CLIN ICAL GASTROENTEROLOGY
Endoscopic injection therapy in bleeding peptic ulcers. Low
mortality in a high risk population
j l)A()UIM BALANi'l\ MD, CANrnn V ILLANUEV.i\, Ml\ jORt,E C ESPINt)S, ML\
SER<~IO SA IN?, M l), GERMAN SORIANl\ MD, DOLORS Gl)NZALEZ, MD. XAVIER RI US, MD.
Jt)Rt;E Plllt, I..'\ C ,\LLF, MD, FACS, FR1\NCl~Ct) VILi\RnELL, MD, FRCP, FACP
J BALANZ6, C VILLANUEVA, JC ESPIN6S, c t al. Endoscopic injection therapy in bleeding peptic ulcers. Lo w mortality in a high risk population. C an J Gastroen terol 1992;6(5 ):265-268. EnJoscoric injectio n the rapy was performeJ in 341 patients consccu ri vc ly admitteJ wirh a b leeding peptic ulce r a t high risk of further he morrhage, assessed by che presence o f active arteria l hlccd ing o r a nonblecJing v isihlc vessel a t emergency endoscopy. In it ia l hc mostasis was achicvcJ in 11 L of 119 actively bleeding pat ie nts (93%). Reblceding llCCurrcd in 75 cases (23%), at a mean interval of 53±52 h. A ~ccond emergency injectilm was a ttempted in 36 the rapeutic fa ilure~, anJ wa~ successful in 20 (55%). Emergency surgery wa~ fina lly req u ired in 52 patien ts ( 15%). Overa ll mortality was 4.9%. Majo r complicaLio ns occurred in four patients ( 1.2%) (two perforat io ns a nd two aspiratio n pneumo nia); therefore, injection therapy is an effecti ve anJ ~imple methoJ for trea t ing bleeding ulcers, achieving the initia l control of hemorrhage in a majori ty of cases altho ugh t he rate of fu rt he r hemorrhage is not negligible and com plicat io ns arc nnt irrelevant.
Key Words: Bleeding pe/nic ulcer, Injection therapy, T hera/>eucic enduscupy
Traitement d'ulceres gastro~duodenaux hemorragiques au moyen d'une injection administree par voie endoscopique. Faible taux de mortalite clans une population a risque eleve
RESUME: U n mi itcmcnt en injec tion par voic cndoscopique a etc administrc a 34 J patients consccut if~ aJmis po ur u lccre gastro-duoJ cnal actif e t a risquc elcvc a l'cgard <l'hcmorragies subseq uences, tel qu'a ttestc par la p resence <J'unc hcmorragie a rtcric lle acti ve o u non a l'em loscopic d'urgence. Unc hemosrnse initiale a ere obtenue ch ez l l l des J l 9 pat ients e n hcmo rragie active (93 %). Le smgnement est reapparu dans 75 cas (23 %), avec un interva l le de te mps moyen
Dcpiirtmcnt <if ( ~,"rn":11tl'rnlC1,!;:V and Di1,ision "I ( ,ener,1/ ond Dite1riw S111J(l'l')', Hos{liw/ Je a Sama Crell i Smu 1'L111, /3cnwlona, Spain
Conl'S/)()lldence w1J rc[lri111,: Dr ./om11iim n11h111~,i. Ser11ei Je J>awlol{ia fJi,zesuve. l-los/1iwl de "' S,111U1 Cret1 1 Sant 1'1111, Av,1;clti.Sanr Anwni M ·' Clam, I 67. 08025. Barcelrma, SJ1ain. Tckplwne 34 93 236 47 21, F,n 34 3 456 0 I 60
Receil'ecl for J>11h/1cauon AJml 19. I 99 2. 1\ccc/nl'd Ma)• I I . / 99 2
BLELl)JNt; PEPTll' Ul.l'l:R Rl:;,.{AINS A
rele\'ant health problem with ~ignifknnt nwrh1di 1y and morrnli 1y des
pite the intr,iduction of d iagnostic enduscnpy, impn1"ement, in technnlugy tor resuscitarion nf hlceding patients ,rnd in medicnl management ot ulcers wirh pharmawlogical agents ( l ). Howcver, diugnnslic endo,uipy has assumed an imporumt rok due tn its ac
cu rncy in detccu ng 1hc hlceding ks i1111, and in dcfining ,t igmata of rccent hemnrrh,1ge ll'h1ch nre \·aluahle prognosnc ind1ca1or, of the risk of an unfo\'\lrahle outCtHne (2). Furthermore, from the rc,ul b 111 thc Clin1rolled
stud ies rep,irtcd to date ( 1.4) and the conclusiom uf Lhc Consen,u, Conference at the USA National Institute · of Health (N IH) (5), therapeutic endo
scopy can he regarded as the fir L hemostatic procedure in patients with ulcer, ,1t high risk of funhcr bleeding.
