***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: BACKGROUND : It is not known if combination therapy of epinephrine injection and multipolar electrocoagulation or hemoclips are a more efficient or effective treatment for patients with acute nonvariceal upper gastrointestinal ( GI ) bleeding . METHODS : Adult patients with active nonvariceal upper GI bleeding , a nonbleeding visible vessel , or after removal of an adherent clot findings of active bleeding or a visible vessel were studied . Patients were r and omized to either therapy and the outcomes were assessed at 30 days . RESULTS : Forty-seven patients were studied : 26 patients r and omized to hemoclips and 21 to combination therapy .  There were 22 patients with active bleeding , 13 with a nonbleeding visible vessel , and 12 with an adherent clot . The median duration of endoscopic therapy  was 17 min in the hemoclip group versus 20 min for the combination therapy , p= 0.29 . Primary hemostasis with successful initial control of bleeding occurred in 26 ( 100 % ) of 26 hemoclip patients and 20 ( 95.2 % ) of 21 combination therapy patients , p= 0.45 . The rebleeding rates were : 4 ( 15.4 % ) of 26 hemoclip patients versus 5 ( 23.8 % ) of 21 combination therapy patients , p= 0.49 . Overall , the length of hospital stay , units of blood transfused , surgery rates , and mortality were not different . CONCLUSIONS : In this prospect i ve , r and omized controlled trial of endoscopic hemoclips versus combination therapy in the nonvariceal upper GI bleeding , the efficiency , efficacy , and complications of the two treatment modalities were not significantly different BACKGROUND & AIMS Treatment of high-risk patients with nonbleeding adherent clots on ulcers is controversial . In a previous r and omized trial , there was no benefit to endoscopic therapies compared with medical therapy for prevention of ulcer rebleeding . Our purpose was to test the hypothesis that patients treated with combination endoscopic therapy  would have significantly lower rebleeding rates than those treated with medical therapy . METHODS In this r and omized , controlled trial , 32 high-risk patients with severe ulcer hemorrhage and nonbleeding adherent clots resistant to target irrigation were r and  omized  to medical therapy or to combination endoscopic therapy ( with epinephrine injection , shaving down the clot with cold guillotining , and bipolar coagulation on the underlying stigmata ) . Physicians blinded to the endoscopic therapy managed all patients . RESULTS Patients were similar at study entry , except for older age in the medical group and lower platelet count in the endoscopic group . By hospital discharge , significantly more medically treated patients ( 6/17 ; 35.3 % ) than endoscopically treated patients ( 0/15 ; 0 % ) rebled ( P = 0.011 ) . There were no complications of endoscopic treatment . CONCLUSIONS Combination endoscopic therapy of nonbleeding adherent clots significantly reduced early ulcer rebleeding rates in high-risk patients compared with medical therapy alone . This endoscopic treatment was safe This is one of a series of statements discussing the use ofGI endoscopy in common clinical situations . The St and ards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text . In preparing this guideline , a MEDLINE search was performed ; additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants . When little or no data exist from well design ed prospect i ve trials , emphasis is given to results from large series and reports from recognized experts . Guidelines for appropriate use of  endoscopy are based on a critical review of the available data and expert consensus . Further controlled clinical studies are needed to clarify aspects of this statement , and revision may be necessary as new data appear . Clinical consideration may justify a course of action at variance to these recommendations BACKGROUND Endoscopic treatment with combined modalities is considered st and ard of care for patients with high-risk peptic ulcer bleeding . This study compared epinephrine injection plus bipolar probe coagulation with bipolar probe coagulation alone in patients with high-risk peptic ulcer bleeding . METHODS Patients with endoscopically confirmed peptic ulcer bleeding ( active or visible vessel ) seen from January 2000 through December 2002 were prospect ively r and omized to two groups . The study group ( n = 58 ) had epinephrine injection followed by bipolar coagulation ; the control group ( n = 56 ) was