Recurrent bleeding from peptic ulcer associated with adherent clot: a randomized study comparing endoscopic treatment with medical therapy

BACKGROUND: Endoscopic therapy reduces the recurrence of bleeding from actively bleeding peptic ulcers and those with visible vessels. However, the use of endoscopic therapy for ulcers with adherent clots remains controversial. The purpose of this study was to determine whether removal of clot from an ulcer and endoscopic therapy reduces the frequency of recurrent bleeding. METHODS: Patients with acute upper GI bleeding from peptic ulcers with adherent clots and no active bleeding were enrolled in a multicenter study. At each center patients were stratified for age, use of nonsteroidal anti-inflammatory drugs, and ulcer location, and were randomized to endoscopic or medical management. Endoscopic therapy consisted of injection of the base of the adherent clot with a solution of epinephrine and mechanical removal of the clot. The base of the ulcer and any stigmata of bleeding were then coagulated until cavitation and adequate coagulation were obtained. Patients in both groups received standard medical therapy for peptic ulcer. Patients were evaluated for recurrence of bleeding for 1 month. RESULTS: Fifty-six patients were enrolled. Rates of recurrent bleeding were 34.3% (12/35) in the medical treatment arm versus 4.8% (1/21) in the endoscopic treatment arm (p < 0.02). CONCLUSIONS: In patients with GI bleeding caused by gastric or duodenal ulcers with an adherent clot found on endoscopy, endoscopic therapy with injection of the base of the clot, clot removal, and heat probe coagulation significantly reduces the rate of recurrent bleeding compared with medical therapy alone.     

The endoscopic Doppler: its value in evaluating gastroduodenal ulcers after hemorrhage and as an instrument of control of endoscopic injection therapy

In this prospective study of 80 patients with active bleeding from the gastrointestinal tract a Doppler ultrasonographic investigation of the gastroduodenal ulcers was performed, in addition to immediate endoscopic examination. Admitted to this study were ulcers with the stigmata of acute bleeding, such as a visible blood vessel in the ulcer floor, a blood clot, or a black base and Forrest III lesions. In 52 patients Doppler ultrasonography was able to document unequivocally a superficial blood vessel. Complete agreement of endoscopic and Doppler results was obtained in only 49% of the cases. When a blood vessel was positively identified, local injection of epinephrine and polidocanol was carried out. Thereupon, in the further course, the acoustic signal was shifted into deeper regions or disappeared entirely. In 8% of the cases initial sclerosing was followed by a rebleed, which was again treated by injection therapy. None of the patients died of their GI hemorrhage. Endoscopic Doppler ultrasonography is a new and effective procedure that enables objectification of the endoscopic findings. It identifies the indication for proceeding to operative endoscopy and can monitor the effectiveness of the latter.     

Optimal injection volume of epinephrine for endoscopic prevention of recurrent peptic ulcer bleeding

BACKGROUND: Although the initial rate of hemostasis achieved by endoscopic epinephrine injection for peptic ulcer bleeding is high, bleeding recurs in 14.6% to 35.5% of patients. The aim of this study was to compare rates of recurrent bleeding after endoscopic injection of two different volumes of epinephrine in patients with peptic ulcer bleeding. METHODS: A total of 72 patients with peptic ulcer with active bleeding or a non-bleeding visible vessel were randomly assigned to 15 to 25 mL or 35 to 45 mL injections of a 1:10,000 solution of epinephrine. RESULTS: The two groups were similar with respect to all background variables. The mean volume of epinephrine injected was 19.4 mL: 95% CI [18.7, 20.1] in the 15 to 25 mL group and 41.1 mL: 95% CI [40.0, 42.2] in the 35 to 45 mL group. Initial hemostasis was achieved in 35 of 36 patients (97.2%) in the 15 to 25 mL group and in all 36 patients in the 35 to 45 mL group. The 35 to 45 mL volume was significantly more effective in preventing recurrent bleeding than the 15 to 25 mL volume (0% vs. 17.1%; p < 0.05). For ulcers in the gastric body, the 35 to 45 mL volume was significantly more effective in preventing recurrent bleeding than the 15 to 25 mL volume (0% vs. 31.6%; p = 0.003). For ulcers in other locations, including the gastric antrum and the duodenum, there were no significant differences in the rate of recurrent bleeding between the two groups. CONCLUSIONS: Injection of 35 to 45 mL of a 1:10,000 solution of epinephrine is more effective than injection of 15 to 25 mL of the same solution for prevention of recurrent bleeding from ulcers in the body of the stomach.     