A recent meta-analysis abo showed that thernpcuc ic endoscopy reduces
rcb lceding and requi rcmcnr for emergency surgery hy nearly Lwo-th irds and
morta lity by nearl y o ne-third ( 4 ). Patie n ts with c linical evidence of a
major hemorrhage and active arterial b leedi ng or a nonhlecdingvi~ihle vessel at endoscopy should he t reated ( 5 ). Thi.:
N IL-I Cnnsen,us Conference Ji.:ter-
265
R.·\l.,\Nll'l t'I ll l
de 53±52 h eurcs. U n e dc ux ic mc injectio n d'urgcnce a e tc administ rec J uns 36 des cas ou la m anoeuvre a ech o ue er a rcussi ch cz 20 d'entre cux (55 %). U n c c hirurgie cl'urgen ce a fina le ment ere necessa ire dam 52 cas (1 5 %). Le taux d e morta lite globa le a e te de 4,9 %. De graves complica t io ns se sont produ ites ch ez 4 patien ts ( 1,2 %). (ll s'agissa it de deux cas de pe rforation c t de deux cas d e pn eumo n ic pa r inh ala tio n . ) On peut don e conclurc q ue le t raitement par injec tion est une methode efficace c t simple de traiter lcs ulcc res acrifs pour parvenir a mat'rriser rapid em cnt l'hcmo rragic clans la majo ri te J es cas, bicn q uc le taux de recurren ce d e I 'h emorragie c t des comp lications n e so it pas n cgligcablc.
min e,( th :it mulL ipolm e lcc trncoagula
tion and h eat probe were the most prn
m i, in g tech niq ue s and th aL injection
therapy wammt ed further study. In th e
past few years se vera l prospective and com rolled rri,, ls ha ve ~hmvn the effi
cacy of injec tion therapy (6- 12 ), irs
simp lic ity, safel y nnd low cost ,1re great
advan rnge, . C ompa rnt ive st ud ies h ,we
a lso sh own th a t its efficacy seems to he
equa l tn th at o f thenm1 l methmb such
as YAC laser ( 12 ) or mulripo lar clcc
t rncoagu lation ( 13 ), while s imi lar m
inferior resul t~ have hcen ac hieved
compared wi th he at prohc~ ( 14, l 5 ).
The prc~elll report descr ibe~ the
re~Lil ts achie ved with injec t ion thernpy
in a large se ries of ra t icn ts ad mi u ed
consecuti ve ly with a h leed ing peptic
ulcer at h igh ris k of furt he r h emor
rhage, assessed hy th e prese nce nf ac tive
arte rial hlced ing, o r a nnnhleed ing
v i, ihle vesse l. s ~m1e technical varia
tio ns suc h as the use of a second emer
gen cy injec tio n in the ma nagement of
thernpcutic fai lures were a lsn evaluated.
PAT IENTS AND METHODS During a 4 2-mon th period ( 19ti7-
9 J) , 1880 p,ltien ts were adm in ed to the
a utho rs' h ospital hecause n( co n fi rmed
upper gastroimestina l hemmrhagc.
Emergency endoscopy was pe rlnrmed
in all within 4 h of adm ission, afte r
resusc itatio n me;1s11res ,ind lavage hy
rnisogast ric tuhe. Endoscopy d isc losed
34 1 patien ts with gastr,,duodenal ul
cers a nd ac tive a rterial bleed ing nr ,1
non hleed ing l'is i hie vessel. J njecrinn
th erapy was pe rformed in a ll uf t hese
p,n ien ts. No pa Li ent wa, cxcl 11, led be
c;1usc uf technic.:;1 [ prnhlem:,, the
se verity of b leeding or t he locm ion ot
the ulce r. No oth er selection c rite ri a
were used .
