Individualized management of bleeding peptic ulcer

Abstract

To the Editor:We read with interest the meta-analysis by Marmo et al.1.Marmo R. Rotondano G. Bianco M.A. Piscopo R. Prisco A. Cippoletta L. Outcome of endoscopic treatment for peptic ulcer bleeding: is a second look necessary? A meta-analysis.Gastrointest Endosc. 2003; 57: 62-67Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar published in Gastrointestinal Endoscopy, which suggests that systemic second-look endoscopy reduces the risk of recurrent bleeding in patients with bleeding peptic ulcer. This topic is highly relevant because bleeding peptic ulcer is still common and the mortality associated with recurrent bleeding remains high. Systematic endoscopic re-treatment may be attractive as a way to reduce further bleeding and improve prognosis. An exploration of this question should be based mainly on 3 studies that logically can be pooled for meta-analysis because the methodology used in each was similar (systematic endoscopic re-treatment vs. no systematic re-treatment, i.e., repeat endoscopic treatment only in cases of clinically recurrent bleeding).2.Villanueva C. Balanzo J. Torras X. Soriano G. Sainz S. Vilardell F. Value of second-look endoscopy after injection therapy for bleeding peptic ulcer: a prospective and randomized trial.Gastrointest Endosc. 1994; 40: 34-39Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar, 3.Saeed Z.A. Cole R.A. Ramirez F.C. Schneider F.E. Hepps K.S. Graham D.Y. Endoscopic retreatment after successful initial hemostasis prevents ulcer rebleeding: a prospective randomized trial.Endoscopy. 1996; 28: 288-294Crossref PubMed Scopus (109) Google Scholar, 4.Messmann H. Schaller P. Andus T. Lock G. Vogt W. Gross V. et al.Effect of programmed endoscopic follow-up examinations on the rebleeding rate of gastric or duodenal peptic ulcers treated by injection therapy: a prospective, randomized controlled trial.Endoscopy. 1998; 30: 583-589Crossref PubMed Scopus (97) Google Scholar, 5.Rutgeerts P. Rauws E. Wara P. Swain P. Hoss A. Solleder E. et al.Randomised trial of single and repeated fibrin glue compared with injection of polidocanol in treatment of bleeding peptic ulcer.Lancet. 1997; 350: 692-696Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar However, in our opinion, the methodology of one study from Europe differs substantially from those of other trials.5.Rutgeerts P. Rauws E. Wara P. Swain P. Hoss A. Solleder E. et al.Randomised trial of single and repeated fibrin glue compared with injection of polidocanol in treatment of bleeding peptic ulcer.Lancet. 1997; 350: 692-696Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar In this randomized trial of Rutgeerts et al.,5.Rutgeerts P. Rauws E. Wara P. Swain P. Hoss A. Solleder E. et al.Randomised trial of single and repeated fibrin glue compared with injection of polidocanol in treatment of bleeding peptic ulcer.Lancet. 1997; 350: 692-696Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar 854 patients with bleeding peptic ulcer initially were assigned to one of 3 endoscopic treatments: single injection of 1% polidocanol, single application of fibrin glue, or applications of fibrin glue repeated daily. In the latter group, all patients (n = 270) underwent daily endoscopy until the vessel observed at initial endoscopy was no longer visible. When data concerning this group that had repeated application of the glue were analyzed, the numbers of patients re-treated 1, 2, 3, and even 4 times were, respectively, 146, 80, 31, and 13 (mean 1.7 treatments). With regard to the recurrence of bleeding in this group, the only information given is that 30 of the 41 episodes occurred after the first application of the fibrin glue. Data concerning further bleeding according to the number of re-treatments are not available. In our opinion, only the subgroup of patients who had a single re-treatment fits the definition proposed by Marmo et al.1.Marmo R. Rotondano G. Bianco M.A. Piscopo R. Prisco A. Cippoletta L. Outcome of endoscopic treatment for peptic ulcer bleeding: is a second look necessary? A meta-analysis.Gastrointest Endosc. 2003; 57: 62-67Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar in the methods section of their article: “a scheduled endoscopy within 24 hours of an index endoscopy.” Only data for patients who had a single re-treatment, if available, should be included in the meta-analysis. Nevertheless, we agree with the conclusion of Marmo et al.1.Marmo R. Rotondano G. Bianco M.A. Piscopo R. Prisco A. Cippoletta L. Outcome of endoscopic treatment for peptic ulcer bleeding: is a second look necessary? A meta-analysis.Gastrointest Endosc. 