Effect of Second-look Endoscopy on Peptic Ulcer Rebleeding in Patients With Early Resumption of Antiplatelet Agents

For patients who are found to have high-risk peptic ulcers on endoscopy, they will be treated by endoscopic combination therapy including adrenaline injection and followed by either thermal coagulation or haemoclips to achieve haemostasis. Peptic ulcers of high-risk stigmata are ulcers with active bleeding, non-bleeding visible blood vessels, or adherent blood clots according to Forrest classification (Ia to IIb).

After initial haemostasis for high-risk ulcers, patients who continue to require anti-platelet agents (namely, aspirin, clopidogrel, prasugrel, or ticagrelor) for treatment or prophylaxis of cardiovascular or cerebrovascular diseases will be eligible for inclusion into study.

Eligible patients will be randomly allocated to have a scheduled second-look endoscopy 16-24 hours after initial endoscopy (i.e. the intervention group), or to receive conventional standard care (i.e. the control group). Randomization will be performed in a 1:1 ratio by computer generated random sequences.

For patients who are allocated to second-look endoscopy group, endoscopic retreatment will be performed if the ulcer shows persistence of high-risk stigmata. Retreatment again will be performed by combination of adrenaline injection follows by thermal coagulation or haemoclips. Standard conventional care will be offered to the other group of patients, in which endoscopy is indicated only in case of suspected clinical bleeding as defined in the subsequent section.

Both the intervention and control groups will receive bolus injection of proton-pump inhibitor (esomeprazole 80mg), follow by high dose infusion of 8mg/h continuously for 72 hours after initial endoscopy. Thereafter, both groups will receive oral form of proton-pump inhibitor (esomeprazole 40mg/d)