Author's reply.

Dr P. Katsinelos’ letter contributes substantially to the discussion on the safety of injection sclerotherapy for peptic ulcer bleeding. Although sclerosant-induced vascular thrombosis can lead to wall necrosis and free perforation, previously published series as well as our study, do not report any occurrence of free perforation with the use of ethanolamine [1-3]. In our Department, one perforation has occurred after the completion of more than 200 procedures. This case was a second attempt to treat recurrent bleeding from a large duodenal ulcer with increased volumes of ethanolamine. Thus we could advise against the use of large ethanolamine volumes (>2 mL) for hemostasis of duodenal ulcers. Taken together, the above data indicate that perforation probably occurs in much lower frequencies than the 3-4%, reported with the use of multipolar electrocoagulation and heater probe [4,5].

The efficacy of combination injection regimens has been challenged by a small number of early studies that included inadequate numbers of patients to establish superiority over epinephrine monotherapy [2]. However, the superiority of combination injection regiments has been highlighted by a number of meta-analyses [6,7], and acknowledged in the most recent consensus recommendation on the management of patients with non-variceal upper gastrointestinal bleeding [8]. Our work is the first to have included enough patients to demonstrate superiority of the combination of ethanolamine and epinephrine injection therapy over the injection of epinephrine alone for at least one of the study outcomes [3].

Since awareness is considered the cornerstone of safety, Dr Katsinelos’ case report has already served its purpose. However, existing literature data as well as our presented study indicate that ethanolamine with epinephrine injection therapy represents a safe and efficacious alternative whenever safer methods like APC or hemoclips are either unavailable or difficult to apply [3,9].