J. W. C. Leung

Octreotide infusion or emergency sclerotherapy for variceal haemorrhage

To compare octreotide with injection sclerotherapy in the treatment of acute variceal haemorrhage, patients admitted with gastrointestinal bleeding and oesophageal varices confirmed by endoscopy were randomised to receive either emergency sclerotherapy with 3% sodium tetradecyl sulphate or octreotide (50 micrograms intravenous bolus plus 50 micrograms per h intravenous infusion for 48 h). At the end of the study period (48 h), the octreotide group also had sclerotherapy to obliterate the varices. 100 patients were recruited. Demographic features including the aetiology of portal hypertension and the Child-Pughs grading of the two groups were similar. Bleeding was initially controlled in 90% of patients by emergency sclerotherapy and in 84% by octreotide infusion (95% confidence interval 0-19.5, p = 0.55). There were no significant differences between the two groups in early (within 48 h of randomisation) rebleeding (16% vs 14%), blood transfusion (3 units vs 3.5), hospital stay (5 days vs 6 days), or hospital mortality (27% vs 20%). No notable side-effects were associated with octreotide. We conclude that octreotide infusion and emergency sclerotherapy are equally effective in controlling variceal haemorrhage.

Endoscopic injection of adrenaline for actively bleeding ulcers: a randomised trial.

A prospective randomised trial was performed to assess the efficacy of endoscopic injection of adrenaline for actively bleeding ulcers. Emergency endoscopy in 961 patients admitted for upper gastrointestinal haemorrhage identified 68 patients with actively bleeding ulcers. These 68 patients were randomised to receive either endoscopic injection of adrenaline or no endoscopic treatment. After endoscopy both groups were managed in an identical manner, and strict criteria for emergency operation were adhered to in both groups. Bleeding was initially controlled in all 34 patients assigned to the treatment group. Significantly fewer patients in the treatment group than in the control group needed emergency operations (five v 14, respectively). In addition, in the treatment group the median transfusion requirement was significantly less (three v five units of blood) and the median hospital stay shorter (six v eight days). No complications were observed with the injection of adrenaline, and the rate of healing of ulcers in those attending for endoscopy six weeks after discharge was similar in both groups (81% (17 out of 21 patients) in the treatment group v 79% (11 out of 14) in the control group). Injection of adrenaline is effective in stopping bleeding from actively bleeding ulcers.

The role of bacteria in the blockage of biliary stents

Recurrent jaundice and cholangitis due to stent occlusion by biliary sludge is a major complication of endoscopic stenting for malignant obstructive jaundice. Scanning electron microscopy study of the blocked stents revealed the sludge to consist of a mixture of bacteria and amorphous material. In vitro study using scanning electron microscopy demonstrated the attachment of bacteria to a segment of stent perfused with infected bile containing live bacteria. Associated with the microcolonies of bacteria was a collection of amorphous material forming a dense concretion on the surface of the stent. This phenomenon was not observed in experiments using sterile bile or with infected bile sterilized by formalin treatment or autoclaving. It was concluded that live bacteria are necessary for the initiation of biliary sludge formation which leads to subsequent stent blockage.

Injection or heat probe for bleeding ulcer

A prospective randomized trial was performed to compare the efficacy of endoscopic epinephrine injection and heat probe treatment in actively bleeding peptic ulcers. Emergency endoscopy in 1758 patients over an 18-month period identified 132 patients with active ulcer bleeding. They were randomized to receive either endoscopic epinephrine injection or heat probe treatment. After endoscopy, the patients were transferred to the surgical gastroenterology ward and were managed by surgeons unaware of the treatment option. Bleeding was initially controlled in 96% by epinephrine injection and in 83% by heat probe (P less than 0.05). There was no significant difference in outcome as measured by transfusion requirement (4.5 units vs. 3.8 units), emergency surgery (20% vs. 22%), hospital stay (8 days vs. 7 days), and mortality (2 vs. 4) between the injection group and the heat probe group. Two patients in the heat probe group experienced perforation. We conclude that both endoscopic epinephrine injection and heat probe treatment are effective in stopping bleeding from actively bleeding ulcers. Epinephrine injection is technically easier to perform and has a higher initial success rate.

Randomised controlled trial of short term treatment to eradicate Helicobacter pylori in patients with duodenal ulcer.

OBJECTIVE--To determine whether one weeks drug treatment is sufficient to eradicate Helicobacter pylori in patients with duodenal ulcer. DESIGN--Single blind, randomised controlled trial. SETTING--Specialised ulcer clinic in a teaching hospital. PATIENTS--155 patients with H pylori and a duodenal ulcer verified endoscopically which had either bled within the previous 24 hours or was causing dyspepsia. INTERVENTIONS--Patients were allocated randomly to receive either omeprazole for four weeks plus bismuth 120 mg, tetracycline 500 mg, and metronidazole 400 mg (all four times a day) for the first week (n = 78), or omeprazole alone for four weeks (n = 77). Further endoscopy was performed four weeks after cessation of all drugs. MAIN OUTCOME MEASURES--Presence or absence of H pylori (by urease testing, microscopy, and culture of antral biopsy specimens), duodenal ulcer, and side effects. RESULTS--Eradication of H pylori occurred in 70 (95%) patients taking the four drugs (95% confidence interval 86% to 97%) compared with three (4%) patients taking omeprazole alone (1% to 11%). Duodenal ulcers were found in four (5%) patients taking the four drugs (2% to 12%) and in 16 (22%) patients taking omeprazole alone (14% to 32%). Mild dizziness was the only reported side effect (six patients in each group) and did not affect compliance. CONCLUSIONS--A one week regimen of bismuth, tetracycline, and metronidazole is safe and effective in eradicating H pylori and reduces the number of duodenal ulcers four weeks after completing treatment.

