Doppler endoscopic probe as a guide to risk stratification and definitive hemostasis of peptic ulcer bleeding

Abstract

Background and aims: For more than 4 decades endoscopists have relied on ulcer stigmata for risk stratification and as a guide to hemostasis. None used arterial blood flow underneath stigmata to predict outcomes. For patients with severe peptic ulcer bleeding (PUB), we used a Doppler endoscopic probe (DEP) for (1) detection of blood flow underlying stigmata of recent hemorrhage (SRH), (2) quantitating rates of residual arterial blood flow under SRH after visually directed standard endoscopic treatment, and (3) comparing risks of rebleeding and actual 30-day rebleed rates for spurting arterial bleeding (Forrest [F] IA) and oozing bleeding (F IB).

Methods: Prospective cohort study of 163 consecutive patients with severe PUB and different SRH.

Results: All blood flow detected by the DEP was arterial. Detection rates were 87.4% in major SRH-spurting arterial bleeding (F IA), non-bleeding visible vessel (F IIA), clot (F IIB)-and were significantly lower at 42.3% (P < .0001) for an intermediate group of oozing bleeding (F IB) or flat spot (F IIC). For spurting bleeding (F IA) versus oozing (F IB), baseline DEP arterial flow was 100% versus 46.7%, residual blood flow detected after endoscopic hemostasis was 35.7% versus 0%, and 30-day rebleed rates were 28.6% versus 0% (all P < .05).

Conclusions: (1) For major SRH versus oozing or spot, the arterial blood flow detection rate by the DEP was significantly higher, indicating a higher rebleed risk. (2) Before and after endoscopic treatment, spurting (F IA) PUB had significantly higher rates of blood flow detection than oozing (F IB) PUB and a significantly higher 30-day rebleed rate. (3) The DEP is recommended as a new endoscopic guide with SRH to improve risk stratification and potentially definitive hemostasis for PUB.

Published by Elsevier Inc.

Figures

Figure 1

Doppler ultrasound unit and disposable probe used in this study. (From Vascular Technology Inc., Nashua, New Hampshire).

Figure 2

A duodenal ulcer with a non-bleeding visible vessel (Forrest IIA) in the base.

Figure 3

Doppler probe placement next to the NBVV (FIIA) to interrogate it for underlying blood flow.

Figure 4

PUB active arterial bleeding (Forrest IA) has a significantly higher risk and rate of rebleeding than oozing bleeding (Forrest IB). Legend. DEP is Doppler endoscopic probe. + is positive signal for arterial blood flow detected underneath the stigma in ulcers. * p