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Factors affecting delection of bleeding lesions in the stomach by initial emergency endoscopy
1Department of Gastroenterology, Chang Gung Memorial Hospital, Taipei, Taiwan, R.OC.
Insights
Inadequate endoscopic preparation frequently causes missed diagnoses in acute gastric bleeding cases. Lesions in the stomach body, often gastric ulcers, are commonly missed, leading to high mortality rates, especially in patients with liver disease.
Area of Science:
- Gastroenterology
- Endoscopy
- Hepatology
Background:
- Accurate diagnosis of acute gastric bleeding via endoscopy is challenging, with missed diagnoses being common.
- Causes of diagnostic difficulty and common locations of missed bleeding sites are not well understood.
Purpose of the Study:
- To identify factors contributing to incomplete endoscopic diagnosis of acute gastric bleeding.
- To determine the most frequent causes and locations of missed gastric bleeding.
Main Methods:
- Analysis of medical records and follow-up for 64 patients with initially undiagnosed acute gastric bleeding.
- Confirmation of bleeding sites through subsequent endoscopic examination or surgery.
Main Results:
- Excessive blood in the field of view was the primary reason for incomplete studies (60/64 patients).
- Commonly missed lesions included gastric ulcers (30), gastric varices (9), and acute gastric mucosal lesions (6).
- Bleeding sites in the stomach body were most frequently missed (21/64), followed by the antrum (9/64) and stoma (7/64).
- The 42-day mortality rate was 20%, with hepatic failure and decompensated liver cirrhosis being prevalent underlying conditions.
Conclusions:
- Inadequate endoscopic preparation is the main procedural issue leading to missed diagnoses.
- Gastric ulcers are the most common unidentified bleeding source, and the stomach body is the most common location for missed diagnoses.
- High mortality is linked to underlying diseases, particularly hepatic failure, rather than the bleeding lesions themselves.
Background:
Accurate endoscopic diagnosis of acute gastric bleeding can be problematic and missing diagnoses are not uncommon. However, the causes of diagnostic difficulty and the most common locations of bleeding resulting in missed diagnosis are not well known.
Methods:
To determine the causative factors of incomplete study, we analyzed the medical records and performed follow-up on 64 patients for whom initial emergency endoscopy had failed to identify the sites of acute gastric bleeding. The bleeding sites were confirmed by the findings of subsequent endoscopic examination or operation in these cases.
Results:
Excessive blood covering the examination field was the most frequent cause of incomplete endoscopic study (60/64). Underlying gastric lesions which were later identified as sources of gastric bleeding included: 30 gastric ulcers, 9 gastric varices, 6 acute gastric mucosal lesions, 3 Dieulafoy's lesions, 3 portal hypertensive gastropathies, 2 gastric tumors, 1 Mallory-Weiss tear and 2 unidentified bleeding sites. Eight patients refused further evaluation. The locations of the bleeding sites included: 1 esophagocardiac junction, 8 cardia, 5 fundus, 21 body, 9 antrum, 7 stoma, 3 diffuse pattern. The 42-day mortality rate of these patients was 20%. Of these patients, decompensated liver cirrhosis (8/13) and hepatic failure (7/13) were the most common underlying diseases.
Conclusion:
Inadequate preparation was the most frequently procedural problem associated with missed diagnosis. Lesions located in the body of the stomach were most likely to go undiagnosed. Gastric ulcers were the most common type of unidentified bleeding ulcer site. Hepatic failure was the most common cause of death. The high mortality rate of these patients appeared to be related to underlying diseases rather than to the nature of the lesions responsible for gastric bleeding.