RESUMEN
BACKGROUND & AIMS: Treatment of high-risk patients with nonbleeding adherent clots on ulcers is controversial. In a previous randomized trial, there was no benefit to endoscopic therapies compared with medical therapy for prevention of ulcer rebleeding. Our purpose was to test the hypothesis that patients treated with combination endoscopic therapy would have significantly lower rebleeding rates than those treated with medical therapy. METHODS: In this randomized, controlled trial, 32 high-risk patients with severe ulcer hemorrhage and nonbleeding adherent clots resistant to target irrigation were randomized to medical therapy or to combination endoscopic therapy (with epinephrine injection, shaving down the clot with cold guillotining, and bipolar coagulation on the underlying stigmata). Physicians blinded to the endoscopic therapy managed all patients. RESULTS: Patients were similar at study entry, except for older age in the medical group and lower platelet count in the endoscopic group. By hospital discharge, significantly more medically treated patients (6/17; 35.3%) than endoscopically treated patients (0/15; 0%) rebled (P = 0.011). There were no complications of endoscopic treatment. CONCLUSIONS: Combination endoscopic therapy of nonbleeding adherent clots significantly reduced early ulcer rebleeding rates in high-risk patients compared with medical therapy alone. This endoscopic treatment was safe.
Asunto(s)
Úlcera Péptica Hemorrágica/prevención & control , Úlcera Péptica/terapia , Anciano , Coagulación Sanguínea , Endoscopía Gastrointestinal , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , RecurrenciaRESUMEN
BACKGROUND: Adults hospitalized with acute, nonvariceal upper GI hemorrhage can be accurately stratified according to their risk of subsequent adverse outcomes by using the Rockall score. Low-risk patients (Rockall score less-than-or-equal 2) may be candidates for early discharge. METHODS: Cases were identified with ICD-9-CM codes for calendar years 1997 and 1998. Medical record data to determine patient Rockall risk score, health care resource utilization, and adverse outcomes were abstracted with standardized forms. RESULTS: Fifty-three of 175 (30%) cases had Rockall scores < or =2. As predicted, those patients with Rockall scores < or =2 had a low risk of adverse outcomes with only 2 of 53 (4%) meeting criteria for recurrent bleeding as defined by the "Rebleed" variable, and no mortality. These low-risk patients had a mean hospital stay of 2.6 plus minus 2.1 days; 49% were admitted to an intermediate or intensive care unit bed and 57% were given H2 receptor antagonists intravenously. CONCLUSIONS: The proportion of patients admitted with acute, nonvariceal, upper GI hemorrhage with Rockall Scores < or =2 was substantial. Adverse outcomes were rare. In contrast, the level of health care resource utilization appeared high. The Rockall score has potential as a clinically based concurrent decision rule to improve the quality of care by finding those patients less likely to require intensive health care services.