Upper GI bleed: there was no clear benefit from adding heat probe coagulation to endoscopic epinephrine injection therapy for patients with peptic ulcer.

Clinical bottom line (level 1b-)

  1. Patients with bleeding peptic ulcers who had injection therapy with epinephrine and heat probe coagulation compared with epinephrine alone were not clearly less likely to rebleed, require surgery or die.
Chung et al: British Medical Journal 1997; 314: 1307-1311
Expires October 2002

The study

Double-blinded ?concealed randomised trial without intention-to-treat
Setting: university hospital, Hong Kong

276 patients (aged 19 to 95; mean 58, 68% male) with actively bleeding peptic ulcers (confirmed on endoscopy within 24 hours of admission)

Excluded if
  • malignant ulcer
  • non-bleeding visible vessels, adherent blood clots, clean based ulcers or ulcers with contact bleeding only


Control Group: (n = 136, 134 analysed): 1:10 000 epinephrine injections into and around the bleeding point
Experimental Group: (n = 140, 136 analysed): 1:10 000 epinephrine injections into and around the bleeding point, and heat probe coagulation until flattening or cavitation of the bleeding point occurred.
All patients had repeated endoscopy after 24 hours and further epinephrine injections as required. Patients took H 2 antagonists, omeprazole or triple therapy for H. pylori eradication on discharge.
98% followed for ? weeks
Outcome notes:
  • recurrent bleeding : fresh haematemesis or melaena associated with tachycardia (pulse > 110 beats/min) or hypotension (systolic blood pressure < 90 mmHg)
  • emergency surgery : arterial bleeding not controlled by endoscopy, clinical rebleeding or total transfusion more than 8 units to maintain Hb > 100 g/l

The evidence

Outcome Time to outcome CEREERRRR
(95% CI)		ARR
(95% CI)		NNT
(95% CI)
recurrent bleeding 4 days 12
(8.96%)		 5
(3.68%)		 59%
(-13% to 85%)		 5.28%
(-0.50% to 11.06%)		 19
(NNT = 9 to infinity;
NNH = 201 to infinity)
emergency surgery 4 days 14
(10.45%)		 8
(5.88%)		 44%
(-30% to 76%)		 4.57%
(-1.95% to 11.08%)		 22
(NNT = 9 to infinity;
NNH = 51 to infinity)
death 4 days 7
(5.22%)		 8
(5.88%)		 -13%
(-202% to 58%)		 -0.66%
(-6.12% to 4.80%)		 -152
(NNT = 21 to infinity;
NNH = 16 to infinity)

A post-hoc subgroup analysis showed those with spurting vessels did better with dual therapy, but this should be regarded as preliminary a finding.

Comments

  1. No difference was noted between the two groups for the length of hospital stay or number of blood units transfused.
  2. The study is too small to show any difference between the two therapies.
  3. With todays' technology, rebleeding should be treated first by further endoscopic interventions.

    Citation

    1. Chung SS, Lau JYW, Sung JJY, et al: Randomised comparison between adrenaline injection alone and adrenaline injection plus heat probe treatment for actively bleeding ulcers. British Medical Journal 1997; 314: 1307-1311
    Contributor: Chris Ball and Musab Hayatli, October 1999
    Reviewer: Horand Meier

    Clinical Question.
    Patient bleeding peptic ulcer
    Intervention or Exposure endoscopic injection of epinephrine and heat probe coagulation
    Comparison endoscopic injection of epinephrine
    Outcome rebleeding, surgery, death