Lack of uniformity in evaluation of endoscopic prognostic features of bleeding ulcers

doi:10.1016/S0016-5107(94)70202-0

Gastrointestinal Endoscopy

Volume 40, Issue 4, July–August 1994, Pages 411-417

https://doi.org/10.1016/S0016-5107(94)70202-0 Get rights and content

Abstract

Management strategies in patients with bleeding ulcers are based on ulcer appearance. We assessed the level of agreement among endoscopists regarding the labeling of endoscopic features of bleeding ulcers and also evaluated the effect of a short teaching session on the level of agreement. Two hundred two endoscopists at the 1992 American College of Gastroenterology Postgraduate Course answered multiple-choice questions using interactive keypads. They were shown 6 slides of typical ulcer stigmata of recent hemorrhage, attended a brief teaching session, and then saw 6 different slides of comparable stigmata plus 2 additional slides. Color of stigmata was assessed in 9 slides. Information on years of endoscopic experience and numbers and types of procedures performed was also obtained. The proportion of correct answers before the teaching session increased significantly with years of experience, reaching a plateau in endoscopists who were 6 years or more beyond training. The proportion of correct answers for physicians performing no more than 5 upper gastrointestinal endoscopies per month was significantly lower than for those performing more than 5 per month: 33/56 (59%) compared with 647/891 (73%), a difference of 14% (95% CI, 0.4% to 27%; p = 0.03), but performance of a greater number of endoscopies was not associated with a further increase in the rate of correct answers. The total number of correct answers increased from 845/1181 (72%) before the teaching session to 1268/1554 (82%) afterwards, a difference of 10% (95% CI, 7% to 13%; p < 0.001). The increase was related to the level of training: fellows, 15% increase in correct answers (95% CI, 9% to 23%; p < 0.001); physicians with 0 to 20 years since training, 8% increase (95% CI, 4% to 12%; p < 0.001); physicians with 20 years or more since training, 3% increase (95% CI, –6% to 12%; p = 0.51), but was not related to the number of procedures performed per month. Agreement on the color of stigmata ranged from 35% to 91%, with a mean of 62%. Endoscopists disagree on labeling of ulcer features more than a quarter of the time, and the rate of disagreement on difficult stigmata is higher. Consensus regarding color is even more variable. Agreement can be modestly improved with a brief period of teaching. Our findings may help explain the variable results in studies of bleeding ulcers. Because patient management is based primarily on interpretation of ulcer features at endoscopy, consensus definitions of stigmata of hemorrhage must be developed and disseminated to ensure appropriate patient care. (Gastrointest Endosc 1994;40:411-7.)

Section snippets

METHODS

Fourteen slides of endoscopic photographs of ulcers with typical SRH or a clean base were chosen by the three authors, all of whom have extensive experience in examining patients with upper gastrointestinal bleeding and all of whom have performed randomized controlled trials in patients with bleeding ulcers to assess the relationship of outcome to SRH.5, 7, 8, 9, 10, 11 More than 250 slides were examined to pick the final 14 photographs, and all three authors independently identified each of

RESULTS

Demographic information is shown in Table 1. One hundred eighty-four (91%) participants were gastroenterologists, 5 (2%) were surgeons, 7 (3%) were internists, and 6 (3%) had other specialties. Twenty-three percent of all respondents (21% of gastroenterology respondents) were fellows, 24% had been out of training 0 to 5 years, and the remainder were more than 5 years removed from their endoscopic training. Ninety-five percent of all respondents (98% of gastroenterologists) performed more than 5

DISCUSSION

The appearance of an ulcer base at endoscopy provides important prognostic information in patients presenting with upper gastrointestinal bleeding. However, definitions of SRH, if they are provided at all, vary from study to study, and no uniform criteria are available. This lack of consensus may make the labeling of SRH as clots or visible vessels especially difficult. For example, the prevalence of clots in patients presenting with bleeding ulcers ranges from 0¹² to 49%¹³; in the former study

Acknowledgements

The authors would like to thank the officers of the American College of Gastroenterology and the directors of the 1992 Postgraduate Course for their assistance in allowing us to perform this study; IRIS, Inc., which ran the interactive session and provided us with the rough data for each of the questions; Dr. Oliver Cass for his assistance with the collection and preparation of the digital endoscopic slides; and, most importantly, the 202 participants who cooperated in answering the questions

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Upper gastrointestinal bleeding is a common emergency and rebleeding is associated with an increased risk of death. Proper assessment of high-risk lesions and appropriate endoscopic hemostasis are required for the best outcomes. The endoscopic Doppler probe examination (DPE) allows for a more complete assessment of the stigmata of hemorrhage, providing better evaluation of the need for endoscopic hemostasis and determination of its completeness. We aimed to evaluate whether use of the DPE provides an additional advantage in cost and effectiveness compared with traditional endoscopic visual assessment (TEA) of high-risk stigmata in patients with nonvariceal upper gastrointestinal bleeding.
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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).
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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).
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Older data predating the routine use of endoscopic hemostasis reveal a natural history with rebleeding rates of 55% (17%–100%) (Forrest IA and IB), 43% (0%–81%) (Forrest IIA), 22% (14%–36%) (Forrest IIB), 10% (0%–13%) (Forrest IIC), and 5% (0%–10%) (Forrest III).34 Significant interobserver variability has been reported in the identification of endoscopic stigmata.35 Nonetheless, when ulcer bleeding stigmata are surveyed with sequential endoscopic evaluations, an evolution of stigmata is noted, suggesting various phases of healing whereby a bleeding vessel progressively evolves after endoscopic therapy into a clean base ulcer.32
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Not all exposed vessels carry the same risk of recurrent bleeding, however, with pale, protuberant vessels shown much more risky than dark, flattened ones.74 The distinction between NBVV and clots can be difficult75,76; hence the presence of an NBVV may not be in itself a sufficiently reliable indicator to select patients for invasive therapy. Enhanced endoscopic imaging of bleeding ulcers to identify and characterize an involved buried vessel may allow for more cost-effective management.
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^☆: From the U.S.C. School of Medicine, Los Angeles, California, and Hennepin County Medical Center, Minneapolis, Minnesota.

^☆☆: Reprint requests: Loren Laine, MD, GI Division (LAC 12-137), Department of Medicine, U.S.C. School of Medicine, 2025 Zonal Ave., Los Angeles, CA 90033.

^★: GASTROINTESTINAL ENDOSCOPY

^★★: 37/1/54113

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Lack of uniformity in evaluation of endoscopic prognostic features of bleeding ulcers☆,☆☆,★,★★

Abstract

Section snippets

METHODS

RESULTS

DISCUSSION

Acknowledgements

Gastrointest Endosc

Gastroenterology

Gastroenterology

Gastrointest Endosc

Surg Clin North Am

Gastroenterology

Epidemiology for upper gastrointestinal bleeding

Gastrointest Endosc

Upper gastrointestinal hemorrhage

West J Med

Therapeutic endoscopy and bleeding ulcers

JAMA

Can ulcer bleeding patients without stigmata of recent haemorrhage be discharged on the same day—a retrospective and prospective study

Gastroenterology

Multipolar electrocoagulation in the treatment of active upper gastrointestinal hemorrhage: a prospective, controlled trial

N Engl J Med