Regular Article
Value of stigmata in decision-making in gastrointestinal haemorrhage

https://doi.org/10.1053/bega.2000.0087Get rights and content

Abstract

The stigmata of recent haemorrhage are endoscopically identified features that have a predictive value for the risk of further bleeding and thus help to determine which patients should receive endoscopic therapy. In conjunction with endoscopic features, clinical features related to the magnitude of bleeding and to patient co-morbidity have important independent effects on the risk of further haemorrhage. Stigmata have been best studied in the context of bleeding ulcers, the most common cause of upper gastrointestinal bleeding. Stigmata in ulcers are usually classified as active bleeding (spurting or oozing), a non-bleeding visible vessel, an adherent clot, a flat pigmented spot, or a clean base, in order of decreasing risk of further haemorrhage. Ulcer size and location may also affect the re-bleeding potential. Recent data suggest that both non-pigmented visible vessels and adherent clots have a higher risk of re-bleeding than was previously thought. The wide variation in prevalence and re-bleeding rates reported for various stigmata in the literature probably reflects variations in the definitions of stigmata and of re-bleeding, the vigour with which the ulcer bases are washed, the co-morbidity and ages of the patients, and the severity of bleeding encountered. Inter-observer agreement in the classification of stigmata is relatively poor and limits the utility of endoscopic features alone in making decisions regarding the management of patients with bleeding peptic ulcers. Imaging devices such as Doppler probes are being evaluated to refine the identification of underlying vessels and their re-bleeding potential, but the utility of these is currently uncertain. The findings of low-risk endoscopic stigmata in a haemodynamically and otherwise stable patient can in many cases allow out-patient management.

References (59)

  • L Laine et al.

    A prospective outcome study of patients with clot in an ulcer and the effect of irrigation

    Gastrointestinal Endoscopy

    (1996)
  • CP Swain et al.

    Nature of the bleeding vessel in recurrently bleeding gastric ulcers

    Gastroenterology

    (1986)
  • ML Freeman et al.

    The non-bleeding visible vessel versus the sentinel clot: natural history and risk of rebleeding

    Gastrointestinal Endoscopy

    (1993)
  • CC Yang et al.

    The natural history (fading time) of stigmata of recent hemorrhage in peptic ulcer disease

    Gastrointestinal Endoscopy

    (1994)
  • P Cales et al.

    Gastroeosphageal endoscopic features in cirrhosis: observer variability, interassociation and relationship to hepatic dysfunction

    Gastroenterology

    (1990)
  • L Laine et al.

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

    Gastrointestinal Endoscopy

    (1994)
  • B Bour et al.

    Interobserver agreement on endoscopic diagnosis of bleeding peptic ulcers

    Gastrointestinal Endoscopy

    (1997)
  • GF Longstreth et al.

    Outpatient care of selected patients with acute non-variceal upper gastrointestinal haemorrhage

    Lancet

    (1995)
  • TA Rockall et al.

    Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage

    Lancet

    (1996)
  • KC Lai et al.

    A retrospective and prospective study on the safety of discharging selected patients with duodenal ulcer bleeding on the same day as endoscopy

    Gastrointestinal Endoscopy

    (1997)
  • L Laine et al.

    Bleeding peptic ulcer

    New England Journal of Medicine

    (1994)
  • JH Kurata et al.

    Current peptic ulcer time trends: an epidemiological profile

    Journal of Clinical Gastroenterology

    (1988)
  • JY Lau et al.

    The evolution of stigmata of hemorrhage in bleeding peptic ulcers: a sequential endoscopic study

    Endoscopy

    (1998)
  • HJ Lin et al.

    Clinical courses and predictors for rebleeding in patients with peptic ulcers and non-bleeding visible vessels: a prospective study

    Gut

    (1994)
  • Gastrointestinal Endoscopy

    (1990)
  • TA Rockall et al.

    Risk assessment after acute upper gastrointestinal haemorrhage

    Gut

    (1996)
  • RT Yovorski et al.

    Analysis of 3294 cases of upper gastrointestinal bleeding in military medical facilities

    American Journal of Gastroenterology

    (1995)
  • HS Sacks et al.

    Endoscopic hemostasis: an effective therapy for bleeding peptic ulcers

    Journal of the American Medical Association

    (1990)
  • TA Rockall et al.

    Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom

    British Medical Journal

    (1995)
  • View full text