Systematic review with network meta-analysis: dual therapy for high-risk bleeding peptic ulcers

Abstract

BackgroundAdding a second endoscopic therapy to epinephrine injection might improve hemostatic efficacy in patients with high-risk bleeding ulcers but the optimum modality remains unknown. We aimed to estimate the comparative efficacy of different dual endoscopic therapies for the management of bleeding peptic ulcers through random-effects Bayesian network meta-analysis.MethodsDifferent databases were searched for controlled trials comparing dual therapy versus epinephrine monotherapy or epinephrine combined with another second modality until September, 30 2016. We estimated the ORs for rebleeding, surgery and mortality among different treatments. Adverse events were also evaluated.ResultsSeventeen eligible articles were included in the network meta-analysis. The addition of mechanical therapy (OR 0.19, 95% CrI 0.07–0.52 and OR 0.10, 95% CrI 0.01–0.50, respectively) after epinephrine injection significantly reduced the probability of rebleeding and surgery. Similarly, patients who received epinephrine plus thermal therapy showed a significantly decreased rebleeding rate (OR 0.30, 95% CrI 0.10–0.91), as well as a non-significant reduction in surgery (OR 0.47, 95% CrI 0.16–1.20). Although differing, epinephrine plus mechanical therapy did not provide a significant reduction in rebleeding (OR 0.62, 95% CrI 0.19–2.22) and surgery (OR 0.21, 95% CrI 0.03–1.73) compared to epinephrine plus thermal therapy. Sclerosant failed to confer further benefits and was ranked highest among the 5 treatments in relation to adverse events.ConclusionsMechanical therapy was the most appropriate modality to add to epinephrine injection. Epinephrine plus thermal coagulation was effective for controlling high risk bleeding ulcers. There was no further benefit with sclerosants with regard to rebleeding or surgery, and sclerosants were also associated with more adverse events than any other modality.Electronic supplementary materialThe online version of this article (doi:10.1186/s12876-017-0610-0) contains supplementary material, which is available to authorized users.

Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021

“…Two recent meta-analyses support the superiority of combination endoscopic therapy (injection plus thermal therapy, and injection plus mechanical therapy) over epinephrine injection monotherapy in peptic ulcers with high risk stigmata [124,125]. Baracat et al performed a systematic review and metaanalysis of 28 RCTs that included 2988 adults with high risk peptic ulcer endoscopic stigmata.…”

“…No significant difference in mortality between hemostasis modalities was observed. In a network meta-analysis, Shi et al reported that the addition of mechanical therapy following epinephrine injection significantly reduced the probability of rebleeding and surgery (OR 0.19, 95 %CI 0.07-0.52 and OR 0.10, 95 %CI 0.01-0.50, respectively), while the addition of thermal therapy only reduced ulcer rebleeding rates (OR 0.30, 95 %CI 0.10-0.91) [125].…”

Perforated and bleeding peptic ulcer: WSES guidelines

“…In a Cochrane review including 19 randomized studies and 2033 patients, Vergara et al [104] has shown that additional endoscopic treatment after epinephrine injection reduces further bleeding and the need for surgery in patients with highrisk bleeding peptic ulcer; however, they cannot conclude that a particular form of dual-modality treatment is equal or superior to another. Shi et al have performed a network meta-analysis on dual therapy choices [105] and shown that the addition of mechanical therapy after epinephrine injection significantly reduced the probability of rebleeding (OR 0.19, 95% CI 0.07-0.52) and surgery (OR 0.10, 95% CI 0.01-0.50). Epinephrine with thermal therapy was shown to reduce the rebleeding rate (OR 0.30, 95% CI 0.10-0.91) but not the need for surgical intervention (OR 0.47, 95% CI 0.16-1.20).…”

The “Difficult” Colorectal Polyps and Adenomas: Practical Aspects

“…For prevention of bleeding in "difficult" pedunculated polyps (with head ≥2 cm or a stalk ≥1.5 cm), injection of dilute adrenaline and/or mechanical hemostasis is recommended [15]. It has been shown that the use of endoloops or endoclips (mechanical prophylaxis) can be superior to adrenaline injection and combination of mechanical prophylaxis with adrenalin injection significantly decreased post polypectomy bleeding in comparison with injection alone [21][22][23]. ESGE recommends that large (≥2 cm), sessile and laterally spreading "difficult" polyps should be always treated and removed by trained and experienced endoscopist in appropriately resourced tertiary endoscopic centre.…”