Value of second-look endoscopy after injection therapy for bleeding peptic ulcer: A prospective and randomized trial

doi:10.1016/S0016-5107(94)70006-0

Gastrointestinal Endoscopy

Volume 40, Issue 1, January–February 1994, Pages 34-39

https://doi.org/10.1016/S0016-5107(94)70006-0 Get rights and content

Abstract

A prospective and randomized trial involving 104 patients was performed to assess whether second-look endoscopy could improve the efficacy of injection therapy for bleeding ulcers. The inclusion criteria were the presence of active arterial bleeding or a non-bleeding visible vessel at emergency endoscopy. All the patients received emergency injection of 1:10,000 adrenaline and were subsequently randomized (52 patients in each group) according to whether or not they would receive a second elective endoscopy within the first 24 hours with repeated injection if a visible vessel was still identified. Both groups were well matched for clinical and endoscopic data. A tendency towards better results was noted in the group that received a second-look endoscopy; the two groups were compared in regard to further bleeding (21% versus 29%, 95% confidence interval of the difference = -24.3 to 8.5), need for emergency surgery (8% versus 15%, 95% confidence interval of the difference = -19.9 to 4.5), transfusion requirements (1.7 ± 1.9 versus 2.5 ± 2.5 units, 95% confidence interval of the difference = -1.6 to 0.07), length of hospital stay (9.3 ± 8.6 versus 11.8 ± 10.8 days, 95% confidence interval of the difference = -6.2 to 1.4), and mortality rate (2% versus 4%). Although these trends did not achieve statistical significance, a type II error cannot be ruled out. However, according to our results, several hundred patients would be required to demonstrate statistically these relatively small differences. In conclusion, our data suggest the possibility of a small benefit with second-look endoscopy, although the difference is unlikely to be very large; second-look endoscopy cannot be recommended routinely at present. (Gastrointest Endosc 1994;40:34-9.)

Section snippets

Inclusion criteria

From February 1990 to July 1991, a total of 495 patients were admitted to our hospital because of upper gastrointestinal hemorrhage diagnosed when melena and/or hematemesis were confirmed by the hospital staff. All patients underwent emergency upper gastrointestinal tract endoscopy. Those in whom endoscopy disclosed a peptic ulcer with active arterial bleeding or a non-bleeding visible vessel were included in the study. Only patients under 18 years of age and those unable or unwilling to give

Characteristics of patients

A total of 104 patients fulfilled the entry criteria and were consecutively included into the study and randomized. Fifty-two patients were placed in each group. Both groups were comparable in regard to age, sex, presence of associated disease, intake of NSAIDs, hemoglobin level at admission, location of ulcers, and type of bleeding (Table 1, Table 2).

In group A a second elective endoscopy was carried out in 49 patients. In the remaining 3 cases endoscopy could not be performed because of

DISCUSSION

Further hemorrhage is the single most important factor determining the outcome of patients with a bleeding ulcer.²³ Endoscopic stigmata of recent hemorrhage provide prognostic information that enables identification of patients with active arterial bleeding and those with non-bleeding visible vessels who are at risk for further hemorrhage.24, 25, 26, 27, 28 The present study was performed in a group of consecutively admitted patients with bleeding peptic ulcers at high risk for further

Acknowledgements

The authors wish to thank the nursing and medical staff of the Gastrointestinal Bleeding Unit of the Hospital de la Santa Creu i Sant Pau for their cooperation in this study.

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Cited by (100)

