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Abstract
Background/Aims
The optimal management of bleeding peptic ulcer with adherent clot remains controversial. The purpose of this study was to compare clinical outcome between endoscopic therapy and medical therapy. We also evaluated the risk factors of rebleeding in Forrest type IIB peptic ulcer.
Methods
Upper gastrointestinal (UGI) bleeding registry data from 8 hospitals in Korea between February 2011 and December 2013 were reviewed and categorized according to the Forrest classification. Patients with acute UGI bleeding from peptic ulcer with adherent clots were enrolled.
Results
Among a total of 1,101 patients diagnosed with peptic ulcer bleeding, 126 bleedings (11.4%) were classified as Forrest type IIB. Of the 126 patients with adherent clots, 84 (66.7%) received endoscopic therapy and 42 (33.3%) were managed with medical therapy alone. The baseline characteristics of patients in two groups were similar except for higher Glasgow Blatchford Score and pre-endoscopic Rockall score in medical therapy group. Bleeding related mortality (1.2% vs.10%; p=0.018) and all cause mortality (3.7% vs. 20.0%; p=0.005) were significantly lower in the endoscopic therapy group. However, there was no difference between endoscopic therapy and medical therapy regarding rebleeding (7.1% vs. 9.5%; p=0.641). In multivariate analysis, independent risk factors of rebleeding were previous medication with aspirin and/or NSAID (OR, 13.1; p=0.025).
References
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Fig. 1.
Study flow showing the causes of upper gastrointestinal bleeding. The numbers in parentheses are the proportions of each group relating to patients with upper gastrointestinal bleeding (UGIB). GI, gastrointestinal; NUB, non-peptic ulcer related bleeding; UB, peptic ulcer bleeding.
Table 1.
Baseline Characteristics of 126 Patients
| Variable | Endoscopic therapy (n=84) | Medical therapy (n=42) | p-value |
|---|---|---|---|
| Age (yr) | 64±15 | 68±15 | NS |
| Sex (male: female) | 63:21 | 29:13 | NS |
| Previous peptic ulcer history | NS | ||
| None | 75 (89.3) | 36 (85.7) | |
| Gastric ulcer | 9 (10.7) | 4 (9.5) | |
| Duodenal ulcer | 0 (0) | 2 (4.8) | |
| Previous aspirin and/or NSAID history | NS | ||
| None | 58 (69.1) | 31 (73.8) | |
| Yes | 26 (31.0) | 11 (26.2) | |
| Previous warfarin and/or LMWH history | NS | ||
| None | 80 (95.2) | 42 (100) | |
| Yes | 4 (4.8) | 0 (0) | |
| Recent PPI medication history | NS | ||
| None | 77 (91.7) | 35 (83.3) | |
| Yes | 7 (8.3) | 7 (16.7) | |
| Hemoglobin <8 g/dL | NS | ||
| None | 49 (58.3) | 24 (57.1) | |
| Yes | 35 (41.7) | 18 (42.9) | |
| Platelet <150,000/mm3 | NS | ||
| None | 72 (85.7) | 37 (88.1) | |
| Yes | 12 (14.3) | 5 (11.9) | |
| Prothrombin time (sec) | NS | ||
| ≤15 | 73 (86.9) | 35 (83.3) | |
| >15 | 11 (13.1) | 7 (16.8) | |
| Systolic blood pressure <90 mmHg | NS | ||
| None | 11 (13.1) | 5 (11.9) | |
| Yes | 73 (86.9) | 37 (88.1) | |
| Heart rate ≥110 beats/min | |||
| None | 72 (85.7) | 37 (88.1) | NS |
| Yes | 12 (14.3) | 5 (11.9) | |
| Endoscopic findings | NS | ||
| Gastric ulcer | 66 (78.6) | 33 (78.6) | |
| Duodenal ulcer | 18 (21.4) | 9 (21.4) | |
| Helicobacter pylori infection | NS | ||
| None | 37 (61.7) | 13 (54.17) | |
| Yes | 23 (38.3) | 11 (45.83) | |
| Glasgow Blatchford score a | 12 (1–20) | 13 (0–17) | 0.004 |
| Pre-endoscopic Rockall score b | 1 (0–7) | 3 (0–10) | 0.006 |
| Full Rockall score c | 4.5 (0–10) | 6 (1–10) | NS |
a Calculated with admission risk marker: blood urea nitrogen (0, 2, 3, 4, 6 points), hemoglobin value (0, 1, 3, 6 points for men and 0, 1, 6 points for women), systolic blood pressure (0 to 3 points) and other markers such as pulse rate (0 to 1 point), presentation with melena (1 point), presentation with syncope (2 points), hepatic disease (2 points), cardiac failure (2 points).
Table 2.
Comparison on Outcomes between Endoscopic Therapy and Medical Therapy
| Variable | Endoscopic therapy (n=84) | Medical therapy (n=42) | p-value |
|---|---|---|---|
| Rebleeding | 6 (7.1) | 4 (9.5) | NS |
| Aggravation of comorbidity a | 3 (3.6) | 5 (11.9) | NS |
| Mortality | |||
| Bleeding related mortality | 1 (1.2) | 3 (7.1) | 0.018 |
| Non bleeding related mortality | 2 (2.4) | 3 (7.1) | |
| All cause mortality | 3 (3.6) | 6 (14.3) | 0.005 |
Table 3.
Univariate Analysis of Risk Factors for Rebleeding
Table 4.
Multivariate Analysis of Risk Factors for Rebleeding
| Variable | OR (95% CI for OR) | p-value |
|---|---|---|
| Previous aspirin and/or NSAID history | ||
| None | 1 | − |
| Yes | 13.1 (1.4–124.2) | 0.025 |
| Pre-endoscopic Rockall score | 2.3 (0.7–7.5) | NS |
| Full Rockall score | 1.6 (0.4–5.6) | NS |
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