Comparision of the hemostatic efficacy from the combined bipolar probe coagulation with epinephrine injection and the bipolar proble coagulation alone in the treatment of peptic ulcer

Journal of military pharmaco-medicine No7-2016

COMPARISION OF THE HEMOSTATIC EFFICACY FROM
THE COMBINED BIPOLAR PROBE COAGULATION WITH
EPINEPHRINE INJECTION AND THE BIPOLAR PROBLE
COAGULATION ALONE IN THE TREATMENT OF
PEPTIC ULCER BLEEDING
Le Quang Duc*; Tran Viet Tu**; Nguyen Quang Duat**
SUMMARY
Objectives: This study compared the combined bipolar probe coagulation with epinephrine
injection during endoscopic process with the bipolar probe coagulation alone in the treatment for
patients suffering from peptic ulcer bleeding. Subjects and methods: Patients who were
endoscopically confirmed of peptic ulcer bleeding (active or visible vessel) during the period
from January, 2010 through December, 2014, were prospectively randomized into two groups.
The control group was treated by the bipolar probe coagulation alone (group 1); and the study
group was treated by the combined bipolar probe coagulation with epinephrine injection during
the endoscopic process (group 2). The primary outcomes, in terms of initial hemostasis, rate of
recurrent bleeding within 72 hours, blood transfusion volume after the intervention, duration of
hospital stay, and the potential risk of blood transfusion after the intervention were assessed.
Results: The common rate of initial hemostasis was 97.5% (95.1% and 100% in group 1 and 2,
respectively); the rate of recurrent bleeding in group 1: 5.2%, and group 2: 0% showing the
remarkable success of hemostasis in group 2 (100%) compared to group 1 (90.2%) (p = 0.043);
the blood transfusion after the intervention in group 1 and 2 were 792.9 ± 125.56 (p = 0.370)
and 557.7 ± 41.76 mL, respectively; duration of hospital stay were 9.6 ± 3,01 and 8.9 ± 3.12 days
(p = 0.167). As such, the combination method showed the reduction of the potential risk of blood
transfusion after the intervention from 1.28 - 1.39 times in comparison with the bipolar probe
coagulation alone method. Conclusion: The combined bipolar probe coagulation with epinephrine
injection during the endoscopic process was proved more effective than the bipolar probe
coagulation alone in the treatment of patients suffering from peptic ulcer bleeding.
* Key words: Peptic ulcer bleeding; Hemostasis; Electrical oagulation.

BACKGROUND
Peptic ulcer bleeding is a common
emergency, and can be life-threatening if
patients are not treated timely. Endoscopic
hemostasis is an effective treatment method
for peptic ulcer bleeding reducing the ratio
of dead and surgery [2, 4, 6]. There are
many methods of endoscopic hemostasis,

in which coagulation injection and probe
coagulation are commonly used [2]. Recently,
some activists have conducted the
combination method and observed the
effectiveness in hemostasis for peptic
ulcers [7]. However, there has not been
any study discussing and comparing
the effectiveness among these methods.

* Haiduong General Hospital
** 103 Hospital
Corresponding author: Le Quang Duc ()

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Journal of military pharmaco-medicine No7-2016
Therefore, this study is aiming at:
Compare the hemostatic efficacy between
the bipolar probe coagulation alone and
the combined bipolar probe coagulation

with epinephrine injection during the
endoscopic process.
SUBJECTS AND METHODS
1. Subjects of the study.
122 selected patients among 1,252
patients suffering from peptic ulcer bleeding
who were being treated at the Internal
Digestive Department of the General
Hospital of Haiduong from 01 - 2010 to
12 - 2014.
* Diagnostic criteria: Symptoms including
vomiting of blood or black stool; active
bleeding of Forrest IA, B showed in
endoscopy taken within 24 hours after
admission, and the ulcer with high-risk of
Forrest II A, B.
* Exclusion criteria: Peptic bleeding
by no ulcer, bleeding ulcer with clean
bottoms, large ulcers by stomach cancer,
patient who does not agree to participate
the study.
2. Methods.
* Study method: Patients were selected
in the two groups in the form of coupling,
based on classifications by gender and
age: alone method group (group 1) and
the combined method group (group 2).
The epinephrine injection was conducted
before the probe coagulation. The step of
conduction included: using the 25G needle

associating with the gold probe (7 Fr) to
inject a dose of 1 - 2 mL adrenalin 1/10.000
into 4 plots around the bleeding point.

