Clips arguably treatment of choice for upper GI bleeding

For patients with acute nonvariceal upper gastrointestinal (GI) tract bleeding, recent data show that the use of endoscopic clips alone or in combination with injection therapy achieves superior durable hemostasis than thermocoagulation alone or in combination with injection therapy.

Whenever feasible, it may be better to apply endoscopic clips than to use thermocoagulation with or without injection therapy for durable hemostasis in patients with nonvariceal acute upper GI bleeding, said by the study’s leader author, an assistant clinical professor of medicine at the University of California San Francisco, Fresno, and School of Medicine. He added that currently, injection therapy combined with coagulation is used more often than endoscopic clips for this indication.

In the study, he and his colleagues retrospectively reviewed the charts of 213 patients treated at their institution for acute nonvariceal upper GI bleeding between 2005 and 2006. Only patients who had active bleeding or were at high risk for rebleeding and who received endoscopic treatment were included in the study. The investigators divided the patients into two groups, those treated with endoscopic clips with or without injection therapy (n=78) and those treated with thermocoagulation with or without injection therapy (n=135).

Based on assessment of in-hospital rebleeding rates, significantly fewer patients treated with endoscopic clips experienced rebleeding compared with patients treated with thermocoagulation (0.0% vs. 5.9%, respectively; P<0.03).

A Professor of medicine and chief, Division of Gastroenterology and Hepatology, John Hopkins Hospital, Baltimore, was not surprised that clips were superior to other treatment modalities.

He said that one of the disadvantages of thermal therapies, and other therapies that cause mucosal injury, are usually followed by mucosal ulceration, which can present with delayed bleeding. On the other hand, clips have the disadvantage of needing to be placed precisely. Location of lesion and the presence of active bleeding make (clips) difficult to use, adding that using clips requires a bit more endoscopic skill, which would be considered a relative disadvantage to thermal or injection therapy in which accuracy is not as critical.

The lead author agrees that the clips can be more technically challenging, but emphasized that the clips used in his study are a new type that have several advantages compared with older models. He explained that the older clips could be closed only once, so if the location was not exactly what the endoscopist wanted, then nothing could be done about it. The newer clip can be opened and closed several times before it is deployed by the assistant, allowing repositioning of the clip to a more optimal location if the endoscopist does not like the original site. Better positioning leads to better outcomes.

Although the author concluded that clips should now be considered the treatment of choice for acute nonvariceal upper GI bleeding.

If to choose therapies for active bleeding, inject first and then once the bleeding has adequately slowed down, use the clips. If there is no active bleeding and seem well, use the clips.