Endoscopic hemostasis of a bleeding marginal ulcer: hemoclipping or dual therapy with epinephrine injection and heater probe thermocoagulation

BACKGROUND AND AIMS: Endoscopic hemoclipping and dual therapy with epinephrine injection and heater probe thermocoagulation have been proven effective in the hemostasis of bleeding peptic ulcers. However, the hemostatic efficacy has not been investigated in bleeding marginal ulcers. The aim of this study is to investigate the hemostatic efficacy of endoscopic hemoclipping and dual therapy with epinephrine injection and heater probe thermocoagulation in bleeding marginal ulcers. METHODS: From November 1997 to July 2000, 50 patients with active marginal ulcer bleeding underwent either hemoclipping (20 patients) or dual therapy (30 patients) for hemostasis. The demographic data, clinicopathological characteristics, endoscopic findings, initial hemostatic rates, rebleeding rates, amount of blood transfusion, the need of surgery, and mortality rates were collected and analyzed. RESULTS: Marginal ulcers were located at the anastomotic site (64%), saddle portion (22%), efferent loop (10%), or at the afferent loop (4%). The bleeding stigmata were classified into spurting artery (32%), oozing vessel (38%), visible vessel (20%), and blood clot adhesion (10%). The overall therapeutic results in 50 patients were initial hemostasis (100%), rebleeding rate (22%), need for surgery (4%), and hospital mortality rate (4%). There was no significant difference in demographic data and clinicopathological characteristics between the two modes of treatments, whereas recurrent bleeding developed in 5% in the hemoclipping group and 33% in the dual therapy group. No complication related to the procedure occurred in either mode of therapy. The hospital mortality rates were 0 and 6.7%, respectively. CONCLUSION: Endoscopy is effective in achieving initial hemostasis from bleeding marginal ulcers. However, the rebleeding rate remains high and repeated endoscopy may be needed to arrest the hemorrhage.     

Role of intravenous omeprazole in patients with high-risk peptic ulcer bleeding after successful endoscopic epinephrine injection: a prospective randomized comparative trial

BACKGROUND: Epinephrine injection is the most common endoscopic therapy for peptic ulcer bleeding. Controversy exists concerning the optimal dose of proton pump inhibitors (PPI) for patients with bleeding peptic ulcers after successful endoscopic therapy. The objective of this study was to determine the optimal dose of PPI after successful endoscopic epinephrine injection in patients with bleeding peptic ulcers. METHODS: A total of 200 peptic ulcer patients with active bleeding or nonbleeding visible vessels (NBVV) who had obtained initial hemostasis with endoscopic injection of epinephrine were randomized to receive omeprazole 40 mg infusion every 6 h, omeprazole 40 mg infusion every 12 h or cimetidine (CIM) 400 mg infusion every 12 h. Outcomes were checked at 14 days after enrollment. RESULTS: Rebleeding episodes were fewer in the group with omeprazole 40 mg infusion every 6 h (6/67, 9%) as compared with that of the CIM infusion group (22/67, 32.8%, p < 0.01). The volume of blood transfusion was less in the group with omeprazole 40 mg every 6 h than in those groups with omepraole 40 mg infusion every 12 h (p= 0.001) and CIM 400 mg infusion every 12 h (p < 0.001). The hospital stay, number of patients requiring urgent operation, and death rate were not statistically different among the three groups. CONCLUSION: A combination of endoscopic epinephrine injection and a large dose of omeprazole infusion is superior to combined endoscopic epinephrine injection with CIM infusion for preventing recurrent bleeding from peptic ulcers with active bleeding or NBVV.     

