Nonbleeding Visible Vessel Research Articles

A prospective, randomized comparison of 10-Fr versus 7-Fr bipolar electrocoagulation catheter in combination with adrenaline injection in the endoscopic treatment of bleeding peptic ulcers

Objectives Our study compared the efficacy of bipolar electrocoagulation (gold probe) with 10-Fr (group A) versus 7-Fr (group B) catheter after adrenaline injection in the treatment of bleeding peptic ulcers. Methods A total of 77 consecutive patients with endoscopic evidence of peptic ulcer with active bleeding or a nonbleeding visible vessel were randomly assigned to one of the above protocols. Thirty-nine patients (31 male, eight female, mean age 62 yr) were included in group A and 38 (28 male, 10 female, mean age 61 yr) in group B. Results The initial hemostasis rate, rebleeding rate, duration of hospital stay, volume of blood transfused, number of operations needed, and number of deaths were not significantly different between the two groups. The mean number of electrocoagulations and the subsequent mean duration of electrocoagulations were significantly higher in group B patients (7.0 ± 3.8 and 14.1 ± 7.6 s, respectively) compared with those of group A (4.6 ± 2.6 and 9.3 ± 5.3 s, respectively) ( p < 0.01). Multivariate stepwise logistic regression analysis revealed that among sex, age, location of bleeding, ulcer size, endoscopic severity of bleeding, and the size of the gold probes, lesser endoscopic severity of bleeding (χ 2 = 31.1, p < 0.01), large size of the gold probe (χ 2 = 23.9, p < 0.01), and small ulcer size (χ 2 = 13.4, p < 0.01) were the only factors significantly associated with a smaller number of electrocoagulations. Conclusions In this study, the use of large-size gold probes was significantly associated with a lower number of electrocoagulations, resulting in the reduction of electrocoagulation duration. However, the clinical relevance of these findings is questionable because the efficacy of both sizes of gold probe after adrenaline injection in the treatment of bleeding peptic ulcers was similar.tk;1

Evaluation of Endoscopic Hemostasis With Metallic Hemoclips for Bleeding Gastric Ulcer: Comparison With Endoscopic Injection of Absolute Ethanol in A Prospective, Randomized Study

Although metallic hemoclips have been used for hemostasis of bleeding ulcer, there have been few prospective trials to evaluate their efficacy. In this study, a prospective, randomized trial was performed to evaluate endoscopic hemoclipping for bleeding gastric ulcer in comparison with endoscopic injection of absolute ethanol. During the period 1995-1998, 126 gastric ulcer patients with bleeding or nonbleeding visible vessel were considered for entry. They were randomly assigned to one of three groups: endoscopic hemostasis performed with injection of absolute ethanol (group I, n = 42), hemoclipping (group II, n = 42), and a combination of the two methods (group III, n = 42). The permanent hemostatic rate was 85.7% in group I, 90.5% in group II, and 92.9% in group III. The mean volume of blood transfusion was 313 +/- 77 ml in group I, 274 +/- 54 ml in group II, and 163 +/- 42 ml in group III, which was significantly less than in groups I or II (p < 0.05). No patients required emergency surgery. Five patients died within a month after initial hemostasis as a result of unrelated conditions. Endoscopic hemostasis with hemoclips for bleeding gastric ulcer was as effective and safe as that with injection of absolute ethanol, and a combination of ethanol injection and hemoclips did not result in a great advantage over the two individual procedures.

A randomized trial comparing heater probe plus thrombin with heater probe plus placebo for bleeding peptic ulcer

