GASTROENTEROLOGY LITERATURE ALERT!
LANDMARK ARTICLE - Required reading
Jensen DM, Kovacs TO, Jutabha R, et al. Randomized trial of medical or endoscopic therapy to prevent recurrent ulcer hemorrhage in patients with adherent clots. Gastroenterology 2002;121:407-413.
Laine L. Management of ulcers with adherent clots. Gastroenterology 2002;121:632-642. (Editorial)
Methods and Major Findings
-- Non-bleeding adherent clot on an ulcer is a stigmata of recent bleed, but it is controversial how it should be managed.
-- Patients with non-bleeding adherent clots randomized to endoscopic therapy underwent injection of the clot base with epinephrine (1:10,000 diluted in saline). Four 1cc injections were placed in all four quadrants. The clot was “shaved” with a snare (not pulled off) without the use of cautery, and the area was treated with coaptive coagulation using a bipolar probe (Gold Probe). In no patient was bleeding started with this maneuver.
-- All patients received oral PPI’s, full liquid diet as soon as recovered from endoscopy and treatment for H. pylori if present. Patients randomized to medical therapy underwent sham-endoscopy without disturbing the clot or applying any endoscopic therapy.
--- 35% (6/17) of medically treated patients re-bled versus 0% (0/15) of endoscopy-treated patients. No complications related to endoscopic therapy were noted.
FACTS TO REMEMBER FOR BOARDS
¨ Risk of rebleed: 50% for
non-bleeding visible vessel; 10% for flat spot, 3% for clean ulcer base.
Prior reported risk for non-bleeding adherent clot was 8% to 36%
¨ Independent risk factors for ulcer re-bleed include: a) Age >65, b) inpatient bleed, c) hypotension or shock, d) red blood emesis or Hematochezia, e) severe comorbidity f) severe coagulopathy, g) large ulcer (>2cm) on endoscopy, h) endoscopic stigmata.
¨ Surgery is required in 0.5% of clean-based ulcers, 6% of those with flat spots, 10% adherent clots, 34% with non-bleeding visible vessels and 35% of those with active bleeding on EGD – if no endoscopic therapy is performed.
¨ A clot that is removed easily with irrigation will likely reveal a high-risk stigmata compared to clots that cannot be easily washed off.
Clinical Application
¨ Prior standard of care for non-bleeding adherent clots was to treat medically and not endoscopically.
¨ This study suggests endoscopic therapy for non-bleeding adherent clots, however, the sample size was rather small.
¨ Younger patients (<65 years) with small ulcers and no other risk factors for rebleeding may do well without endoscopic therapy
¨ As discussed in the editorial, this study is not definitive and does not imply that all adherent clots should be removed
