Brief Article
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World J Gastroenterol. Nov 21, 2010; 16(43): 5490-5495
Published online Nov 21, 2010. doi: 10.3748/wjg.v16.i43.5490
Predictors of rebleeding after initial hemostasis with epinephrine injection in high-risk ulcers
Ming-Luen Hu, Keng-Liang Wu, King-Wah Chiu, Yi-Chun Chiu, Yeh-Pin Chou, Wei-Chen Tai, Tsung-Hui Hu, Shue-Shian Chiou, Seng-Kee Chuah
Ming-Luen Hu, Keng-Liang Wu, King-Wah Chiu, Yi-Chun Chiu, Yeh-Pin Chou, Wei-Chen Tai, Tsung-Hui Hu, Shue-Shian Chiou, Seng-Kee Chuah, Division of Hepatogastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Niao-Song Hsiang 833, Kaohsiung, Taiwan
Author contributions: Chuah SK designed the research; Hu ML performed the research and wrote the paper; Tai WC, Chiu YC, Chou YP, Hu TH and Chiou SS contributed equally to this work; Wu KL and Chiu KW and Chuah SK performed critical revision.
Supported by No Financial Interests or Grants support that might have an impact on the views expressed in this study
Correspondence to: Dr. Seng-Kee Chuah, Division of Hepatogastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, 123, Ta-Pei Road, Niao-Song Hsiang 833, Kaohsiung, Taiwan. chuahsk@seed.net.tw
Telephone: +886-7-7317123 Fax: +886-7-7322402
Received: July 31, 2010
Revised: August 25, 2010
Accepted: September 1, 2010
Published online: November 21, 2010
Abstract

AIM: To identify the predictors of rebleeding after initial hemostasis with epinephrine injection (EI) in patients with high-risk ulcers.

METHODS: Recent studies have revealed that endoscopic thermocoagulation, or clips alone or combined with EI are superior to EI alone to arrest ulcer bleeding. However, the reality is that EI monotherapy is still common in clinical practice. From October 2006 to April 2008, high-risk ulcer patients in whom hemorrhage was stopped after EI monotherapy were studied using clinical, laboratory and endoscopic variables. The patients were divided into 2 groups: sustained hemostasis and rebleeding.

RESULTS: A total of 175 patients (144, sustained hemostasis; 31, rebleeding) were enrolled. Univariate analysis revealed that older age (≥ 60 years), advanced American Society of Anesthesiology (ASA) status (category III, IV and V), shock, severe anemia (hemoglobin < 80 g/L), EI dose ≥ 12 mL and severe bleeding signs (SBS) including hematemesis or hematochezia were the factors which predicted rebleeding. However, only older age, severe anemia, high EI dose and SBS were independent predictors. Among 31 rebleeding patients, 10 (32.2%) underwent surgical hemostasis, 15 (48.4%) suffered from delayed hemostasis causing major complications and 13 (41.9%) died of these complications.

CONCLUSION: Endoscopic EI monotherapy in patients with high-risk ulcers should be avoided. Initial hemostasis with thermocoagulation, clips or additional hemostasis after EI is mandatory for such patients to ensure better hemostatic status and to prevent subsequent rebleeding, surgery, morbidity and mortality.

Keywords: Epinephrine injection; High-risk ulcers; Initial hemostasis; Predictors; Rebleeding