Major stigmata of recent hemorrhage on rectal ulcers in patients with severe hematochezia: Endoscopic diagnosis,treatment, and outcomes

BACKGROUND: Endoscopic diagnosis and treatment of hematochezia caused by rectal ulcers is poorly described. METHODS: Consecutive patients hospitalized with severe hematochezia underwent urgent colonoscopy after purge. Those with rectal ulcers were divided into 2 groups based on the absence or presence of major stigmata of recent hemorrhage: active bleeding, visible vessel, or adherent clot. Major stigmata were treated with epinephrine injection and coagulation with a bipolar probe. The primary outcome endpoint was recurrent bleeding within 4 weeks of diagnosis. RESULTS: Rectal ulcers were identified in 23 of 285 (8%) patients. Twelve of 23 patients had major stigmata; these patients had an arithmetically greater decrease in hematocrit and required more blood transfusions than patients without major stigmata. Initial hemostasis was achieved in all, but bleeding recurred in 5 with stigmata. Four patients died of comorbid conditions. There was no recurrent bleeding or death in those without stigmata. CONCLUSIONS: Patients with rectal ulcers harboring major stigmata are at high risk for severe bleeding, recurrent bleeding, and death. For ulcers with major stigmata, endoscopic hemostasis is feasible but rates of recurrent bleeding are high.     

Bleeding peptic ulcer--risk factors for rebleeding and sequential changes in endoscopic findings.

From September 1991 to December 1992, a prospective study was conducted to determine the risk factors and residual risk of rebleeding, and the evolutionary endoscopic changes in peptic ulcers that rebled. Emergency endoscopies were performed on 452 patients with haematemesis or a melaena, or both within 24 hours of admission. If the lesions were actively bleeding, then the patients were treated with injection sclerotherapy. A multivariate analysis of clinical, laboratory, and endoscopic variables of 204 patients with ulcer bleeding showed that hypovolaemic shock, a non-bleeding visible vessel, and an adherent clot on the ulcer base were independently significant in predicting rebleeding (p < 0.05). Considering these three factors according to the estimates of their regression coefficients showed that a non-bleeding visible vessel was the strongest predictor of rebleeding. The study of the residual risk of rebleeding after admission showed that most rebleeding episodes (94.1%), including all associated with hypovolaemic shock, surgical treatment, and death, occurred within 96 hours of admission. After this time, the residual risk of rebleeding was less than 1%. Study of the changes in endoscopic findings before and after rebleeding illustrated that all ulcers with a visible vessel or adherent clot showed at follow up endoscopy were derived from ulcers with initial major stigmata. It is concluded that hypovolaemic shock, a non-bleeding visible vessel, and an adherent clot on an ulcer base are of independent significance in predicting rebleeding. Observation for 96 hours is sufficient to detect most rebleeding episodes after an initial bleed from peptic ulcer.     

Different implications of stigmata of recent hemorrhage in gastric and duodenal ulcers

A prospective study was conducted to evaluate the prognostic value of stigmata of recent hemorrhage in patients with bleeding peptic ulcer. Of 193 patients suffering from peptic ulcer bleeding identified by emergency gastrointestinoscopy, 52 patients were found to have bleeding gastric ulcer (spurt 5, active oozing 9, fresh clot 11, black clot 17, protruding vessel 4, and clear base without stigmata 6); the other 141 had bleeding duodenal ulcer (spurt 5, active oozing 26, fresh clot 43, black clot 23, protruding vessel 15, and clear base without stigmata 31). Patient with continuous bleeding or rebleeding was grouped as unstable bleeders. The rate of unstable bleeders was 39.1% (continuous bleeding 23.9% and rebleeding 15.2%) in patients with gastric ulcer, compared to 9.0% (4.5% and 4.5%) in duodenal ulcer (P less than 0.001). The unstable bleeder rate of ulcers with spurt, active oozing, clot, and protruding vessel was 80%, 44%, 35.7%, and 0%, respectively, in patients with bleeding gastric ulcer; and 33.3%, 19.2%, 6%, and 0%, respectively, in patients with bleeding duodenal ulcer. The data suggest that the stigmata of recent hemorrhage, excluding protruding vessel, has prognostic significance in bleeding gastric ulcer but less in bleeding duodenal ulcer.     

