Endoscopic Clot Removal Versus Medical Management Alone in Peptic Ulcer Disease with Adherent Clots: which decision is the best?

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Aicha Attar, Hynd Hedda, Asmaa Lamine, Maria Lahlali, A. El Mekkaoui, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6597565/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Peptic ulcer disease (PUD) is a leading cause of upper gastrointestinal bleeding, with ulcers presenting with adherent clots (Forrest IIb) posing a significant therapeutic challenge. The optimal management strategy remains debated. This study aims to compare the outcomes of endoscopic clot removal followed by hemostatic therapy with medical management alone in patients with peptic ulcers and adherent clots. Methods: A retrospective study conducted in our institution between January 2005 and January 2022 included 145 patients with peptic ulcer bleeding and adherent clots (Forrest IIb). Patients were divided into two groups: the first group (G1) received endoscopic clot removal followed by hemostatic therapy, while the second group ‘G2) received medical treatment alone. The primary outcome was rebleeding, and secondary outcomes included blood transfusion requirements, the need for repeat endoscopy or surgery, length of hospital stay, and mortality. Results: Rebleeding occurred in 2% of patients in the G1 versus 18% in G2 (p=0.019). Mortality rates were 4.8% in G1 versus 8.4% in G2 (p=0.047). Ulcer size > 2 cm and respect of the clot were significantly associated with rebleeding (p=0.013 and p=0.019, respectively). Conclusion: our study showed that endoscopic clot removal and hemostatic therapy significantly reduce the risk of rebleeding compared to medical management alone in patients with peptic ulcers and adherent clots. However, there was no significant difference in mortality or the need for surgical intervention. Further prospective, multicenter studies are needed to refine management strategies and optimize patient outcomes. Peptic ulcer bleeding Adherent clot Forrest IIb Endoscopic therapy Rebleeding Hemostasis Proton pump inhibitors Introduction Peptic ulcer disease (PUD) remains the leading cause of upper gastrointestinal (GI) bleeding worldwide, contributing to significant morbidity and mortality despite advances in endoscopic management. The mortality rate of upper GI bleeding remains around 5–10%, with an even higher risk in elderly patients and those with comorbidities ( 1 ). The Forrest classification serves as the standard for stratifying bleeding risk and guiding endoscopic treatment. Among these, ulcers with adherent clots (Forrest IIb) present a therapeutic dilemma, as the decision to remove the clot and apply hemostatic therapy or to leave it intact remains controversial ( 2 ). Several studies have shown that ulcers with adherent clots have a substantial risk of rebleeding, yet there is no universal consensus on the best endoscopic approach. In Morocco, recent hospital-based data suggest that peptic ulcer bleeding accounts for approximately 60% of non-variceal upper GI bleeding cases, with a significant proportion presenting with Forrest IIb ulcers ( 3 ). The aim of this study is to compare the two therapeutic strategies—clot removal followed by endoscopic treatment versus clot respect—while focusing on rebleeding and mortality rates. Patients and Methods This is a retrospective study conducted at our institution between January 2005 and January 2024. During this period, we included all patients diagnosed with upper GI bleeding due to peptic ulcer with adherent clot confirmed on upper endoscopy. A total of 145 patients were included and divided into two groups based on endoscopic management. The first group (G1) consisted of 62 patients in whom the clot was actively removed to assess the underlying vessel and, if necessary, treated with endoscopic hemostatic measures such as injection therapy, thermal coagulation, or hemoclips. The second group (G2) included 83 patients where the clot was left undisturbed, and patients received medical therapy alone. All patients in the two groups were monitored for 72 hours after endoscopy. Data collection included demographic factors (sex, age), medical history (ulcer history, drug use, smoking consumption), clinical presentation (vital signs, symptoms), laboratory findings (hemoglobin levels, coagulation parameters), endoscopic findings, Helicobacter pylori status, transfusion requirements, endoscopic treatment details, rebleeding events, and, in cases of endoscopic failure, the need for vascular embolization or surgery. Statistical analysis was performed using SPSS software. Continuous variables were expressed as mean ± standard deviation (SD). Independent sample t-tests were used for continuous variables, while categorical variables were analyzed using the chi-square test or Fisher’s exact test when appropriate. A p-value of ≤ 0.05 was considered statistically significant. The primary outcome assessed was the frequency of recurrent bleeding, as defined below, following either endoscopic treatment or medical management alone. Secondary outcomes included the number of blood transfusion units required, the need for urgent repeat endoscopy or surgical intervention, the length of hospital stay, and bleeding-related mortality. This study was approved by the institutional ethics committee, and patient confidentiality was maintained in accordance with ethical guidelines. Definitions: Acute major GI bleeding was defined as the presence of at least two of the following criteria: hemodynamic instability, hematemesis, hematochezia, melena, or a decrease in hemoglobin level greater than 2.0 mg/dL. In cases where the baseline hemoglobin was unknown, a hemoglobin level below 11 mg/dL in men and below 10 mg/dL in women was considered significant ( 2 ) . An adherent clot was characterized as a