Em ergency endoscnpy \\':l~ perfor
med using a n O lympus !T IO nr IT20
fih rescope. V igomus washing of the
u lce r floor 11·as carri ed nut when re
qu ired to remove c luts and de hri s. A drl•n a li nc injec tio n was pe rfo rmed
with a Micn>vas ive l 123 need le {Mas
sachusetts ), during the same emergency
p rocedure. Snme patients were a lso in
c luded in twn cnn t rn lled t riab to
evaluat e whe ther addi Lion o( rh n lmhin
( 16 ) or 1% pnlidornn n l (1 7 ) cou ld im
pruve th e results achie ved wit h ad ren .1li ne ,done. Adrerd ine ( l / 10,000) was
injec ted in a liquots n f l .0 to 2.0 ml firsl
a round and t he n in to th e visible vessel
m (Wer and a round rhe bleeding a rcn,
up to a w t al of IO LO 15 ml. A fte r
therapeu tic e ndoscopy, nil pat ien ts
were admi t ted to t he gastrointest inal
hlecding unit.
W h enever r oss ih lc a second clec
ti \'e endoscn py was performed be tween
the second and the t hird day after th e
emergency procedure. W he n a , ·isihlc
vessel was identifi ed a t the time ,if t h b
e lect ive endnscopy, ,, Sl'Cond injec t i( l!l
was carried o ut by the sam e meth od as descri bed ahove.
Pe rmanen t h em nstas is was d efined
.1s cessatio n o f b leeding ( initia l h emostasis ) and absence of recurrence du ring
lh )spi La lizatio n. T rea l me nc was con
s ide red a failure if th e re were s igns of further bleed ing afLer t he emergen cy
injec tion treatmen t. Furth e r bleeding
was defin eJ as one of the fo llowing:
act h'C bleeding m repe:n ed endo,copy;
vomit ing of fresh h lood or bloody
nsp irn te., a fter pre\' icius cle,, r la"ages hy
nasogast ri c t uhe; u r th e passage of fresh
melena , p lus: hernodyn am ic and c lini
ca l e\' iden ce ofhypovll lemia; lll' a fo ll of
h l'llHlgl,lhin requiring transfusion. Rc
pe,u cd endoscopy when the rapeuti c
fai lure occurred ll'as nrn mancla ted hv
the prow col and \\'ils only pe rfllrmed Ill c ase nf do u ht.
' S tuden t \ r test and th e x.- test with the Y,1tcs' correc tio n when necessary.
were used for swtisti cal ,u1alysis.
P<0.0 5 was conside red stmht ically significan t. Cont in uo us , ·m iah b , were ex
pressed as mean ± one standard dc,·iation.
RESULTS Ot the 14 l patients included , 1 h ere
were 230 males and l I l fema les, wi1 h a
mean age of 64.9± 15 years. T he lucatio n of Lhe ulce r wm, gastri c in I l O casl's
(12.3%). duodenal in 198 (58 "o).
pyloric in 16 ( 4. 7% ) nnd ~wm al in l 7 ( 5'\, ). A ct ivc sp urt mg h leed mg was d is· c losed in 12 patients (3 .5% ), Oll: ing 111
107 (3 l .41}h ) and a no n hlccd m g \'isihlc
\'esse l in th e rem aini ng 222 (65. I 'X,). In I 3 7 pat ien ts there 11·,is ,1ssoci ,1ted
l h rnnic di-.ease (40.2°h). In itial hemostasis w,is .1chie \'cd 111
Ill of the 119 pa tients wit h ,K th-e
b leed in g (93%) . Only in twu pa tien ts
was injec t io n therapy impossihle due rn o ngoing h emorrhage with hemu
dyr\ilm 1c imt ahi Ii t y 111 ho t!, cases.
