Introduction: Peptic ulcer disease (PUD) is the leading cause of upper GI bleeding. PUDs with an adherent clot (Forrest IIb) are associated with a high risk of rebleeding and mortality. However, the optimal management of bleeding PUD with adherent clots, including endoscopic or conservative therapy, remains unclear. The most recent ACG guidelines in 2021 did not clearly endorse endoscopic treatment for bleeding PUDs with adherent clot as opposed to medical therapy. We performed this systematic review and meta-analysis to compare the endoscopic and conservative therapeutic approaches to managing bleeding PUDs with adherent clot. Methods: We systematically searched MEDLINE, EMBASE, and the Web of Science databases through May 15, 2022, to include all randomized controlled trials (RCTs) comparing the endoscopic and conservative therapeutic approaches for bleeding PUDs with adherent clots. The outcomes of interest in our meta-analysis were rebleeding, need for surgery, and mortality. The random-effects model was used to calculate the weighted pooled risk ratio (RR) with the corresponding 95% confidence intervals (CI) of our desired outcome. A P-value , 0.05 was considered statistically significant. Heterogeneity was assessed using the Higgins I 2 index (I 2 values .50% implied the presence of significant heterogeneity). Results: Eleven RCTs with 839 patients (434 received endoscopic therapy vs. 405 received conservative therapy) were included. Endoscopic therapy group underwent clot removal and treatment of the underlying lesion with thermocoagulation, electrocoagulation, injection of sclerosants such as epinephrine or ethanol, or hemoclipping. Rebleeding occurred in 8.1% of patients in the endoscopic therapy group, compared to 20.7% in the conservative therapy group (RR 0.45, 95% CI 0.26-0.78, P50.004, I 2 534%, Figure A). We observed lower mortality of 3.7% in the endoscopic therapy group compared to 8% in the conservative therapy group (RR 0.49, 95% CI 0.25-0.96, P50.04, I 2 50%, Figure B). In addition, the need for surgery was significantly lower in the endoscopic therapy group (4.3%) compared to the conservative therapy group (9.9%) (RR 0.48, 95% CI 0.24-0.97, P50.04, I 2 50%, Figure C). Conclusion: Our meta-analysis demonstrated that endoscopic therapy is superior to conservative treatment for bleeding PUDs with an adherent clot regarding rebleeding, need for surgery, and mortality. However, large-scale RCTs are needed to validate our findings.
Figure 1. (A) There is mild pericellular fibrosis, but no periportal or bridging fibrosis. Mild steatosis supportive of a component of NASH accompany the Gaucher's cells is seen (Trichrome, 100X). (B) Sinusoidal cells are enlarged and show pale-gray striated cytoplasm representing Gaucher's cells whereas the hepatocytes are ballooned. Inflammatory infiltrates are absent(hematoxylin and eosin, 200X). (C) The Gaucher's cell are positive for the histiocytic marker CD68 (Immunohistochemistry, 200X).
Figure 1. (A) Trichrome stain showing markedly active chronic hepatitis consistent with cirrhosis. (B) Immunohistochemical stains demonstrate patchy staining with HBV surface antigen but (C) negative for HBV core antigen.
Figure 1. a) Ductal polypoid mass near common hepatic duct identified via endoscopic retrograde cholangiopancreatography with cholangioscopy. b) Intrahepatic biliary ductal dilatation seen on magnetic resonance cholangiopancreatography. c) Occlusion cholangiogram during endoscopic retrograde cholangiopancreatography showing a Bismuth Type IV common bile duct stricture. d) Occlusion cholangiogram during endoscopic retrograde cholangiopancreatography showing resolution of the common bile duct stricture after steroid treatment. e) Biliary stricture biopsies showing fragments of bile duct mucosa with acute and chronic inflammation with marked eosinophilia. f) Ductal mass/biliary stricture biopsy demonstrating inflammation and eosinophilia on Hematoxylin-eosin stain.
Introduction: Given the high recurrence rate and the risk of fecal incontinence with surgical options, Injection of adipose tissue-derived stem cells (ASC) has been arising as a novel method for treating complex perianal fistulas (CPAF). Therefore, we conducted a meta-analysis to evaluate the efficacy and safety of ASC in the management of CPAF not associated with Crohn's disease. Methods: We systematically searched Medline and Embase databases through April 20, 2022, for all studies that assessed the efficacy and safety of ASC for the treatment of CPAF not associated with Crohn's disease. We excluded patients with rectovaginal fistulas and perianal fistulas associated with Crohn's disease. Our primary outcome was the complete closure. The secondary outcomes included overall nonserious adverse events (NSAE), serious adverse events (SAE), and perianal abscess rate. All meta-analyses were conducted using a random-effect model. The publication bias was assessed by Egger's test. Results: Ten studies (eight clinical trials and two observational studies) with 271 patients were included in the pooled analysis. Eight studies used autologous stem cells, one used allogeneic stem cells, and one did not report the source of stem cells. The mean age of the patients was 43.7 years. The follow-up period ranged from 3 months to 2 years. The pooled complete closure rate was 59.7% (95% confidence interval (CI): 0.46-0.73, Figure 1A). On subgroup analysis based on country of origin, six studies with 213 patients were conducted in European countries, and four studies with 58 patients were conducted in non-European countries. The complete closure rate was higher in European countries than non-European countries, 64.1% vs. 52.6%. Eight studies reported overall NSAEs with the pooled NSAE rate of 22.5% (95% CI: 0.11-0.34, Figure 1B). Seven studies reported SAEs with the pooled SAE rate of 1.7% (95% CI: 0.001-0.034, Figure 1C). Seven studies reported the perianal abscess rate with a pooled perianal abscess rate of 7.1% (95% CI: 0.016-0.125, Figure 1D). No evidence of publication bias was found (Egger's test: P50.36). Conclusion: Our meta-analysis demonstrated that ASC is a promising therapeutic option for CPAF not associated with Crohn's disease with a clinically adequate efficacy and low rate of adverse events. However, more studies with larger sample sizes are needed to provide a definitive assessment of the effectiveness of ASCs for CPAF not associated with Crohn's disease.
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