Probe coagulation was conducted after
that around or directly into the vessels
or the bleeding point with the intensity of
10 - 15 in 5 - 10 seconds. The entire
intervention was implemented using the
Olympus-CV 240 endoscopic system, the
ICC-ERBE 300 probe coagulation system,
the bipolar interject gold probe (Boston
Scientific) which is the probe association
with the injection needle and the probe
coagulation needle. Patients were clinically
monitored, re-tested, screened after 72 hours.
If bleeding recurrence was found, endoscopic
hemostasis shall be applied again.
* Criteria for evaluation:
- Primary hemostasis: (1) Hemostasis:
no evident of bleeding via endoscopic
after the last hemostasis: no flow of blood;
(2) If the bleeding is on-going: other
endoscopical hemostasis shall be conducted
(such as combination of injection and probe
coagulation or clip hemostasis, etc.); (3) If
the bleeding keeps going: patient shall
be intervented by surgery. Monitoring of
bleeding recurrence based on the symptoms
such as vomiting of red blood or

discharging of black tool, or continuous
reduction of Hb within 24h. If the bleeding
recurrence was suspicious, endoscopic
would be conducted again right away and
the treatment would be taken again from
the beginning.
- Assessment after 72 hour: (1) Good
(entire ulcers was hemostasised, no evident
of bleeding); (2) Average (primary hemostasis,
bleeding recurrence afterward causing
reintervention, then being success within
72 hours); (3) Poor (hemostasis failed at
the primary endoscopical intervention and
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Journal of military pharmaco-medicine No7-2016
other method had to be used including
surgery, or the patient was dead).
Assessment of hemostasis (first time,
second time or third time if bleeding
recurrence over and over): “Success” if no
blood flow was found; “Fail” if bleeding is
on-going or recurrent. Assessment of
intervention duration; assessment of the
ratio of recurrent bleeding, the volume of

transfused blood, duration of hospital
stays and some other criteria were included.
The studied data were processed by

SPSS 15.0 using percentage algorithm (%,)
average algorithm accepting standard
deviations, % comparison, and average
values. Test t-student was used for square
algorithm and Mann-Whitney was used with
appropriate deviations for accreditation test.

RESULTS
1. General features.
Table 1: Age, gender and the status of blood coagulation before intervention.
Research targets
Average age

Total, n (%)

Group 1, n (%)

Group 2, n (%)

55.4 ± 16.83

55.4 ± 16.78

55.3 ± 17.02

(15 - 91)

(15 - 87)

(15 - 91)

61/38

42/19

42/19

Gender (male/female)

p
0.957
1

Male patients took 68.9%. Male/female ratio = 2.2/1. There was no difference in terms
of age and gender between the two groups.
Table 2: RBC count, hemoglobin and hematocrit concentration, and blood transfusion
before intervention.
Features
Volume of erythrocytes (T/L)

Concentration of hemoglobin (g/L)

Hematocrit (%)
Ratio of blood transfusion before
intervention
Volume of blood transfusion before
intervention (mL)

Total

Group 1

Group 2

2.9 ± 0.91

2.8 ± 0.92

2.9 ± 0.90

(1,11 - 1,53)

(1.11 - 5.13)

(1,38 - 5.06)

82.7 ± 25.90

79.7 ± 24.47

85.8 ± 27.12

(25 - 144)

(25 - 138)

(41 - 144)

p
0.729

0.200

25.5 ± 7.66

24.9 ± 7.38

25.9 ± 7.95

(10.2 - 43.5)

(10.2 - 42.2)

(12.8 - 43.5)

80/122
(65.6%)

44/61 (72.1%)

36/61 (59.0%)

0.127

n = 54
502.8 ± 23.95
(250 - 1,250)

n = 30
533.3 ± 33.33

(250 - 1,250)

n = 24
464.58 ± 33.31
(250 - 750)