Comparison of hemostatic efficacy for epinephrine injection alone and injection combined with hemoclip therapy in treating high-risk bleeding ulcers

BACKGROUND: Rebleeding occurs in 10% to 30% of bleeding ulcer patients receiving endoscopic epinephrine injection therapy. It remains unclear whether addition of a secondary clip therapy following epinephrine injection may reduce the rebleeding rate of high-risk bleeding ulcers. OBJECTIVE: To compare the efficacies of epinephrine injection alone and epinephrine injection combined with hemoclip therapy in treating high-risk bleeding ulcers. DESIGN: Prospective randomized controlled trial. SETTING: A medical center in Taiwan. PATIENTS: One hundred five bleeding ulcer patients with active spurting, oozing, nonbleeding visible vessels or adherent clots in ulcer bases. INTERVENTIONS: Endoscopic combination therapy (n = 52) or diluted epinephrine injection alone (n = 53). MAIN OUTCOME MEASUREMENTS: Initial hemostasis rates and recurrent bleeding rates. RESULTS: Initial hemostasis was achieved in 51 patients treated with combination therapy and 49 patients with epinephrine injection therapy (98% vs 92%, P = .18). Bleeding recurred in 2 patients in the combination therapy group and 11 patients in the epinephrine injection group (3.8% vs 21%, P = .008). Among the patients with rebleeding, repeated combination therapy was more effective than repeated injection therapy in achieving permanent hemostasis (100% vs 33%, P = .02). No patient required an emergency operation in the combination therapy group. However, 5 patients in the epinephrine injection group underwent emergency surgery to arrest bleeding (0% vs 9%, P = .023). LIMITATIONS: Treatment outcome of endoscopic hemoclip therapy is related to the techniques of endoscopists. CONCLUSION: Endoscopic combination therapy is superior to epinephrine injection alone in the treatment of high-risk bleeding ulcers.     

Active, Bleeding Marginal Ulcer of Billroth II Gastric Resection: A Clinical Experience of 18 Patients

Objectives: From July 1988 to April 1993, 18 patients with active, marginal ulcer bleeding were investigated for their clinical presentation, endoscopic findings, and successful rate of therapeutic endoscopy. Methods: Through endoscopic survey, data on the ulcer number, ulcer location, and prevalence rate of each major stigmata of recent hemorrhage were obtained. Therapeutic methods used include heater probe thermocoagulation and local injection with diluted epinephrine (0.01%) or 95% alcohol through the endoscope. Results: All patients were male with a mean age of 65.3 years. Tarry stool passage (15/18; 83.3%) was the most common clinical presentation. Fifteen patients (15/18; 83.3%) had single marginal ulcer. Ulcerations were located in the jejunal site (12/18; 66.6%) and gastro-jejunal anastomosis (5/18; 27.7%). There were two patients with spurting artery, six with nonbleeding visible vessel, two with blood clot adhesion, four with oozing, three with visible vessel-associated oozing and three, with blood clot adhesion accompanying oozing. The rate of therapeutic endoscopy to successfully stop bleeding or prevent rebleeding was 94.4% (17/18). Sixteen cases (16/17) received one session of endoscopic therapy, and one patient (1/17) accepted two sessions. One patient with multiple underlying diseases died of persistent bleeding after three sessions of therapy. No complication was found to be related to the endoscopic procedure. Conclusions: Marginal ulcer bleeding exhibits the same endoscopic findings as peptic ulcer hemorrhage. Most marginal ulcers are single and located at the saddle area of the jejunal site. Endoscopy can be useful in diagnosing marginal ulcer, and it is safe and effective in managing active marginal ulcer bleeding.     

