Epinephrine injection versus epinephrine injection and a second endoscopic method in high risk bleeding ulcers

Endoscopic therapy reduces re-bleeding rate, need for surgery, and death in patients with peptic ulcer and active bleeding or visible blood vessels in the stomach and upper intestine.
Injection of epinephrine is the most popular method to stop bleeding. Experts disagree on the need for a second procedure immediately after epinephrine; although it seems to reduce further bleeding, its effects on continuing illness (morbidity), surgery rates and death (mortality) remain unclear. We performed an extensive search for randomised trials comparing epinephrine alone versus epinephrine plus a second method. Eighty clinical trials involving 1868 participants were analysed. We found that adding a second procedure reduced the further bleeding rate and the need for emergency surgery. Death rates also fell although the difference was not statistically proven. In conclusion, additional endoscopic treatment after epinephrine injection reduces further bleeding and need for surgery in patients with high risk bleeding peptic ulcer.