Ascending infection of the biliary tract after surgical sphincterotomy and biliary stenting

It has been widely accepted that there is an ascending route of bacterial infection of the biliary tract but there is a lack of direct evidence. This hypothesis was tested in an animal experiment using the cat as an animal model. The implantation of biliary stents and surgical sphincterotomy were performed in these animals, with sham controls. Stents bypassing the sphincter of Oddi with the tip in the duodenal lumen were colonized by duodenal micro‐organisms and the biliary tract was heavily contaminated. Blockage of these stents resulted in biliary obstruction. Stents implanted within the common bile duct, proximal to the sphincter were largely unaffected by biofilm formation. After surgical sphincterotomy the biliary tract was also contaminated but, in the absence of obstruction, the animals did not develop any symptoms. It was concluded that ascending infection by duodenal biliary reflux, via the sphincter of Oddi, is an important route of infection in the biliary system.

Decreased bacterial adherence to silver-coated stent material: an in vitro study

Bacteria are important in causing biliary stent blockage through adherence and subsequent biofilm formation. In our in vitro system, surface modification using test polyurethane discs with silver coating led to a reduction in the number of adherent bacteria compared with untreated controls by 10- to 100-fold in an apparently dose-related manner. The effect was more marked in the presence of bile. These results suggest that silver coating may have a potential benefit in preventing stent blockage.

Adding a sclerosant to endoscopic epinephrine injection in actively bleeding ulcers: a randomized trial

We compared the efficacy of epinephrine injection and epinephrine injection followed by sodium tetradecyl sulfate in controlling active ulcer bleeding. Out of 2814 patients who underwent endoscopy for gastrointestinal bleeding, 200 patients with actively bleeding ulcers seen at the time of endoscopy were randomized to receive epinephrine injection alone (99 patients) or epinephrine injection followed by 3% sodium tetradecyl sulfate (101 patients). After the procedure the patients were transferred to the surgical gastroenterology ward and were treated by surgeons who were unaware of the mode of treatment. The patients underwent routine endoscopy 24 hours later, and epinephrine injection was repeated if active bleeding was seen again. Emergency surgery was performed for the following: (1) arterial spurting not controlled endoscopically, (2) failure of the blood pressure or pulse to stabilize after 4 units of blood, (3) total transfusion of more than 8 units of blood, or (4) rebleeding as defined by hematemesis with pulse greater than 100 beats/min or blood pressure less than 100 mm Hg after stabilization. The two groups were comparable in age, sex, site of ulcer, and severity of bleeding. Initial hemostasis was obtained at the time of endoscopy in 94% of the epinephrine group and 97% of the epinephrine plus sodium tetradecyl sulfate group. No difference in outcome was seen in the two groups as measured by emergency surgery requirement, blood transfusion, hospital stay, and hospital mortality. Endoscopic epinephrine injection is effective in controlling active ulcer bleeding. The additional injection of sodium tetradecyl sulfate confers no additional advantage.

Systemic absorption of epinephrine after endoscopic submucosal injection in patients with bleeding peptic ulcers

Epinephrine injection is an effective, simple, and economical method of endoscopic hemostasis for bleeding peptic ulcers. We measured catecholamine levels in 18 patients with actively bleeding ulcers (8 gastric ulcers and 10 duodenal ulcers) treated by endoscopic injection. Injection of epinephrine (1:10,000 IU) was given until bleeding from the ulcers stopped. Catecholamine levels were assayed by high-pressure liquid chromatography. Immediately after the injection the plasma level of epinephrine rose by four to five times above the basal level and returned to the baseline in 20 minutes. Norepinephrine levels were not significantly raised in these patients. No cardiovascular complications were seen. Although adverse cardiac events have not been recorded, it seems prudent to monitor these patients closely during and immediately after epinephrine injection.

Management of hepatocellular carcinoma presenting as obstructive jaundice.

Eleven (3%) of 340 patients with hepatocellular carcinoma (HCC) presented with obstructive jaundice. The tumor extensively infiltrated the major bile ducts in eight patients. Jaundice was relieved by endoscopic endoprosthesis in four patients, nasobiliary drainage in two patients, percutaneous transhepatic stenting in one patient, and surgical intubation in one patient. The survival interval of these eight patients (mean +/- SD) was 35 +/- 20 days. Three patients had tumor fragments in the common bile ducts. In two patients, major hepatic resection was done after initial tube decomposition of the biliary system. One patient remained tumor-free on follow-up at 24 months, and the other patient had recurrent tumor detected on follow-up at 17 months after surgery. The tumor was irresectable in the third patient. Multiple surgical and endoscopic procedures kept the bile duct patent for 17 months before the patient died of the disease. Not all patients who present with obstructive jaundice due to HCC are terminally ill. With proper management, good palliation and occasional cure are possible.