Is endoscopic hemostasis useful in peptic ulcer with an adherent clot?

Endoscopic Hemostasis for Peptic Ulcer with Adherent Clot

Endoscopic therapy should be performed for peptic ulcers with adherent clots after vigorous irrigation, as it significantly reduces rebleeding compared to medical therapy alone, though the approach remains somewhat controversial and may be tailored based on patient risk factors. 1

Initial Management Approach

Vigorous irrigation is the critical first step when encountering an adherent clot in an ulcer bed. 1

• Target irrigation should be attempted for at least 5 minutes using water pump irrigation to dislodge the clot and expose underlying stigmata 1, 2
• Successfully dislodging the clot occurs in 26-43% of cases, revealing high-risk stigmata in 70% of those cases 1
• If underlying stigmata are exposed after irrigation, treat them according to standard protocols for high-risk lesions 1

Endoscopic Therapy Decision-Making

For clots that remain adherent after vigorous irrigation, endoscopic therapy reduces rebleeding from 24.7% to 8.2% (number needed to treat = 6.3). 3

When to Perform Endoscopic Therapy:

• High-risk patients (those with serious concurrent illness, hemodynamic instability, or ongoing NSAID use) should receive endoscopic therapy 1
• Patients requiring ≥4 units of red blood cell transfusion benefit from more aggressive endoscopic management 4
• The WSES advocates a cautious approach to clot dislodgment, with individual endoscopist judgment until further evidence emerges 1

When Intensive PPI Therapy Alone May Suffice:

• Low-risk patients, particularly those who are Asian or Helicobacter pylori-positive, may be managed with high-dose intravenous PPI therapy alone 1
• One RCT in 24 Asian patients with clots resistant to irrigation found zero rebleeding with PPI therapy alone 1

Endoscopic Technique for Adherent Clots

The standard technique involves pre-injection with epinephrine, cold guillotining snare removal without disrupting the clot pedicle, followed by dual-modality treatment of residual stigmata. 1

• Dual-modality therapy is superior to monotherapy: mechanical therapy (clips or thermal coagulation) combined with epinephrine injection reduces rebleeding (OR 0.19,95% CI 0.07-0.52) and need for surgery (OR 0.10,95% CI 0.01-0.50) 1, 2
• Epinephrine injection alone is inadequate and should never be used as monotherapy 1
• For very deep ulcers or large visible vessels, hemoclips may be preferable to thermal coagulation to avoid perforation risk 5

Post-Endoscopic Management

After successful endoscopic hemostasis, administer high-dose PPI as an 80 mg bolus followed by 8 mg/hour continuous infusion for 72 hours. 1

• This regimen reduces rebleeding from 10.3% to 5.9% (p=0.03) 1
• Continue PPI therapy for 6-8 weeks following endoscopic treatment 1, 2
• Test all patients for Helicobacter pylori and eradicate if positive 6

Evidence Nuances and Controversy

The controversy stems from conflicting meta-analyses: one showed no significant benefit (RR 0.48, CI 0.18-1.30), while patient-level analysis demonstrated significant rebleeding reduction (RR 0.30, CI 0.10-0.77). 1

However, the most recent individual RCT data strongly supports endoscopic therapy, showing rebleeding rates of 4.8% with endoscopic therapy versus 34.3% with medical therapy alone (p<0.02). 7

The rebleeding risk for untreated adherent clots ranges widely from 0-8% in some studies to 25-35% in clinically high-risk patients, explaining the divergent recommendations. 1

Common Pitfalls

• Avoid mechanical dislodgment without preparation: The WSES specifically advocates against aggressive mechanical dislodgment, preferring cautious irrigation-based approaches 1
• Don't use epinephrine injection alone: This provides suboptimal efficacy and must be combined with mechanical or thermal therapy 1
• Don't skip Doppler assessment if available: Doppler probe-guided hemostasis reduces 30-day rebleeding rates with a number needed to treat of 7, though availability limits widespread use 1
• Scheduled second-look endoscopy is not routinely necessary unless initial hemostasis was unsatisfactory, NSAID use continues, or large transfusion volumes were required 4