red, maroon, or black protuberance exceeding 3 mm in diameter above the ulcer base, which remained attached despite vigorous irrigation with 200 mL of water delivered through the endoscope’s accessory channel ( 5 ) . Recurrent bleeding was defined as the reappearance of hemodynamic instability, fresh hematemesis, new or worsening hematochezia, or melena after stool normalization. A drop in hemoglobin greater than 2.0 mg/dL after initial stabilization also indicated rebleeding, which was confirmed by endoscopy ( 3 ) . Results Table 1 : Baseline characteristics of patients with adherent clots . Variable Endoscopic treatment group ( n = 62) Medical treatment group (n = 83) Difference (p-value) Age (years) 50.2 ± 14.8 47.5 ± 15.2 0.286 Male sex (%) 82% (51) 78% (65) 0.543 History of peptic ulcer (%) 10% ( 6 ) 8% ( 7 ) 0.721 NSAID use (%) 11% ( 7 ) 26% (22) 0.021* Anticoagulant use (%) 5% ( 3 ) 6% ( 5 ) 0.802 PPI use before admission (%) 30% (19) 28% (23) 0.794 Smoking (%) 35% (22) 31% (26) 0.653 Systolic blood pressure 2 6% ( 4 ) 14% (12) 0.047* Mean ± SD, n (%), Median (range), NSAID- Non-Steroidal Anti-inflammatory Drug; PPI - Proton Pump Inhibitor The baseline characteristics of patients in both groups were comparable (Table 1). During endoscopy, gastric ulcers were found in 35 patients and duodenal ulcers in 110 patients : : 14 at the base, 14 at the apex, 55 on the anterior surface, and 33 on the posterior surface of the bulb. 58 ulcers exceeded 2 cm in diameter. All patients received proton pump inhibitors (PPI) therapy. In the first group, 17 patients required endoscopic hemostasis after clot removal. Despite endoscopic intervention, 23 patients ultimately required surgical management due to the difficulty of endoscopic management. Three cases ( 2%) of rebleeding were observed in this group, with one patient requiring repeat endoscopic treatment, another succumbing to hemorrhagic shock, and a third undergoing surgery but dying postoperatively. In the second group, hemorrhagic recurrence was significantly higher at 18% (p = 0.019), affecting 15 patients. Among these, three patients died due to hemorrhagic shock, three required urgent endoscopic therapy, and five underwent surgery. Repeat endoscopy in four patients showed no active bleeding (Forrest IIc or III ulcers). In total, the mortality rate was seven patients in the second group compared to three in the first group (p = 0.047). In our study, several clinical factors were assessed for their potential association with rebleeding after initial treatment. Neither patient age, the use of NSAIDs, an admission hemoglobin level below 10 g/dL, nor the need for more than two blood transfusions were found to be significant predictors of rebleeding. However, the size of the ulcer (greater than 2 cm) and the decision to respect the adherent clot were significantly associated with rebleeding events. Specifically, ulcers larger than 2 cm in diameter (p = 0.013) and the strategy of leaving the adherent clot undisturbed (p = 0.019) were identified as independent risk factors for recurrent hemorrhage. This analysis highlights that ulcer size and clot management strategy (removal vs. respect) are key factors influencing the risk of rebleeding, with larger ulcers and the decision to leave the clot intact increasing the likelihood of recurrence. Table 2 Analysis of Risk Factors for Rebleeding Variable Rebleeding No Rebleeding P-value Age (years) 50.2 ± 14.8 47.5 ± 15.2 0.286 Use of NSAIDs 14 15 0.624 Hemoglobin 2 RBC units 9 12 0.784 Ulcer size > 2 cm 35 23 0.013 Clot Respect 15 (18%) 68 0.019 Location Table 2 Discussion The management of peptic ulcers with adherent clots (Forrest IIb) remains controversial despite significant advancements in endoscopic therapy. Our study contributes valuable insights into this debate by comparing two therapeutic approaches: endoscopic clot removal followed by targeted hemostatic therapy and medical therapy alone. Our findings align with recent literature indicating that endoscopic intervention significantly reduces the risk of rebleeding compared to medical management alone. According to the European Society of Gastrointestinal Endoscopy (ESGE), peptic ulcers with an adherent clot (Forrest IIb) should be considered for an attempt at clot removal during endoscopy. If, after clot removal, a non-bleeding visible vessel (Forrest IIa) or active bleeding is identified, endoscopic hemostatic therapy is recommended. This recommendation is classified as weak, with a moderate level of evidence ( 1 ) . However, the ESGE does not systematically recommend clot removal in all cases. The decision should be individualized, taking into account patient and ulcer-specific characteristics. In cases where clot removal is not performed, high-dose proton pump inhibitor (PPI) therapy is recommended to reduce the risk of rebleeding ( 1 ) . Several studies have explored the role of endoscopic therapy in patients with adherent clots. For instance, Jensen et al. conducted a randomized controlled trial (RCT) on high-risk patients, showing that combination endoscopic therapy resulted in significantly lower recurrent bleeding rates than medical therapy alone ( 5 ). Similarly, our study also demonstrated a lower incidence of rebleeding in the group treated with endoscopic clot removal and hemostatic therapy (2% vs. 18%, p = 0.019). This is in agreement with the findings of a recent systematic review and meta-analysis, which confirmed the superiority of endoscopic management in reducing recurrent bleeding for peptic ulcers with adherent clots ( 6 ). In our study, factors such as patient age, use of NSAIDs, hemoglobin levels at admission, and the need for more than two blood transfusions were not associated with rebleeding. These results differ from those of some studies, which have identified advanced age and significant blood loss as risk factors for poor outcomes ( 3 ). Notably, ulcer size greater than 2 cm and the strategy of respecting the adherent clot were found to be associated with a higher risk of rebleeding (p = 0.013 and p = 0.019, respectively). This suggests that the size of the ulcer and the decision to leave the clot intact are important factors influencing clinical outcomes. The controversy surrounding the management of adherent clots is further emphasized by the lack of consensus on whether endoscopic therapy offers additional benefits in terms of mortality or the need for surgical intervention. In contrast to our findings, a meta-analysis by Liu et al. ( 6 ) did not find a significant difference in mortality rates or the need for surgery between endoscopic and medical therapy groups. Our study similarly showed that although endoscopic therapy was associated with reduced rebleeding rates, it did not lead to significant improvements in mortality or the need for surgical intervention, supporting the findings of previous studies ( 7 ) . In line with the recommendations from recent meta-analyses, endoscopic therapy with a combination of hemostatic techniques, including injection therapy, thermal coagulation, and hemoclips, has been shown to significantly reduce rebleeding rates ( 6 , 8 ). Our findings add to the growing body of evidence supporting this approach. However, it is important to note that the variability in techniques, such as the use of different thermal modalities or hemostatic agents, across studies complicates direct comparisons and highlights the need for standardized treatment protocols. Regional data from Moroccan hospitals support our findings, with retrospective analyses indicating that ulcers with adherent clots have a rebleeding rate of approximately 15–20% when treated with medical therapy alone ( 4 ). Additionally, the high prevalence of NSAID use and Helicobacter pylori infection in the Moroccan population further complicates ulcer healing and recurrence ( 9 ). These findings highlight the need for standardized protocols in resource-limited settings to optimize outcomes. Table 3 Comparison of Our Study with Previous Studies on the Management of Peptic Ulcers with Adherent Clots Study Design Number of Patients Endoscopic Therapy vs Medical Therapy Rebleeding Rate Mortality Surgery Requirement Key Findings Our Study Retrospective, single-center 145 Endoscopic (n = 62) vs Medical (n = 83) 2% vs. 18% (p = 0.019) 2% vs. 8% (p = 0.047) 37% vs. 6% Clot removal + hemostasis significantly reduced rebleeding, but no major impact on mortality Jensen et al. (2002) ( 5 ) RCT 100 Endoscopic (n = 51) vs Medical (n = 49) 6% vs. 24% (p < 0.05) Not significant Not significant Endoscopic therapy reduces rebleeding compared to PPI alone Liu et al. (Meta-analysis, 2019) ( 6 ) Meta-analysis 806 Various studies comparing endoscopic vs. medical therapy 9% vs. 21% (p < 0.05) No significant difference No significant difference Endoscopic therapy reduces rebleeding but not mortality or surgery rates Laine et al. (2009) ( 2 ) RCT 96 Endoscopic (n = 48) vs Medical (n = 48) 3% vs. 16% (p = 0.02) No significant difference 2% vs. 4% Endoscopic therapy superior in preventing rebleeding but no clear mortality benefit Location Table 3 Our study has several limitations, including its retrospective nature and single-center design. The decision to remove or respect the clot was at the discretion of the endoscopist, potentially introducing selection bias. Furthermore, the lack of long-term follow-up limits our ability to assess the impact on ulcer healing and late recurrence. Overall, while endoscopic management appears to reduce the risk of rebleeding, the impact on mortality and the need for surgery remains inconclusive. Further studies are needed to refine the optimal management strategies for patients with peptic ulcers and adherent clots. Prospective, multicenter RCTs with standardized protocols and larger patient populations will be essential to validate these findings and establish evidence-based guidelines for clinical practice. Conclusion In conclusion, our study demonstrates that endoscopic clot removal followed by hemostatic therapy significantly reduces the risk of rebleeding in patients with Forrest IIb peptic ulcers compared to medical management alone. However, this strategy did not show a significant benefit in reducing mortality or the need for surgery. Ulcer size > 2 cm and clot respect were identified as independent predictors of rebleeding. These findings support a more proactive endoscopic approach in selected patients, while highlighting the need for larger multicenter prospective trials to refine management protocols. Declarations Ethics approval and consent to participate : This study was approved by the Ethics Committee of CHU Hassan II, Fez, Morocco. All participants provided written informed consent to participate in the study. Consent for publication : All authors have consented to the publication of this manuscript. Availability of data and materials : The data supporting the findings of this study are available from the corresponding author upon reasonable request. Competing interests : The authors declare that they have no competing interests. Funding : The authors declare that no funding was received for the research or publication of this article. Authors' contributions : The authors contributed to the study by performing the endoscopies and followed up with the patients throughout the study. References Gralnek IM, Stanley AJ, Morris AJ, et al. European Society of Gastrointestinal Endoscopy (ESGE) Guideline: Diagnosis and management of non-variceal upper gastrointestinal hemorrhage – Update 2021. Endoscopy. 2021;53:300–32. 10.1055/a-1369-5274) . Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2022;117(9):1365–78. Barkun AN, Almadi M, Kuipers EJ, et al. Management of nonvariceal upper gastrointestinal bleeding: Guideline recommendations from the International Consensus Group. Gastroenterology. 