Comparison of hemostatic efficacy for epinephrine injection alone and injection combined with hemoclip therapy in treating high-risk bleeding ulcers

BackgroundRebleeding occurs in 10% to 30% of bleeding ulcer patients receiving endoscopic epinephrine injection therapy. It remains unclear whether addition of a secondary clip therapy following epinephrine injection may reduce the rebleeding rate of high-risk bleeding ulcers.ObjectiveTo compare the efficacies of epinephrine injection alone and epinephrine injection combined with hemoclip therapy in treating high-risk bleeding ulcers.DesignProspective randomized controlled trial.SettingA medical center in Taiwan.PatientsOne hundred five bleeding ulcer patients with active spurting, oozing, nonbleeding visible vessels or adherent clots in ulcer bases.InterventionsEndoscopic combination therapy (n = 52) or diluted epinephrine injection alone (n = 53).Main Outcome MeasurementsInitial hemostasis rates and recurrent bleeding rates.ResultsInitial hemostasis was achieved in 51 patients treated with combination therapy and 49 patients with epinephrine injection therapy (98% vs 92%, P = .18). Bleeding recurred in 2 patients in the combination therapy group and 11 patients in the epinephrine injection group (3.8% vs 21%, P = .008). Among the patients with rebleeding, repeated combination therapy was more effective than repeated injection therapy in achieving permanent hemostasis (100% vs 33%, P = .02). No patient required an emergency operation in the combination therapy group. However, 5 patients in the epinephrine injection group underwent emergency surgery to arrest bleeding (0% vs 9%, P = .023).LimitationsTreatment outcome of endoscopic hemoclip therapy is related to the techniques of endoscopists.ConclusionEndoscopic combination therapy is superior to epinephrine injection alone in the treatment of high-risk bleeding ulcers.