Background & Aims: This multicenter, double-blind, controlled trial compared the efficacy of combined endoscopic hemostatic treatment using the heater probe plus thrombin injection with that of the heater probe plus placebo injection as treatment for peptic ulcers with active bleeding or nonbleeding visible vessels. Efficacy was defined in terms of primary hemostasis, prevention of rebleeding, and need for urgent surgery. Methods: Two hundred forty-seven patients presenting with major peptic ulcer bleeding were randomized to heater probe plus thrombin or to heater probe plus placebo. The groups were well matched for all risk categories including age, endoscopic stigmata, shock, and severity of comorbid diseases. Endoscopic therapy was applied using the heater probe followed by injection of thrombin or placebo. Results: Successful primary hemostasis was achieved in 97% of patients. Rebleeding developed in 19 (15%) of thrombin plus heater probe patients and 17 (15%) of placebo plus heater probe patients. Emergency surgery was necessary in 16 and 13 patients, respectively. Eight patients in the thrombin group had adverse events compared with 4 in the placebo group. Eight (6%) of thrombin plus heater probe patients and 14 (12%) of placebo plus heater probe patients died ( P = 0.21). Conclusions: The combination of thrombin and the heater probe does not confer an additional benefit over heater probe and placebo as endoscopic treatment for bleeding peptic ulcer. Our trial does not support the use of this combination of hemostatic therapy.

Randomized controlled trial comparing epinephrine injection plus heat probe coagulation versus epinephrine injection plus argon plasma coagulation for bleeding peptic ulcers

Epinephrine injection with heat probe coagulation is an effective treatment for bleeding peptic ulcer. Few studies have investigated the efficacy of dual therapy with epinephrine injection plus either heat probe or argon plasma coagulation for high-risk bleeding peptic ulcers. This study compared epinephrine injection plus heat probe coagulation to epinephrine injection plus argon plasma coagulation for the treatment of high-risk bleeding peptic ulcers. The study design was prospective, randomized, and controlled. Patients with actively bleeding peptic ulcers, ulcers with adherent clots, or ulcers with nonbleeding visible vessels were randomly assigned to epinephrine injection plus heat probe coagulation or epinephrine injection plus argon plasma coagulation. Patients with previous gastric surgery, malignant ulcers, and unidentifiable ulcers because of torrential bleeding were excluded. The primary outcome measure was recurrence of bleeding. Secondary outcome measures were initial hemostasis, endoscopic procedure duration, number of patients requiring surgery, mortality within 30 days, and ulcer status at 8 week follow-up endoscopy. One hundred ninety-two patients were enrolled; 7 with malignant ulcers were excluded after randomization. One hundred eighty-five cases were analyzed, 97 in the heat probe group and 88 in the argon plasma coagulation group. Patient demographics and ulcer characteristics were comparable between the groups. There was no significant difference in terms of initial hemostasis (95.9% vs. 97.7%), frequency of recurrent bleeding (21.6% vs. 17.0%), requirement for emergency surgery (9.3% vs. 4.5%), mean number of units of blood transfused (2.4 vs. 1.7 units), mean hospital stay (8.2 vs. 7.0 days), and hospital mortality (6.2% vs. 5.7%). Sixty (61.8%) patients in the heat probe group and 52 (52.9%) in the argon plasma coagulation group underwent endoscopy at 8 weeks. There was no significant difference between these groups in the relative frequency of nonhealing ulcer at 8 weeks. Epinephrine injection plus argon plasma coagulation is as safe and effective as epinephrine injection plus heat probe coagulation in the treatment of patients with high-risk bleeding peptic ulcers.

A prospective, randomized trial of endoscopic hemoclip versus heater probe thermocoagulation for peptic ulcer bleeding

OBJECTIVES: Endoscopic heater probe thermocoagulation and hemoclip are considered to be safe and very effective in the treatment of bleeding peptic ulcer. So far, there are only few reports concerning hemostasis with endoscopic hemoclip. The aims of this study were to compare the hemostatic effects of both therapeutic modalities in patients with peptic ulcer bleeding. METHODS: A total of 80 patients with active bleeding or nonbleeding visible vessels were randomized to receive endoscopic hemoclip (n = 40) or heater probe thermocoagulation (n = 40). RESULTS: Initial hemostasis was achieved in 34 patients (85%) in the hemoclip group and 40 patients (100%) in the heater probe group ( p = 0.01277). Rebleeding occurred in three patients (8.8%) in the hemoclip group and two patients (5%) in the heater probe group ( p > 0.1). Among patients with difficult-to-approach bleeding, we obtained a better hemostatic rate in the heater probe group (nine of 11 patients vs three of 10, p = 0.02417). The volume of blood transfused after entry into the study, duration of hospital stay, number of patients requiring urgent surgery, and the mortality rate were not statistically significantly different between the two groups. CONCLUSIONS: For patients with peptic ulcer bleeding, heater probe thermocoagulation offers an advantage in achieving hemostasis than hemoclip. In difficult-to-approach bleeders, heater probe is a more suitable therapeutic modality.