treated by bipolar coagulation alone . The primary outcomes assessed were the rate of initial hemostasis and the rate of recurrent bleeding . Secondary outcomes were the following : need for surgical intervention to control bleeding , transfusion requirements , length of hospital stay ( in days ) , and 30-day mortality . RESULTS The rate of initial hemostasis was significantly higher in the combination therapy group ( p = 0.02 ; absolute risk reduction 31.6 % : 95 % CI [ 5.4 , 57.7 ] ) . There was no significant difference between the two treatment groups with respect to all other outcomes measures , except that significantly fewer units of blood were transfused in the combination therapy group ( p = 0.006 ) . CONCLUSIONS In patients with active peptic ulcer bleeding , epinephrine injection plus bipolar coagulation achieved significantly higher rate of initial hemostasis . All other outcome measures were similar with either treatment in patients with non-bleeding stigmata One hundred and seven consecutive patients presenting with significant peptic ulcer haemorrhage were r and omised to endoscopic injection with 3 - 10 ml of 1:100,000 adrenaline ( 55 patients , group 1 ) or to a combination of adrenaline and 5 % ethanolamine ( 52 patients , group 2 ) . All had major stigmata of haemorrhage and endoscopic injection was undertaken by a single endoscopist . The groups were well matched with regard to risk factors . Rebleeding occurred in eight of the group 1 patients and seven in the group 2 patients ; surgical operation rates , median blood transfusion requirements , and hospital stay were similar in both groups . The efficacy of either form of injection was similar whether patients presented with active bleeding or a non-bleeding visible vessel . No complications occurred . In patients presenting with significant peptic ulcer bleeding , the addition of a sclerosant confers no advantage over injection with adrenaline alone BACKGROUND Treating patients of bleeding peptic ulcers with heater probe thermocoagulation and haemoclip is considered to be safe and very effective . Yet , there is no report comparing the haemostatic effects of endoscopic haemoclip versus heater probe thermocoagulation plus hypertonic saline-epinephrine injection in these patients . AIM To compare the clinical outcomes of both therapeutic modalities in patients with peptic ulcer bleeding . METHODS A total of 93 patients with active bleeding or non-bleeding visible vessels were r and omised to receive either endoscopic haemoclip ( n = 46 ) or heater probe thermocoagulation plus hypertonic saline-epinephrine injection ( n = 47 ) . Five patients from the haemoclip group were excluded because of the inability to place the haemoclip . RESULTS Initial haemostasis was achieved in 39 patients ( 95.1 % ) of the haemoclip group and 47 patients ( 100 % ) of the heater probe group ( P > 0.1 ) . Rebleeding occurred in four patients ( 10.3 % ) of the haemoclip group and three patients ( 6.4 % ) of the heater probe group ( P > 0.1 ) . The volume of blood transfused after entry into the study , duration of hospital stay , number of patients requiring urgent surgery and the mortality rates were not statistically different between the two groups . CONCLUSIONS If the haemoclip can be applied properly , the clinical outcomes of the haemoclip group would be similar to those of the heater probe group in patients with peptic ulcer bleeding . However , if the bleeders are located at the difficult-to-approach sites , heater probe plus hypertonic saline injection is the first choice therapy We compared the efficacy of epinephrine injection and epinephrine injection followed by sodium tetradecyl sulfate in controlling  active ulcer bleeding .  Out of 2814 patients who underwent endoscopy for gastrointestinal bleeding , 200 patients with actively bleeding ulcers seen at the time of endoscopy were r and omized to receive epinephrine injection alone ( 99 patients ) or epinephrine injection followed by 3 % sodium tetradecyl sulfate ( 101 patients ) . After the procedure the patients were transferred to the surgical gastroenterology ward and were treated by surgeons who were unaware of the mode of treatment . The patients underwent routine endoscopy 24 hours later , and epinephrine injection was repeated if active bleeding was seen again . Emergency surgery was performed for the following : ( 1 ) arterial spurting not controlled endoscopically , ( 2 ) failure of the blood pressure or pulse to stabilize after 4 units of blood , ( 3 ) total transfusion of more than 8 units of blood , or ( 4 ) rebleeding as defined by hematemesis with pulse greater than 100 beats/min or blood pressure less than 100 mm Hg after stabilization . The two groups were comparable in age , sex , site of ulcer , and severity of bleeding . Initial hemostasis was obtained at the time of endoscopy in 94 % of the epinephrine group and 97 % of the epinephrine plus sodium tetradecyl sulfate group . No difference in outcome was seen in the two groups as measured by emergency surgery requirement , blood transfusion , hospital stay , and hospital mortality . Endoscopic epinephrine injection is effective in controlling active ulcer bleeding . The additional injection of sodium tetradecyl sulfate confers no additional advantage Seventy five patients with severely bleeding peptic ulcer were included in a controlled comparative trial to assess the efficacy and safety of endoscopic injection therapy in preventing rebleeding from peptic ulcers that presented at endoscopy with a protruding vessel . Twenty five patients were treated with  injection of epinephrine followed by polidocanol , 25 were treated with injection of absolute alcohol , and 25 with sham injection .  Rebleeding occurred in 44 % of patients in the sham group , 40 % of those treated with epinephrine and polidocanol , and in 20 % of those treated with absolute ethanol . The difference in the haemostasis rate between the control and ethanol treated subjects nearly reached significance ( p = 0.07 ) . A second therapy session result ed in haemostasis rates of 68 % in the epinephrine-polidocanol group and of 88 % in the absolute ethanol group . These rates after two treatments as well as the emergency surgery rates ( 32 % in the epinephrine-polidocanol group and 8 % in the absolute ethanol group ; p = 0.07 ) were not significantly different . In eight of the 11 patients with rebleeding in the sham treatment group , definitive haemostasis was achieved by elective injection therapy .  Overall transfusion requirements were mean ( SD ) 6.0 ( 0.7 ) units in the sham group , 6.0 ( 0.9 ) in the epinephrine-polidocanol group , and 3.9 ( 0.5 ) in the absolute ethanol group . Only the difference between ethanol and sham was significant ( p = 0.02 ) . This study shows that injection with absolute ethanol reduces rebleeding in these patients and significantly lowers transfusion requirements .  Absolute ethanol was superior to epinephrine-polidocanol , which was not significantly better than sham therapy Forty two patients with haemorrhage from peptic ulcers with visible vessels were enrolled in a r and omised study comparing endoscopic haemostasis with adrenaline ( 1:10,000 ) injections ( adrenaline group ) and adrenaline injection + neodymium yttrium-aluminium-garnet ( Nd : YAG ) laser photocoagulation ( adrenaline + laser group ) . The two groups ( 21 patients each ) were well matched for factors affecting outcome . Surgery was performed for continued haemorrhage uncontrolled by endoscopic treatment or rebleeding after two endoscopic treatments . Haemostasis after one treatment was similar in the two groups : adrenaline 16/21 ( 76 % ) , adrenaline + laser 18/21 ( 86 % ) . Haemostasis after two treatments was numerically ( 0.05 less than p less than 0.10 ) greater in the adrenaline + laser group : 21/21 ( 100 % ) v 18/21 ( 86 % ) . Three patients ( 14 % ) in the adrenaline group underwent uneventful emergency surgery . There were no deaths or procedure related complications in either group . Most bleeds from peptic ulcers with visible vessels can be controlled endoscopically without the need for surgery . Both treatments in this study proved highly efficacious in securing haemostasis .  Adrenaline injection treatment seems to be the treatment of choice in view of its simplicity , low cost , and availability . Additional Nd : YAG laser treatment may provide a marginal improvement in efficacy , although a much larger trial would be required to prove this Background : Continued or recurrent bleeding after endoscopic treatment for bleeding ulcer is a major adverse prognostic factor . Identification of such ulcers may allow for alternate treatments . Aim : To determine factors predicting treatment failure with combined adrenaline 
    Output:
    
CONCLUSIONS : Dual endoscopic therapy proved significantly superior to epinephrine injection alone , but had no advantage over thermal or mechanical monotherapy in improving the outcome of patients with high-risk peptic ulcer bleeding