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Title: Endoscopic therapy for major peptic ulcer haemorrhage
Author: Church, Nicholas I.
Awarding Body: University of Edinburgh
Current Institution: University of Edinburgh
Date of Award: 2004
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This thesis is based on a randomized, placebo controlled trial comparing heater probe plus thrombin injection with heater probe plus placebo injection for the treatment of high-risk patients with peptic ulcer bleeding. Two hundred and fifty six patients were randomized. There were nine protocol violations, and these were excluded from the analysis. One hundred and twenty seven patients were treated with the heater probe plus thrombin injection; the remainder received heater probe plus placebo injection. Re-bleeding developed in 9 (15%) of thrombin plus heater probe and 17 (15%) of placebo plus heater probe patients. Emergency surgery was necessary in 16 (13%) and 13 (11%) patients respectively. Eight patients in the thrombin group had adverse events compared with four in the placebo group. Eight (6%) of thrombin plus heater probe patients and 14 (12%) of placebo plus heater probe patients and 14 (12%) of placebo plus heater probe patients died (p = 0.21). These results suggest that the combination of thrombin and the heater probe does not confer additional benefit over heater probe and placebo as endoscopic treatment for bleeding peptic ulcer. This trial does not support the use of this combination of haemostatic therapy. A detailed score was used to document the extent of comorbid disease in the trail patients. Outcome was closely related to overall score, higher scores being associated with re-bleeding, surgery and mortality. The impact of different comorbid conditions were assessed using logistic regression analysis. Neurological disease and malignancy were independently associated with re-bleeding. Surgery was required more commonly in patients with neurological and respiratory conditions, and neurological disease, respiratory conditions and renal failure were associated with death. It is a widespread view that endoscopy should be performed as soon as possible after resuscitation in patients with significant upper gastrointestinal bleeding. An analysis of outcomes of the trial patients according to timing of endoscopy showed that re-bleeding and surgery rates were higher in the group in whom endoscopy was performed early, but mortality was unaffected. Endoscopy performed outwith normal working hours was not associated with adverse outcomes. Re-bleeding rates of 15-20% can be expected after initially successful endoscopic therapy. Accurate prediction of those patients at highest risk and allow for better use of intensive monitoring.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available