Peptic ulcer diseases (PUD) remain the most common cause of hospitalized upper GI bleeding patients (30%-60%). Upper endoscopy is needed for diagnosis, stratification, and endoscopic hemostatic therapy of these ulcers depending on the presence of stigmata of increased risk of rebleeding. PUDs with adherent clot (Forrest classification IIb) are at 20-30% risk of rebleeding with a 7% mortality rate. Recent ACG guidelines could not reach a recommendation for or against endoscopic interventions for ulcers with adherent clot resistant to vigorous irrigation. This systematic review and meta-analysis aims to analyze the randomized studies for the treatment of PUD with adherent clot.


The OVID/Medline and Google Scholar databases were screened through June 2021 for randomized studies reporting outcomes (rebleeding and mortality rates) in patients with adherent clot undergoing either endoscopic or medical intervention. Random effects models were used for the meta-analysis. I2 statistics were used to interpret heterogeneity, with I2>75% indicating substantial inter-study variation. A sensitivity analysis was performed using the leave one out method. A p-value < 0.05 was considered statistically significant.


Initial database search yielded 1568 articles, of which 8 randomized studies were finally included (Table 1). The total sample size consisted of 713 patients with adherent clot; of which 359 underwent endoscopic intervention while 354 were treated with medical therapy alone (proton pump inhibitors). Meta-analysis of re-bleeding and mortality rates between endoscopic and medical treatment groups revealed a decreased risk of rebleeding with endoscopic intervention (OR 0.247, 95%CI: 0.122-0.498, P=< 0.001) (Figure 1A). Mortality rates (OR 0.573, 95% CI: 0.273-1.204, P=0.151) (Figure 1B), and rates of surgery did not differ significantly between the two cohorts (OR 1.177, 95%CI: 0.598-2.317, P=0.638). However, there was heterogeneity in the type of endoscopic interventions used.


The results of our meta-analysis show that endoscopic interventions could benefit patients presenting to the hospital with UGIB due to PUD with adherent clot by decreasing risk of rebleeding. However, there was no effect of endoscopic therapy on mortality. Further, high-quality randomized controlled studies are needed to guide the endoscopists about managing PUD with adherent clot.

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The American Journal of Gastroenterology