Endoscopic management better for ulcers with adherent clots: study

By Geir O'Rourke

10 Jul 2024

Endoscopic techniques can reduce recurrent bleeding of peptic ulcers with adherent clots versus medical management alone, but do not change rates of mortality or need for surgery, an Australian study has found.

But the systematic review also highlighted the inadequacies of the currently-available evidence on the subject, prompting the authors to call for future studies needed to increase confidence in its results.

Seven RCTs reporting on endoscopic versus medical management of peptic ulcers with adherent clots were included in the meta-analysis, with a combined cohort of 268 patients and a mean follow-up of 20 days.

Pooled results showed a significant reduction in the risk of recurrent bleeding with endoscopic haemostatic treatment for peptic ulcers with adherent clots, compared with medical management alone (risk ratio [RR] = 0.40).

However, there was no difference in mortality (RR = 0.90) or need for ulcer surgery (RR = 0.48) between endoscopic and medical management groups, reported the team in Journal of Gastroenterology and Hepatology (link here).

They noted findings from two previous meta-analyses on the subject had been mixed; a 2005 study had also identified a reduced risk of recurrent bleeding with endoscopic management, while 2009 paper had found no such difference.

Findings had also differed with respect to need for ulcer surgery, while mortality outcomes had been the same in both the present and previous reviews, said the researchers, led by Dr Daniel Tassone and Associate Professor Nik Ding of St Vincent’s Hospital, Melbourne.

But as with the earlier reviews, there were several limitations to the results in the considerable clinical variation between the endoscopic and medical treatments used in the included studies and heterogeneity in the definition used for recurrent bleeding and clot adherence.

“Five of seven studies utilised a combination therapy of adrenaline injection and thermal devices to achieve haemostasis, while one study used ethanol injection alone and another study used haemoclipping alone,” they wrote.

“There was also limited information available in most of the included RCTs on both baseline patient characteristics such as age, sex, and comorbidities and clinical data such as ulcer location.”

“As a result, we are unable to comment on the generalisability of the findings of this review.”

The authors concluded: “Our review highlights the potential benefit of endoscopic haemostatic methods over medical therapy alone when treating UGIB due to peptic ulcers with adherent clots.”

“While endoscopic and medical management modalities appear equivalent in terms of mortality and the need for ulcer surgery, it is apparent from this analysis that there remains a paucity of high-quality randomised evidence that addresses this question, and future studies are needed to further increase confidence in this result.”

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