Comparison of oral omeprazole and endoscopic ethanol injection therapy for prevention of recurrent bleeding from peptic ulcers with nonbleeding visible vessels or fresh adherent clots

OBJECTIVES: Omeprazole is a potent inhibitor of gastric acid secretion. Recently it was reported that p.o. omeprazole therapy reduced the rebleeding rate in patients with nonbleeding visible vessels or adherent clots. The aim of this study was to ascertain whether p.o. administration of omeprazole can be an effective alternative to endoscopic injection therapy in peptic ulcers with stigmata of recent hemorrhage. METHODS: A total of 101 patients who had peptic ulcer bleeding based on endoscopic findings of nonbleeding visible vessels or fresh adherent clots were randomly assigned to receive omeprazole (40 mg p.o. every 12 h) or endoscopic ethanol injection therapy. RESULTS: Rebleeding rates were 22.9% (11 of 48) in the omeprazole group and 20.8% (11 of 53) in the endoscopic injection therapy group. The rebleeding rates of clinical significance were 14.6% and 13.2%, respectively. There was no significance difference in the rebleeding rate, requirement for surgery, total units of blood transfused, or mortality between the two groups. CONCLUSIONS: Oral omeprazole administration is comparable to endoscopic ethanol injection therapy for prevention of rebleeding in patients with nonbleeding visible vessels or adherent clots.

A prospective, randomized trial of large- versus small-volume endoscopic injection of epinephrine for peptic ulcer bleeding

Background: Endoscopic injection of epinephrine in the treatment of bleeding peptic ulcer is considered highly effective, safe, inexpensive, and easy to use. However, bleeding recurs in 6% to 36% of patients. The aim of this study was to determine the optimal dose of epinephrine for endoscopic injection in the treatment of patients with bleeding peptic ulcer. Methods: One hundred fifty-six patients with active bleeding or nonbleeding visible vessels were randomized to receive small- (5-10 mL) or large-volume (13-20 mL) injections of a 1:10,000 solution of epinephrine. Results: The mean volume of epinephrine injected was 16.5 mL (95% CI [15.7, 17.3 mL]) in the large-volume group and 8.0 mL (95% CI [7.5, 8.4 mL]) in the small-volume group. Initial hemostasis was achieved in all patients studied. The number of episodes of recurrent bleeding was smaller in the large-volume group (12/78, 15.4%) compared with the small-volume group (24/78, 30.8%, p = 0.037). The volume of blood transfused after entry into the study, duration of hospital stay, numbers of patients requiring urgent surgery, and mortality rates were not statistically different between the 2 groups. Conclusions: Injection of a large volume (>13 mL) of epinephrine can reduce the rate of recurrent bleeding in patients with high-risk peptic ulcer and is superior to injection of lesser volumes of epinephrine when used to achieve sustained hemostasis. (Gastrointest Endosc 2002;55:615-9.)

Acute Nonvariceal Upper Gastrointestinal Hemorrhage.

