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.