Emergency surgery was perfn rmed in six
l ) f c ighr pa t ien ts with pe rsistent h leed
ing, and definiti ve hemosrnsis wa,
achieved. The re m;1 ining two patient,
d ied withou t furrh e r h emnstmic treat m ent.
Rehleed ing occurred in 75 nf rhl·
33 3 patie nt~ in whnm the hemnrrha.~e had heen cont rn lled initia ll y (22%) at
a mean of 5 3±52 h. In 10 of thesl'
pat ient s emergen cy surge ry was per
form ed (o n e dea th ). In 36 rehleeders a second endoscopic m jection wa, ,ll · tempted and was ~uccessfu l in 20 cases
(55%), hut e me rgency surger~ was re
qu ired in 15 (one J emh) . A nother
r a ti en l d ied withm n surge ry a ft e r the
fai lu re of the second emergency in jec
tion . In rhe remrnning nine rehlceJcrs
no furth e r tre.itment was attempted,
due LO the gravity o f a~soc iated d iseases.
Re hleed ing was se l(- limi tcd in tw11 .ind
the ,it he r seven d ied .
Four ma jo r cum pl icaw ins resu I red
fmm the injec tion tech niq ue { l .2'\1), rwo pe rfor,1110 11, (,m e dent!, after
surgc rv) and t \\'11 asp ira tio n pnc urnoni,1
(o ne dc.irh ). N,, :td \'l· r,e systl' llliL l'f .
266 C:\N J t ~ .. \ ~TRl WNTFR, )[ V( )[ 6 N, l 'i SFl'n:-.tl\l· R/l )c Tl 1111 R J 992
TABLE l Global results of endoscopic injection therapy in 341 patients
Results Initial hemostasis
Rebleeding Emergency surgery Major complications Mortality
Number(%)
333 (97%)
75/333 (22%) 52 (15%) 4 (1.2%) 17 (4.9%)
'Transfusion (mean ± SD) 2.7-t2.7 Hospital stay (days.
mean± SD) 10.9±9.9
'Units of pocked red cells
tects in re latio n to the injected agent~
were observed. Emergency surgery was requ ired in
52 patients ( 15%), in 51 hecause of uncontrolled hemorrhage and in one due ma complication of t he technique.
Injection therapy was successful in 2 58
l'atients after one emergency injection {75 .6%) while permanent hemosrasis
wa, fina lly achieved in 278 cases (81.5%). Transfusinnal requ in.:ment~ were 2.7±2.7 un its nf packed red h lood cells and the du rnrion o( the hospiw l scay was l0.9±9.9 days (Tahle l ).
Overall morta lit y wa~ 17 patients (4.9%) due to the hemorrhage or re
lated to procedurnl complicat1om in 12 cases (3.5%). The remain ing five p.:1-nenrs died from associated diseases after
Jefinitive control of t he hemorrhage. Re ults were also evaluated acc11rd
ing co the stigmata 1l hemorrhage ob
served at the time of the in it ia l emergency endoscopy (T,1hle 2). Pmient~
with a non bleeding visible vesse l had a tendency towards lower rates of therapeutic fai lure, fewer nct:d~ for
emergency surgery, luwcr trnnsfusinnal requiremenrs and ,1 shorter lengrh nf hospital stay alt hough nnne u( the rrends reached ~tatistical significance.
The result~ were alsu analyzed ac
cording to the locmion of the ulcer in regard to large vcsseb. T h erapeutic lailures were signifirnntly more cnm
mon in ulce rs !neared in the poste rior wall of the d uoJ cna I hu I h ( 24 of 48,
50%) than in those at other sites (P<0.05). Therapeutic fo ilu res were nn more frequent in ulcers located at the inferior wall of rhe bulh (zero o( I 0) m
!ugh in the lesser gastric curvat urc ( fi vc
of 19, 26%).