Multipolar electrocoagulation versus injection therapy in the treatment of bleeding peptic ulcers. A prospective, randomized trial

This study prospectively compares multipolar electrocoagulation and injection therapy in high-risk patients with bleeding ulcers. Patients were considered for entry if they had a bloody nasogastric aspirate, melena, or hematochezia and unstable vital signs, transfusion of greater than or equal to 2 U of blood in 12 hours, or a decrease in hematocrit of greater than or equal to 6% in 12 hours. Sixty patients with endoscopic evidence of an ulcer with active bleeding (n = 26) or a nonbleeding visible vessel (n = 34) were randomly assigned to receive multipolar electrocoagulation or injection with absolute ethanol. Hemostasis was achieved in 14 of 14 actively bleeding patients with multipolar electrocoagulation vs. 10 of 12 (83%) treated with injection. No significant differences were observed between electrocoagulation and injection therapy in any parameter assessed during the hospitalization: incidence of further bleeding (6% vs. 10%), units of blood transfused after treatment (1.8 +/- 0.6 vs. 1.3 +/- 0.4), incidence of surgery for bleeding (6% vs. 7%), length of hospital stay in days (5.8 +/- 0.9 vs. 7.2 +/- 2.5), cost of hospitalization (+7160 +/- +1630 vs. +8520 +/- +2960), or mortality rate (3% vs. 3%). Treatment induced bleeding in nonbleeding visible vessels in 35% of subjects in each group, but this was controlled with continued treatment in all patients. One delayed perforation occurred 9 days after multipolar electrocoagulation. Multipolar electrocoagulation and injection therapy are of comparable efficacy in the treatment of patients with clinical evidence of a major upper gastrointestinal bleed and endoscopic evidence of an ulcer with active bleeding or a nonbleeding visible vessel.     

Efficacy of endoscopic clipping for actively bleeding peptic ulcer: comparison with polidocanol injection therapy

BACKGROUND/AIMS: The use of hemostatic clips is conceptually attractive for achieving definitive hemostasis in peptic ulcer bleeding. There are only a few clinical trials comparing clipping with other endoscopic hemostatic methods. The aim of this study is to assess the efficacy and safety of endoscopic clipping with that of injection of polidocanol for hemostasis from actively (spurting or oozing) bleeding peptic ulcer. METHODOLOGY: 61 patients with active (spurting or oozing) bleeding gastroduodenal ulcers were randomly assigned to one of two endoscopic treatments: injection therapy with polidocanol 1% (injected in 0.5-1.0 mL increments at three to five sites around the bleeding vessel to a total of 5 mL) (n=30), or endoscopic clipping using a clipping device and clips (n=31). All patients from the polidocanol group and 22 (68.8%) patients from the clipping group received pretreatment with epinephrine. Hemostatic rates, rebleeding rates, amounts of blood transfusion, and durations of hospital stay were analyzed. RESULTS: The initial hemostatic rate was 96.8% in the clipping group, and 96.7% in the polidocanol group, respectively. Mean transfusion requirements, mean number of hospital days and percentage needing surgery were comparable in both groups. Recurrent bleeding rates were higher, although not statistically significant in the polidocanol group than in the clipping group (13.3% vs. 6.5%, respectively). CONCLUSIONS: Our data suggest that injection therapy with polidocanol and endoscopic hemoclips seems to be equivalent for actively (spurting and oozing) bleeding peptic ulcer.     

Factors related to the failure of endoscopic injection therapy for bleeding gastric ulcer.

BACKGROUND: Although endoscopic injection therapy is effective in controlling initial haemorrhage from peptic ulcer, between 10% to 30% of patients suffer rebleeding. AIM: To assess the factors that may predict the failure of endoscopic injection in patients bleeding from high risk gastric ulcer. SUBJECTS: One hundred and seventy eight patients admitted for a gastric ulcer with a bleeding or a non-bleeding visible vessel were included. METHODS: Patients received endoscopic therapy by injection for adrenaline and polidocanol. Twelve clinical and endoscopic variables were entered into a multivariate logistic regression model to ascertain their significance as predictive factor of therapeutic failure. RESULTS: Eighty seven per cent (155 of 178) of patients had no further bleeding after endoscopic therapy. Endoscopic injection failed in 23 (13%) patients: 20 (12%) continued to bleed or rebleed, and three (1%) patients could not be treated because of inaccessibility of the lesion. Logistic regression analysis showed that therapeutic failure was significantly related to: (1) the presence of hypovolaemic shock (p = 0.09, OR 2.38, 95% CI: 0.86, 6.56), (2) the presence of active bleeding at endoscopy (p = 0.02, OR 2.98, 95% CI: 1.12, 7.91), (3) ulcer location high on the lesser curvature (p = 0.04, OR 2.79, 95% CI: 1.01, 7.69), and (4) ulcer size larger than 2 cm (p = 0.01, OR 3.64, 95% CI: 1.34, 9.89). CONCLUSION: These variables may enable identification of those patients bleeding from gastric ulcer who would not benefit from injection therapy.     

