appeared to fail because of difficulty with hemoclip placement and incomplete vessel compression. Complications included 1 perforation in the injection group and possibly 1 case of septic arthritis in the combination therapy group. Conclusion: In this study, endoscopic treatment of bleeding peptic ulcers with the hemoclip was inferior overall to injection therapy. (Gastrointest Endosc 2002;55:466-9.)

Aim:Evaluation of management in patients with peptic ulcer hemorrhage (PUH) in the Netherlands. Methods: A questionnaire was sent to gastroenterologists and internists, performing endoscopy, in every hospital in the Netherlands (N=123). Endoscopic therapy, acid suppressant therapy, endoscopic re-intervention and management of Helicobacter pylori were evaluated. Results: 90/123 (73%) questionnaires were returned. Endoscopic hemostatic therapy is given in ulcers classified as Forrest Ia/ Ib/ IIa/ IIb by respectively 89%/ 93%/ 83% and 47% of responders. Gastroenterologists perform more often endoscopic therapy in Forrest Ib (p=0.03), IIa (p=0.002) and IIb (p=0.001) ulcers compared to internists. As first modality , endoscopic injection therapy is used by 93%. Adrenaline combined with polidocanol is used in 60%, adrenaline alone in 14%, polidocanol alone in 6%, adrenaline and histoacryl/ thrombine/ fibrine/ alchohol in 7%, 4%, 1% and 1% respectively. 68% of responders add a sclerosant to adrenaline injections. Acid suppressant therapy is given by 97% of responders; 71% preferred proton pump inhibitors, 26% H2-receptorantagonists, both mainly given intravenously (80% and 92% respectively). In case of suspected rebleeding 71% perform endoscopic re-intervention (89% of gastroenterologists vs. 60% of internists, p=0.005), whereas the others refer the patient directly for surgery. Detection of H. pylori is performed by almost all responders. Eradication is confirmed by only 64% (80% of gastroenterologists vs. 50% of internists, p=0.004). Conclusions: There are important differences in management of PUH between gastroenterologists and internists in the Netherlands. Despite consensus conferences and results of randomised trials, a significant percentages of patients with PUH are still not adequately treated endoscopically, nor is H. pylori eradication confirmed in all patients.

A 31-year-old white male, A.A, presented to our hospital with severe hematemesis. He referred a history of several coughing spells prior to the admission, but no vomiting. During the first hours in the hospital, he had repeated episodes of hematemesis. An accurate history confirmed the previous occurrence of several violent coughing spells for the last few days, but excluded any prior vomiting. Patient was hemodynamically unstable, with hypotension, sinus tachycardia and postural changes. The laboratory data revealed a severe anemic condition (hemoglobin level: 6.0 g/dL), that required three blood transfusions. Chest X-ray was normal. The upper gastrointestinal (GI) endoscopy, performed after transfusions (12 hours after the admission), showed four longitudinal tears (maximum lenght: 20 mm): one of these tears was actively bleeding (“oozing”). Therefore, injection therapy for the active bleeding was performed, using a combined treatment strategy (polidocanol 0.5% and epinephrine 1:10000, total amount: 10 mL), with subsequent hemostasis. Afterwards, a medical therapy with omeprazole i.v. (40 mg bid) was started. Patient recovered uneventfully and at the follow-up endoscopy, performed two days later, tears showed a clean base. We present a case of severe persistent upper GI hemorrhage, precipitated by coughing, with endoscopic evidence of multiple tears at the gastroesophageal junction and in the lower esophagus. In our opinion, the severity and persistence of bleeding event, its apparent etiology (coughing), and the number of tears (four) make this case of Mallory Weiss syndrome an intesting one.

Background and Objectives: Endoscopic sclerotherapy (ES) and endoscopic variceal ligation (EVL) are accepted treatment for bleeding esophageal varices. We aim to determine which group of patients with esophageal variceal bleeding at index endoscopy treated with either injection sclerotherapy or variceal ligation and maintained on propranolol, had early rebleeding. In addition, we want to determine the variable that would best predict early rebleeding between the two groups. Methods: Fifty-four (54) documented cirrhotics with esophageal variceal bleeding at index endoscopy were included in the study. ES was performed with paravariceal/intravariceal injection of 1% polidocanol every 7 days, while Saeed 6-shooter multiband ligator (Wilson Cook, Winston-Salem, NC) was used every 10 days to the EVL group. Both procedures were repeated until there was complete obliteration of varices. All patients were then administered propranolol until there was 25% reduction in resting heart rate. Recurrence of bleeding was defined as any episode/s of melena or hematemesis occurring after complete variceal obliteration. Results: Forty-two out of 54 patients (78%) had episodes of rebleeding. Of these, 20 patients belonged to the ES group and 22 patients in the EVL group. There were no differences between the two groups in terms of age, sex, etiology of cirrhosis, variceal grade at index endoscopy and rebleeding and Child- Pugh class. (p>0.05). Mean follow-up period for the ES and EVL groups were 111.3+71 days and 197.9+124 days, respectively. Mean propranolol dose taken was 27.5±19.74 milligrams per day in the ES group and 27.7±18.39 for EVL patients (p>0.05). Mean treatment sessions for the ES and EVL group was 3.05±.37 and 2.82±.35, respectively (p>0.05). Time interval of bleeding recurrence in the ES group was 100.3±67 days while in the EVL group it was 195.4±135 days (p=0.007). Using multivariate analysis, Child-Pugh class and the type of endoscopic procedure were independent variables that could predict early rebleeding (p Conclusion: After complete variceal obliteration and propranolol maintenance, patients treated with endoscopic sclerotherapy had significantly earlier rebleeding interval compared to endoscopic variceal ligation. Furthermore, poorer Child-Pugh class and variceal obliteration by injection sclerotherapy may predict early rebleeding.

Acid gastroesophageal reflux was determined by long-term pH monitoring in 19 consecutive variceal bleeders after 5 to 20 (mean, 10.3 +/- 1 SEM) sclerotherapy sessions with the flexible endoscope using polidocanol 1% as sclerosant. Fifteen cirrhotics with untreated varices served as controls. Percentage time of esophageal pH less than 4 (3.3 +/- 0.7 SEM vs. 5.2 +/- 2.2 in the controls) and mean duration of reflux episodes (2.9 +/- 0.4 vs. 3.0 +/- 0.7 min) showed no significant differences between both groups. The findings indicate that repeated injection sclerotherapy with the flexible endoscope does not lead to an enhancement of acid gastroesophageal reflux.

Between 1982 and 1987, 43 patients with variceal bleeding due to extrahepatic portal obstruction were treated by repeated endoscopic injection sclerotherapy using 1% polidocanol intravariceally. This decreased rebleeding, as evidenced by a decrease in bleeding risk factor (BRF), mean transfusion requirement, and mean number of transfusions per patient per month of follow-up. Differences between pre- and postsclerotherapy parameters were significant (p less than 0.001). The varices were eradicated in 86% of patients. The mean sclerotherapy sessions required were 7.68 +/- 2.39 (SD). Complications were infrequent. Forty-three patients were followed from 5 to 68 months: cumulative survival was 97.7% and varices recurred in 16%. Sclerotherapy avoided a second operation in 21 postsurgical patients. Sclerotherapy for managing variceal bleeding due to extrahepatic portal obstruction is a reasonable alternative to surgery.