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Endoscopic Versus Conservative Therapy for Bleeding Peptic Ulcer with Adherent Clot: A Comprehensive Systematic Review and Meta-Analysis

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An Invited Commentary to this article was published on 27 August 2023

Abstract

Introduction

Peptic ulcers with adherent clots are associated with a high-risk of rebleeding and mortality. However, the optimal management of bleeding ulcers with adherent clots remains unclear. We conducted this systematic review and meta-analysis to compare endoscopic therapy and conservative therapy to manage bleeding ulcers with adherent clots.

Methods

We systematically searched PubMed, Embase, and Web of Science databases through October 2022 to include all studies comparing the endoscopic and conservative therapeutic approaches for bleeding ulcers with adherent clots. Our primary outcome was rebleeding (overall and 30-day). The secondary outcomes were mortality (overall and 30-day), need for surgery, and length of hospital stay (LOS). The random-effects model was used to calculate the pooled odds ratios (OR) and mean differences (MD) with the corresponding confidence intervals (CI) for proportional and continuous variables, respectively.

Results

Eleven studies (9 RCTs) with 833 patients (431 received endoscopic therapy vs. 402 received conservative therapy) were included. Overall, endoscopic therapy was associated with lower overall rebleeding (OR 0.41, 95% CI 0.22–0.79, P = 0.007), 30-day rebleeding (OR 0.43, 95% CI 0.21–0.89, P = 0.002), overall mortality (OR 0.47, 95% CI 0.23–0.95, P = 0.04), 30-day mortality (OR 0.43, 95% CI 0.21–0.89, P = 0.002), need for surgery (OR 0.44, 95% CI 0.21–0.95, P = 0.04), and LOS (MD − 3.17 days, 95% CI − 4.14, − 2.19, P < 0.00001). However, subgroup analysis of randomized controlled trials (RCTs) showed no significant difference in overall mortality (OR 0.78, 95% CI 0.24–2.52, P = 0.68) between the two strategies, with numerically lower but statistically non-significant rates of overall rebleeding (7.2% vs. 18.5%, respectively; OR 0.42, 95% CI 0.17–1.05, P = 0.06), statistically lower rate of need for surgery (OR 0.28, 95% CI 0.08–0.96, P = 0.04) with endoscopic therapy compared to conservative therapy.

Conclusions

Our meta-analysis demonstrates that endoscopic therapy was overall associated with lower rates of rebleeding (overall and 30-day), mortality (overall and 30-day), need for surgery, and LOS, compared to conservative therapy for the management of bleeding ulcers with adherent clots. However, subgroup analysis of RCTs showed that endoscopic therapy was associated with numerically lower but statistically non-significant rates of overall rebleeding and a statistically lower rate of need for surgery compared to conservative therapy with similar overall mortality rates. Combined treatment with thermal therapy and injection therapy was the most effective treatment modality in reducing rebleeding risk. Further large-scale RCTs are needed to validate our findings.

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Authors and Affiliations

  1. Divison of Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, Ste 225, Indianapolis, IN, 46202, USA

    Azizullah Beran, Umer Bhatti, Khaled Abdeljawad & Mohammad Al-Haddad

  2. Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA

    Yasir Al-Abboodi & Sami Ghazaleh

  3. Divison of Gastroenterology and Hepatology, University of Missouri, Columbia, MO, USA

    Abdul Mounaem Majzoub

  4. Department of Medicine, University of Toledo, Toledo, OH, USA

    Wasef Sayeh

  5. Department of Medicine, Warren Alpert Medical School Brown University, Providence, RI, USA

    Mouhand F. H. Mohamed

  6. Department of Medicine, St. Barnabas Hospital Health System, Bronx, NY, USA

    Khaled Elfert

  7. Division of Cardiology, University of Iowa, Iowa City, IA, USA

    Mohammed Mhanna

  8. Department of Medicine, Indiana University, Indianapolis, IN, USA

    Eleazar Montalvan-Sanchez

  9. Department of Medicine, Case Western Reserve University, Cleveland, OH, USA

    Rami Musallam

  10. Department of Medicine, University of MO – Kansas City, Kansas City, MO, USA

    Fouad Jaber

Authors
  1. Azizullah Beran
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  2. Yasir Al-Abboodi
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  3. Abdul Mounaem Majzoub
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  4. Sami Ghazaleh
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  11. Fouad Jaber
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  12. Umer Bhatti
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  14. Mohammad Al-Haddad
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Contributions

AB, YA-A, AMM and SG: study design; data revision, manuscript drafting and revision. AB and MM: statistical analysis. WS, MFHM, KE, RM, EM-S and FJ: data acquisition and interpretation; manuscript drafting. MA-H, KA and UB: study supervision; critical revision for intellectual content.

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Correspondence to Azizullah Beran.

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The authors declared no conflict of interest.

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An editorial commenting on this article is available at https://doi.org/10.1007/s10620-023-08082-1.

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Beran, A., Al-Abboodi, Y., Majzoub, A.M. et al. Endoscopic Versus Conservative Therapy for Bleeding Peptic Ulcer with Adherent Clot: A Comprehensive Systematic Review and Meta-Analysis. Dig Dis Sci 68, 3921–3934 (2023). https://doi.org/10.1007/s10620-023-08078-x

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