Combined epinephrine and bipolar probe coagulation vs. bipolar probe coagulation alone for bleeding peptic ulcer: a randomized, controlled trial

BACKGROUND: Endoscopic treatment with combined modalities is considered standard of care for patients with high-risk peptic ulcer bleeding. This study compared epinephrine injection plus bipolar probe coagulation with bipolar probe coagulation alone in patients with high-risk peptic ulcer bleeding. METHODS: Patients with endoscopically confirmed peptic ulcer bleeding (active or visible vessel) seen from January 2000 through December 2002 were prospectively randomized to two groups. The study group (n = 58) had epinephrine injection followed by bipolar coagulation; the control group (n = 56) was treated by bipolar coagulation alone. The primary outcomes assessed were the rate of initial hemostasis and the rate of recurrent bleeding. Secondary outcomes were the following: need for surgical intervention to control bleeding, transfusion requirements, length of hospital stay (in days), and 30-day mortality. RESULTS: The rate of initial hemostasis was significantly higher in the combination therapy group ( p = 0.02; absolute risk reduction 31.6%: 95% CI [5.4, 57.7]). There was no significant difference between the two treatment groups with respect to all other outcomes measures, except that significantly fewer units of blood were transfused in the combination therapy group ( p = 0.006). CONCLUSIONS: In patients with active peptic ulcer bleeding, epinephrine injection plus bipolar coagulation achieved significantly higher rate of initial hemostasis. All other outcome measures were similar with either treatment in patients with non-bleeding stigmata.     

Randomized controlled trial comparing epinephrine injection plus heat probe coagulation versus epinephrine injection plus argon plasma coagulation for bleeding peptic ulcers

BACKGROUND: Epinephrine injection with heat probe coagulation is an effective treatment for bleeding peptic ulcer. Few studies have investigated the efficacy of dual therapy with epinephrine injection plus either heat probe or argon plasma coagulation for high-risk bleeding peptic ulcers. This study compared epinephrine injection plus heat probe coagulation to epinephrine injection plus argon plasma coagulation for the treatment of high-risk bleeding peptic ulcers. METHODS: The study design was prospective, randomized, and controlled. Patients with actively bleeding peptic ulcers, ulcers with adherent clots, or ulcers with nonbleeding visible vessels were randomly assigned to epinephrine injection plus heat probe coagulation or epinephrine injection plus argon plasma coagulation. Patients with previous gastric surgery, malignant ulcers, and unidentifiable ulcers because of torrential bleeding were excluded. The primary outcome measure was recurrence of bleeding. Secondary outcome measures were initial hemostasis, endoscopic procedure duration, number of patients requiring surgery, mortality within 30 days, and ulcer status at 8 week follow-up endoscopy. RESULTS: One hundred ninety-two patients were enrolled; 7 with malignant ulcers were excluded after randomization. One hundred eighty-five cases were analyzed, 97 in the heat probe group and 88 in the argon plasma coagulation group. Patient demographics and ulcer characteristics were comparable between the groups. There was no significant difference in terms of initial hemostasis (95.9% vs. 97.7%), frequency of recurrent bleeding (21.6% vs. 17.0%), requirement for emergency surgery (9.3% vs. 4.5%), mean number of units of blood transfused (2.4 vs. 1.7 units), mean hospital stay (8.2 vs. 7.0 days), and hospital mortality (6.2% vs. 5.7%). Sixty (61.8%) patients in the heat probe group and 52 (52.9%) in the argon plasma coagulation group underwent endoscopy at 8 weeks. There was no significant difference between these groups in the relative frequency of nonhealing ulcer at 8 weeks. CONCLUSION: Epinephrine injection plus argon plasma coagulation is as safe and effective as epinephrine injection plus heat probe coagulation in the treatment of patients with high-risk bleeding peptic ulcers.     

