Key messages
- Prophylactic transarterial embolization (blocking blood supply to the ulcer as a precaution) may make little to no difference in reducing rebleeding, need for reoperation, or death for people whose bleeding peptic ulcer had been successfully treated with endoscopy (a tube through the mouth into the stomach), but length of stay in hospital may be shorter, compared with endoscopy alone.
- We found only two small studies, so we need more studies with more people to draw firm conclusions.
What are peptic ulcers, and how are they treated?
A peptic ulcer is a sore that develops in the lining of the stomach (gastric ulcer) or the upper part of the small intestine (duodenal ulcer). It is a common condition. It may be caused by bacteria (Helicobacter pylori), or anti-inflammatory medication, such as ibuprofen. It can also be a very dangerous condition, which causes internal bleeding. When the ulcer bleeds, it can result in symptoms such as black, tarry stools or vomiting of blood, which require prompt attention and treatment in hospital. Peptic ulcer bleeding is treated by using an ‘endoscope’, a flexible tube with a light and a camera on the end. The endoscope is inserted through the mouth and down into the digestive tract. Doctors can see the ulcer and take actions to stop the bleeding, such as injecting medications, applying heat, or using clips to close off the bleeding blood vessel. An endoscopy helps the medical team to both diagnose and treat bleeding peptic ulcers without the need for surgery.
What is prophylactic transarterial embolization?
Even after successful endoscopic treatment, some peptic ulcers will start bleeding again (rebleeding). Patients who rebleed from their peptic ulcers have a higher risk of dying compared with patients whose ulcers do not rebleed. In order to stop this happening, doctors may choose to carry out a preventive (prophylactic) procedure to block the blood supply to certain arteries (arterial embolization). There are various methods of doing this, but it is usually carried out by a radiologist using X-ray to guide them to the right place through the arteries (transarterially), and they then use coils (small coiled metal wires) or a type of glue to block the blood vessels.
What did we want to find out?
We wanted to know if prophylactic transarterial embolization following earlier successful endoscopic treatment of bleeding peptic ulcer affects:
- risk of rebleeding
- risk of needing reoperation
- risk of dying
- duration of hospitalization
- complications of the treatment
What did we do?
We searched for studies that investigated the effects of prophylactic transarterial embolization less than 48 hours following successful endoscopy compared with endoscopy alone in patients suffering from peptic ulcer bleeding.
We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We included 2 studies with 346 people. Of these, 145 underwent prophylactic transarterial embolization following successful endoscopic treatment of bleeding peptic ulcer, and 179 just had endoscopic treatment. People who did not undergo prophylactic transarterial embolization were given normal care.
We found that prophylactic transarterial embolization may make little to no difference to the risk of rebleeding, risk of needing reoperation, and death within 30 days compared with endoscopic treatment only. It may reduce the time participants spend in hospital. The included studies did not report any complications other than rebleeding, need for reoperation and death.
What are the limitations of the evidence?
The quality of the two included studies was generally high, but our confidence in the evidence is limited because we only found two studies, and they did not include many people.
How up to date is this evidence?
The evidence is current up to August 2023.
In conclusion, there is low-certainty evidence that prophylactic TAE may not reduce the odds of rebleeding, reintervention or mortality for participants following peptic ulcer bleeding. It may, however, reduce the duration of hospitalization. Ultimately, due to the limited number of studies and participants, further research with larger populations is warranted to validate these findings and explore additional outcomes, including adverse events other than rebleeding, reintervention and mortality.
Bleeding peptic ulcer is a serious condition that often requires immediate endoscopic or surgical intervention to stop the bleeding (haemostasis). Following haemostasis, patients are at risk of rebleeding, leading to reintervention and risk of morbidity or mortality. In order to prevent rebleeding and associated complications, prophylactic measures have been developed and investigated. Prophylactic transarterial embolization (TAE), where the blood vessel leading to the site of the bleeding ulcer is closed via embolization (e.g. using coils to stop blood flow), has emerged as a potential therapeutic approach to address this challenge. However, a comprehensive evaluation of its efficacy and impact on patient outcomes is essential.
To assess the effects of prophylactic transarterial embolization after successful endoscopic treatment compared with endoscopic haemostasis only on the risk of rebleeding after bleeding peptic ulcer, in patients where endoscopic haemostasis has been successful.
In August 2023 we searched CENTRAL, MEDLINE, Embase, PubMed Central, Clinicaltrials.gov and the International Clinical Trials Registry Platform (ICTRP). There were no language or publication status constraints.
This review included prospective randomized controlled trials that evaluated prophylactic TAE in patients with bleeding peptic ulcers. The selection process involved meticulous screening, full-text reviews, and considerations of study design, intervention, and patient populations.
Two review authors extracted data and conducted risk of bias assessments. The outcomes of interest were rebleeding within 30 days, need for reintervention within 30 days, 30-day mortality, complications within 30 days, duration of hospitalization and success rate of the embolization. We contacted authors of included studies for missing and more detailed data, allowing us to carry out sensitivity analyses. We used GRADE to assess the certainty of evidence.
The review includes two studies involving 346 participants. Prophylactic TAE may not reduce the odds of rebleeding within 30 days (odds ratio (OR) 0.58, 95% confidence interval (CI) 0.18 to 1.83; 2 studies, 346 participants; low-certainty evidence). There may be little or no effect on reintervention rates per event (OR 0.68, 95% CI 0.35 to 1.35; 2 studies, 346 participants; low-certainty evidence) or per participant (OR 0.65, 95% CI 0.25 to1.69; 2 studies, 346 participants; low-certainty evidence), and there may be no reduction in 30-day mortality (OR 0.41, 95% CI 0.14 to 1.21; 2 studies, 346 participants; low-certainty evidence). Unfortunately, we were unable to analyze complications other than rebleeding, reintervention and mortality, as data for these outcomes were not available in the included studies. The duration of hospitalization may be shorter for participants undergoing prophylactic TAE (mean difference (days) −2.41, 95% CI −4.06 to −0.76; 2 studies, 346 participants; low-certainty evidence).
Overall, the risk of bias in the included studies was low, but there was a high risk of performance bias and detection bias as none of the included studies were blinded. Further, one study had a high risk of selection bias as the randomization lists were created by the primary investigator.