MEDICAL VERSUS COMBINED THERAPY OF PEPTIC ULCERS WITH ADHERENT CLOTS

Aims: The optimal therapeutic approach of peptic ulcers with adherent clots, Forrest IIb Classification, is not consensual. The results of the studies performed so far are somewhat contradictory and both isolated medical treatment and medical treatment combined with endoscopic treatment are considered by the European Society of Gastrointestinal Endoscopy (ESGE) guidelines. We aimed to compare evolution and prognosis of patients with Forrest IIb ulcers approached with isolated medical treatment versus combined treatment (medical and endoscopic). Methods: All patients with Forrest IIb gastric or duodenal ulcer, diagnosed between January 2010 and December 2015 were selected. A clot was considered adherent when resistant to endoscopic aspiration and/or irrigation, with no signs of active bleeding. All patients that underwent any method of endoscopic haemostasis (injection, thermal and/or mechanic) were included in the endoscopic treatment group. Results: We included 58 patients (69,0% male; mean age 67,0 ± 13,9 years), 43,1% (n = 25) in the isolated medical treatment and 56,9% (n = 33) in the combined treatment group. Demographic and clinical features were identical between both groups (p > 0.05). Recurrence rate was 9,1% (n = 3) in the combined treatment group Vs. 28,0% (n = 7) in the medical treatment group; p = 0.059. Patients in the combined treatment group had shorter duration of hospitalization (5,9 ± 3,2 Vs. 7,8 ± 3,8 days; p = 0.042) and required less transfusions (1,2 ± 2,4 Vs. 2,7 ± 2,8 units of blood; p = 0.031). Surgery requirement (6,1% Vs. 20,0%; p = 0.221), bleeding-related mortality (3,0% Vs 4,0%; p = 0,841) and all-cause mortality (12,1% Vs. 24,0%; p = 0.302) did not reach statistical difference between both groups. There was an association between syncope at admission, Blatchford score and ulcer size and recurrence rate (p < 0.05). Conclusions: Combined treatment, medical and endoscopic, of Forrest IIb ulcers is associated with shorter hospitalization, less transfusion requirement and a tendency towards recurrence rate reduction.