Prediction of therapeutic failure after adrenaline injection plus heater probe treatment in patients with bleeding peptic ulcer

BACKGROUND: Continued or recurrent bleeding after endoscopic treatment for bleeding ulcer is a major adverse prognostic factor. Identification of such ulcers may allow for alternate treatments. AIM: To determine factors predicting treatment failure with combined adrenaline injection and heater probe thermocoagulation. Methods: Consecutive patients with bleeding peptic ulcers who received endoscopic therapy between January 1995 and March 1998 were studied. Data on clinical presentation, endoscopic findings, and treatment outcomes were collected prospectively. Multiple logistic regression analysis was used to identify independent risk factors for treatment failure. RESULTS: During the study period, 3386 patients were admitted with bleeding peptic ulcers: 1144 (796 men, 348 women) with a mean age of 62.5 (SD 17.6) years required endoscopic treatment. There were 666 duodenal ulcers (58.2%), 425 gastric ulcers (37.2%), and 53 anastomotic ulcers (4.6%). Initial haemostasis was successful in 1128 patients (98.6%). Among them, 94 (8.2%) rebled in a median time of 48 hours (range 3-480). Overall failure rate was 9.6%. Mortality rate was 5% (57/1144). Multiple logistic regression analysis revealed that hypotension (odds ratio (OR) 2.21, 95% confidence interval (CI) 1.40-3.48), haemoglobin level less that 10 g/dl (OR 1.87, 95% CI 1.18-2.96), fresh blood in the stomach (OR 2.15, 95% CI 1.40-3.31), ulcer with active bleeding (OR 1.65, 95% CI 1.07-2.56), and large ulcers (OR 1.80, 95% CI 1.15-2.83) were independent factors predicting rebleeding. CONCLUSIONS: Larger ulcers with severe bleeding at presentation predict failure of endoscopic therapy.     

Omeprazole as adjuvant therapy to endoscopic combination injection sclerotherapy for treating bleeding peptic ulcer

BACKGROUND: Therapeutic endoscopy has provided a new means of treating bleeding peptic ulcers. Additional medical therapy may enhance the therapeutic benefit. Hemostasis is highly pH dependent and is severely impaired at low pH. Proton pump inhibitors, by achieving a significantly higher inhibition of gastric acidity, may improve the therapeutic outcomes after endoscopic treatment of ulcers. PATIENT AND METHODS: We enrolled 166 patients with hemorrhage from duodenal, gastric, or stomal ulcers and signs of recent hemorrhage, as confirmed by endoscopy. Twenty-six patients had ulcers with an arterial spurt, 41 patients had active ooze, 37 had a visible vessel, and 62 patients had an adherent clot. All patients received endoscopic injection sclerotherapy using 1:10,000 adrenaline and 1% polidocanol and were randomly assigned to receive omeprazole (40 mg orally) every 12 hours for 5 days or an identical-looking placebo. The outcome measures used were recurrent bleeding, surgery, blood transfusion, and hospital stay. RESULTS: Six (7%) of 82 patients in the omeprazole group had recurrent bleeding, as compared with 18 (21%) in the placebo group (P = 0.02). Two patients in the omeprazole group and 7 patients in the placebo group needed surgery to control their bleeding (P = 0.17). One patient in the omeprazole group and 2 patients in the placebo group died (P = 0.98). Twenty-nine patients (35%) in the omeprazole group and 61 patients (73%) in the placebo group received blood transfusions (P <0.001). The average hospital stay was 4.6 +/- 1.1 days in the omeprazole group and 6.0 +/- 0.7 days in the placebo group (P <0.001). CONCLUSION: The addition of oral omeprazole to combination injection sclerotherapy decreases the rate of recurrent bleeding, reduces the need for surgery and transfusion, and shortens the hospital stay for patients with stigmata of recent hemorrhage.     

