Endoscopic dual versus monotherapy in patients bleeding from high-risk peptic ulcers

Aim: Dual endoscopic and pharmacologic therapy is currently the standard treatment for patients with high-risk peptic ulcer bleeding. The authors assess the efficacy of dual (endoscopic and pharmacologic) therapy versus endoscopic monotherapy in reducing rates of recurrent bleeding and death in patients with high-risk peptic bleeds.Methods: The authors carried out a post-hoc analysis of data on the use of intravenous proton pump inhibitors for the prevention of rebleeding ulcers and death (from an investigator-supported multicenter randomized trial in Italy). All the patients bleeding from high-risk peptic ulcers with a successful endoscopic hemostasis were treated with epinephrine injections alone (n = 157) or in combination with thermal therapy (n = 219).Results: Rebleeding occurred in 20 individuals (12.7%) in the monotherapy group, and in 21 individuals (9.6%) in the dual group (P = 0.33). Seven patients (4.5%) in the former group and 2 (0.9%) in the latter group died, with a 3.6% (95% CI: 0.3 to 8.1) absolute risk reduction. The mean number of units of blood transfused were 2.7 ± 1.7 and 3.2 ± 2.5 (P = 0.14), respectively, and the mean hospital stay was 6.7 ± 3.9 and 7.1 ± 4.3 days (P = 0.40), respectively. Multivariate analysis revealed that the sole independent predictor of death was ulcer size ≥ 20 mm [odds ratio (OR) = 6.56, 95% CI: 1.57 to 27.4]. Dual endoscopic and pharmacologic therapy provided a non-significant reduction in the risk of death (OR = 0.26, 95% CI: 0.05 to 1.34).Conclusion: When adjuvant proton pump inhibitors were administered, dual endoscopic and pharmacologic therapy was not superior to injection monotherapy for reducing rates of rebleeding and death