Impact of epinephrine volume on further bleeding due to high-risk peptic ulcer disease in the combination therapy era.

Saad Saffo, Anil Nagar
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Abstract

Background: In monotherapy studies for bleeding peptic ulcers, large volumes of epinephrine were associated with a reduction in rebleeding. However, the impact of epinephrine volume in patients treated with combination endoscopic therapy remains unclear.

Aim: To assess whether epinephrine volume was associated with bleeding outcomes in individuals who also received endoscopic thermal therapy and/or clipping.

Methods: Data from 132 patients with Forrest class Ia, Ib, and IIa peptic ulcers were reviewed. The primary outcome was further bleeding at 7 d; secondary outcomes included further bleeding at 30 d, need for additional therapeutic interventions, post-endoscopy blood transfusions, and 30-day mortality. Logistic and linear regression and Cox proportional hazards analyses were performed.

Results: There was no association between epinephrine volume and all primary and secondary outcomes in multivariable analyses. Increased odds for further bleeding at 7 d occurred in patients with elevated creatinine values (aOR 1.96, 95%CI 1.30-3.20; P < 0.01) or hypotension requiring vasopressors (aOR 6.34, 95%CI 1.87-25.52; P < 0.01). Both factors were also associated with all secondary outcomes.

Conclusion: Epinephrine maintains an important role in the management of bleeding ulcers, but large volumes up to a range of 10-20 mL are not associated with improved bleeding outcomes among individuals receiving combination endoscopic therapy. Further bleeding is primarily associated with patient factors that likely cannot be overcome by increased volumes of epinephrine. However, in carefully-selected cases where ulcer location or size pose therapeutic challenges or when additional modalities are unavailable, it is conceivable that increased volumes of epinephrine may still be beneficial.

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联合治疗时代肾上腺素量对高风险消化性溃疡进一步出血的影响。
背景:在出血性消化性溃疡的单药治疗研究中,大量肾上腺素与再出血的减少有关。然而,肾上腺素量对联合内镜治疗患者的影响尚不清楚。目的:评估肾上腺素量是否与同时接受内窥镜热治疗和/或夹夹的个体出血结局相关。方法:回顾了132例Forrest Ia、Ib和IIa型消化性溃疡患者的资料。主要结局是第7天进一步出血;次要结局包括30 d进一步出血、需要额外的治疗干预、内镜检查后输血和30天死亡率。进行Logistic回归、线性回归和Cox比例风险分析。结果:在多变量分析中,肾上腺素量与所有主要和次要结局均无相关性。肌酐值升高的患者在第7天进一步出血的几率增加(aOR 1.96, 95%CI 1.30-3.20;P < 0.01)或低血压需要血管加压药物(aOR 6.34, 95%CI 1.87-25.52;P < 0.01)。这两个因素也与所有次要结果相关。结论:肾上腺素在出血溃疡的治疗中发挥着重要作用,但在接受联合内镜治疗的个体中,大剂量肾上腺素(10- 20ml)与出血结局的改善并不相关。进一步出血主要与患者因素有关,这些因素可能无法通过增加肾上腺素量来克服。然而,在精心挑选的病例中,溃疡的位置或大小对治疗构成挑战,或者当其他方式不可用时,可以想象,增加肾上腺素的体积可能仍然是有益的。
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