Category: Routine second look endoscopy

Routine second look endoscopy: SUMMARY

Only two of the six randomized studies were positive: 1) a seven-year-old abstract, still not published in full and 2) a study of 40 extremely high risk patients, mostly active bleeders with a high unexplained delayed bleeding rate. The Marmo meta-analysis may have been flawed, was heavily influenced by the one small positive study in highly selected patients and yet still showed only a very…

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Routine second look endoscopy: DISCUSSION

endoscopic hemoclipping

It is important to emphasize that 20% to 50% of rebleeding episodes occur in patients who are considered ‘low risk’, as determined by findings at the second endoscopy. Therefore, it may be dangerous to discharge a patient early, based on a favourable (according to the Forrest classification) endoscopic appearance. The rebleeding rate for a low risk lesion that is found one or two days after…

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Routine second look endoscopy: A recent meta-analysis

Marmo et al recently published a meta-analysis on this topic. Unfortunately, it is plagued by several problems. First, in the plot of odds ratios for rebleeding, the CIs for Messmann et al’s study are shown as not crossing 1.0, in spite of the fact that the differences in rebleeding rates in that study were clearly not significant. Second, there was significant clinical heterogeneity in patient…

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Routine second look endoscopy: Evidence from six randomized trials (Part 4)

multicentre randomized trial

Rutgeerts et al published the fourth study, a very large (854-patient) multicentre randomized trial that included three groups: polidocanol; fibrin glue; and daily fibrin glue injections until high risk stigmata disappeared. Recurrent bleeding occurred in 19% of the 266 patients in the fibrin glue arm and 15% of the 270 patients randomized to repeated fibrin glue injections. There were no significant differences in rates of…

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Routine second look endoscopy: Evidence from six randomized trials (Part 3)

The third randomized trial by Saeed et al was restricted to extremely high risk patients, in that they had high risk stigmata as well as a high Baylor bleeding score (pre-endoscopy score greater than five or postendoscopy score greater than 10). Many patients were excluded because they failed to meet the latter criteria, despite having high risk stigmata. Heater probe was the main method of…

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Routine second look endoscopy: Evidence from six randomized trials (Part 2)

second look endoscopy

At the second look endoscopy, potentially treatable lesions were seen in 59% of patients, a small proportion of which were actively bleeding. Of the 11 patients who had recurrent bleeding in this group, two (18%) rebled before the date of their second endoscopy and, therefore, would not have been helped by this strategy. Another five (45%) rebled despite retreatment of their lesions and four (36%)…

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Routine second look endoscopy: Evidence from six randomized trials (Part 1)

Third, endoscopic high risk stigmata are frequently discovered at the second endoscopy and this observation is often used to justify repeat endoscopic therapy; however, the natural history of these lesions after therapy has already been applied is unknown. A randomized trial addresses the above problems, allowing known and unknown con-founders to be balanced, and allows the natural history of residual high risk stigmata to be…

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Routine second look endoscopy: Ineffective, costly and potentially misleading (Part 1)

endoscopic treatment

Despite advances in the endoscopic treatment of bleeding peptic ulcer disease, there remains a significant rebleeding rate of 10% to 20% . Adjuvant intravenous proton pump inhibitor therapy has been proven to reduce the rebleeding rate when used with successful endoscopic hemostasis . Endoscopic hemoclip application also appears to be effective in selected cases. Certainly more controversial, however, is the question of whether a routine…

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