Addition of a second endoscopic treatment following epinephrine injection improves outcome in high-risk bleeding ulcers

Calvet, Xavier; Vergara, Mercedes; Brullet, Enric; Gisbert, Javier P.; Campo, Rafel

doi:10.1053/j.gastro.2003.11.006

Cited by 237 publications

(117 citation statements)

References 45 publications

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“…Calvet et al [29] completed a systematic review and meta-analysis in 2004 which included 16 studies and > 1600 patients with UGIH secondary to PUD, and who underwent endoscopic therapy with epinephrine alone or epinephrine plus a second hemostatic modality. Adding an adjunct therapy reduced the rebleeding rate from 18.4% to 10.6% [odds ratio (OR): 0.53, 95% CI: 0.40-0.69], reduced the need for emergency surgery from 11.3% to 7.6% (OR: 0.64, 95% CI: 0.46-0.90), and reduced mortality from 5.1% to 2.6% (OR: 0.51, 95% CI: 0.31-0.84).…”

Section: Choice Of Endoscopic Hemostatic Techniquementioning

confidence: 99%

Management of non-variceal upper gastrointestinal tract hemorrhage: Controversies and areas of uncertainty

Trawick

Yachimski²

2012

WJG

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Upper gastrointestinal tract hemorrhage (UGIH) remains a common presentation requiring urgent evaluation and treatment. Accurate assessment, appropriate intervention and apt clinical skills are needed for proper management from time of presentation to discharge. The advent of pharmacologic acid suppression, endoscopic hemostatic techniques, and recognition of Helicobacter pylori as an etiologic agent in peptic ulcer disease (PU�) has revolutionized the treatment of UGIH. �espite this, acute UGIH still carries considerable rates of morbidity and mortality. This review aims to discuss current areas of uncertainty and controversy in the management of UGIH. Neoadjuvant proton pump inhibitor (PPI) therapy has become standard empiric treatment for UGIH given that PU� is the leading cause of non-variceal UGIH, and PPIs are extremely effective at promoting ulcer healing. However, neoadjuvant PPI administration has not been shown to affect hard clinical outcomes such as rebleeding or mortality. The optimal timing of upper endoscopy in UGIH is often debated. Upon completion of volume resuscitation and hemodynamic stabilization, upper endoscopy should be performed within 24 h in all patients with evidence of UGIH for both diagnostic and therapeutic purposes. With rising healthcare cost paramount in today's medical landscape, the ability to appropriately triage UGIH patients is of increasing value. Upper endoscopy in conjunction with the clinical scenario allows for accurate decision making concerning early discharge home in low-risk lesions or admission for further monitoring and treatment in higher-risk lesions. Concomitant pharmacotherapy with non-steroidal anti-inflammatory drugs (NSAI�s) and antiplatelet agents, such as clopidogrel, has a major impact on the etiology, severity, and potential treatment of UGIH. Long-term PPI use in patients taking chronic NSAI�s or clopidogrel is discussed thoroughly in this review.

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Section: Choice Of Endoscopic Hemostatic Techniquementioning

confidence: 99%

Management of non-variceal upper gastrointestinal tract hemorrhage: Controversies and areas of uncertainty

Trawick

Yachimski²

2012

WJG

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“…Calvet et al [13] pooled results from 16 studies comparing epinephrine injection alone vs. epinephrine plus other endoscopic methods: no single study provided a statistically significant result, but analysis of the pooled data showed that the additional endoscopic treatments after epinephrine injection significantly reduced further bleeding, need for surgery, and mortality, regardless of which second procedure was applied. An updated meta-analysis that pooled 22 randomized trials proved that dual therapy was superior to epinephrine injection alone, but showed no advantage over primary thermal or mechanical monotherapy in improving the outcome of patients.…”

Section: -15]mentioning

confidence: 99%

Endoscopic dual versus monotherapy in patients bleeding from high-risk peptic ulcers

Andriulli¹,

Loperfido²,

Napolitano³

et al. 2017

JUMD

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Aim: Dual endoscopic and pharmacologic therapy is currently the standard treatment for patients with high-risk peptic ulcer bleeding. The authors assess the efficacy of dual (endoscopic and pharmacologic) therapy versus endoscopic monotherapy in reducing rates of recurrent bleeding and death in patients with high-risk peptic bleeds. Methods: The authors carried out a post-hoc analysis of data on the use of intravenous proton pump inhibitors for the prevention of rebleeding ulcers and death (from an investigator-supported multicenter randomized trial in Italy). All the patients bleeding from high-risk peptic ulcers with a successful endoscopic hemostasis were treated with epinephrine injections alone (n = 157) or in combination with thermal therapy (n = 219). Results: Rebleeding occurred in 20 individuals (12.7%) in the monotherapy group, and in 21 individuals (9.6%) in the dual group (P = 0.33). Seven patients (4.5%) in the former group and 2 (0.9%) in the latter group died, with a 3.6% (95% CI: 0.3 to 8.1) absolute risk reduction. The mean number of units of blood transfused were 2.7 ± 1.7 and 3.2 ± 2.5 (P = 0.14), respectively, and the mean hospital stay was 6.7 ± 3.9 and 7.1 ± 4.3 days (P = 0.40), respectively. Multivariate analysis revealed that the sole independent predictor of death was ulcer size ≥ 20 mm [odds ratio (OR) = 6.56, 95% CI: 1.57 to 27.4]. Dual endoscopic and pharmacologic therapy provided a non-significant reduction in the risk of death (OR = 0.26, 95% CI: 0.05 to 1.34). Conclusion: When adjuvant proton pump inhibitors were administered, dual endoscopic and pharmacologic therapy was not superior to injection monotherapy for reducing rates of rebleeding and death. Key words:Peptic ulcer, gastric ulcer, duodenal ulcer, bleeding, non-variceal gastrointestinal bleeding, endoscopic therapy, epinephrine injection, outcome ABSTRACTArticle history:

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“…Over the last few decades improvements in endoscopic therapy have been shown to reduce risks of rebleeding, for example by the increased use of combination therapies 55 and variceal banding. 56 The use of proton pump inhibitors has been demonstrated to reduce stomach pH and promote clot stability, 57 a similar approach to that originally intended by early feeding.…”

Section: Mortality Trends 231 Natural Historymentioning

confidence: 99%

Epidemiology of Upper Gastrointestinal Bleeding

Crooks¹,

Sung²,

Card³

2014

GI Epidemiology

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Addition of a second endoscopic treatment following epinephrine injection improves outcome in high-risk bleeding ulcers

Cited by 237 publications

References 45 publications

Management of non-variceal upper gastrointestinal tract hemorrhage: Controversies and areas of uncertainty

Management of non-variceal upper gastrointestinal tract hemorrhage: Controversies and areas of uncertainty

Endoscopic dual versus monotherapy in patients bleeding from high-risk peptic ulcers

Epidemiology of Upper Gastrointestinal Bleeding

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