Upper endoscopy to assess the risk of rebleeding in patients with nonvariceal upper gastrointestinal bleeding may be used for triage, allowing outpatient care of selected patients and leading to significant cost savings. Over the last 10 years, hospitalization days required for upper gastrointestinal bleeding have decreased significantly and the majority of patients with upper gastrointestinal bleeding undergo endoscopy within 24 hours of admission. Twenty percent to 35% of these endoscopies include endoscopic hemostatic therapy. Endoscopic treatment is recommended for actively bleeding (ie, spurting or oozing) visible vessels and nonbleeding visible vessels that are raised and cannot be washed off. Endoscopic methods can be divided into thermal (multipolar coagulation, heater probe, argon plasma coagulator, Nd:YAG laser) and nonthermal (eg, injection therapy); both types are effective. A combination of injection and thermal therapy with initial injection to slow the bleeding or "clear the field" followed by coagulation of the identified vessel is popular. Bleeding recurs in 15% of patients. A recent randomized controlled trial of repeat endoscopic treatment versus surgery for patients with recurrent ulcer bleeding concluded that endoscopic retreatment is superior to surgery. Most peptic ulcer rebleeding occurs within the first 3 days of presentation. A comparison of omeprazole and placebo therapy in high-risk ulcer patients with bleeding stigmata at endoscopy who were not treated endoscopically found that high-dosage omeprazole (40 mg twice a day) significantly lowered the rates of further bleeding and surgical intervention. Although unlikely to replace endoscopic therapy, this study demonstrated the efficacy of potent acid suppression, perhaps due to stabilization of clotting activity. A recent placebo-controlled trial of high-dosage parenteral omeprazole after endoscopic treatment of bleeding peptic ulcers demonstrated a substantial reduction in the risk of rebleeding.

Randomized trial of normal saline solution injection versus bipolar electrocoagulation for treatment of patients with high-risk bleeding ulcers: Is local tamponade enough?

Background: Endoscopic injection of normal saline solution is reportedly an effective treatment for bleeding ulcers. If it is as effective as standard therapy, low cost, wide availability, and lack of injury would make saline solution injection an attractive option. Methods: Patients with clinical evidence of major bleeding from an ulcer with active bleeding or a nonbleeding visible vessel were randomly assigned to injection with normal saline solution (1-2 mL boluses; mean volume 30 mL) or bipolar electrocoagulation (20 W, 10-sec applications; mean time 100 sec). Patients, those caring for patients, and those collecting data were blinded to therapy. Results: Further bleeding occurred in 14 (29%) of 48 patients in the saline solution group versus 6 (12%) of 52 patients in the bipolar group (95% CI [2%, 33%]; p = 0.04). Significantly more units of blood were transfused in the saline solution group (median 2 units vs. 0 units; p = 0.01). Hospital days (median 4 vs. 3) and mortality (6% vs. 2%) were not significantly different in the 2 groups. Independent risk factors for further bleeding were saline solution injection (p = 0.02), units transfused before therapy (p = 0.02), and ulcer size (p = 0.03). Conclusion: Local tamponade with saline solution injection is less effective than bipolar electrocoagulation for the treatment of bleeding ulcers. (Gastrointest Endosc 2002;55:6-10.)

Outpatient management of “low-risk” nonvariceal upper GI hemorrhage. Are we ready to put evidence into practice?

Outpatient management of “low-risk” nonvariceal upper GI hemorrhage. Are we ready to put evidence into practice?

Diverticular bleeding: An appraisal based on stigmata of recent hemorrhage

Diverticulosis of the colon is often diagnosed as the bleeding site in patients who are hospitalized with severe hematochezia and anemia. In the past, indirect evidence, such as the presence of diverticula on barium enema or elective colonoscopy, was used to make a diagnosis and plan therapy. Surgery was considered definitive management. Various investigators are now recommending a change in this approach because of reports of the success of thoroughly cleansing the colon of blood and clots, the safety and efficacy of urgent colonoscopy, the recognition of incidental diverticulosis, and finding of stignata of diverticular hemorrhage. Also, there are reports that the outcomes of definitive diverticular hemorrhage are significantly improved by endoscopic treatment, compared with medical-surgical therapy, for active bleeding or nonbleeding visible vessels or adherent clots. Furthermore, long-term medical therapy of patients with definitive diverticular hemorrhage (after endoscopic hemostasis) and presumed diverticular hemorrhage appears to prevent most recurrences of colonic diverticular hemorrhage. In other words, surgery to prevent an inevitable recurrence of diverticulosis is not required. A standardized approach to patients with severe hematochezia and colonic diverticulosis is discussed and recommended.

