O Cianoacrilato na Terapêutica Endoscópica de Úlceras Pépticas em Doentes de Alto Risco: a propósito de 8 casos.

 

P. Peixoto¹, P. Ministro¹, A. Sadio¹, A. Castanheira¹, E. Cancela¹, A. Silva¹, A. Caldas¹

 

 

RESUMO

Introdução/Objectivos: A úlcera péptica sangrante é a principal causa de hemorragia digestiva alta. São vários os métodos hemostáticos endoscópicos disponíveis com eficácias similares. O cianoacrilato, utilizado na hemorragia varicosa com sucesso, é ainda controverso na hemorragia de etiologia péptica. Os autores apresentam uma casuística com a utilização de cianoacrilato, em doentes de alto risco cirúrgico, com úlcera hemorrágica refractária à hemostase endoscópica convencional.

Material/Métodos: Estudo retrospectivo baseado na análise de processos clínicos de 8 doentes (7 homens, idade média de 78 anos), entre Janeiro/2004-Julho/2006. Medidas de evolução desfavorável: persistência/recidiva hemorrágicas e mortalidade. Foram analisadas as complicações associadas à terapêutica.

Resultados: Localização das úlceras: 2 gástricas, 5 duodenais e 1 úlcera com componente gastro-duodenal; estigmas endoscópicos (Forrest): 2 IA, 1 IB e 5 IIA. Utilização de cianoacrilato em 3 (37,5%) doentes por persistência hemorrágica e em 5 (62,5%) por recidiva. A hemostase foi bem sucedida em todos os doentes. Não houve recidivas. Ocorreram duas complicações embólicas. A mortalidade foi de 12,5% (1 doente).

Conclusões: O cianoacrilato mostrou ser um método hemostático eficaz no tratamento da úlcera péptica sangrante, contudo com potencial de causar complicações graves; pode ser uma alternativa à falência das técnicas endoscópicas convencionais, em doentes com elevado risco cirúrgico.

 

 

SUMMARY

Background/Study aims: Bleeding peptic ulcer is still the main cause of upper gastrointestinal haemorrhage. Several endoscopic haemostatic methods with similar efficacy are currently available. Cyanoacrylate is successfully used in variceal haemorrhage, however, its use is controversial in bleeding peptic ulcer. The authors present a study with endoscopic injection of cyanoacrylate for the treatment of haemorrhagic ulcers refractory to conventional endoscopic haemostasis in surgical high-risk patients.

Patients and methods: Retrospective study based on the analysis of medical records of 8 patients (7 men, mean age 78 years), between January/2004-July/2006. End points: ongoing haemorrhage, rebleeding and mortality. Complications caused by endoscopic treatment were analised.

Results: Ulcers location: 2 gastric, 5 duodenal, and 1 extensive ulcer with gastro-duodenal component; endoscopic stigmata (Forrest): 2 IA, 1 IB and 5 IIA. Cyanoacrylate was used in 3 (37.5%) patients due to ongoing bleeding and in 5 (62.5%) due to rebleeding. Haemostasis was successful in all patients. No rebleeding occurred. There were two embolic complications. The mortality rate was 12.5% (1 patient).

Conclusions: Cyanoacrylate proved to be an effective haemostatic method for the treatment of bleeding peptic ulcer, although it has the potential to cause serious complications. It may be an alternative after failure of conventional endoscopic techniques in surgical high-risk patients.

 

 

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Bibliografia

 

1 - Vreeburg EM, Snel P, de Bruijne JW, Bartelsman JF, Rauws EA, Tytgat GN. Acute upper gastrointestinal bleeding in the Amsterdam area: incidence, diagnosis, and clinical outcome. Am J Gastroenterol 1997; 92: 236-43.

2 – Rockall TA, Logan RF, Devlin HB, Northfield TC. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Br Med J 1995; 311: 222-6.

3 - Huang CS, Lichtenstein DR. Nonvariceal upper gastrointestinal bleeding. Gastroenterol Clin N Am 2003; 32: 1053-78.

4 - Ministro P., Cancela E., Peixoto P., Sadio. A, Castanheira A., Silva A. et al. Hemorragia digestiva alta: estudo epidemiológico. J Port Gastroenterol 2004; 11 (Supl): 62.        [ Links ]

5 - Simoens M, Gevers AM, Rutgeerts P. Endoscopic therapy for upper gastrointestinal hemorrhage: a state of the art. Hepatogastroenterology 1999; 46: 737-45.

6 - Soehendra N, Werner B. New technique for endoscopic treatment of bleeding gastric ulcer. Endoscopy 1977; 8: 85-7.

7 - Sacks HS, Chalmers TC, Blum AL. Endoscopic hemostasis. an effective therapy for bleeding peptic ulcers JAMA 1990; 264:494-9.

8 - Cook DJ, Guyatt GH, Salena BJ, Laine LA. Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: A metaanalysis. Gastroenterology 1992; 102: 139-48.

9 – Naveau S, Perrier C, Mory B, Poynard T, Chaput JC. Endoscopic hemostasis for hemorrhagic gastroduodenal ulcer. Meta-analysis of randomized clinical trials. Gastroenterol Clin Biol 1991; 15: 580-7.

10 - Naveau S, Borotto E, Giraud J. Meta-analysis of endoscopic injection therapy versus thermal methods in peptic ulcer haemorrhage. Gastroenterology 1996; 110: A207.

11 - Laine L, Peterson WL. Bleeding peptic ulcer. N Engl J Med 1994; 331: 717-27.

12 - Lau JY, Sung JJ, Lam YH, Chan AC, Ng EK, Lee DW et al. Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med 1999; 340: 751-6.

