Final results and cost assessment of endoscopic vs. nedical therapies for prevention of recurrent ulcer hemorrhage from adherent clots in a randomized controlled trial

Dm, Jensen; Kovacs, Tog; Jutabha, Rome; Randall, GM; Cheng, Su-Ting; Jensen, ME; Freeman, M. A. R.; Gralnek, IM; Sue, M.; Machicado, G; Gornbein, Jeff

doi:10.1016/s0016-5107(05)80315-3

Cited by 12 publications

(14 citation statements)

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“…Laine et al [5] found that Endoscopic therapy was effective for active bleeding and a nonbleeding visible vessel but not for a clot. In a randomized controlled study of 27 patients with adherent clots, Jensen et al [27] noted recurrent bleeding rates of 33% for patients treated with a heat probe, 37.5% with injection therapy, and 30.0% with medical therapy. Based on these findings, these investigators recommended that adherent clots should not be forcibly removed and be managed with medical therapy.…”

Section: Discussionmentioning

confidence: 99%

Endoscopic vs. Medical Therapy for Bleeding Peptic Ulcers with Adherent Clot: A Randomized Comparative Trial

Telwani¹,

Baba²,

Mujoo³

et al. 2017

J Hepatol Gastroint Dis

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Upper gastrointestinal bleeding is the most common and potentially life threatening emergency. Despite great advances in the field of medicine, the optimal management of bleeding peptic ulcer with adherent clot on endoscopy is still controversial. The aim of this study is to compare the combined endoscopic and medical therapy with medical therapy alone for bleeding peptic ulcer with adherent clot (Forrest type IIB). During two-year study period, around 342 patients presented to our Tertiary care hospital with acute upper gastrointestinal bleeding. Out of these, 81 patients were noted to have adherent clot (Forrest type IIB) during endoscopy and were included in study. 40 patients received combined endoscopic and medical treatment, whereas 41 patients received medical treatment only. The base line characteristics of patients in two groups were comparable and statistically significant. Primary Outcome being recurrence of bleeding within 7 days of treatment was less in combined therapy group compared to medical therapy group (2.5% vs. 17.1%) This was statistically significant. Secondary outcome like recurrence of bleed in 30 days and need for repeat endoscopy were less in combined group compared to medical therapy group. These were statistically significant as well. Other secondary outcomes like necessity for surgery and mortality were fewer in combined group, but these were not statistically significant. In conclusion combination endoscopic therapy consisting of epinephrine injection, removal of the adherent clot, and treatment of underlying stigmata is more effective than medical therapy alone.

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Section: Discussionmentioning

confidence: 99%

Endoscopic vs. Medical Therapy for Bleeding Peptic Ulcers with Adherent Clot: A Randomized Comparative Trial

Telwani¹,

Baba²,

Mujoo³

et al. 2017

J Hepatol Gastroint Dis

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“…Endoscopic major stigmata of hemorrhage (active bleeding or nonbleeding visible vessels) and large ulcers (>2 cm) also increase the risk of rebleeding. Rebleeding rates for patients on medical therapy with nonbleeding adherent clots vary in the literature and appear to depend upon other risk factors than the clot alone [1,10,11,13,14,15,16]. Elderly patients with large ulcers (e.g., at least 12 mm in diameter), severe comorbid conditions, hospitalized for severe UGI hemorrhage, with nonbleeding adherent clots on endoscopy, and treated medically were reported to have rebleeding rates of about 33% in two prior CURE randomized trials [1,16].…”

Section: Stigma Is Verified By Vigorous Washing and Tangential Viewsmentioning

confidence: 99%

“…Rebleeding rates for patients on medical therapy with nonbleeding adherent clots vary in the literature and appear to depend upon other risk factors than the clot alone [1,10,11,13,14,15,16]. Elderly patients with large ulcers (e.g., at least 12 mm in diameter), severe comorbid conditions, hospitalized for severe UGI hemorrhage, with nonbleeding adherent clots on endoscopy, and treated medically were reported to have rebleeding rates of about 33% in two prior CURE randomized trials [1,16]. The rebleeding rate of 31.3% in a recent CURE study for the Medical Therapy Group (with high-dose oral proton pump inhibitors) is similar to the rebleeding rates for medical therapy in these earlier reports.…”

Section: Stigma Is Verified By Vigorous Washing and Tangential Viewsmentioning

confidence: 99%

“…In contrast, the rebleeding rate on medical therapy of low-risk, younger patients with smaller ulcers and no comorbid conditions was 8% in another recent prospective study [14]. Based on the potential of endoscopic treatment or removal of clots to induce bleeding [13, 16,17], the poor results of earlier randomized prospective endoscopic trials [13, 16,17], and the low rebleeding rate reported for young low-risk patients on medical therapy [14], the standard of care in most major medical centers previously has been medical therapy alone for ulcer patients with severe UGI hemorrhage and nonbleeding adherent clots.…”

Section: Stigma Is Verified By Vigorous Washing and Tangential Viewsmentioning

confidence: 99%

“…The endoscopic combination therapy used in the treatment of adherent clots by the CURE Hemostasis Research Group appears to be safer and significantly more effective than previous endoscopic monotherapies [16]. The rebleeding rate in the combination group was 0% [7].…”

Section: Stigma Is Verified By Vigorous Washing and Tangential Viewsmentioning

confidence: 99%

See 2 more Smart Citations

Clots and spots on ulcers: why and how to treat

Jensen

2001

Langenbeck's Archives of Surgery

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The clinical indication for urgent endoscopy with combined diagnosis and treatment is bleeding severe enough to warrant urgent medical attention. Stigmata of ulcer hemorrhage are utilized as a guide to endoscopic therapy. Active arterial bleeding, nonbleeding visible vessels, and adherent nonbleeding clots are always treated endoscopically. In randomized trials, patients with these "major stigmata" had better outcomes from endoscopic therapies than with medical therapies alone. Flat spots, gray or black sloughs, and clean ulcer bases are not treated endoscopically, since medical therapy alone affords good outcome. The current recommendation is to treat major stigmata of hemorrhage endoscopically for the initial bleeding episode and a second time for rebleeding before considering ulcer surgery. Clinical presentation and comorbidity and the endoscopic appearance of the ulcer (i.e., stigmata of hemorrhage) of patients with UGI bleeding are used to determine the subsequent level of care (e.g., discharge or ward or intensive care).

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Nonvariceal Upper Gastrointestinal Bleeding

Khan¹,

Gunaratnam²

2012

Clinical Gastrointestinal Endoscopy

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Final results and cost assessment of endoscopic vs. nedical therapies for prevention of recurrent ulcer hemorrhage from adherent clots in a randomized controlled trial

Cited by 12 publications

References 0 publications

Endoscopic vs. Medical Therapy for Bleeding Peptic Ulcers with Adherent Clot: A Randomized Comparative Trial

Endoscopic vs. Medical Therapy for Bleeding Peptic Ulcers with Adherent Clot: A Randomized Comparative Trial

Clots and spots on ulcers: why and how to treat

Nonvariceal Upper Gastrointestinal Bleeding

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