0.423

0.450

There was no difference in terms of volume of hemoglobin as well as volume of
blood transfusion between the two groups before and after intervention. The ratio of
patients who had blood transfused as well as volume of blood transfusion before
intervention also showed no difference.
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Journal of military pharmaco-medicine No7-2016
Table 3: Endoscopic picture before hemostasis.
Endoscopic pictures
before hemostasis

Total

Group 1

Group 2

n (%)

n (%)

n (%)

p

Forrest classification
Forrest IA

2 (1.6)

1 (1.6)

1 (1.6)

1

Forrest IB

39 (32.0)

20 (32.8)

19 (31.1)

0.845

Forrest IIA

28 (23.0)

14 (23.0)

14 (23.0)

1

Forrest IIB

53 (43.4)

26 (42.6)

27 (44.3)

0.856

Total

122 (100)

61 (100)

61 (100)

Location of ulcer
Stomach

30 (24.6)

17 (27.9)

13 (21.3)

0.400

Duodenum

86 (70.5)

41 (67.2)

45 (73.8)

0.427

Stomach + duodenum

6 (4.9)

3 (4.9)

3 (4.9)

1

Ulcer size
< 1 cm

25 (20.5)

12 (19.7)

13 (21.3)

0.823

1 - 2 cm

91 (74.6)

46 (75.4)

45 (73.8)

0.836

> 2 cm

6 (4.9)

3 (4.9)

3 (4.9)

1

Endoscopic pictures were mainly seen in Forrest IB, IIA and IIB with respective ratios
32.0%, 23.0% and 43.4%. The ratio of Forrest IA was rarely seen taking only 1.6%.
There was no difference between the two groups in terms of bleeding level. The common

location of ulcer was seen at duodenum. The ratio ulcer location at duodenum/stomach
= 2.4/1. Ulcer sizes of about 1 - 2 cm took 74.6%. There was no difference between the
two groups in terms of location and size of ulcer.
2. Results from the endoscopic intervention.
Table 4: Pictures of primary hemostasis.
Hemostatic result

Total, n (%)

Group 1, n (%)

Group 2, n (%)

p

Picture of primary hemostasis
Complete hemostasis

119 (97.5)

58 (95.1)

61 (100)

Incomplete hemostasis

3 (2.5)

3 (4.9)

0

On-going bleeding

0

0

0

0.079

Ratio of bleeding recurrence
Yes

3 (2.6)

3 (5.2)

0

No

116 (97.4)

55 (94.8)

61 (100)

0.072

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Journal of military pharmaco-medicine No7-2016
Results from the first time hemostasis
Success

116 (95.1)

55 (90.2)

61 (100)

Fail

6 (4.9)

6 (9.8)

0

0.012
General results of hemostasis
Good

116

55 (90.2)

61 (100)

Average

3

3 (4.9)

0

Poor

3

3 (4.9)

0

The ratio of complete hemostasis after intervention was 97.5%, in which group 1
was 95.1%, group 2 was 100%. 4.9% in group 1 showed incomplete hemostasis therefore
other endoscopic hemostasis methods were mobilized. There was no case of impossible
intervention via endoscopy. Group 1 showed the bleeding recurrence ratio of 5.2%,
which reflected no statistical meaning of p = 0.072 in comparison with group 2.
Table 5: Volume of blood transfusion after intervention and the duration of hospital stays.
Feature

Total (n = 54)

Group 1 (n = 28)

Group 2 (n = 26)

p

Volume of blood transfusion
after intervention

679.6 ± 510.23
(250 - 3,000)

792.9 ± 664.40
(250 - 3,000)

557.7 ± 212.92
(250 - 1,000)

0.091

9.3 ± 3.07
(3 - 22)

9.7 ± 3.01
(4 - 18)

8.9 ± 3.04
(3 - 22)

0.167

Duration of hospital stays

There was no difference in terms of volume of blood transfusion and duration of hospital
stays between the two groups.
3. Assessment of risks factors after intervention.
Table 6: Ratio of required blood transfusion among the sub-groups of light and
heavy blood lost.
Ratio of required blood transfusion
HR
Group with high blood lost (required
blood transfusion before intervention)
Group with low blood lost (no requirement
of blood transfusion before intervention)

Group 1 (n = 30)

