Rebleeding from gastroduodenal peptic ulcers in the age of endoscopic therapy

Introduction: Data regarding outcome of endoscopic therapy of UGI bleeding are derived primarily from selected patients enrolled in randomized controlled trials. There are few data regarding rebleeding and mortality in unselected patients with potentially severe comorbidity. Methods: We reviewed all inpatient EGD's for acute upper GI bleeding over a 1 year period at a critical-care/trauma oriented hospital in which a peptic gastroduodenal ulcer was found. Rebleeding was defined stringently per Laine's criteria (any clinical evidence of bleeding plus either hemodynamic changes or hematocrit fall >4%). Mortality was determined for the index hospitalization. Results: There were 83 cases of bleeding in which peptic ulcers were found (representing 30% of all UGI bleeding). Further ulcer bleeding occurred in 18/83 cases(22%). 12/30 (40%) patients rebled after initial endoscopic hemostasis. Rebleeding occurred in 4/37 (11%) without specific identifiable stigmata (3 were subsequently found to have visible vessels), 0/10 (0%) with pigmented spots, 3/10 (30%) with adherent clots. Despite initial endoscopic therapy, further bleeding occurred in 7/16 (44%) non-bleeding visible vessels and 3/10 (30%) active bleeders. Of patients with further bleeding, all but 3 were eventually controlled with endoscopic therapy, one of which was anatomically inaccessible to endoscopic therapy; the other two were non-surgical candidates who exsanguinated from posterior duodenal ulcers after failed endoscopic therapy. Overall, 1/18 rebleeding patients underwent urgent surgery and death occurred in 2/18 (11%) compared to 2/65(3.1%) in those without further bleeding. All 4 deaths occurred in pts over age 80 or with severe comorbidity. Conclusions: In an unselected cohort of patients with bleeding peptic ulcer, rebleeding after endoscopic therapy was more common than reported in randomized controlled trials, but the ultimate success of endoscopic therapy remained high (96%), with very few patients requiring surgery and low overall mortality (4.8%). Mortality in patients rebleeding was lower (11%) than generally reported and occurred exclusively in elderly patients with significant comorbidity.