13 – Lee GH, Kim JH, Lee KJ, Yoo BM, Hahm KB, Cho SW et al. Life threatening intraabdominal arterial embolization after Histoacryl injection for bleeding gastric ulcer. Endoscopy 2000; 32: 422-4.

14 - Lee KJ, Kim JH, Hahm KB, Cho SW, Park YS. Randomized trial of N-butyl-2-cyanoacrylate compared with injection of hypertonic saline-epinephrine in the endoscopic treatment of bleeding peptic ulcers. Endoscopy 2000; 32: 505-11.

15 - Repici A, Ferrari A, De Angelis C, Caronna S, Barletti C, Paganin S et al. Adrenaline plus cyanoacrylate injection for treatment of bleeding peptic ulcers after failure of conventional endoscopic haemostasis. Digestive liver disease 2002; 34: 349-55.

16 – Kok KYY, Kum CK, Goh PM. Endoscopic hemostasis of upper gastrointestinal bleeding with histoacryl: last resort before surgery. Endoscopy 1996; 28: 256-8.

17 - Aronson WL, McAuliffe MS, Miller K. Variability in the American Society of Anesthesiologists Physical Status Classification Scale. AANA J. 2003; 71: 265-74.

18 - Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in Gastrointestinal bleeding. Lancet 1974; 7877: 394-7.

19 – Ardis AE. US patent nº 2467926 and 2457927 (Ardis).

20 - Technology status evaluation report. Tissue adhesives and fibrin glues. Gastrointestinal Endoscopy 2004; 60: 327-33.

21 - Binmoeller KF, Soehendra N. New haemostatic techniques: histoacryl injection, banding/endoloop ligation and haemoclipping. Baillieres Best Pract Res Clin Gastroenterol 1999; 13: 85-96.

22 – Gotlib JP, Zimmermann P. Une nouvelle technique de traitement endoscopique des varices oesophagiennes: L´obliteration. Endoscopia Digestiva 1984; 7: 10-2.        [ Links ]

23 – Soehendra N, Nam VC, Grimm H, Kempeneers I. Endoscopic obliteration of large esophagogastric varices with bucrylate. Endoscopy 1986; 18: 25-6.

24 - Tan PC, Hou MC, Lin HC, Liu TT, Lee FY, Chang FY et al.. A randomized trial of endoscopic treatment of acute gastric variceal hemorrhage: N-Butyl-2-Cyanoacrylate injection versus band ligation. Hepatology 2006; 43: 690-7.

25 - Seewald S, Mendoza G, Seitz U, Salem O, Soehendra N. Variceal bleeding and portal hypertension: has there been any progress in the last 12 months? Endoscopy 2003; 35: 136-44.

26 - Lérias C, Rosa A, Maçõas F, Souto P, Pina Cabral JE, Gregório C et al. Úlcera péptica sangrante: que lugar para as colas? J Port Gastroenterol 2001; 8: 254-6.        [ Links ]

27 – Vallieres E, Jamieson C, Haber GB, Mackenzie RL. Pancreatoduodenal necrosis after endoscopic injection of cyanoacrylate to treat a bleeding duodenal ulcer: a case report. Surgery 1989; 106: 901-3.

28 – Cheah WK, So J, Chong SM, Goh P. Duodenal ulcer perforation following cyanoacrylate injection. Endoscopy 2000; 32: S23.

29 – Lee KJ, Kim JH, Hahm KB, Kim YS, Cho SW. Randomized trial of Histoacryl injection compared with fibrin glue injection in treatment of bleeding peptic ulcer. Gastrointest Endosc 1999; vol 49, nº 4 part 2, AB167 – 444.

30 – Santos Pérez H, Cordoví Gutiérrez MR. Endoscopic therapy of bleeding peptic. gastroduodenal ulcer: a comparison of. Tisuacryl vs polidocanol. Memorias II Congreso Latinoamericano de Ingeniería Biomédica, Habana 2001, Mayo 23 al 25.

31 – Cheng PN, Sheu BS, Chen CY, Chang TT, Lin XZ. Splenic infarction after histoacryl injection for bleeding gastric varices. Gastrointest Endosc 1998; 48: 426-7.

32 – Yu LK, Hsu CW, Tseng JH, Liu NJ, Sheen IS. Splenic infarction complicated by splenic artery occlusion after N-butyl-2-cyanoacrylate injection for gastric varices: case report. Gastrointest Endosc 2005; 61: 343-5.

33 – Turler A, Wolff M, Dorlars D, Hirner A. Embolic and septic complications after sclerotherapy of fundic varices with cyanoacrylate. Gastrointest Endosc 2001; 53: 228-30.

34 - Tan YM, Goh KL, Kamarulzaman A, Tan PS, Ranjeev P, Salem O et al. Multiple systemic embolisms with septicemia after gastric variceal obliteration with cyanoacrylate. Gastrointest Endosc 2002; 55: 276-8.

35 – Chen WC, Hou MC, Lin HC, Yu KW, Lee FY, Chang FY et al. Bacteremia after endoscopic injection of N-butyl-2-cyanoacrylate for gastric variceal bleeding. Gastrointest Endosc 2001; 54: 214-8.

36 - Wahl P, Lammer F, Conen D, Schlumpf R, Bock A. Septic complications after injection of N-butyl-2-cyanoacrylate: report of two cases and review. Gastrointest Endosc 2004; 59: 911-6.

 

 

¹Serviço de Gastrenterologia – Hospital de São Teotónio – Viseu

Correspondência:

Paula Cristina Pereira Peixoto

Hospital S. Teotónio

Avenida Rei D. Duarte, 3504-509 Viseu

Telefone: 232 420500

Fax: 232 420591

Email: paulacristinapeixoto@iol.pt

Recebido para publicação: 04/04/2008

Aceite para publicação: 24/02/2009