The aim of this study was to determine appropriate endoscopic treatment of patients with
bleeding ulcers by synthesizing results of randomized controlled trials. We performed dual independent bibliographic database searches to identify randomized trials of thermal
therapy, injection
therapy, or clips for
bleeding ulcers with active
bleeding, visible vessels, or clots, focusing on results from studies without second-look endoscopy and re-treatment. The primary end point was further (persistent plus recurrent)
bleeding. Compared with
epinephrine, further
bleeding was reduced significantly by other monotherapies (relative risk [RR], 0.58 [95% CI, 0.36-0.93]; number-needed-to-treat [NNT], 9 [95% CI, 5-53]), and
epinephrine followed by another modality (RR, 0.34 [95% CI, 0.23-0.50]; NNT, 5 [95% CI, 5-7]);
epinephrine was not significantly less effective in studies with second-look and re-treatment. Compared with no endoscopic
therapy, further
bleeding was reduced by thermal contact (heater probe, bipolar
electrocoagulation) (RR, 0.44 [95% CI, 0.36-0.54]; NNT, 4 [95% CI, 3-5]) and
sclerosant therapy (RR, 0.56 [95% CI, 0.38-0.83]; NNT, 5 [95%
CI, 4-13]). Clips were more effective than
epinephrine (RR, 0.22 [95% CI, 0.09-0.55]; NNT, 5 [95%
CI, 4-9]), but not different than other
therapies, although the latter studies were heterogeneous, showing better and worse results for clips. Endoscopic
therapy was effective for active
bleeding (RR, 0.29 [95% CI, 0.20-0.43]; NNT, 2 [95% CI, 2-2]) and a nonbleeding visible vessel (RR, 0.49; [95% CI, 0.40-0.59]; NNT, 5 [95%
CI, 4-6]), but not for a clot. Bolus followed by continuous-infusion
proton pump inhibitor after endoscopic
therapy significantly improved outcome compared with placebo/no
therapy (RR, 0.40 [95% CI, 0.28-0.59]; NNT, 12 [95% CI, 10-18]), but not compared with histamine(2)-receptor antagonists. Thermal devices,
sclerosants, clips, and
thrombin/
fibrin glue appear to be effective endoscopic
hemostatic therapies.
Epinephrine should not be used alone. Endoscopic
therapy should be performed for
ulcers with active
bleeding and nonbleeding visible vessels, but efficacy is uncertain for clots. Bolus followed by continuous-
infusion intravenous proton pump inhibitor should be used after endoscopic
therapy.