Could immediate second-look endoscopy reduce post-endoscopic submucosal dissection bleeding?
2023, Arab Journal of Gastroenterology
Gastric endoscopic submucosal dissection (ESD) is a curative treatment for gastric neoplasm. A scheduled second-look endoscopy could be performed to prevent delayed post-ESD bleeding. However, no studies on the efficacy of second-look endoscopy for the prevention of early delayed post-ESD bleeding have been conducted. So, the aim of this study was to be the first to investigate the efficacy of immediate second-look endoscopy for the prevention of post-ESD bleeding.
The 266 gastric ESD cases were included. Immediate second-look endoscopy was defined as repeated upper endoscopy soon after complete hemostasis of the ESD site and specimen fixation. Early and late delayed bleeding were classified as before or after 24 h after the ESD, respectively.
The 262 ESD cases were enrolled and divided into three groups: the immediate second-look (n = 79), scheduled second-look (n = 86), and no second-look (n = 97). Post-ESD bleeding occurred in 19 cases (7.3%). Of these, 13 (68.4%) were early delayed post-ESD bleeding. The immediate second-look endoscopy had a lower incidence of early delayed post-ESD bleeding compared to the groups without immediate second-look endoscopy, (3.8% vs. 0.8%, p = 0.009). In a multivariate analysis, immediate second-look endoscopy significantly reduced early delayed post-ESD bleeding (OR 0.39, p = 0.022). The resected specimen area ≥ 1,000 mm² was an independent risk factor for early delayed post-ESD bleeding (OR 8.98, p = 0.010). However, the frequency of delayed post-ESD bleeding did not differ between the three groups.
Immediate second-look endoscopy after gastric ESD may prevent early delayed post-ESD bleeding under certain circumstances.
Role of routine second-look endoscopy in patients with acute peptic ulcer bleeding: meta-analysis of randomized controlled trials
2021, Gastrointestinal Endoscopy
Studies evaluating the role of routine second-look endoscopy in patients with acute upper GI bleed because of peptic ulcer disease (PUD) have reported conflicting results. This meta-analysis evaluates the usefulness of routine second-look endoscopy in these patients.
We reviewed several databases from inception to September 15, 2020 to identify randomized controlled trials (RCTs) that compared routine second-look endoscopy with no planned second-look endoscopy in patients with acute upper GI bleed because of PUD. Our outcomes of interest were recurrent bleeding, mortality, need for surgery, and mean number of units of blood transfused. For categorical variables, we calculated pooled risk ratios (RRs) with 95% confidence intervals (CIs); for continuous variables, we calculated standardized mean difference with 95% CIs. Data were analyzed using a random effects model. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to ascertain the quality of evidence.
We included 9 RTCs comprising 1452 patients; 726 patients underwent planned/routine second-look endoscopy and 726 did not. We found no significant difference in recurrent bleeding (RR, .79; 95% CI, .51-1.23), need for surgery (RR, .58; 95% CI, .29-1.15), mortality (RR, .69; 95% CI, .33-1.45), or mean number of units of blood transfused (standardized mean difference, –.06; 95% CI, –.19 to .07). Quality of evidence ranged from low to moderate based on the GRADE framework.
Single endoscopy with complete endoscopic hemostasis is not inferior to routine second-look endoscopy in reducing the risk of recurrent bleeding, mortality, or need for surgery in patients with acute upper GI bleed because of PUD.
Acute upper gastrointestinal bleeding: A review
2020, Surgery in Practice and Science
Gastrointestinal haemorrhage is potentially life threatening. Resuscitation, clinically diagnosing and treating the underlying problem are the principles of management. As most gastrointestinal haemorrhage cease spontaneously, there is greater importance in non- operative intervention. Radio-embolisation is a growing useful adjunct in available armamentarium for non-operative management. The definitive management of upper GI hemorrhage is indicated by the overall risk of re-bleeding and morbidity (Rockall risk score). Failure to respond to endoscopic and medical management is an indication for urgent surgery. New endoscopic techniques and radiological embolisation have decreased the role of surgery in management, but collaboration between the endoscopist and the surgeon remains.
Effect of scheduled second-look endoscopy on peptic ulcer bleeding: a prospective randomized multicenter trial
2018, Gastrointestinal Endoscopy
This study aimed to investigate the effectiveness of scheduled second-look endoscopy (EGD) with endoscopic hemostasis on peptic ulcer rebleeding and to identify the risk factors related to the need for second-look EGD.
We prospectively randomized patients who had endoscopically confirmed bleeding peptic ulcer with stigmata of active bleeding, visible vessel, or adherent clot into 2 groups between August 2010 and January 2013. Hemoclip application or thermal coagulation and/or epinephrine injection were allowed for initial endoscopic therapy. The same dosage of proton pump inhibitor was injected intravenously. The study group received scheduled second-look EGD 24 to 36 hours after the initial hemostasis, and further therapy was applied if endoscopic stigmata persisted, as above. Those patients who developed rebleeding underwent operation or radiologic intervention despite the additional endoscopic therapy. Outcome measures included rebleeding, amount of transfusion, duration of hospitalization, and mortality.
After initial endoscopic hemostasis, 319 eligible patients were randomized into 2 groups. Sixteen (10.1%) and 9 (5.6%) patients developed rebleeding (P = .132), respectively. There was also no difference in surgical intervention (0, 0% vs 1, .6%, P >.999) or radiologic intervention (3, 1.9% vs 2, 1.2%, P = .683), median duration of hospitalization (6.0 vs 5.0 days, P = .151), amount of transfusion (2.4 ± 1.7 vs 2.2 ± 1.6 units, P = .276), and mortality (2, 1.3% vs 2, 1.2%, P > .999) between the 2 groups. Multivariate analysis showed that grades 3 to 4 of endoscopists’ estimation to success of initial hemostasis, history of nonsteroidal anti-inflammatory drug (NSAID) use, and larger amounts of blood transfusions (≥4 units of red blood cells) were the independent risk factors of rebleeding.
A single EGD with endoscopic hemostasis is not inferior to scheduled second-look endoscopy in terms of reduction in rebleeding rate of peptic ulcer bleeding. Repeat endoscopy would be helpful in the patients with unsatisfactory initial endoscopic hemostasis, use of NSAIDs, and larger amounts of transfused blood. (Clinical trial registration number: KCT0000565; 4-2010-0348.)
Second look endoscopy in acute non-variceal upper gastrointestinal bleeding
2013, Best Practice and Research: Clinical Gastroenterology
Citation Excerpt :
The aim of this surveillance is to pick up persistent stigmata of recent hemorrhage and commence another round of treatment to prevent rebleeding [17]. Controversies abound upon the effectiveness of second look endoscopy in preventing peptic ulcer rebleeding [18–23]. Villanueva et al reported that patients receiving second look endoscopy had 7% absolute risk reduction in rebleeding when compared to control(no routine scheduled second look endoscopy), though this did not reach statistical significance (95% CI 1.3–11.1) [18].
Bleeding peptic ulcer remained an important cause of hospitalization worldwide. Primary endoscopic hemostasis achieved more than 90% of initial hemostasis for bleeding peptic ulcer. Recurrent bleeding amounted to 15% after therapeutic endoscopy, and rebleeding is an important risk factor to peptic ulcer related mortality. Routine second look endoscopy was one of the strategies targeted at prevention of rebleeding. The objective of second look endoscopy was to treat persistent stigmata of recent hemorrhage before rebleeding. Three meta-analyses showed that performance of routine second look endoscopy significantly reduced ulcer rebleeding especially when the endoscopic therapy was performed with thermal coagulation. Two cost-effectiveness analyses, however, demonstrated that selective instead of routine second look endoscopy is the most cost-effective approach to prevent ulcer rebleeding. While international consensus and guidelines did not recommend routine performance of second look endoscopy for prevention of ulcer rebleeding, further research should focus on identification of patients with high risk of rebleeding and investigate the effect of selective second look endoscopy in prevention of rebleeding among these patients.
Second-look endoscopy is not associated with better clinical outcomes after gastric endoscopic submucosal dissection: A prospective, randomized, clinical trial analyzed on an as-treated basis
2013, Gastrointestinal Endoscopy
The efficacy of routine second-look endoscopy (SLE) to detect or prevent bleeding after gastric endoscopic submucosal dissection (ESD) has not yet been validated.
The aim of this study was to determine whether SLE affects clinical outcomes including bleeding and morbidity after gastric ESD.
A prospective, randomized, controlled study with consecutive data analyzed on an as-treated basis.
A single, tertiary-care referral center.
A total of 182 patients.
Gastric ESD and SLE.
Incidence of and risk factors related to bleeding after ESD and outcomes by univariate or multivariate analysis.
Among 182 patients enrolled, 74 and 81 patients were assigned to the SLE and no-SLE groups, respectively. Two groups were observed closely for 4 weeks. Bleeding occurred after ESD in 21 patients (13.5%). Hemoglobin loss (≥2.0 g/dL) was observed in 20 patients, and melena developed in 1 patient after ESD. However, only 1 patient needed a transfusion. Twelve patients (16.2%) in the SLE group and 9 in the no-SLE group (11.1%) experienced bleeding after ESD. The frequency of bleeding after ESD was not significantly different between the 2 groups (P = .66). There were no risk factors related to bleeding after ESD.
Single-center analysis.
SLE is not routinely necessary because it does not affect clinical outcomes, including bleeding and morbidity after ESD. (Clinical trial registration number: KCT0000146.)

