The most common cause of hospitalization for upper gastrointestinal (GI) bleeding in the United States is still peptic ulcers.
Such ulcers account for 140,000 hospitalizations annually, and represent nearly half of all admissions for upper GI bleeding.
Hemodynamic instability, concurrent illness and age all provide independent predictors of outcome in-patients with upper GI bleeding.
However, the appearance of an ulcer at endoscopy can also provide useful prognostic information and can be essential in assessing risk and hence subsequent management in patients presenting with ulcer bleeding.
Nonetheless, the treatment of high-risk patients with non-bleeding adherent clots on ulcers remains controversial.
A previous randomized trial found no benefit to endoscopic therapies compared with medical treatment for prevention of ulcer re-bleeding.
However, in a paper with accompanying editorial, Dr Dennis M. Jensen and colleagues tested the hypothesis that patients treated with combination endoscopic therapy would have much reduced re-bleeding rates compared to those treated with medical therapy.
The randomized, controlled trial involved 32 high-risk patients with severe ulcer hemorrhage and non-bleeding adherent clots resistant to target irrigation.
Each patient was randomized to medical therapy or to combination endoscopic therapy (with epinephrine injection, shaving down the clot with cold guillotining and bipolar coagulation on the underlying stigmata).
Physicians blinded to the endoscopic therapy managed all patients.
| Medical therapy:|
35% had ulcer re-bleeding
None had ulcer re-bleeding
| Gastroenterology |
Apart from older age in the medical group, and lower platelet count in the endoscopic group, all patients were similar at study entry.
However, by hospital discharge, there was a significant difference in the levels of re-bleeding between the two groups.
In patients treated using medical therapies, 6 out of 17 (35%) experienced re-bleeding episodes.
This compared to 0 out of 15 subjects (0%) in the endoscopically treated group. There were no complications of endoscopic treatment.
Concluding on behalf of his fellow authors, Dr Jensen said the study showed, "Combination endoscopic therapy of non-bleeding adherent clots significantly reduced early ulcer re-bleeding rates in high-risk patients compared with medical therapy alone."