Epinephrine versus epinephrine plus fibrin glue injection in peptic ulcer bleeding: a prospective randomized trial

BACKGROUND: Peptic ulcer bleeding remains a disease with considerable morbidity and mortality. Epinephrine is the most widely used endoscopic injection agent, but bleeding recurs in 20% of high-risk cases. Fibrin glue might be an ideal injection agent, based on its physiologic properties, despite its demanding injection technique and high cost. The aim of this study was to determine whether the injection of fibrin glue in combination with epinephrine improves outcome for patients at high risk of recurrent bleeding. METHODS: Patients were prospectively randomized to injection of epinephrine alone (n = 70) or epinephrine plus fibrin glue (n = 65). Endoscopy was repeated daily until the ulcer base was clean. All patients were treated with high-dose omeprazole. RESULTS: Initial hemostasis was 100% in both groups. There was no significant overall difference in rates of recurrent bleeding (24.3% and 21.5%, respectively, for epinephrine and epinephrine plus fibrin). When patients were stratified according to Forrest criteria, no significant difference could be found, although there was a trend toward less recurrent bleeding after fibrin injection of actively bleeding ulcers. There was no significant difference in the proportions of patients who required surgery (10% and 6%, respectively, for epinephrine and epinephrine plus fibrin). Mortality was the same (3%) in each group. CONCLUSIONS: Adding fibrin glue to epinephrine for injection treatment of bleeding peptic ulcers does not improve outcome. Fibrin glue might be of some value in selected cases.     

Endoscopic sclerosis in the treatment of bleeding peptic ulcers with a visible vessel

We have assessed the efficacy of endoscopic sclerosis in the routine clinical management of patients with bleeding ulcers, in whom a visible vessel was identified at endoscopy. Over a period of 14 months, a visible vessel at the base of an ulcer was identified in 53 patients. Three patients could not undergo sclerosis, one because of torrential bleeding and two because of ulcer location. Fifty patients, 18 with a bleeding vessel and 32 with a nonbleeding vessel, were subjected to endoscopic sclerosis with adrenaline plus polidocanol. Permanent hemostasis was achieved in 45 patients (90%), 31 (62%) cases with one session and 14 (28%) cases with two sessions of sclerosis. Four patients had persistent rebleeding in spite of two sessions of sclerosis, and one patient had a massive rebleeding after the first session; all underwent emergency surgery. We believe that endoscopic sclerosis has a primary role in the treatment of ulcer bleeding, particularly in those patients in whom a visible vessel is identified at endoscopy.     

A prospective, randomized trial comparing mechanical methods of hemostasis plus epinephrine injection to epinephrine injection alone for bleeding peptic ulcer

BACKGROUND: The hemostatic efficacy of mechanical methods of hemostasis, together with epinephrine injection, was compared with that of epinephrine injection alone in bleeding peptic ulcer. METHODS: Ninety patients with a peptic ulcer with active bleeding or a non-bleeding visible vessel were randomly assigned to undergo a mechanical method of hemostasis (23 hemoclip application, 22 band ligation) plus epinephrine injection, or epinephrine injection alone. RESULTS: The two groups were similar with respect to all background variables. Initial hemostasis was achieved in 44/45 (97.8%) patients in both groups. The mean number of hemoclips and elastic bands applied were 2.8: 95% CI[2.5, 3.1] and 1.1: 95% CI[1.0, 1.2], respectively, and the mean volume of epinephrine injected was 19.9 mL: 95% CI[19.3 mL, 20.5 mL]. The rate of recurrent bleeding in the combination group (2/44, 4.5%) was significantly lower in comparison with the injection group (9/44, 20.5%, p < 0.05). The mean number of therapeutic endoscopic sessions needed to achieve permanent hemostasis in the combination group (1.04: 95% CI[1.01, 1.07]) was significantly lower vs. the injection group (1.22: 95% CI[1.15, 1.30]). CONCLUSIONS: The combination of an endoscopic mechanical method of hemostasis plus epinephrine injection is more effective than epinephrine injection alone for the treatment of bleeding peptic ulcer.