Approach to adherent clot in peptic ulcer bleeding in a real-life setting: what happens after removing the clot?

Aims Peptic ulcer bleeding (PUB) is a common cause of non-variceal upper gastrointestinal bleeding (NVUGIB). In cases with high-risk stigmata (HRS) endoscopic therapy is recommended. Our aim was to analyze the course of patients with adherent clots found on index endoscopy.

Methods Patients undergoing emergency endoscopy for upper GI bleeding at the Department of Emergency Medicine at Semmelweis University between January 1, 2022 and December 31, 2023 were included in a retrospective cohort analysis. In case of a peptic ulcer with adherent clot, its removal was encouraged according to our in-house protocol. If needed endoscopic treatment was applied as defined by ESGE based on the Forrest classification.

Results There were 92 patients (56 males, 36 females, mean age 74) with PUB and HRS. In 33 patients (35.8%) an adherent clot (Forrest IIb) was detected during index endoscopy, 13 cases in the stomach and 20 cases in the duodenum. The frequency of further HRS was as follows: Forrest Ia: 8.7% (n=8/92), Forrest Ib: 34.4% (n=31/92), Forrest IIa: 22.8% (n=21/92). Rebleeding rate was 10.8% (n=10/92), 30-day mortality was 21.7% (n=20/92). Of the 33 cases with adherent clot, in 25 cases (75.8%) there was an attempt to remove the clot. In eight cases (24.2%) the clot could not be removed. In the 17 cases (51.5%), where the clot was removed successfully, the underlying ulcer got upgraded in four cases (23.5%) to Forrest Ib; and downgraded in 13 cases (76.5%): to Forrest IIc in five cases (29.4%), Forrest III in eight cases (47.1%). During post-endoscopy course six out of the 33 patients (18.1%) experienced rebleeding. In four patients, where clot removal led to active bleeding (Forrest Ib), after initial hemostasis at index endoscopy, one patient required additional treatment during second look endoscopy. In those 13 patients, who got downgraded, three (21.4%) needed repeated endoscopic treatment; whereas in the eight patients, where clot removal was not endeavoured, two needed endoscopic re-treatment. Overall, in five cases endoscopic hemostasis was achieved and one patient required surgery. During a 30-day follow-up 12 patients (36.3%) died, but only one patient related to bleeding and one patient due to complications of surgery.

Conclusions Based on our finding in a small cohort of patients with PUB and an adherent clot, endoscopic removal can be attempted and accomplished. Irrespective of the subsequent finding on the ulcer base, successful endoscopic hemostasis can be achieved on index endoscopy. However, the risk of rebleeding and mortality is comparable to patients with other HRS. Further prospective studies on larger patient cohorts are encouraged.

 

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Conflicts of Interest

Authors do not have any conflict of interest to disclose.

Publication History

Article published online:
27 March 2025