Randomized trial of medical or endoscopic therapy to prevent recurrent ulcer hemorrhage in patients with adherent clots.
OBJECTIVE
Treatment of high-risk patients with nonbleeding adherent clots on ulcers is controversial. In a previous randomized trial, there was no benefit to endoscopic therapies compared with medical therapy for prevention of ulcer rebleeding. Our purpose was to test the hypothesis that patients treated with combination endoscopic therapy would have significantly lower rebleeding rates than those treated with medical therapy.


METHODS
In this randomized, controlled trial, 32 high-risk patients with severe ulcer hemorrhage and nonbleeding adherent clots resistant to target irrigation were 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.


RESULTS
Patients were similar at study entry, except for older age in the medical group and lower platelet count in the endoscopic group. By hospital discharge, significantly more medically treated patients (6/17; 35.3%) than endoscopically treated patients (0/15; 0%) rebled (P = 0.011). There were no complications of endoscopic treatment.


CONCLUSIONS
Combination endoscopic therapy of nonbleeding adherent clots significantly reduced early ulcer rebleeding rates in high-risk patients compared with medical therapy alone. This endoscopic treatment was safe.
Jensen
Dennis M
DM
CURE Digestive Disease Research Center, UCLA School of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California 90073, USA. djensen@mednet.ucla.edu
Kovacs
Thomas O G
TO
Jutabha
Rome
R
Machicado
Gustavo A
GA
Gralnek
Ian M
IM
Savides
Thomas J
TJ
Smith
James
J
Jensen
Mary Ellen
ME
Alofaituli
Gwen
G
Gornbein
Jeff
J
D000368:Aged; D001777:Blood Coagulation; D016099:Endoscopy, Gastrointestinal; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010437:Peptic Ulcer / Q000628:therapy*; D010438:Peptic Ulcer Hemorrhage / Q000517:prevention & control*; D011446:Prospective Studies; D012008:Recurrence