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Dual Therapy or Monotherapy for Bleeding Peptic Ulcers?

Injection therapy should be followed by thermal or mechanical therapy.

Endoscopic therapy decreases rebleeding and bleeding-associated mortality in patients with peptic ulcers and active bleeding or nonbleeding visible vessels. Thermal, mechanical, and injection therapies all are beneficial. However, some results have suggested that injection therapy alone is not as effective as thermal therapy alone, mechanical therapy alone, or combination therapy for long-term hemostasis.

To address this issue, investigators performed a meta-analysis of existing data from 1990 through 2006 on injection of dilute epinephrine as monotherapy versus dual therapy (injection followed by another method) in patients with high-risk lesions. Twenty studies, with 2472 patients, met criteria for inclusion. Dual therapy was superior to injection therapy alone for reducing rebleeding (odds ratio, 0.59; 95% CI, 0.44–0.80) and lowering risk for surgery (OR, 0.66; 95% CI, 0.49–0.89), and dual therapy resulted in somewhat lower mortality risk (OR, 0.68; 95% CI, 0.46–1.02). No difference in outcomes was noted between dual therapy and either thermal or mechanical (hemostatic clip) therapy alone. The authors concluded that dual therapy is superior to injection monotherapy but that it is not significantly better than either thermal or mechanical methods alone for hemostasis.

Comment: This analysis is consistent with prior data suggesting that injection of dilute epinephrine or saline can aid in controlling acute bleeding but that it is not as effective as either thermal coagulation or clips in definitive hemostasis. The optimal role for injection therapy probably is to slow or stop active bleeding prior to definitive thermal therapy. Injection therapy also is recommended prior to the removal of adherent clots, which can precipitate bleeding from underlying vessels. In all cases, injection therapy should be followed by thermal or mechanical therapy. Injection is not necessary if either definitive therapy can be provided alone.

— David J. Bjorkman, MD, MSPH (HSA), SM (Epid.)

Published in Journal Watch Gastroenterology May 4, 2007

Citation(s):

Marmo R et al. Dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers: A meta-analysis of controlled trials. Am J Gastroenterol 2007 Feb; 102:279-89.

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