2003; 57: 62-67Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar that “a second-look endoscopy may be recommended only for patients at high risk of further bleeding.” These might include, for example, patients with a high Baylor score as suggested by Saeed et al.3.Saeed Z.A. Cole R.A. Ramirez F.C. Schneider F.E. Hepps K.S. Graham D.Y. Endoscopic retreatment after successful initial hemostasis prevents ulcer rebleeding: a prospective randomized trial.Endoscopy. 1996; 28: 288-294Crossref PubMed Scopus (109) Google Scholar As Marmo et al.1.Marmo R. Rotondano G. Bianco M.A. Piscopo R. Prisco A. Cippoletta L. Outcome of endoscopic treatment for peptic ulcer bleeding: is a second look necessary? A meta-analysis.Gastrointest Endosc. 2003; 57: 62-67Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar suggest, management for high-risk patients might include intravenous administration of high doses of omeprazole,6.Lau J.Y.W. Sung J.J.Y. Lee K.K.C. Yung M.E. Wong S.K.H. Wu J.C.Y. et al.Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.N Engl J Med. 2000; 343: 310-316Crossref PubMed Scopus (595) Google Scholar together with combination endoscopic therapy7.Lin H.J. Tseng G.Y. Perng C.L. Lee F.Y. Chang F.Y. Lee S.D. Comparison of adrenaline injection and bipolar electrocoagulation for the arrest of peptic ulcer bleeding.Gut. 1999; 44: 715-719Crossref PubMed Scopus (93) Google Scholar or a large volume injection of epinephrine.8.Lin H.J. Hsieh Y.H. Tseng G.Y. Perng C.L. Chang F.Y. Lee S.D. A prospective, randomized trial of large- versus small-volume endoscopic injection of epinephrine for peptic ulcer bleeding.Gastrointest Endosc. 2002; 55: 615-619Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar As we have proposed elsewhere, it is now time to individualize management of the patient with peptic ulcer bleeding by using such things as the Forrest classification and endoscopic predictors of treatment failure (ulcer location, size).9.Lesur G. Bour B. Toward individualized management of bleeding peptic ulcer?.Gastroenterol Clin Biol. 2003; 27: 394-397PubMed Google Scholar To the Editor: We read with interest the meta-analysis by Marmo et al.1.Marmo R. Rotondano G. Bianco M.A. Piscopo R. Prisco A. Cippoletta L. Outcome of endoscopic treatment for peptic ulcer bleeding: is a second look necessary? A meta-analysis.Gastrointest Endosc. 2003; 57: 62-67Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar published in Gastrointestinal Endoscopy, which suggests that systemic second-look endoscopy reduces the risk of recurrent bleeding in patients with bleeding peptic ulcer. This topic is highly relevant because bleeding peptic ulcer is still common and the mortality associated with recurrent bleeding remains high. Systematic endoscopic re-treatment may be attractive as a way to reduce further bleeding and improve prognosis. An exploration of this question should be based mainly on 3 studies that logically can be pooled for meta-analysis because the methodology used in each was similar (systematic endoscopic re-treatment vs. no systematic re-treatment, i.e., repeat endoscopic treatment only in cases of clinically recurrent bleeding).2.Villanueva C. Balanzo J. Torras X. Soriano G. Sainz S. Vilardell F. Value of second-look endoscopy after injection therapy for bleeding peptic ulcer: a prospective and randomized trial.Gastrointest Endosc. 1994; 40: 34-39Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar, 3.Saeed Z.A. Cole R.A. Ramirez F.C. Schneider F.E. Hepps K.S. Graham D.Y. Endoscopic retreatment after successful initial hemostasis prevents ulcer rebleeding: a prospective randomized trial.Endoscopy. 1996; 28: 288-294Crossref PubMed Scopus (109) Google Scholar, 4.Messmann H. Schaller P. Andus T. Lock G. Vogt W. Gross V. et al.Effect of programmed endoscopic follow-up examinations on the rebleeding rate of gastric or duodenal peptic ulcers treated by injection therapy: a prospective, randomized controlled trial.Endoscopy. 1998; 30: 583-589Crossref PubMed Scopus (97) Google Scholar, 5.Rutgeerts P. Rauws E. Wara P. Swain P. Hoss A. Solleder E. et al.Randomised trial of single and repeated fibrin glue compared with injection of polidocanol in treatment of bleeding peptic ulcer.Lancet. 