title: Endoclips vs large or small-volume epinephrine in peptic ulcer recurrent bleeding.
abstract: OBJECTIVE
  To compare the recurrent bleeding after endoscopic injection of different epinephrine volumes with hemoclips in patients with bleeding peptic ulcer.
  
  
  METHODS
  Between January 2005 and December 2009, 150 patients with gastric or duodenal bleeding ulcer with major stigmata of hemorrhage and nonbleeding visible vessel in an ulcer bed (Forrest IIa) were included in the study. Patients were randomized to receive a small-volume epinephrine group (15 to 25 mL injection group; Group 1, n = 50), a large-volume epinephrine group (30 to 40 mL injection group; Group 2, n = 50) and a hemoclip group (Group 3, n = 50). The rate of recurrent bleeding, as the primary outcome, was compared between the groups of patients included in the study. Secondary outcomes compared between the groups were primary hemostasis rate, permanent hemostasis, need for emergency surgery, 30 d mortality, bleeding-related deaths, length of hospital stay and transfusion requirements.
  
  
  RESULTS
  Initial hemostasis was obtained in all patients. The rate of early recurrent bleeding was 30% (15/50) in the small-volume epinephrine group (Group 1) and 16% (8/50) in the large-volume epinephrine group (Group 2) (P = 0.09). The rate of recurrent bleeding was 4% (2/50) in the hemoclip group (Group 3); the difference was statistically significant with regard to patients treated with either small-volume or large-volume epinephrine solution (P = 0.0005 and P = 0.045, respectively). Duration of hospital stay was significantly shorter among patients treated with hemoclips than among patients treated with epinephrine whereas there were no differences in transfusion requirement or even 30 d mortality between the groups.
  
  
  CONCLUSIONS
  Endoclip is superior to both small and large volume injection of epinephrine in the prevention of recurrent bleeding in patients with peptic ulcer.
authors.affiliation: Department of Internal Medicine, 'Sestre milosrdnice' University Hospital Center, 10000 Zagreb, Croatia. neven.ljubicic@kbcsm.hr
authors.forename: Neven
authors.initials: N
authors.lastname: Ljubicic
authors.forename: Ivan
authors.initials: I
authors.lastname: Budimir
authors.forename: Alen
authors.initials: A
authors.lastname: Biscanin
authors.forename: Marko
authors.initials: M
authors.lastname: Nikolic
authors.forename: Vladimir
authors.initials: V
authors.lastname: Supanc
authors.forename: Davor
authors.initials: D
authors.lastname: Hrabar
authors.forename: Tajana
authors.initials: T
authors.lastname: Pavic
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001803:Blood Transfusion; D016009:Chi-Square Distribution; D003131:Combined Modality Therapy; D017523:Croatia; D004381:Duodenal Ulcer / Q000401:mortality / Q000628:therapy*; D004837:Epinephrine / Q000008:administration & dosage* / Q000009:adverse effects; D004867:Equipment Design; D005260:Female; D016558:Hemostasis, Endoscopic / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D006490:Hemostatics / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D007267:Injections; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010438:Peptic Ulcer Hemorrhage / Q000401:mortality / Q000628:therapy*; D011446:Prospective Studies; D012008:Recurrence; D013276:Stomach Ulcer / Q000401:mortality / Q000628:therapy*; D013525:Surgical Instruments; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D006490:Hemostatics; D004837:Epinephrine