In this issue of “Sharma’s Endoscopy Insights,” I review the role of over-the-scope clipping for large peptic ulcers, the long-term impact of COVID-19 on gastrointestinal symptoms and the role of upper endoscopy in examining dyspepsia patients.

Upper GI bleeding from peptic ulcer disease remains a common clinical scenario and, despite the use of acid-suppressive medications and endoscopic treatment, recurrent or ongoing bleeding is observed in 10% to 20% of patients. Current endoscopic therapy with clips or thermal coagulation can be challenging for large ulcers as well as chronic ulcers with a fibrotic basis. In a randomized controlled trial, investigators found that routine use of an over-the-scope clip (OTSC) as the primary modality of hemostasis for large bleeding peptic ulcers was not associated with a significant reduction in 30-day re-bleeding rates.

COVID-19–related gastrointestinal symptoms, which include diarrhea, vomiting and abdominal pain, can be seen in up to 20% of infected patients. Some patients recovering from COVID-19 can have prolonged systemic symptoms or can develop new symptoms, which has been termed “long COVID” or “post-acute COVID-19 syndrome.” A case-control study showed that COVID-19 led to a significantly higher number of either new-onset symptoms or prolonged symptoms of functional gastrointestinal disorders in affected patients compared with healthy controls at six months follow-up.

Dyspepsia can occur in up to 20% of adults and is a common reason for outpatient consultation or an open-access endoscopy. For patients with uninvestigated dyspepsia, either routine noninvasive testing or upper endoscopy are reasonable options. In this study, investigators showed that strategies that promote more routine endoscopy to manage these types of patients may be preferable to empiric acid-suppressant therapy or a test-and-treat H. pylori strategy, from both cost-effectiveness and patient satisfaction perspectives.

Over-the-Scope Clips and Rebleeding in Large Peptic Ulcers

Gut 2023;72:638-643

This international, multicenter randomized controlled trial, which ran from July 2017 to October 2020, investigated the efficacy of OTSC in the primary treatment of patients with bleeding peptic ulcers 1.5 cm or larger. The researchers recruited 100 patients, treating 50 with OTSC and 50 with standard endoscopic therapy. The primary outcome was 30-day clinical rebleeding.

Successful primary hemostasis was achieved in 46 of 50 patients (92%) in the OTSC arm and 48 of 50 patients (96%) in the conventional arm. Of patients who had success in primary hemostasis, two (4.35%) in the OTSC arm and nine (18.75%) in the conventional arm developed 30-day rebleeding (P=0.03).

However, rebleeding rate did not differ significantly between OTSC and standard therapy (10% vs. 18%, respectively; P=0.234).

They noted that although the learning curve for OTSC is high, there could be a role for the tool when it is used by an experienced practitioner.

Following Up on COVID-19 Patients

Clin Gastroenterol Hepatol 2023;21[3]:789-796

In this prospective study, researchers looked at the frequency and types of, and risk factors for, functional gastrointestinal disorders (FGID) or disorders of the gut–brain interaction (DGBI), after COVID-19.

The study was conducted from April 2021 to January 2022 at the All India Institute of Medical Sciences, in New Delhi, a dedicated COVID-19 care center. The study included 320 patients with COVID-19 and two control groups: 320 healthy spouses and family controls as well as 280 healthy individuals who were COVID-19 serology-negative (including healthcare workers at the institution). The researchers performed follow-up at one, three and six months, either in person or by telephone, using a self-administered/interview-based questionnaire.

Of the 320 patients with COVID-19, 36 (11.3%) developed FGID symptoms at one month. Persistent symptoms were noted in 27 patients (8.4%) at three months and 21 (6.6%) patients at six months. No controls developed FGID during up to six months of follow-up (P<0.01).

The findings indicate that COVID-19 led to a significantly higher number of cases of new-onset FGID/DGBI compared with healthy controls at three and six months follow-up.

Uninvestigated Dyspepsia and Up-Front Endoscopy

Clin Gastroenterol Hepatol 2023 Jan 13; S1542-3565(23)00030-7

In this study, researchers in the United States created a decision-analytic model and performed cost-effectiveness and cost satisfaction analyses over a one-year period for patients with uninvestigated dyspepsia without alarm features who were referred to a gastroenterologist.

In the model, the researchers evaluated four competing diagnostic and management strategies: prompt endoscopy, testing for Helicobacter pylori and eradicating if present (test-and-treat), testing for H. pylori and performing endoscopy if present (test-and-scope), and empiric acid suppression.

From the patient perspective, costs and outcomes were similar for all strategies. The maximum out-of-pocket difference was about $30, and quality-adjusted life-years gained was less than 0.01, regardless of strategy.

However, prompt endoscopy maximized cost satisfaction and health system reimbursement. Prompt endoscopy also maximized patient satisfaction (68.1% increase vs. usual care), whereas patient satisfaction was lowest with test-and-scope, although that strategy was the most cost-effective one for both patients and insurers.

—Compiled and written by Jillian Mock