Group 2 (n = 24)

p1 = 16/30 (53.3%)

p2 = 10/24 (41.7%)

n = 31

n = 37

p1 = 14/31 (45.2%)

p2 = 12/37 (32.4%)

p1/p2 = 1.28

p1/p2 = 1.39

Group with high blood lost: risk of blood transfusion again in group 1 was 1.28 time
higher than group 2. Group with low blood lost: risk of blood transfusion again in group
1 was 1.39 time higher than group 2.
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DISCUSSION
1. General features.
*Age and gender:
Average age of the studied groups was
55.4 ± 16.83, the youngest was 15 and
the highest was 91 years old. Among the
122 patients, male took 68.9%, male/female
ratio = 2.24. This ratio was similar with the
ratio of the studies from in-country activist
such as Tran Viet Tu [3], and from outcountry activist such as Bianco et al
75% [5], Chau et al 64.9% and 70,5%,
Soon et al 73.0% [9]. There was no
difference in terms of average age and
gender ratio between the two studied
groups.
* Clinical and subclinical features:
Regarding the CBC value, average
hemoglobin concentration was 82.8 ±
25.91 g/L, similarly to the study taken by
Bianco [5]. Results showed that majority

of patients suffered from average to high
blood lost levels and this feature is shown
similarly in both groups.
* Characteristics of peptic ulcers:
In this study, the endoscopic pictures
were mainly Forrest IB, IIA and IIB with
respective ratios of 32.0%, 23.0% and
43.4%. The ratio of Forrest IA was rarely
seen taken 1.6%. Majority of ratios were
similar to the studies conducted by in and
out country activists, but showed lower
ratio of Forrest IA compared with the
studies conducted by Dao Van Long [1],
Tran Viet Tu [2]. Ulcer size of more than
1 cm took 79.5% associating with potential
risk of bleeding and high blood lost.

The observation of endoscopical pictures
showed no difference in terms of ulcers’
characteristics.
2. Results from the endoscopic
intervention.
Results from endoscopic intervention
were assessed based on the primary
hemostasis. The overall results from the
combined groups reached 100%. The bipolar
probe coagulation alone group reached
95.1%; the other 4.9% of patients was
seen on-going bleeding, therefore other
endoscopic hemostatic methods including

hemostatic injection and clipping were
applied.
Although the intervention of endoscopic
alone was effective in the treatment of
ulcer in stomach and duodenum, a small
recurrent ratio remained [2]. As such, later
studies tried to improve the results by the
combined methods. Based on different
hemostatic theories, adrenalin was proved
to be the active factor for hemostasis
inside the endogenous arteries resulting
vasoconstriction and therefore making it
easier for coagulation. The thermal probe
can result in the artery inflow causing
organizational coagulation and therefore
activate the coagulation in the arteries
and cause the swelling which help to
pinch the artery. Via each probe point, the
blood flow would be seen decreasing and
coagulating completely [4, 6]. This study
showed the good result on 100% of
patients in their initial hemostasis. This
result fit with the conclusion by Bianco
and Chau confirming the role of adrenalin
associating with other methods [5].
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Journal of military pharmaco-medicine No7-2016
The long-term hemostasis was assessed

by the clinical criteria such as color of
discharge of patients was gradually brighten
and the picture of ulcer bottom was clean.
After 72h, patients were re-endoscopically
tested. The general hemostatic result in
the combined group was 100% good.
3. Assessment of post-intervention
risks.
The result showed that the primary
hemostasis in the combined group was
remarkable good compared to the bipolar
probe coagulation alone group. The analysis
of post-intervention criteria such as the
duration of hospital stays and the volume

CONCLUSION
The bipolar probe coagulation alone
and the combined bipolar probe coagulation
with epinephrine injection were proved to
be effective in treatment of peptic ulcer
bleeding. Particularly, the combination
of the bipolar probe coagulation alone
associating with adrenalin injection during
the endoscopic process showed better
result. 100% of patients enjoyed the
complete hemostasis only after the first
intervention reducing the risk of blood
re-transfusion after intervention from
1.28 - 1.39 compared to the bipolar probe
coagulation alone.

of blood transfusion after the intervention
were conducted. However, no difference

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Digestive Science. Episol VII. 2012, No 28,
pg.1827-1834.

The volume of blood transfusion in the
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