Upper GI bleed: peptic ulcer: ulcer size and position predicted rebleeding

Clinical bottom line (level 2b)

  1. A quarter of patients with bleeding peptic ulcers rebled.
  2. The risk of rebleeding was increased with
    • associated diseases
    • a duodenal ulcer on the superior or posterior bulb
    • ulcer size > 10 mm
Villanueva et al: Digestive Diseases and Sciences 1993; 38 (11): 2062-2070
Expires January 2003

The study

Inception cohort study with objective outcomes, adjusted for confounding factors, validated in an independent set of patients.

Setting: university hospital, Spain

233 patients (aged mean 65, 66% male) with upper GI bleeding (melaena or haematemesis) due to a bleeding peptic ulcer (on endoscopy).


Factors studied:
  • age, sex, associated diseases, NSAID use, previous ulcers, shock, haemoglobin level, endoscopic findings


All patients had emergency endoscopy within 4 hours, and received injection therapy using epinephrine (with thrombin or polidocanol in some cases). Patients subsequently received ranitidine 50 mg intravenously 6 hourly, and then 150 mg by mouth twice daily.

Logistic regression analysis was performed to adjust for confounding factors.

100% followed for length of hospital stay
Outcomes studied:

therapeutic failure active bleeding on repeated endoscopy, vomiting of fresh blood or bloody aspirate after previous clear lavages by nasogastric tube, or passage of fresh melaena AND clinical evidence of hypovolaemia or a fall in haemoglobin requiring transfusion


The evidence

outcome time to outcome number of patients/total number %
(95% CI)		 NNF
(95% CI)
therapeutic failure 9 days 57/233 25%
(19% to 30%)		 4
( to )

  • Therapeutic failure was independently predicted by
    • presence of associated diseases
    • ulcer position on posterior and superior wall of duodenal bulb
    • ulcer size > 10 mm

Comments

  1. Patients were enrolled as part of a randomised controlled trial.
  2. The three independent factors were prospectively validated in 81 other patients, and remained significant.

Citation

  1. Villanueva C, Balanzo J, Espinos JC, et al: prediction of therapeutic failure in patients with bleeding peptic ulcer treated with endoscopic injection. Digestive Diseases and Sciences 1993; 38 (11): 2062-2070
Contributor: Chris Ball and Musab Hayatli, December 1999
Reviewer:

Clinical Question.
    Patient bleeding peptic ulcer injected with epinephrine
    Intervention or Exposure clinical features
    Outcome therapeutic failure (rebleeding)