Although peptic ulcer continues to be the commonest cause of acute upper gastrointestinal bleeding, obscure haemorrhage from the Dieulafoy malformation and haemobilia must be considered, and may be amenable to endoscopic therapy. The patients who are at the highest risk of rebleeding and death are elderly, in shock at presentation, and have major stigmata of recent haemorrhage (SRH). The endoscopist must identify SRH, and identification may be made easier by washing the area with hydrogen peroxide. The natural history of SRH has been defined. There is wide interobserver variation in the interpretation of SRH, and there is probably therefore little value in the endoscopist describing subtle appearances. Although the value of endoscopic haemostatic therapy is established, it has still not been taken up by all institutions.
Endoscopic injection of fibrin glue into the bleeding ulcer is a logical and relatively easy approach, and a systematic histological study of resected ulcers has shown that this does not adversely affect the ulcer healing process. Thermal therapies such as argon plasma coagulation and the heater probe have comparable efficacy. Although a combination of injection and thermal treatments may be logical, there are only trends suggesting that this is better than monotherapy. Nevertheless, the gold probe continues to be used in clinical practice. Experiments in an animal model of gastric bleeding suggest that the gold probe is effective, and that the version with a wide-gauge needle is best. Haemoclips may stop acute upper gastrointestinal bleeding from a range of sources.
Patients who rebleed after initial endoscopic haemostasis have a tenfold increase in the risk of death. An important study from Hong Kong suggests that repeat endoscopic treatment after rebleeding has comparable morbidity and mortality to a policy of urgent surgery without endoscopic repeat intervention.
References (Key References are highlighted)
-
1
Dinu F, Devière J, Van Gossum A, et al.
The wirsungorrhagies: causes and management in 14 patients.
Endoscopy.
1998;
30
595-600
-
2
Rockey DC, Koch J, Cello JP, et al.
Relative frequency of upper gastrointestinal and colonic lesions in patients with positive fecal occult blood tests.
N Engl J Med.
1998;
339
153-159
-
3
Rockall TA, Logan RFA, Devlin HB, et al.
Risk assessment after acute upper gastrointestinal haemorrhage.
Gut.
1996;
38
316-321
-
4
Vreeburg EM, Terwee CB, Snel P, et al.
Validation of the Rockall risk scoring system in upper gastrointestinal bleeding.
Gut.
1999;
44
331-335
-
5
Hasselgren G, Carlsson J, Lind T, et al.
Risk factors for rebleeding and fatal outcome in elderly patients with acute peptic ulcer bleeding.
Eur J Gastroenterol Hepatol.
1998;
10
667-672
-
6
Daneshmend TK, Hawkey CJ, Langman MJS, et al.
Omeprazole verses placebo for acute upper gastrointestinal bleeding: randomised double-blind controlled trial.
Br Med J.
1992;
304
143-147
-
7
Khuroo MS, Yattoo GN, Javid G, et al.
A comparison of omeprazole and placebo for bleeding peptic ulcer.
N Engl J Med.
1997;
336
1054-1058
-
8
Schaffalitzky de Muckadell OB, Havelund T, Harling H, et al.
Effect of omeprazole on the outcome of endoscopically treated bleeding peptic ulcers: randomized double-blind placebo-controlled multicentre study.
Scand J Gastroenterol.
1997;
32
320-327
-
9
Cooper GS, Chak A, Way LE, et al.
Early endoscopy in upper gastrointestinal hemorrhage: associations with recurrent bleeding, surgery, and length of hospital stay.
Gastrointest Endosc.
1999;
49
145-152
-
10
Bornman PC, Theodorou N, Shuttleworth RD, et al.
Importance of hypovolaemic shock and endoscopic signs in predicting recurrent haemorrhage from peptic ulceration: a prospective evaluation.
Br Med J.
1985;
291
245-247
-
11
Lau JY, Chung SC, Leung JW, et al.
The evolution of hemorrhage in bleeding peptic ulcers: a sequential endoscopic study.
Endoscopy.
1998;
30
513-518
-
12
Wu DC, Lu CY, Lu CH, et al.