Endoscopic injection in bleeding ulcers
TABLE 2 Results of endoscopic injection therapy in 341 patients according to the stigmata of hemorrhage disclosed at admission
Active bleeding Nonbleeding visible Results (n=l 19) vessel (n=222) Therapeutic failure 35 (29%) 48 (220,.i,)
Emergency surgery 23 (19%) 30(14%) ' Transfusion (mean ± SD) 3.1±3.4 2.5±2.4 Hospital stay (days, mean ± SD) 11.1±9.9 10.7±9.8 Mortality 7 (5%) 10 (5%) Time of rebleeding (h. mean ± SD) 64.9±61.7 44 1±53. l
'Units of pocked red cells. No significant differences between two groups
DISCUSSION Further hemorrhage is the single
most important prognostic focrnr for pau ents with ,1 hlecJmg ulcer ( 18). The presence of act ive arteria l bleeding at
emergency endoscopy b associarcd
with furrhcr hetnllrrhngc in 85% of cases (2), while a nonhlceding vbihlc
vessel on the u lcer floor results 111 a reblecding rate of 35 to 551X, (2). Stigmata of bleed ing also prm·ide a target to
which endoscopic therapy must he addressed rn oblireratc the underlying arte ry ( l 9,20). In the p resent study, all pnrients in whom emergency cnLlo
scopy disc losed srigmma of hemorrhage rece ived injec t ion therapy. The procedure could he performed in a ll hut two o( the 341 cases (0.6%) because of ex
sanguinaring hemnrrhage. Initial hemosrasis was achieved in 93'Xi of cases and permanent hc1m1stasis in 81. 5%, while emergency surgery was required in J 51X, , with an ovcrn ll mor
tality of only 5%. A previous cnntro llcd trd had
simibr rates of efficacy u,ing inject inn
t herapy in a selected high risk popul.1 -1 inn (6) . The results ach ieved in orlwr
controlled trials c,·n luat ing injectHm thcrnpy have hccn simi lar (7- 12) and have been confi rmed by a recent mewana lysis (4). Huwe\'cr, in on ly one of Lhe~e tria ls was morta l ity s ignificrntly improved (9).
T here were four severe comp I icat inns ( 1.2%) in the present study, with
t wo deaths, indicaLing that despite the safe1-y of the tech nique the rate of cnmplicariom is nrn irrelevant. T h u~, a~
suggested by the N l H C o nsensus Confe rence (5), cnrrect ind ication, careful performance n( injections and close
monitoring of patients arc mandatory to improve safct y.
The present results indicated that there was a tendency w11·nrds hcttcr results in patienb injected with a non
hleed ing visible vessel cnmparcd with patients with act ive arteria l hlecding. although the trend d id nm ach ieve statistical significance. ln keeping wllh
nther .iutl·wrs (2 1-23 ). therapeutiL fa ilure 11·as signifirnnrly more frequent in pa1 1cni,, with ulcers at the poslcri,ir
wall o( Lhc duodenal hu lh, clnse to rhc
gasrrndundena I artery. As in previous controlled trials (6-
J 0), the init ial contrul nf hemmrhauc w,b achieved 111 more than 90% o( active bleeders, ~uggcsung that mmt n(
the tinw surgery could he performed ,in
hcmndynamically ,rnhk· patients. The mu1 inc use of a second endo
scopic rrcmmcnt in the presence nf foilurc must he considered with caur inn
as it cnuld incre,1se the mortality by ,lc l:1ying surgery. In the present study ,urgcry was perf1 mned ,1, soon w, evidence nf rcbleeding was elicited. only when a major surgical contrai ndi
c.H inn was present, a second endoscopic treaunent wm, performed. Th is happened in 36 patients and bleeding
was cnnrrnlled in 22 (53.6%) while the remaining required surgery. With this approach there was a very low total
morrnlity ( 17 pat ient~. 4.9%); in on ly 12 cases was death related to the hemorrhage or w complications of treatment (3.5%) .
Few comparative studies have heen
pe,formed to evaluate the mo~t suirnhlc solut ion for injection therapy. In previou~ control led t rinb, the prc~ent
a uthor~ as~c~sed the efficacy nf
267
BALAN7t'I i!C al
adre naline alone Llr comhined with either thrombin ( 15) or I% polido
canol ( 16). Combined injections did not imprnvc outcome.
Present results indicate that cndo,cnpic injection of adrenaline is a simple and effective fir,r therapeutic approach fnr bleeding peptic ulcers at risk of further hemorrhage. Major com
plicarions, although rnrc, arc nnt ir-
REFERENCES I. Cilben L)A. Epidemiol,igy ,ii uppL'r
g;i:-tromresunal hkedmg. G,1,1ro1nte,1 Enclose I 990; 16:S~- I 1.