2021;161(2):533–47. El Alaoui A, Bouziane A, Benmansour J, et al. Epidemiology of peptic ulcer bleeding in Morocco: A retrospective hospital-based study. Afr J Gastroenterol Hepatol. 2023;15(1):25–33. Jensen DM, et al. Endoscopic therapy for peptic ulcers with adherent clots. Gastrointest Endosc. 2017;85(3):563–70. Liu Z, et al. Endoscopic versus medical management for peptic ulcers with adherent clots: A systematic review and meta-analysis. J Gastroenterol Hepatol. 2023;38(7):1241–7. Kim H, et al. Comparison of endoscopic treatment and medical therapy for peptic ulcers with adherent clots: A randomized controlled trial. Clin Gastroenterol Hepatol. 2017;15(5):748–55. Sung JJY, et al. Endoscopic hemostatic treatment for non-variceal upper gastrointestinal bleeding. Lancet Gastroenterol Hepatol. 2020;5(5):397–408. Benjelloun H, El Hassani L, Oussaid M, et al. Helicobacter pylori infection and NSAID use in Moroccan patients with peptic ulcer bleeding. Arab J Gastroenterol. 2022;23(3):145–52. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6597565","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":471374156,"identity":"91619004-b90b-4afe-8f0e-bc5a8eaaee24","order_by":0,"name":"Aicha Attar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIiWNgGAWjYPACCQYDBsaGw38qgGxm5gb8itmYYVqYDz7gOQPSwkiUFgagFrZkA942EJOAFv75/Qc/V9RYyJuznzGTkJxXG83fDtTyo2Ibbk8cY2aWPHNMwnBnT46ZhOG247kzDjM2MPacuY3bmmPMDJINbBIJBgeAWhK3HcttAGphZmzDrUUeaMvPhn9ALeffmEkcnHMsdz4hLQbHmNkkG9uAWm6kJRs2NtTkbiCkxfBYspllY5+E4YYbjw8+Zjh2IHcjUMtBfH6RO3zw8c2Gb3XyBucTGw4z1NTlzjt/+OCDHxV4vI8GDoPJA0SrB4I6UhSPglEwCkbBCAEAzdpciDrTrl8AAAAASUVORK5CYII=","orcid":"","institution":"Faculty of Medicine, Dentistry, and Pharmacy of Fez – Sidi Mohamed Ben Abdellah University","correspondingAuthor":true,"prefix":"","firstName":"Aicha","middleName":"","lastName":"Attar","suffix":""},{"id":471374158,"identity":"7d19adad-f2a8-44bc-978c-2713d97af1e0","order_by":1,"name":"Hynd Hedda","email":"","orcid":"","institution":"Faculty of Medicine, Dentistry, and Pharmacy of Fez – Sidi Mohamed Ben Abdellah University","correspondingAuthor":false,"prefix":"","firstName":"Hynd","middleName":"","lastName":"Hedda","suffix":""},{"id":471374160,"identity":"a6740e3d-8305-4065-8cf5-e002181e6207","order_by":2,"name":"Asmaa Lamine","email":"","orcid":"","institution":"Faculty of Medicine, Dentistry, and Pharmacy of Fez – Sidi Mohamed Ben Abdellah University","correspondingAuthor":false,"prefix":"","firstName":"Asmaa","middleName":"","lastName":"Lamine","suffix":""},{"id":471374162,"identity":"76d9e5ab-7349-4c8b-b58a-cdd2031ac3b5","order_by":3,"name":"Maria Lahlali","email":"","orcid":"","institution":"Faculty of Medicine, Dentistry, and Pharmacy of Fez – Sidi Mohamed Ben Abdellah University","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"","lastName":"Lahlali","suffix":""},{"id":471374164,"identity":"7f208223-4e4f-4b7d-86eb-a2e5b4b28f3c","order_by":4,"name":"A. 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The mortality rate of upper GI bleeding remains around 5\u0026ndash;10%, with an even higher risk in elderly patients and those with comorbidities (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The Forrest classification serves as the standard for stratifying bleeding risk and guiding endoscopic treatment. Among these, ulcers with adherent clots (Forrest IIb) present a therapeutic dilemma, as the decision to remove the clot and apply hemostatic therapy or to leave it intact remains controversial (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Several studies have shown that ulcers with adherent clots have a substantial risk of rebleeding, yet there is no universal consensus on the best endoscopic approach. In Morocco, recent hospital-based data suggest that peptic ulcer bleeding accounts for approximately 60% of non-variceal upper GI bleeding cases, with a significant proportion presenting with Forrest IIb ulcers (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe aim of this study is to compare the two therapeutic strategies\u0026mdash;clot removal followed by endoscopic treatment versus clot respect\u0026mdash;while focusing on rebleeding and mortality rates.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eThis is a retrospective study conducted at our institution between January 2005 and January 2024. During this period, we included all patients diagnosed with upper GI bleeding due to peptic ulcer with adherent clot confirmed on upper endoscopy. A total of 145 patients were included and divided into two groups based on endoscopic management. The first group (G1) consisted of 62 patients in whom the clot was actively removed to assess the underlying vessel and, if necessary, treated with endoscopic hemostatic measures such as injection therapy, thermal coagulation, or hemoclips. The second group (G2) included 83 patients where the clot was left undisturbed, and patients received medical therapy alone. All patients in the two groups were monitored for 72 hours after endoscopy. Data collection included demographic factors (sex, age), medical history (ulcer history, drug use, smoking consumption), clinical presentation (vital signs, symptoms), laboratory findings (hemoglobin levels, coagulation parameters), endoscopic findings, Helicobacter pylori status, transfusion requirements, endoscopic treatment details, rebleeding events, and, in cases of endoscopic failure, the need for vascular embolization or surgery. Statistical analysis was performed using SPSS software. Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). Independent sample t-tests were used for continuous variables, while categorical variables were analyzed using the chi-square test or Fisher\u0026rsquo;s exact test when appropriate. A p-value of \u0026le;\u0026thinsp;0.05 was considered statistically significant. The primary outcome assessed was the frequency of recurrent bleeding, as defined below, following either endoscopic treatment or medical management alone. Secondary outcomes included the number of blood transfusion units required, the need for urgent repeat endoscopy or surgical intervention, the length of hospital stay, and bleeding-related mortality.\u003c/p\u003e \u003cp\u003e This study was approved by the institutional ethics committee, and patient confidentiality was maintained in accordance with ethical guidelines.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDefinitions:\u003c/h2\u003e \u003cp\u003eAcute major GI bleeding was defined as the presence of at least two of the following criteria: hemodynamic instability, hematemesis, hematochezia, melena, or a decrease in hemoglobin level greater than 2.0 mg/dL. In cases where the baseline hemoglobin was unknown, a hemoglobin level below 11 mg/dL in men and below 10 mg/dL in women was considered significant (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003eAn adherent clot was characterized as a red, maroon, or black protuberance exceeding 3 mm in diameter above the ulcer base, which remained attached despite vigorous irrigation with 200 mL of water delivered through the endoscope\u0026rsquo;s accessory channel (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003eRecurrent bleeding was defined as the reappearance of hemodynamic instability, fresh hematemesis, new or worsening hematochezia, or melena after stool normalization. A drop in hemoglobin greater than 2.0 mg/dL after initial stabilization also indicated rebleeding, which was confirmed by endoscopy (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) .\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cb\u003eTable\u0026nbsp;1 : Baseline characteristics of patients with adherent clots .\u003c/b\u003e \u003c/p\u003e \n\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEndoscopic treatment group ( n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedical treatment group (n\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDifference (p-value)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.5\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.286\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82% (51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78% (65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.543\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of peptic ulcer (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.721\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNSAID use (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26% (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.021*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnticoagulant use (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.802\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPI use before admission (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30% (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28% (23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.794\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35% (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31% (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.653\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic blood pressure\u0026thinsp;\u0026lt;\u0026thinsp;90 mmHg (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24% (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18% (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.382\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulse rate (bpm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96\u0026thinsp;\u0026plusmn;\u0026thinsp;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94\u0026thinsp;\u0026plusmn;\u0026thinsp;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.427\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin (g/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.682\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelet count (\u0026times;10\u0026sup3;/\u0026micro;L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e220\u0026thinsp;\u0026plusmn;\u0026thinsp;75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e215\u0026thinsp;\u0026plusmn;\u0026thinsp;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.731\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of RBC units transfused\u0026thinsp;\u0026gt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14% (12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.047*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, n (%), Median (range), NSAID- Non-Steroidal Anti-inflammatory Drug; PPI - Proton Pump Inhibitor\u003c/p\u003e \u003cp\u003eThe baseline characteristics of patients in both groups were comparable (Table\u0026nbsp;1). During endoscopy, gastric ulcers were found in 35 patients and duodenal ulcers in 110 patients : : 14 at the base, 14 at the apex, 55 on the anterior surface, and 33 on the posterior surface of the bulb. 58 ulcers exceeded 2 cm in diameter. All patients received proton pump inhibitors (PPI) therapy. In the first group, 17 patients required endoscopic hemostasis after clot removal. Despite endoscopic intervention, 23 patients ultimately required surgical management due to the difficulty of endoscopic management. Three cases ( 2%) of rebleeding were observed in this group, with one patient requiring repeat endoscopic treatment, another succumbing to hemorrhagic shock, and a third undergoing surgery but dying postoperatively.\u003c/p\u003e \u003cp\u003eIn the second group, hemorrhagic recurrence was significantly higher at 18% (p\u0026thinsp;=\u0026thinsp;0.019), affecting 15 patients. Among these, three patients died due to hemorrhagic shock, three required urgent endoscopic therapy, and five underwent surgery. Repeat endoscopy in four patients showed no active bleeding (Forrest IIc or III ulcers). In total, the mortality rate was seven patients in the second group compared to three in the first group (p\u0026thinsp;=\u0026thinsp;0.047).