Relevance of the Rockall score in patients undergoing endoscopic therapy for peptic ulcer haemorrhage

To assess the ability of the Rockall score to predict outcome in patients who undergo endoscopic therapy for peptic ulcer haemorrhage. Retrospective data analysis. Patients admitted to the three major acute hospitals in Lothian, UK. Details of 211 patients involved in two randomized trials of endoscopic therapy between 1995 and 1999 were accessed, and Rockall scores calculated. All patients had ulcers with active bleeding or non-bleeding visible vessels requiring endoscopic therapy. The patients were followed up for 6 months and end points included rebleeding and death. A comparison of mean Rockall scores for those patients who did not rebleed, those who re-bled and those who died. Identification of those patients at greatest risk of rebleeding or death after endoscopic therapy. One hundred and seventy-six patients did not rebleed, with mean score 6.17 (SD = 1.61). Rebleeding occurred in 35 patients whose mean score was 6.97 (SD = 1.52). There were 29 deaths with mean score 7.34 (SD = 1.40). The differences between the three groups were significant by one-way ANOVA (P < 0.001). Fifty-six patients had a Rockall score of 8 or over and, of these, 16 (29%) re-bled and 14 (25%) died. Of the 155 patients with scores of 7 or less, 19 (12%) re-bled and 15 (10%) died. The difference between these groups was significant with chi2 = 7.912 (P = 0.005) for rebleeding and chi2 = 8.147 (P = 0.004) for death. The Rockall score can be used to predict poor outcome in patients who undergo therapeutic endoscopy for major peptic ulcer bleeding.

Clots and spots on ulcers: why and how to treat.

The clinical indication for urgent endoscopy with combined diagnosis and treatment is bleeding severe enough to warrant urgent medical attention. Stigmata of ulcer hemorrhage are utilized as a guide to endoscopic therapy. Active arterial bleeding, nonbleeding visible vessels, and adherent nonbleeding clots are always treated endoscopically. In randomized trials, patients with these "major stigmata" had better outcomes from endoscopic therapies than with medical therapies alone. Flat spots, gray or black sloughs, and clean ulcer bases are not treated endoscopically, since medical therapy alone affords good outcome. The current recommendation is to treat major stigmata of hemorrhage endoscopically for the initial bleeding episode and a second time for rebleeding before considering ulcer surgery. Clinical presentation and comorbidity and the endoscopic appearance of the ulcer (i.e., stigmata of hemorrhage) of patients with UGI bleeding are used to determine the subsequent level of care (e.g., discharge or ward or intensive care).

Non-variceal upper gastrointestinal bleeding

Severe upper gastrointestinal bleeding remains a common medical emergency. In the last two decades endoscopy has become the cornerstone of diagnosis, risk stratification and treatment of peptic ulcer bleeding. Clinical assessment and endoscopic recognition of the stigmata of recent haemorrhage can allow the identification of patients with a high risk of rebleeding. Patients with active bleeding at the time of endoscopy and with non-bleeding visible vessels should receive endoscopic treatment. Studies comparing different treatment modalities are mostly single centre studies with relatively small groups of patients and therefore lack statistical power. Furthermore most of those trials were heterogeneous because of differences in the end points, differences in the risk factors for rebleeding and differences in the levels of experience of the endoscopists in both recognition and treatment of bleeding ulcers. Recently different treatment modalities have been studied. The injection of clot-inducing factors, a combination of injection and thermal therapies, repeat endoscopies and the use of mechanical devices such as clips and ligatures are promising new techniques. However, there are, at present, no convincing data to suggest that any one of these treatment modalities is superior when looking at the overall group of patients with bleeding peptic ulcer. Larger randomized controlled trials must focus on tailoring therapies and using the optimal therapy for different subgroups of patients.

Regular-dose versus High-dose Omeprazole in Peptic Ulcer Bleeding A Prospective Randomized Double-blind Study