J Johnston J 11. Emlnscop1c ri,k foct()rs fllr hlccding peptic ulcer. Ua,trointcst Endnsc I 990; 36:S I 6-20.
). I knry L)A, White I. Endnscopic coagul.11 ion for g.ist ru1111c,1 in:d hlceding. N Engl J Med 1988;118:186-7.
4. S,1cb I IS, Ch:ilmL·r, TC. Blum AL, Bcrril.!r J, Pa.l.(an,, D. En,l,"cupic he1m1,1a,1,. An cffcct1v1.! thernpy fnr bleeding peptic ukc•rs. JAMA I 99();264:494-9.
'i. Proceeding, of the Cllnscmu, Conlen:ncc. Therapeutic cmlosc,,py and h lced111g ulcer,: N 111 Consen,us Conlcrcncc:.JAMA 1989;262:I 369-72.
6. R.il,im,1 J, S,1 1n: S. Such J, ct :d. Endn,copi<.. hcmu,w,i, hy l,,cal injection ,ii epinephrine ,md polidncan,11 in hlccding uker. A pwspccuvc randomi:cd trial. End,1,wp1 1988;20:289-91.
7. Pani:.,J. Vl\·erJ, F\lm<: M, Uarrn1-Oli,·;irL':- E, Man.:n C, Carnu J. CPmmlled t nal nf endoscopic ,clcrllsi, in hleeding pcpuc ulcer,. Lancet 1987;1i:1292+
8. Chung SCS. Leun.~ JWC. Steele RIC, Crofts TJ, L1 AKC. Endo,cnp1c injection ,,f ,1dren:1l inc 1;ir;icm·cl1 hleeding ulcer,:,, rnndomi:ed t nal. RrMcdJ 1988;296:1631-3.
9. Pa,cu (), lkighici A, Ac.1 lnuchi I. The effect nl endoscopic hcmnsta,1, with aknhul 011 the mortality rate nf
268
rdcvant. With endoscopic injection, initial hemosrasis can be achieved inn majority of cases. However, the in
cide nce of further hemorrhage i, not negligible, as with any ocher method of 1 hcrnpcutic endn~c,lpy. The prc~ent study shows thar rcbk:ed ing occur, early (at a mean time of 53 h). Further
randomi:cd and controlled triab arc required to evaluate whether pcrfor-
nnnvaricenl upper gastroinre,tin:il hcm,,rrhage. Endo,copy 1989;2 I :5 3-5.
10. Ran.!<lpal C, l\1lmcr KR. Endnswpic injccrion ,clem.,i,: Effective rrcmmenr lnr hlecdmg ulcer. Gut I 991; 12: 727-9.
I I. Chioz:ini G, Bonolu::i F. Pallini P, ct nl. Cnntrnllcd rrif!l of ahsnlute cthannl versu, epinephrine,,, inject.inn agc.:nt in gastrmlundenal hlceding. Cim,t rncntmilogy I 989;96:A86. (Ab,t)
12. Ru1gecn, r. Vantrapcn G. Bmeckacn L, Cnrcman, <.~. Janssen, J, I liclc M. Comp.irisnn ,if cndoscnpic poliJncanol 1nJcctinn and Yag lrn,er therapy lor hkc,ling papt ic 11lcL'r,. Lmcet 1989;1:I 164-7.
I 1. Laine L. Mult ipolnr clectrncoagulminn vcrsu, 111jcc1 i()n therapy in the t rcat mcnt of hked i ng papric ulcer,. A pnispecnve n111dnm1:ed trial. U.1:-1 rncntcrnlngy I 990;99: I 30'l-6.
14. Lin I-IL. T;;ai YT. Lee SL), ct ,11. A pn,,pccuve rand,lmi:cd trial of hem pmhe thcrmncnagulanon versus pure alcolwl mjl'ctilH1 in nunvnrice:il peptic ulcer hem,irrhage. Am J Gast roenterol 1989;8 3:28 3-6.
