Saffo S, Nagar A. Impact of epinephrine volume on further bleeding due to high-risk peptic ulcer disease in the combination therapy era. World J Gastrointest Pharmacol Ther 2022; 13(5): 67-76 [PMID: PMC9453442 DOI: 10.4292/wjgpt.v13.i5.67]
Corresponding Author of This Article
Saad Saffo, MD, Academic Fellow, Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, United States. saad.saffo@yale.edu
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Cohort Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastrointest Pharmacol Ther. Sep 5, 2022; 13(5): 67-76 Published online Sep 5, 2022. doi: 10.4292/wjgpt.v13.i5.67
Impact of epinephrine volume on further bleeding due to high-risk peptic ulcer disease in the combination therapy era
Saad Saffo, Anil Nagar
Saad Saffo, Anil Nagar, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT 06520, United States
Author contributions: Saffo S and Nagar A designed the study, interpreted the data and revised the manuscript; Saffo S collected and analyzed the data and wrote the initial draft of the manuscript; Nagar A is the guarantor of the study.
Supported bythe National Institutes of Health, No. T32 2T32DK007356-42.
Institutional review board statement: The study was exempted by the Institutional Review Board at Yale-New Haven Hospital (protocol number 2000029322).
Informed consent statement: Because of the retrospective and anonymous nature of this study, the need for informed consent was waived by the Institutional Review Board at Yale-New Haven Hospital.
Conflict-of-interest statement: All the Authors have no conflict of interest related to the manuscript.
Data sharing statement: The data supporting the results can be made available upon request via email at the discretion of the corresponding author.
STROBE statement: The authors have read the STROBE statement checklist. They have prepared and revised the manuscript in accordance with the principles outlined in the checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Saad Saffo, MD, Academic Fellow, Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, United States. saad.saffo@yale.edu
Received: April 13, 2022 Peer-review started: April 13, 2022 First decision: June 16, 2022 Revised: June 22, 2022 Accepted: August 1, 2022 Article in press: August 1, 2022 Published online: September 5, 2022 Processing time: 139 Days and 18.1 Hours
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.
Core Tip: To our knowledge, this is the only study specifically aimed at clarifying the impact of epinephrine volume in patients treated with combination endoscopic therapy. Our findings suggest that larger volumes of epinephrine are unlikely to improve clinical outcomes among patients who also receive thermal therapy and/or clipping.
