Predictors of peptic ulcer rebleeding after scheduled second endoscopy: clinical or endoscopic factors?

Background and study aims: In a previous study we demonstrated the efficacy of second-look endoscopy with therapy within 16 - 24 hours after index endoscopy in reducing major recurrent peptic ulcer bleeding. In this study, we sought to identify factors that might predict further rebleeding after this scheduled second-look endoscopy.
Patients and methods: We studied 249 patients (181 men, 68 women) with acute bleeding peptic ulcers who were treated at the United Christian Hospital, Hong Kong from 1999 to 2002 and who underwent a scheduled second endoscopy. Those patients who developed rebleeding after the second endoscopy were evaluated, and possible predictive factors for rebleeding were analyzed using a logistic regression model.
Results: Of the 249 patients who underwent scheduled second-look endoscopy, 17 patients (6.8 %) developed rebleeding: seven of these patients were treated by another endoscopic therapy; ten patients required surgery. The overall mortality rate was 3.1 %. A logistic regression analysis performed on the possible predictive factors for rebleeding found that the following factors were associated with a significant risk of further rebleeding after scheduled second endoscopy: American Society of Anesthesiologists (ASA) grade III or grade IV status (odds ratio 3.81, 95 % CI 1.27 - 11.44), ulcer size greater than 1.0 cm (odds ratio 4.69, 95 % CI 1.60 - 13.80), and a finding of persistent stigmata of recent hemorrhage at the scheduled second endoscopy (odds ratio 6.65, 95 % CI 2.11 - 20.98).
Conclusions: Endoscopic factors, including large ulcer size and the persistence of endoscopic stigmata of recent hemorrhage are important predictors for recurrent bleeding after scheduled second endoscopy.

References

• 1 Laine L, Peterson W L. Bleeding peptic ulcer.  N Engl J Med. 1994;  331 717-727
• 2 Chung S CS. Preventing ulcer rebleeding: the role of second look endoscopy.  Can J Gastroenterol. 1999;  13 409-411
• 3 Saeed Z. A. Second thoughts about second-look endoscopy for ulcer bleeding?.  Endoscopy. 1998;  30 650-652
• 4 Chiu P WY, Lam C YW, Lee S W. et al . The effect of scheduled second therapeutic endoscopy on peptic ulcer rebleeding: a prospective randomized trial.  Gut. 2003;  52 1403-1407
• 5 Lau J YW, Sung J JY, Lee K KC. et al . Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.  N Engl J Med. 2000;  343 310-316
• 6 Marmo R, Rotondano G, Bianco M A. et al . Outcome of endoscopic treatment for peptic ulcer bleeding: is a second look necessary? A meta-analysis.  Gastrointest Endosc. 2003;  57 62-67
• 7 Chiu P WY, Lau T S, Kwong K H. et al . Impact of programmed second endoscopy with appropriate re-treatment on peptic ulcer rebleeding: a systematic review.  Ann Coll Surg Hong Kong. 2003;  7 106-115
• 8 Rolhauser C, Fleisher D E. Non-variceal upper gastrointestinal bleeding: an update.  Endoscopy. 1997;  29 91-105
• 9 Villanueva C, Balanzo J, Espinos J C. et al . Prediction of therapeutic failure in patients with bleeding peptic ulcer treated with endoscopic injection.  Dig Dis Sci. 1993;  38 2062-2070
• 10 Saeed Z A, Winchester C B, Michaletz P A. et al . A scoring system to predict rebleeding after endoscopic therapy of non-variceal upper gastrointestinal hemorrhage, with a comparison of heat probe and ethanol injection.  Am J Gastroenterol. 1993;  88 1842-1849
• 11 Brullet E. Campo R, Calvet X, et al. Factors related to the failure of endoscopic injection therapy for bleeding gastric ulcer.  Gut. 1996;  39 155-158
• 12 Park K G, Steele R J, Mollison J. et al . Prediction of recurrent bleeding after endoscopic hemostasis in non-variceal upper gastrointestinal bleeding.  Br J Surg. 1994;  81 1465-1468
• 13 Wong S KH, Yu L M, Lau J YW. et al . Prediction of therapeutic failure after adrenaline injection plus heater probe treatment in patients with bleeding peptic ulcer.  Gut. 2002;  50 322-325
• 14 Guglielmi A, Ruzzenente A, Sandri A. et al . Risk assessment and prediction of rebleeding in bleeding gastroduodenal ulcer.  Endoscopy. 2002;  34 778-786
• 15 Lau J YW, Sung J JY, Chan A CW. et al . Stigmata of hemorrhage in bleeding peptic ulcers: an interobserver agreement study among international experts.  Gastrointest Endosc. 1997;  46 33-36
• 16 Morris D L, Hawker P C, Brearley S. et al . Optimal timing of operation for bleeding peptic ulcer: prospective randomized trial.  BMJ. 1984;  288 1277-1280
• 17 Saeed Z A, Cole R A, Ramirez F C. et al . Endoscopic retreatment after successful initial hemostasis prevents ulcer rebleeding: a prospective randomized trial.  Endoscopy. 1996;  28 288-294