Background: It has been suggested that profound acid inhibition along with endoscopic therapy might prevent rebleeding and reduce mortality in patients with peptic ulcer bleeding. The aim of the study was to test the possible equivalence of a high dose and the regular dose of omeprazole in peptic ulcer bleeding. Methods: We performed a prospective randomized double-blind study involving 142 patients with acute peptic ulcer bleeding (Forrest classification I-II: spurting or oozing bleeding, non-bleeding visible vessel, clot and black base). One-hundred-and-two (71.8%) patients received endoscopic treatment (adrenaline injection and/or heater probe) in pre-entry. Patients were randomly assigned to receive the regular dose of omeprazole intravenously (20 mg once a day for 3 days, i.e. 60 mg/72 h) or a high dose of omeprazole (80 mg bolus + 8 mg/h for 3 days, i.e. 652 mg/72 h). Rebleeding, surgery and death were the outcome measures. Results: Six (8.2%) of the 73 patients receiving the regular dose of omeprazole and 8 (11.6%) of the 69 patients receiving the high dose of omeprazole rebled ( P = 0.002 for equivalence, equivalence limit 0.15). Three (4.1%) of the former patients and 5 (7.2%) of the latter group underwent surgery. Four (5.5%) patients in the regular-dose and 2 (2.9%) in the high-dose group died within 30 days. Conclusion: Under the defined tolerance limits, the regular dose of omeprazole is as successful as a high dose in preventing peptic ulcer rebleeding.

Do we need more technology to reduce recurrence of bleeding from ulcers?

Do we need more technology to reduce recurrence of bleeding from ulcers?

Randomized Trial of N-Butyl-2-Cyanoacrylate Compared with Injection of Hypertonic Saline-Epinephrine in the Endoscopic Treatment of Bleeding Peptic Ulcers

Theoretically, the injection of cyanoacrylate may be effective for peptic ulcer bleeding, but randomized clinical trials are rare. The aim of this study was to compare the efficacy of N-butyl-2-cyanoacrylate (Histoacryl) and hypertonic saline-epinephrine (HSE) in the endoscopic treatment of major peptic ulcer hemorrhage. A total of 126 patients with major peptic ulcer hemorrhage and active bleeding or a nonbleeding visible vessel were randomly allocated to endoscopic injection with HSE (63 patients; group 1) or to injection with Histoacryl (63 patients; group 2). The two groups were well matched for age, sex, initial hemoglobin values, ulcer size and location, and bleeding stigmata. Initial hemostasis was achieved in 58 cases (92.1%) in group 1 and in 60 cases (95.2%) in group 2 (P=0.717). Rebleeding rates were 16 of 58 in group 1 and seven of 60 in group 2 (P=0.051). There were no significant differences regarding the rates of permanent hemostasis (51 of 63 in group 1 vs. 57 of 63 in group 2, P=0.203), emergency surgery (seven of 58 in group 1 vs. three of 60 in group 2, P=0.200), or hospital mortality due to bleeding (0 in group 1 and 0 in group 2). With regard to the rebleeding rate, there was a significant difference between group 1 and group 2 in the subgroup with active arterial bleeding (11 of 26 in group 1 and four of 29 in group 2, P=0.039) but not in the subgroup with a nonbleeding visible vessel (five of 32 in group 1 and three of 31 in group 2, P=0.708). There were no statistically significant differences in hemostatic results between the two treatment groups in the subgroups with gastric ulcers or duodenal ulcers. Although no complications followed HSE therapy, arterial embolization with infarction occurred in two patients in the Histoacryl group, of whom one died. Compared with HSE injection, Histoacryl injection showed no statistically significant differences in hemostatic results, except for decreasing the rebleeding rate in the patients with active arterial bleeding. However, the use of Histoacryl to control peptic ulcer bleeding should be reserved as a last resort before surgery, because of possible embolic complication.

Thermal probes alone or with epinephrine for the endoscopic haemostasis of ulcer haemorrhage

