A prospective outcome study of patients with clot in an ulcer and the effect of irrigation

Background: The proper management of patients with clots in an ulcer base has not been clearly defined by prospective studies. Variable prevalence and rebleeding rates may be explained by differing degrees of vigor used to clear the clot, as removal may reveal other stigmata. We prospectively assessed the natural histories of patients with clots after vigorous irrigation, employing a management strategy of endoscopic therapy for patients with high-risk stigmata and observation of those with clots resistant to washing or low-risk findings. Methods: Forty-six patients with upper gastrointestinal bleeding found to have a clot in an ulcer had irrigation with a 3.2 mm bipolar probe for up to 5 minutes. Stigmata after washing were recorded; endoscopic therapy was given for active bleeding that persisted greater than or equal to 5 min or for nonbleeding visible vessels. Patients were observed in the hospital for greater than or equal to 3 days. Results: Findings revealed after irrigation were adherent clot, 26 (57%); clean base, 1 (2%); flat spot, 5 (11%); nonbleeding visible vessel, 7 (13%); oozing, 6 (13%); and spurting, 1 (2%). Two of the 26 (8%) with adherent clots after washing rebled; endoscopic therapy resulted in no further bleeding. One of the 14 (7%) with active bleeding or visible vessels treated with hemostatic therapy rebled; repeat endoscopic therapy resulted in no further bleeding. No deaths occurred. Conclusions: Irrigation appears to be useful in patients with upper gastrointestinal bleeding who have ulcers with clots. The endoscopic findings present after washing can be used to dictate the appropriate management at initial endoscopy. Application of hemostatic therapy in patients with active bleeding or nonbleeding visible vessels and observation of patients with other stigmata, including clots resistant to washing, resulted in an excellent outcome.