Epinephrine injection versus epinephrine injection and a second endoscopic method in high risk bleeding ulcers

Vergara M, Calvet X, Gisbert JP

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Summary

Epinephrine injection versus epinephrine injection and a second endoscopic method in high risk bleeding ulcers

Endoscopic therapy reduces rebleeding rate, need for surgery, and mortality in patients with peptic ulcer and active bleeding or visible vessel.
Injection of epinephrine is the most popular therapeutic method. Guidelines disagree on the need for a second haemostatic procedure immediately after epinephrine; although it seems to reduce further bleeding, its effects on morbidity, surgery rates and mortality remain unclear. We performed an extensive search for randomised trials comparing epinephrine alone versus epinephrine plus a second method. Selected articles were included in a meta-analysis. Seventeen studies involving 1763 participants met inclusion criteria. Adding a second procedure reduced the further bleeding rate from 18.8% to 10.4% and emergency surgery from 10.3% to 7.1%. Mortality fell from 5 % to 2.5%. Additional endoscopic treatment after epinephrine injection reduces further bleeding, need for surgery and mortality in participants with bleeding peptic ulcer.

This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2010 Issue 1, Copyright © 2010 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
This record should be cited as: Vergara M, Calvet X, Gisbert JP. Epinephrine injection versus epinephrine injection and a second endoscopic method in high risk bleeding ulcers. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005584. DOI: 10.1002/14651858.CD005584.pub2.

This version first published online: April 18. 2007

Abstract

Background

Endoscopic therapy reduces rebleeding rate, need for surgery, and mortality in patients with bleeding peptic ulcers. Injection of epinephrine is the most popular therapeutic method. Guidelines disagree on the need for a second haemostatic procedure immediately after epinephrine.

Objectives

The objective of this review was to determine whether the addition of a second procedure improves efficacy or patient outcomes or both after epinephrine injection in adults with high risk bleeding ulcers.

Search strategy

We searched the Cochrane Central Register of Controlled Trials - CENTRAL (which includes the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register) (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006) and reference lists of articles. We also contacted experts in the field.

Selection criteria

Randomised studies comparing endoscopic treatment: epinephrine alone versus epinephrine associated with a second haemostatic method in adults with haemorrhage from peptic ulcer disease with major stigmata of bleeding as defined by the Forrest classification. Bleeding must have been confirmed by endoscopy.

Data collection and analysis

Two authors independently assessed trial quality and extracted data.

Main results

Seventeen studies including 1763 people were included. Adding a second procedure reduced further bleeding rate from 18.8% to 10.4%; Peto Odds Ratio 0.51; 95% confidence interval (CI) 0.39 to 0.66, and emergency surgery from 10.8% to 7.1%; OR 0.63; 95% CI 0.45 to 0.89. Mortality fell from 5% to 2.5% OR 0.50; 95% CI 0.30 to 0.82. Subanalysis showed that the risk of further bleeding decreased regardless of which second procedure was applied. In addition, the risk was reduced in all subgroups.

Authors' conclusions

Additional endoscopic treatment after epinephrine injection reduces further bleeding, the need for surgery and mortality in patients with bleeding peptic ulcer.

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