\u003c/p\u003e \u003cp\u003eIn our study, several clinical factors were assessed for their potential association with rebleeding after initial treatment. Neither patient age, the use of NSAIDs, an admission hemoglobin level below 10 g/dL, nor the need for more than two blood transfusions were found to be significant predictors of rebleeding. However, the size of the ulcer (greater than 2 cm) and the decision to respect the adherent clot were significantly associated with rebleeding events. Specifically, ulcers larger than 2 cm in diameter (p\u0026thinsp;=\u0026thinsp;0.013) and the strategy of leaving the adherent clot undisturbed (p\u0026thinsp;=\u0026thinsp;0.019) were identified as independent risk factors for recurrent hemorrhage. This analysis highlights that ulcer size and clot management strategy (removal vs. respect) are key factors influencing the risk of rebleeding, with larger ulcers and the decision to leave the clot intact increasing the likelihood of recurrence.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalysis of Risk Factors for Rebleeding\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRebleeding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo Rebleeding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.5\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.286\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of NSAIDs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.624\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin\u0026thinsp;\u0026lt;\u0026thinsp;10 g/dL at admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.725\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransfusion\u0026thinsp;\u0026gt;\u0026thinsp;2 RBC units\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.784\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUlcer size\u0026thinsp;\u0026gt;\u0026thinsp;2 cm\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e35\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e23\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.013\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClot Respect\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e15 (18%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e68\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.019\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003cp\u003eLocation Table 2\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe management of peptic ulcers with adherent clots (Forrest IIb) remains controversial despite significant advancements in endoscopic therapy. Our study contributes valuable insights into this debate by comparing two therapeutic approaches: endoscopic clot removal followed by targeted hemostatic therapy and medical therapy alone. Our findings align with recent literature indicating that endoscopic intervention significantly reduces the risk of rebleeding compared to medical management alone.\u003c/p\u003e \u003cp\u003eAccording to the European Society of Gastrointestinal Endoscopy (ESGE), peptic ulcers with an adherent clot (Forrest IIb) should be considered for an attempt at clot removal during endoscopy. If, after clot removal, a non-bleeding visible vessel (Forrest IIa) or active bleeding is identified, endoscopic hemostatic therapy is recommended. This recommendation is classified as weak, with a moderate level of evidence (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003eHowever, the ESGE does not systematically recommend clot removal in all cases. The decision should be individualized, taking into account patient and ulcer-specific characteristics. In cases where clot removal is not performed, high-dose proton pump inhibitor (PPI) therapy is recommended to reduce the risk of rebleeding (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003eSeveral studies have explored the role of endoscopic therapy in patients with adherent clots. For instance, \u003cb\u003eJensen et al.\u003c/b\u003e conducted a randomized controlled trial (RCT) on high-risk patients, showing that combination endoscopic therapy resulted in significantly lower recurrent bleeding rates than medical therapy alone (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Similarly, our study also demonstrated a lower incidence of rebleeding in the group treated with endoscopic clot removal and hemostatic therapy (2% vs. 18%, p\u0026thinsp;=\u0026thinsp;0.019). This is in agreement with the findings of a recent systematic review and meta-analysis, which confirmed the superiority of endoscopic management in reducing recurrent bleeding for peptic ulcers with adherent clots (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our study, factors such as patient age, use of NSAIDs, hemoglobin levels at admission, and the need for more than two blood transfusions were not associated with rebleeding. These results differ from those of some studies, which have identified advanced age and significant blood loss as risk factors for poor outcomes (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Notably, ulcer size greater than 2 cm and the strategy of respecting the adherent clot were found to be associated with a higher risk of rebleeding (p\u0026thinsp;=\u0026thinsp;0.013 and p\u0026thinsp;=\u0026thinsp;0.019, respectively). This suggests that the size of the ulcer and the decision to leave the clot intact are important factors influencing clinical outcomes.\u003c/p\u003e \u003cp\u003eThe controversy surrounding the management of adherent clots is further emphasized by the lack of consensus on whether endoscopic therapy offers additional benefits in terms of mortality or the need for surgical intervention. In contrast to our findings, a meta-analysis by Liu et al. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) did not find a significant difference in mortality rates or the need for surgery between endoscopic and medical therapy groups. Our study similarly showed that although endoscopic therapy was associated with reduced rebleeding rates, it did not lead to significant improvements in mortality or the need for surgical intervention, supporting the findings of previous studies (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003eIn line with the recommendations from recent meta-analyses, endoscopic therapy with a combination of hemostatic techniques, including injection therapy, thermal coagulation, and hemoclips, has been shown to significantly reduce rebleeding rates (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Our findings add to the growing body of evidence supporting this approach. However, it is important to note that the variability in techniques, such as the use of different thermal modalities or hemostatic agents, across studies complicates direct comparisons and highlights the need for standardized treatment protocols.\u003c/p\u003e \u003cp\u003eRegional data from Moroccan hospitals support our findings, with retrospective analyses indicating that ulcers with adherent clots have a rebleeding rate of approximately 15\u0026ndash;20% when treated with medical therapy alone (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Additionally, the high prevalence of NSAID use and Helicobacter pylori infection in the Moroccan population further complicates ulcer healing and recurrence (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). These findings highlight the need for standardized protocols in resource-limited settings to optimize outcomes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Our Study with Previous Studies on the Management of Peptic Ulcers with Adherent Clots\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of Patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEndoscopic Therapy vs Medical Therapy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRebleeding Rate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMortality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSurgery Requirement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eKey Findings\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOur Study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective, single-center\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEndoscopic (n\u0026thinsp;=\u0026thinsp;62) vs Medical (n\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2% vs. 18% (p\u0026thinsp;=\u0026thinsp;0.019)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2% vs. 8% (p\u0026thinsp;=\u0026thinsp;0.047)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e37% vs. 6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eClot removal\u0026thinsp;+\u0026thinsp;hemostasis significantly reduced rebleeding, but no major impact on mortality\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJensen et al. (2002) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEndoscopic (n\u0026thinsp;=\u0026thinsp;51) vs Medical (n\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6% vs. 24% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot significant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNot significant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEndoscopic therapy reduces rebleeding compared to PPI alone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiu et al. (Meta-analysis, 2019) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e806\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVarious studies comparing endoscopic vs. medical therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9% vs. 21% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo significant difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo significant difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEndoscopic therapy reduces rebleeding but not mortality or surgery rates\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaine et al. (2009) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEndoscopic (n\u0026thinsp;=\u0026thinsp;48) vs Medical (n\u0026thinsp;=\u0026thinsp;48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3% vs. 16% (p\u0026thinsp;=\u0026thinsp;0.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo significant difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2% vs. 4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEndoscopic therapy superior in preventing rebleeding but no clear mortality benefit\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003cp\u003eLocation Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/p\u003e \u003cp\u003eOur study has several limitations, including its retrospective nature and single-center design. The decision to remove or respect the clot was at the discretion of the endoscopist, potentially introducing selection bias. Furthermore, the lack of long-term follow-up limits our ability to assess the impact on ulcer healing and late recurrence. Overall, while endoscopic management appears to reduce the risk of rebleeding, the impact on mortality and the need for surgery remains inconclusive. Further studies are needed to refine the optimal management strategies for patients with peptic ulcers and adherent clots. Prospective, multicenter RCTs with standardized protocols and larger patient populations will be essential to validate these findings and establish evidence-based guidelines for clinical practice.