15. Chun.g SCS, Lcung JWC, Sung J Y, Ln KK, Li AKC. Inject inn or hem probe for hleeding ulcer. Ga,trnentcmlogy I 99 I ; I 00: 33-7.
16. Balan:6 J, \/ illanul'va C, S,iin: S, ct al. I njcct i< ,n therapy < if bleeding papt ic ulcer. A pro,pcctivc, rnml,Hni:ed trial u,ing adrcrn1linc and thromhin. Endn,rnpy I 990;22: 157-9.
17. Balam6 J, Villanueva C, S,\in: S, ct al. Inject ion therapy in hlecdmg papt ic ulcer in a prospective wndnmi:cd trial
mance nf a second early elective treat
ment after the initial con trol nfhcmorrhagc hy injection could improve results by avllid ing rcbleeding (16,24,25). The present authors ,1dvise
surgery in the prc~encc llf therapeutic fa il ure, except when there ,ire major contraindic,1tions. With this approach they achieved a very low morrality rare (4.9%).
u,mg epinephrine v, cpincphn nl' ,ind actuxi,clcrol. Pre,ented ,it the WorlJ Cmgrc,, ul (. ~,1,1 roe men ,logy, I 990.
18. l)c Domhal Ff, Clarke JR, Clamp SE, tvh1lt:i,1 G, Kotwnl MR. Mnrg,111 AG. Pmgnn,ric fac11 ,r, m upper Ci I hleeding. End,1,cnpy 1986; 18(Suppl 2);18:6-10.
19. Swam er, Swre~ DW, Bown SC, ct nl. N ,11ure llf' the hlccd1ng ,·c,,el 111
recurrently hlccdmg gastric ulcers. (~;iwocmemlogy I 986;90:'i95-608.
20. Swain CP. Pa1hophy,1ology of hleedmg lc,ion,. G.1,tnli111e,t Endo,c J 990;36:S2 l-2.
21. Sw;iin Cr, Salm()n PR, Nunhftckl TC. l)oc, ulcer p,is iti,111111flul'llCC prcsenrnt 11111 llr pn lgno,1s ,if upper ga,trointe,tinal hlecding! Gut I 986;27:A6 'lZ.
22. Brullet E. Campn R. Fledo, (;, Rarrnm S, Guhcrn JM . Borda,JM . Site ,rnd ,1:e ul hlceding p,1p11c ulcer. I, thcre :my relatinn to the efficacy d hcmo;;t,11 ic sclerothernpy! Endn,Cl>py I 99 I ;2 3: 73-5.
2l Steele RJC, l\1rK KCM, Croft, TJ. Aclrcnaline injectilin for endn,cnpic hac1rn1:,1a,1, in non-varice,11 upper g,1,Lrointc,1 inal haemorrhage. Rr J Surg 199 I; 78:4 77-9.
24. Pimp! W, Boeck! 0, l lei1wrman lvl, l)aup11nt 0. Emcrgcncy endn,u,py: A b.1,i, (llr l hcrapeut ic deci,ion, in the rremmem nf wvere ga,trnduudcn:1 1 hleedmg. Wl,rld J Surg 1989: I 'l:592-7.
25. Srcelc RJC. Endoscopic haemostasis fnr nnn-\',iricL·,d 11ppcr g;i,tniimc,unal lwmmrhage. RrJ Surg 19S9;76:219-25.
CAN J GA~Tl\01::NTl::Rllt Vrn 6 Nl) 5 Srl'TFMllrn/Ol T lll11:R 1992
Submit your manuscripts athttp://www.hindawi.com
Stem CellsInternational
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
MEDIATORSINFLAMMATION
of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Behavioural Neurology
EndocrinologyInternational Journal of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Disease Markers
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
BioMed Research International
OncologyJournal of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Oxidative Medicine and Cellular Longevity
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
PPAR Research
The Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014
Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Journal of
ObesityJournal of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Computational and Mathematical Methods in Medicine
OphthalmologyJournal of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Diabetes ResearchJournal of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Research and TreatmentAIDS
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Gastroenterology Research and Practice
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Parkinson’s Disease
Evidence-Based Complementary and Alternative Medicine
Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com