Endoscopic injection of adrenaline for actively bleeding ulcers: a randomised trial

Abstract

A prospective randomised trial was performed to assess the efficacy of endoscopic injection of adrenaline for actively bleeding ulcers. Emergency endoscopy in 961 patients admitted for upper gastrointestinal haemorrhage identified 68 patients with actively bleeding ulcers. These 68 patients were randomised to receive either endoscopic injection of adrenaline or no endoscopic treatment. After endoscopy both groups were managed in an identical manner, and strict criteria for emergency operation were adhered to in both groups. Bleeding was initially controlled in all 34 patients assigned to the treatment group. Significantly fewer patients in the treatment group than in the control group needed emergency operations (five v 14, respectively). In addition, in the treatment group the median transfusion requirement was significantly less (three v five units of blood) and the median hospital stay shorter (six v eight days). No complications were observed with the injection of adrenaline, and the rate of healing of ulcers in those attending for endoscopy six weeks after discharge was similar in both groups (81% (17 out of 21 patients) in the treatment group v 79% (11 out of 14) in the control group). Injection of adrenaline is effective in stopping bleeding from actively bleeding ulcers.

Where next with endoscopic ulcer hemostasis?

“…In recent studies by Hong Kong investigators, initial hemostasis rates were more than 95% using combination therapy (epinephrine and heater probe) for spurting ulcer bleeding, and rebleeding rates of patients in two randomized, prospective studies treated with i.v. omeprazole were less than 10% (5,14). Given these very good results reported by different investigators with current treatments, there appears to be only a small margin for improvement in ulcer rebleeding rates after successful endoscopic hemostasis because the current ulcer rebleeding rates are about 10% with i.v.…”

“…Also, endoscopic treatment of those with major stigmata of ulcer hemorrhage (active bleeding, nonbleeding visible vessel [NBVV], or an adherent clot) is highly recommended because outcomes improve (1)(2)(3). Oozing bleeding without another stigmata (such as a NBVV or clot) is often self-limited and does not usually require endoscopic therapy, although some endoscopists report rebleeding rates on medical therapy alone of up to 28% and recommend endoscopic hemostasis for this stigma (5). Endoscopic treatment of minor stigmata of ulcer hemorrhage (flat spots or gray slough) or clean ulcer bases is not recommended because outcomes do not improve and may worsen (1)(2)(3)(4)(5)(6).…”

“…Oozing bleeding without another stigmata (such as a NBVV or clot) is often self-limited and does not usually require endoscopic therapy, although some endoscopists report rebleeding rates on medical therapy alone of up to 28% and recommend endoscopic hemostasis for this stigma (5). Endoscopic treatment of minor stigmata of ulcer hemorrhage (flat spots or gray slough) or clean ulcer bases is not recommended because outcomes do not improve and may worsen (1)(2)(3)(4)(5)(6). For all patients with ulcer hemorrhage, biopsy for H. pylori and subsequent eradication of infection, early refeeding, treatment with high-dose proton pump inhibitors (PPIs) to heal ulcers, and counseling about the dangers of subsequent nonsteroidal anti-inflammatory drugs or aspirin ingestion are highly recommended also (4).…”

“…Mechanical techniques such as hemoclips, endoloops, rubber bands, or sutures have been applied to both variceal and nonvariceal lesions (1). For emergency endoscopic hemostasis of ulcers with major stigmata of hemorrhage, most endoscopists rely upon their own training and experience, using techniques that are available on their emergency hemostasis carts, and catheters or probes that are easily applied, effective, and safe (1)(2)(3)(4)(5)(6)(7)(8).…”

Nonvariceal Upper Gastrointestinal Bleeding

“…Adrenaline injection results in haemostasis in up to100% of patients with bleeding peptic ulcers, probably by a combination of vascular tamponade and vasoconstriction, with a concomitant reduction in re-bleeding rates from 40 to 15%. 22,23 The dose of adrenaline required to achieve haemostasis is variable but larger volumes (13-20ml vs. 5-10ml) in high risk patients (Forrest type I or IIa lesions) results in less re-bleeding (15.4% vs. 30.8%). 24 Although injection with adrenaline is successful in achieving initial haemostasis, 15-36% of patients rebleed, a figure that is unacceptably high.…”