Retrospective Cohort Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
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 by the 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
ARTICLE HIGHLIGHTS
Research background

In monotherapy studies for bleeding peptic ulcers, the volume of epinephrine injected had an impact on clinical outcomes. Large volumes up to a range of 30-45 mL were associated with a reduction in rebleeding. However, the impact of epinephrine volume on patients treated with combination endoscopic therapy remains unclear.

Research motivation

Understanding whether epinephrine volume can impact clinical outcomes among patients treated with combination endoscopic therapy can help inform clinical practice for the management of bleeding ulcers, a condition commonly encountered by endoscopists.

Research objectives

To examine whether epinephrine volume could impact the risk for further bleeding, need for additional medical or procedural interventions, and survival while accounting for other important clinical and endoscopic factors.

Research methods

Comprehensive clinical and endoscopic data from 132 patients with Forrest class Ia, Ib, and IIa peptic ulcers treated at our tertiary care center were reviewed. We assessed for relevant clinical outcomes such as rebleeding within 7 and 30 d, need for additional intervention, post-endoscopy blood transfusions, and mortality. We used logistic regression analysis to determine the impact of clinical and endoscopic factors.

Research results

There was no association between epinephrine volume and rebleeding, need for additional intervention, post-endoscopy blood transfusions, or mortality. 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.

Research conclusions

Volumes of epinephrine 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, including the presence of shock and renal failure.

Research perspectives

It is unlikely that large volumes of epinephrine are routinely necessary for the management of high-risk peptic ulcer disease. However, in select cases where ulcer characteristics pose therapeutic challenges or additional modalities are unavailable, it is conceivable that large volumes of epinephrine may still be beneficial.