title: Predictors of rebleeding after initial hemostasis with epinephrine injection in high-risk ulcers.
abstract: OBJECTIVE
  To identify the predictors of rebleeding after initial hemostasis with epinephrine injection (EI) in patients with high-risk ulcers.
  
  
  METHODS
  Recent studies have revealed that endoscopic thermocoagulation, or clips alone or combined with EI are superior to EI alone to arrest ulcer bleeding. However, the reality is that EI monotherapy is still common in clinical practice. From October 2006 to April 2008, high-risk ulcer patients in whom hemorrhage was stopped after EI monotherapy were studied using clinical, laboratory and endoscopic variables. The patients were divided into 2 groups: sustained hemostasis and rebleeding.
  
  
  RESULTS
  A total of 175 patients (144, sustained hemostasis; 31, rebleeding) were enrolled. Univariate analysis revealed that older age (≥ 60 years), advanced American Society of Anesthesiology (ASA) status (category III, IV and V), shock, severe anemia (hemoglobin < 80 g/L), EI dose ≥ 12 mL and severe bleeding signs (SBS) including hematemesis or hematochezia were the factors which predicted rebleeding. However, only older age, severe anemia, high EI dose and SBS were independent predictors. Among 31 rebleeding patients, 10 (32.2%) underwent surgical hemostasis, 15 (48.4%) suffered from delayed hemostasis causing major complications and 13 (41.9%) died of these complications.
  
  
  CONCLUSIONS
  Endoscopic EI monotherapy in patients with high-risk ulcers should be avoided. Initial hemostasis with thermocoagulation, clips or additional hemostasis after EI is mandatory for such patients to ensure better hemostatic status and to prevent subsequent rebleeding, surgery, morbidity and mortality.
authors.affiliation: Division of Hepatogastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, 123, Ta-Pei Road, Niao-Song Hsiang 833, Kaohsiung, Taiwan.
authors.forename: Ming-Luen
authors.initials: ML
authors.lastname: Hu
authors.forename: Keng-Liang
authors.initials: KL
authors.lastname: Wu
authors.forename: King-Wah
authors.initials: KW
authors.lastname: Chiu
authors.forename: Yi-Chun
authors.initials: YC
authors.lastname: Chiu
authors.forename: Yeh-Pin
authors.initials: YP
authors.lastname: Chou
authors.forename: Wei-Chen
authors.initials: WC
authors.lastname: Tai
authors.forename: Tsung-Hui
authors.initials: TH
authors.lastname: Hu
authors.forename: Shue-Shian
authors.initials: SS
authors.lastname: Chiou
authors.forename: Seng-Kee
authors.initials: SK
authors.lastname: Chuah
mesh_terms: D000367:Age Factors; D000368:Aged; D000740:Anemia / Q000150:complications; D003131:Combined Modality Therapy; D004564:Electrocoagulation; D004837:Epinephrine / Q000494:pharmacology / Q000627:therapeutic use*; D005260:Female; D006487:Hemostasis / Q000187:drug effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010438:Peptic Ulcer Hemorrhage / Q000453:epidemiology / Q000628:therapy*; D011237:Predictive Value of Tests; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D013276:Stomach Ulcer / Q000150:complications*; D013525:Surgical Instruments; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000494:pharmacology* / Q000627:therapeutic use*
chemical_list: D014662:Vasoconstrictor Agents; D004837:Epinephrine