In the last two decades, significant progress has been made in the diagnosis, prognostication and treatment of patients with severe peptic ulcer haemorrhage. Patients can now be risk stratified by clinical presentation and endoscopic stigmata of ulcer haemorrhage. The purposes of this chapter are to discuss: (1) the techniques of thermal probe with or without epinephrine for haemostasis of ulcers with major stigmata of haemorrhage and (2) the outcomes of treatment of patients with ulcer haemorrhage treated with endoscopic thermal probes or other therapies, medical therapy and/or surgery. Compared to medical therapy alone, patients with major stigmata actively bleeding ulcers, non-bleeding visible vessels and non-bleeding adherent clots have been shown to benefit from endoscopic haemostasis with bipolar probe, heater probe, lasers or epinephrine injection. Outcomes showing significant improvement include blood transfusions, emergency surgery rates and length of hospital stay. Meta-analyses have also reported improvements in mortality for endoscopic compared with medical therapy of patients with severe ulcer haemorrhage and major stigmata. Patients with minor stigmata of ulcer haemorrhage (such as flat spots) or no stigmata (clean-based ulcers) do not benefit from endoscopic haemostasis. Thermal probes have the advantages of good coaptive coagulation, target irrigation, portability and relative inexpense. Recently, patients with active arterial bleeding, non-bleeding adherent clots or non-bleeding visible vessels have been reported to have better results with combination epinephrine injection and thermal probe compared to monotherapy alone (such as injection, bipolar or heater probe). In addititon, repeat endoscopic combination therapy has been reported to be as effective but safer than emergency surgery for management of recurrent ulcer haemorrhage.

Value of stigmata in decision-making in gastrointestinal haemorrhage

The stigmata of recent haemorrhage are endoscopically identified features that have a predictive value for the risk of further bleeding and thus help to determine which patients should receive endoscopic therapy. In conjunction with endoscopic features, clinical features related to the magnitude of bleeding and to patient co-morbidity have important independent effects on the risk of further haemorrhage. Stigmata have been best studied in the context of bleeding ulcers, the most common cause of upper gastrointestinal bleeding. Stigmata in ulcers are usually classified as active bleeding (spurting or oozing), a non-bleeding visible vessel, an adherent clot, a flat pigmented spot, or a clean base, in order of decreasing risk of further haemorrhage. Ulcer size and location may also affect the re-bleeding potential. Recent data suggest that both non-pigmented visible vessels and adherent clots have a higher risk of re-bleeding than was previously thought. The wide variation in prevalence and re-bleeding rates reported for various stigmata in the literature probably reflects variations in the definitions of stigmata and of re-bleeding, the vigour with which the ulcer bases are washed, the co-morbidity and ages of the patients, and the severity of bleeding encountered. Inter-observer agreement in the classification of stigmata is relatively poor and limits the utility of endoscopic features alone in making decisions regarding the management of patients with bleeding peptic ulcers. Imaging devices such as Doppler probes are being evaluated to refine the identification of underlying vessels and their re-bleeding potential, but the utility of these is currently uncertain. The findings of low-risk endoscopic stigmata in a haemodynamically and otherwise stable patient can in many cases allow out-patient management.

3576 Randomized, prospective study of bipolar coagulation alone compared to combination epinephrine injection and bipolar coagulation for prevention of rebleeding from ulcers with nonbleeding visible vessels.

Endoscopic monotherapies have been shown to be signifcantly better than medical therapy alone for prevention of rebleeding from non-bleeding visible vessels (NBVV) in ulcers. Our hypothesis was that combination epinephrine injection (EPI) and thermal therapy together (COMBO) would be superior to thermal therapy alone for permanent hemostasis of ulcers with non-bleeding visible vessels. Our purpose was to compare the outcomes of patients with clinically severe ulcer hemorrhage and NBVV at emergency endoscopy treated with COMBO vs thermal therapy. Methods: We conducted a multicenter, prospective randomized blinded study of high risk patients. Patients were randomized to endoscopic treatment with COMBO (injection in 4 quadrants of 1:10,000 EPI and Gold probe-GP-coagulationlarge probe, 15W, firm tamponade & 10 sec pulses) or GP alone without EPI. Physicians who were blinded as to the endoscopic therapies managed these patients. All patients received PPI's BID. Results: 71 patients with mean age of 64 and all with comorbidity were randomized. The two groups were similar at study entry. See table for outcomes. None of the differences are significant, although there were higher rates of severe rebleeding and death in the GP alone group*. The death rate was secondary to comorbidity. Conclusions: For high risk patients with non-bleeding visible vessels and clinically severe UGI hemorrhage: 1) Rebleeding and surgery rates were similar and low with either bipolar coagulation or COMBO therapy. 2) There were non-significantly higher death rates in the bipolar coagulation, related to co-morbidity. Funded by NIH DK33273 and partially by Microvasive-Boston Scientific.