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Peptic ulceration remains the commonest cause of acute upper gastrointestinal (UGI) bleeding, accounting for 30%-50% of cases. 1- 3 In the United Kingdom, bleeding peptic ulcer accounts for approximately 15 000 hospital admissions per year, 2 with a district general hospital admitting one to two patients with a bleeding peptic ulcer per week. Although bleeding ceases spontaneously in at least 80% of cases, a subgroup of patients either continue to bleed or re-bleed at a later time, 4, 5 and this is associated with an increased mortality. Upper gastrointestinal endoscopy has not only been useful in stratifying this "high risk" group of patients, but has evolved over the last two decades into the initial therapeutic intervention of choice. 6, 7
Since the landmark study by Chung et al , 8 in which adrenaline injection of bleeding ulcers was shown to be significantly better than no treatment, multiple single centre randomised controlled trials (RCTs) have confirmed the efficacy of endoscopic haemostasis. 9- 20 Endoscopic haemostasis modalities that have been proved to be beneficial include either single agents (adrenaline or a sclerosant 8, 10, 12 ) or combination therapy (usually adrenaline/sclerosant plus a thermal modality such as heater probe application 11, 13- 15 ). As recurrent bleeding after initial haemostasis is the single most important prognostic factor contributing to mortality, 5 the re-bleeding rate has been a useful reference endpoint to compare various trial results. Peptic ulcers which have an actively bleeding/spurting vessel, non-bleeding visible vessel, or adherent clot seen at initial endoscopy are known to have re-bleeding rates of 70%-95%, 50%-70%, and 30%-45% respectively. 6, 7 Although trials of endoscopic haemostasis have clearly demonstrated reduced re-bleeding overall, the results have been very variable. While some units have reported re-bleeding rates between 5%-10% using either single or combination therapy, 9- 14 others have reported re-bleeding rates as high as 40%. 18- 20 The different endoscopic modalities used may be an explanation for variable re-bleeding rates, although other factors such as endoscopist experience and patient co-morbidity are also likely to have contributed to variability in published outcome data.
A possible role for therapeutic endoscopy in peptic ulcer re-bleeding after initial endoscopic haemostasis has been addressed recently. 21 Traditionally, patients who have re-bled after initial endoscopic haemostasis have...