Adherent Clots- To Treat Or Not to Treat?

Abstract

Background/Aims: The appropriate management of adherent clots remains controversial. The aim of this study is to evaluate the management of adherent clots in peptic ulcer bleeding in a large consortium of diverse GI practices (Clinical Outcomes Research Initiative, CORI). Methods: Between 1/00 and 12/04 we identified all adult patients in the CORI database who underwent upper endoscopy (EGD) for non-variceal upper GI bleeding. Peptic ulcer disease was characterized by endoscopic stigmata (active bleeding, non-bleeding visible vessel- NBVV, adherent clot, flat pigmented spot, clean based), endoscopic therapy instituted (monotherapy-multipolar contact thermal therapy, heater probe, injection, combination therapy, or no therapy) and the need for repeat EGD within 72 hours of initial EGD. Results: 4,763 ulcers were identified in 3,604 patients; adherent clots comprised 7% (340) of all ulcers (clean based 60%, flat pigmented spot 13%, active bleeding 11%, non-bleeding visible vessel 6%). 52% (178/340) of clots were not endoscopically treated on initial EGD. The most common forms of endoscopic therapy employed on clots were multipolar/injection (60/162, 37%) and injection only (56/162, 35%). At least 57% (193/340) of the clots were irrigated (nature of washing not specified); 45% (87/193) reported success in clot removal. Once the clot was removed, underlying stigmata was: active bleeding 36% (31), NBVV 15% (13), no active bleeding 49% (43). Active bleeding and NBVV were treated >97% of the time; when there was no active bleeding, the treatment rate was 65%. Of initial exams with an adherent clot (340), 11% (36) required a repeat EGD within 72 hours. Among patients requiring a repeat EGD for adherent clot, endoscopic therapy employed on first exam included: monotherapy 17% (6/36), combination therapy 28% (10/36), no therapy 55% (20/36). 10% (16/162) of clots endoscopically treated on initial EGD required repeat EGD compared with 11% (20/178) for clots that were not endoscopically treated on initial EGD (p = 0.69). Conclusion: Significant variability exists in the management of adherent clots. Endoscopic therapy did not appear to influence the need for repeat EGD. Given the ongoing controversy in the management of adherent clots, studies are required to better evaluate the existing treatment strategies and establish standards of care.