Systematic review of the predictors of recurrent hemorrhage after endoscopic hemostatic therapy for bleeding peptic ulcers.

BACKGROUND: An increased knowledge regarding the predictors of rebleeding after endoscopic therapy for bleeding ulcers should improve clinical management and outcomes. The aim of this systematic review was to identify the strongest and most consistent predictors of rebleeding to assist in the development of tools to stratify and appropriately manage patients after endoscopic therapy.

METHODS: Bibliographic database searches for prospective studies assessing rebleeding after endoscopic therapy for bleeding ulcers were performed. Relevant studies were identified, and data were abstracted in a duplicate and independent fashion. The primary outcomes sought were significant independent predictors of rebleeding by multivariable analyses in > or =2 studies.

RESULTS: Ten articles met the prespecified inclusion criteria. The pooled rate of rebleeding after endoscopic therapy was 16.4%. The independent pre-endoscopic predictors of rebleeding were hemodynamic instability (significant in 5 of 5 studies; summary odds ratio [OR] 2.75, 95% confidence interval [CI] 1.99-3.51) and comorbid illness (significant in 2 of 7 studies; insufficient data to calculate summary OR or report OR range). The independent endoscopic predictors of rebleeding were active bleeding at endoscopy (significant in 5 of 8 studies; summary OR 1.93, 95% CI 1.30-2.55), large ulcer size (significant in 4 of 5 studies; summary OR 2.01, 95% CI 1.21-2.80), posterior duodenal ulcer (significant in 2 of 3 studies; insufficient data to calculate summary OR or report OR range), and lesser gastric curvature ulcer (significant in 2 of 2 studies; insufficient data to calculate summary OR or report OR range).

CONCLUSIONS: The independent predictors of recurrent hemorrhage after endoscopic therapy, particularly those that are the strongest and most consistent in the literature, may be used to select patients who are most likely to benefit from aggressive post-hemostasis care, including intensive care unit (ICU) observation and second-look endoscopy. Prospective studies designed to formally assess the relative utilities of these factors in predicting rebleeding and dictating management are needed.