Improving the view in emergency endoscopy

Epinephrine or epinephrine plus alcohol for injection of bleeding ulcers: a prospective randomized trial

BACKGROUND

Rebleeding following epinephrine injection of bleeding peptic ulcers occurs in 10% to 20% of all cases. The addition of a sclerosant has the theoretical advantage of inducing vessel thrombosis and permanent hemostasis.

METHODS

A prospective randomized controlled trial was conducted to compare injections with epinephrine alone or epinephrine plus absolute alcohol in patients with actively bleeding ulcers at endoscopy. Repeat endoscopy was performed 24 hours later; treatment was repeated in the presence of endoscopic signs of rebleeding. Surgery was performed when arterial bleeding could not be controlled endoscopically, clinical rebleeding with hematemesis or shock occurred, or the transfusion total exceeded 8 units.

RESULTS

One hundred sixty patients were enrolled (epinephrine alone, 81; epinephrine and absolute alcohol, 79). They were matched in age, sex, location of ulcers, hemoglobin on admission, shock, and severity of bleeding. Initial hemostasis was comparable: 79 of 81 with epinephrine alone (97.5%) versus 75 of 79 with epinephrine and absolute alcohol (94.9%). No difference was observed between the two with respect to either rebleeding (9 vs 6), need for emergency operation (12 vs 9), transfusion requirement (median, three units vs two units), hospital stay (median, 5 days vs 4 days), mortality (4 vs 7) and ulcer healing at 4 weeks (50 vs 46).

CONCLUSIONS

The additional injection of absolute alcohol after endoscopic epinephrine injection confers no advantage.

Prediction of recurrent bleeding after endoscopic haemostasis in non-variceal upper gastrointestinal haemorrhage

Endoscopic haemostasis by injection of adrenaline was attempted in 135 consecutive patients with active upper gastrointestinal bleeding. Initial haemostasis was obtained in 127 patients following injection of 5-15 ml 1:10,000 adrenaline; eight patients in whom haemostasis was not achieved underwent immediate laparotomy. There was further haemorrhage in 25 patients, which was successfully treated by further injection of adrenaline in ten. Fifteen patients had major rebleeding requiring emergency surgery. Stepwise logistic regression analysis identified three factors that, taken together, were highly predictive of the need for surgery: pulse rate on admission, the position of the ulcer and whether the patient was obese. A scoring system was derived from the logistic analysis equation that was found to predict correctly the need for emergency surgery in 84 per cent of patients. In patients with a high probability of rebleeding surgery should be considered after initial endoscopic haemostasis and stabilization. In the majority of patients endoscopic treatment alone is sufficient for permanent haemostasis.

Injection or heat probe for bleeding ulcer

A prospective randomized trial was performed to compare the efficacy of endoscopic epinephrine injection and heat probe treatment in actively bleeding peptic ulcers. Emergency endoscopy in 1758 patients over an 18-month period identified 132 patients with active ulcer bleeding. They were randomized to receive either endoscopic epinephrine injection or heat probe treatment. After endoscopy, the patients were transferred to the surgical gastroenterology ward and were managed by surgeons unaware of the treatment option. Bleeding was initially controlled in 96% by epinephrine injection and in 83% by heat probe (P less than 0.05). There was no significant difference in outcome as measured by transfusion requirement (4.5 units vs. 3.8 units), emergency surgery (20% vs. 22%), hospital stay (8 days vs. 7 days), and mortality (2 vs. 4) between the injection group and the heat probe group. Two patients in the heat probe group experienced perforation. We conclude that both endoscopic epinephrine injection and heat probe treatment are effective in stopping bleeding from actively bleeding ulcers. Epinephrine injection is technically easier to perform and has a higher initial success rate.

Endoscopic haemostasis for non-variceal upper gastrointestinal haemorrhage

Endoscopic haemostasis can be effective in non-variceal upper gastrointestinal haemorrhage, and should be regarded as potential front-line treatment. Diverse methods are available, and although no single technique has become firmly established, current evidence favours thermal coagulation and injection therapy.

Endoscopic injection of adrenaline for actively bleeding ulcers: a randomised trial

A prospective randomised trial was performed to assess the efficacy of endoscopic injection of adrenaline for actively bleeding ulcers. Emergency endoscopy in 961 patients admitted for upper gastrointestinal haemorrhage identified 68 patients with actively bleeding ulcers. These 68 patients were randomised to receive either endoscopic injection of adrenaline or no endoscopic treatment. After endoscopy both groups were managed in an identical manner, and strict criteria for emergency operation were adhered to in both groups. Bleeding was initially controlled in all 34 patients assigned to the treatment group. Significantly fewer patients in the treatment group than in the control group needed emergency operations (five v 14, respectively). In addition, in the treatment group the median transfusion requirement was significantly less (three v five units of blood) and the median hospital stay shorter (six v eight days). No complications were observed with the injection of adrenaline, and the rate of healing of ulcers in those attending for endoscopy six weeks after discharge was similar in both groups (81% (17 out of 21 patients) in the treatment group v 79% (11 out of 14) in the control group). Injection of adrenaline is effective in stopping bleeding from actively bleeding ulcers.

Heater-probe treatment of bleeding peptic ulcers

Fifty-six patients with actively bleeding peptic ulcers were treated with the heater-probe unit. Initial haemostasis was achieved in 48 patients (85.7%). The mean number of heater-probe applications was 6.7 pulses at a setting of 25-30 J. Rebleeding occurred in 11 patients (19.6%). Five were successfully treated with repeat heater-probe treatment, 5 required emergency surgery, and 1 rebleeding was stopped by adrenaline injection. The complications included one perforation in a patient with duodenal ulcer. The overall mortality was 2/56 (3.6%). Heater-probe treatment is an effective and safe haemostatic method for controlling actively bleeding ulcers.