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^☆: From the Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.

^☆☆: 0016-5107/94/4001-0034$1.00 + .10

^★: GASTROINTESTINAL ENDOSCOPY

^★★: Reprint requests: Joaquim Balanzó, Servei de Patologia Digestiva, Hospital de la Santa Creu i Sant Pau, Avgda Sant Antoni M^a Claret, 167, 08025, Barcelona, Spain.

^♢: 37/1/51190

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Value of second-look endoscopy after injection therapy for bleeding peptic ulcer: A prospective and randomized trial☆,☆☆,★,★★,♢

Abstract

Section snippets

Inclusion criteria

Characteristics of patients

DISCUSSION

Acknowledgements

Gastroenterology

Lancet

Lancet

Lancet

Gastroenterology

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

Gastroenterology

Gastroenterology

Gastroenterology

Endoscopic coagulation for gastrointestinal bleeding

N Engl J Med

Endoscopic hemostasis: an effective therapy for bleeding peptic ulcers

JAMA

Therapeutic endoscopy and bleeding ulcers—NIH Consensus Conference

JAMA

Endoscopic hemostasis by local injection of epinephrine and polidocanol in bleeding ulcer: a prospective randomized trial

Endoscopy

Endoscopic injection of adrenaline for actively bleeding ulcers: a randomized trial

BMJ