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

Background Rebleeding 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. Objective To compare the efficacies of epinephrine injection alone and epinephrine injection combined with hemoclip therapy in treating high-risk bleeding ulcers. Design Prospective randomized controlled trial. Setting A medical center in Taiwan. Patients One hundred five bleeding ulcer patients with active spurting, oozing, nonbleeding visible vessels or adherent clots in ulcer bases. Interventions Endoscopic combination therapy (n = 52) or diluted epinephrine injection alone (n = 53). Main Outcome Measurements Initial hemostasis rates and recurrent bleeding rates. Results Initial 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). Limitations Treatment outcome of endoscopic hemoclip therapy is related to the techniques of endoscopists. Conclusion Endoscopic combination therapy is superior to epinephrine injection alone in the treatment of high-risk bleeding ulcers.