1997; 350: 692-696Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar However, in our opinion, the methodology of one study from Europe differs substantially from those of other trials.5.Rutgeerts P. Rauws E. Wara P. Swain P. Hoss A. Solleder E. et al.Randomised trial of single and repeated fibrin glue compared with injection of polidocanol in treatment of bleeding peptic ulcer.Lancet. 1997; 350: 692-696Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar In this randomized trial of Rutgeerts et al.,5.Rutgeerts P. Rauws E. Wara P. Swain P. Hoss A. Solleder E. et al.Randomised trial of single and repeated fibrin glue compared with injection of polidocanol in treatment of bleeding peptic ulcer.Lancet. 1997; 350: 692-696Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar 854 patients with bleeding peptic ulcer initially were assigned to one of 3 endoscopic treatments: single injection of 1% polidocanol, single application of fibrin glue, or applications of fibrin glue repeated daily. In the latter group, all patients (n = 270) underwent daily endoscopy until the vessel observed at initial endoscopy was no longer visible. When data concerning this group that had repeated application of the glue were analyzed, the numbers of patients re-treated 1, 2, 3, and even 4 times were, respectively, 146, 80, 31, and 13 (mean 1.7 treatments). With regard to the recurrence of bleeding in this group, the only information given is that 30 of the 41 episodes occurred after the first application of the fibrin glue. Data concerning further bleeding according to the number of re-treatments are not available. In our opinion, only the subgroup of patients who had a single re-treatment fits the definition proposed by Marmo et al.1.Marmo R. Rotondano G. Bianco M.A. Piscopo R. Prisco A. Cippoletta L. Outcome of endoscopic treatment for peptic ulcer bleeding: is a second look necessary? A meta-analysis.Gastrointest Endosc. 2003; 57: 62-67Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar in the methods section of their article: “a scheduled endoscopy within 24 hours of an index endoscopy.” Only data for patients who had a single re-treatment, if available, should be included in the meta-analysis. Nevertheless, we agree with the conclusion of Marmo et al.1.Marmo R. Rotondano G. Bianco M.A. Piscopo R. Prisco A. Cippoletta L. Outcome of endoscopic treatment for peptic ulcer bleeding: is a second look necessary? A meta-analysis.Gastrointest Endosc. 2003; 57: 62-67Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar that “a second-look endoscopy may be recommended only for patients at high risk of further bleeding.” These might include, for example, patients with a high Baylor score as suggested by Saeed et al.3.Saeed Z.A. Cole R.A. Ramirez F.C. Schneider F.E. Hepps K.S. Graham D.Y. Endoscopic retreatment after successful initial hemostasis prevents ulcer rebleeding: a prospective randomized trial.Endoscopy. 1996; 28: 288-294Crossref PubMed Scopus (109) Google Scholar As Marmo et al.1.Marmo R. Rotondano G. Bianco M.A. Piscopo R. Prisco A. Cippoletta L. Outcome of endoscopic treatment for peptic ulcer bleeding: is a second look necessary? A meta-analysis.Gastrointest Endosc. 2003; 57: 62-67Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar suggest, management for high-risk patients might include intravenous administration of high doses of omeprazole,6.Lau J.Y.W. Sung J.J.Y. Lee K.K.C. Yung M.E. Wong S.K.H. Wu J.C.Y. et al.Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.N Engl J Med. 2000; 343: 310-316Crossref PubMed Scopus (595) Google Scholar together with combination endoscopic therapy7.Lin H.J. Tseng G.Y. Perng C.L. Lee F.Y. Chang F.Y. Lee S.D. Comparison of adrenaline injection and bipolar electrocoagulation for the arrest of peptic ulcer bleeding.Gut. 1999; 44: 715-719Crossref PubMed Scopus (93) Google Scholar or a large volume injection of epinephrine.8.Lin H.J. Hsieh Y.H. Tseng G.Y. Perng C.L. Chang F.Y. Lee S.D. A prospective, randomized trial of large- versus small-volume endoscopic injection of epinephrine for peptic ulcer bleeding.Gastrointest Endosc. 2002; 55: 615-619Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar As we have proposed elsewhere, it is now time to individualize management of the patient with peptic ulcer bleeding by using such things as the Forrest classification and endoscopic predictors of treatment failure (ulcer location, size).9.Lesur G. Bour B. Toward individualized management of bleeding peptic ulcer?.Gastroenterol Clin Biol. 2003; 27: 394-397PubMed Google Scholar