Routine second look endoscopy: Evidence from six randomized trials (Part 3)
The third randomized trial by Saeed et al was restricted to extremely high risk patients, in that they had high risk stigmata as well as a high Baylor bleeding score (pre-endoscopy score greater than five or postendoscopy score greater than 10). Many patients were excluded because they failed to meet the latter criteria, despite having high risk stigmata. Heater probe was the main method of hemostasis, but epinephrine was used in 50% of patients (eg, combination therapy). Forty patients were randomized to either routine second look endoscopy or conservative treatment, which were associated with rebleeding rates of 0% and 24%, respectively.
There were several concerns with the Saeed study. First, an extremely high proportion of active bleeders (70%) were enrolled, which makes it difficult to generalize the results to the average patient with bleeding peptic ulcer disease. Persistent high risk stigmata led to retreatment in 84% of the patients, which is a much higher proportion than in most other studies (19% to 59%) . Third, there was no case of early (within 24 h) rebleeding. In most other studies, approximately 20% of patients had already experienced rebleeding before the second endoscopy at 24 h . Fourth, 40% of rebleeding episodes occurred extremely late (more than 72 h after initial endoscopy), at six and 10 days, respectively. This finding is unexplained but illustrates the extremes that can occur by chance in small studies.