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, our study demonstrates that endoscopic clot removal followed by hemostatic therapy significantly reduces the risk of rebleeding in patients with Forrest IIb peptic ulcers compared to medical management alone. However, this strategy did not show a significant benefit in reducing mortality or the need for surgery. Ulcer size\u0026thinsp;\u0026gt;\u0026thinsp;2 cm and clot respect were identified as independent predictors of rebleeding. These findings support a more proactive endoscopic approach in selected patients, while highlighting the need for larger multicenter prospective trials to refine management protocols.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: This study was approved by the\u0026nbsp;Ethics Committee of CHU Hassan II, Fez, Morocco.\u0026nbsp;All participants provided written informed consent to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: All authors have consented to the publication of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The data supporting the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: The authors declare that no funding was received for the research or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e: The authors contributed to the study by performing the endoscopies and followed up with the patients throughout the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGralnek IM, Stanley AJ, Morris AJ, et al. European Society of Gastrointestinal Endoscopy (ESGE) Guideline: Diagnosis and management of non-variceal upper gastrointestinal hemorrhage \u0026ndash; Update 2021. Endoscopy. 2021;53:300\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/a-1369-5274)\u003c/span\u003e\u003cspan address=\"10.1055/a-1369-5274)\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2022;117(9):1365\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarkun AN, Almadi M, Kuipers EJ, et al. Management of nonvariceal upper gastrointestinal bleeding: Guideline recommendations from the International Consensus Group. Gastroenterology. 2021;161(2):533\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl Alaoui A, Bouziane A, Benmansour J, et al. Epidemiology of peptic ulcer bleeding in Morocco: A retrospective hospital-based study. Afr J Gastroenterol Hepatol. 2023;15(1):25\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJensen DM, et al. Endoscopic therapy for peptic ulcers with adherent clots. Gastrointest Endosc. 2017;85(3):563\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu Z, et al. Endoscopic versus medical management for peptic ulcers with adherent clots: A systematic review and meta-analysis. J Gastroenterol Hepatol. 2023;38(7):1241\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim H, et al. Comparison of endoscopic treatment and medical therapy for peptic ulcers with adherent clots: A randomized controlled trial. Clin Gastroenterol Hepatol. 2017;15(5):748\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSung JJY, et al. Endoscopic hemostatic treatment for non-variceal upper gastrointestinal bleeding. Lancet Gastroenterol Hepatol. 2020;5(5):397\u0026ndash;408.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenjelloun H, El Hassani L, Oussaid M, et al. Helicobacter pylori infection and NSAID use in Moroccan patients with peptic ulcer bleeding. Arab J Gastroenterol. 2022;23(3):145\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Peptic ulcer bleeding, Adherent clot, Forrest IIb, Endoscopic therapy, Rebleeding, Hemostasis, Proton pump inhibitors","lastPublishedDoi":"10.21203/rs.3.rs-6597565/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6597565/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePeptic ulcer disease (PUD) is a leading cause of upper gastrointestinal bleeding, with ulcers presenting with adherent clots (Forrest IIb) posing a significant therapeutic challenge. The optimal management strategy remains debated. This study aims to compare the outcomes of endoscopic clot removal followed by hemostatic therapy with medical management alone in patients with peptic ulcers and adherent clots.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA retrospective study conducted in our institution between January 2005 and January 2022 included 145 patients with peptic ulcer bleeding and adherent clots (Forrest IIb). Patients were divided into two groups: the first group (G1) received endoscopic clot removal followed by hemostatic therapy, while the second group ‘G2) received medical treatment alone. The primary outcome was rebleeding, and secondary outcomes included blood transfusion requirements, the need for repeat endoscopy or surgery, length of hospital stay, and mortality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eRebleeding occurred in 2% of patients in the G1 versus 18% in G2 (p=0.019). Mortality rates were 4.8% in G1 versus 8.4% in G2 (p=0.047). Ulcer size \u0026gt; 2 cm and respect of the clot were significantly associated with rebleeding (p=0.013 and p=0.019, respectively).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e our study showed that endoscopic clot removal and hemostatic therapy significantly reduce the risk of rebleeding compared to medical management alone in patients with peptic ulcers and adherent clots. However, there was no significant difference in mortality or the need for surgical intervention. Further prospective, multicenter studies are needed to refine management strategies and optimize patient outcomes.\u003c/p\u003e","manuscriptTitle":"Endoscopic Clot Removal Versus Medical Management Alone in Peptic Ulcer Disease with Adherent Clots: which decision is the best?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-17 10:56:39","doi":"10.21203/rs.3.rs-6597565/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3fd51f67-34ba-4a18-b39e-df02762973ce","owner":[],"postedDate":"June 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T06:25:06+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-17 10:56:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6597565","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6597565","identity":"rs-6597565","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}