Endoscopic hydrogen peroxide spray may facilitate localization of the bleeding site in acute upper gastrointestinal bleeding.
Endoscopy.
1999;
31
237-241
-
13
Mondardini A, Barletti C, Rocca G, et al.
Nonvariceal upper gastrointestinal bleeding and Forrest's classification: diagnostic agreement between endoscopists from the same area.
Endoscopy.
1998;
30
508-512
-
14
Skok P.
Endoscopic hemostasis in exulceratio simplex - Dieulafoy's disease hemorrhage: a review of 25 cases.
Endoscopy.
1998;
30
590-594
-
15
Henry DA, White I.
Endoscopic coagulation for gastrointestinal bleeding.
N Engl J Med.
1988;
318
186-187
-
16
Cook DJ, Gayatt GH, Salena BJ, et al.
Endoscopic therapy for acute nonvariceal hemorrhage: a metaanalysis. Gastroenterol.
1992;
102
139-148
-
17
Gralnek M, Jensen DM, Gorbein J, et al.
Clinical and economic outcomes of individuals with severe peptic ulcer hemorrhage and nonbleeding visible vessel: an analysis of two prospective clinical trials.
Am J Gastroenterol.
1998;
93
2047-2053
-
18
Cooper CS, Chak A, Way LE, et al.
Endoscopic practice for upper gastrointestinal hemorrhage: differences between major teaching and communitybased hospitals.
Gastrointest Endosc.
1998;
48
348-353
-
19
Rutgeerts P, Rauws E, Wara P, et al.
Randomised trial of single and repeated fibrin glue compared with injection of polidocanol in treatment of bleeding peptic ulcer.
Lancet.
1997;
350
692-696
-
20
Pescatore P, Verbeke C, Härle M, Manegold BC.
Fibrin sealing in peptic ulcer bleeding: the fate of the clot.
Endoscopy.
1998;
30
519-523
-
21
Rajgopal C, Palmer KR.
Endoscopic injection sclerosis: effective treatment for bleeding peptic ulcer.
Gut.
1991;
32
727-729
-
22
Messmann H, Schaller P, Andus T, et al.
Effect of programmed endoscopic followup examinations on the rebleeding rate of gastric or duodenal peptic ulcers treated by injection therapy: a prospective, randomized controlled trial.
Endoscopy.
1998;
30
583-589
-
23
Villanueva C, Balanzo J, Espinoz JC.
Prediction of therapeutic failure in patients with bleeding peptic ulcers treated with endoscopic injection.
Dig Dis Sci.
1993;
38
2062-2070
-
24
Choudari CP, Rajgopal C, Elton RA, Palmer KR.
Failures of endoscopic therapy for bleeding peptic ulcers: an analysis of risk factors.
Am J Gastroenterol.
1994;
89
1968-1972
-
25
Cipolletta L, Bianco MA, Rotandano G, et al.
Prospective comparison of argon plasma coagulator and heater probe in the endoscopic treatment of major peptic ulcer bleeding.
Gastrointest Endosc.
1998;
48
191-195
-
26
Chung SCS, Lau JL, Sung JJ.
Randomised comparison between adrenaline injection alone and adrenaline injection plus heater probe treatment for actively bleeding peptic ulcers.
Br Med J.
1997;
314
1307-1311
-
27
Jutabha R, Jensen DM, Machicado G, Hirabayashi K.
Randomized controlled studies of injection: gold probes compared with monotherapies for hemostasis of bleeding canine gastric ulcers.
Gastrointest Endosc.
1998;
48
598-605
-
28
Chung IK, Ham JS, Kim HS.
Comparison of the hemostatic efficacy of the endoscopic hemoclip method with hypertonic saline-epinephrine injection and a combination of the two for the management of bleeding peptic ulcers.
Gastrointest Endosc.
1999;
49
13-18
-
29
AbiHanna D, Williams SJ, Gillespie PE, Bourke MJ.
Endoscopic band ligation for nonvariceal nonulcer gastrointestinal hemorrhage.
Gastrointest Endosc.
1998;
48
510-514
-
30
Wong RM, Ota S, Katoh A, et al.
Endoscopic ligation for nonesophageal variceal upper gastrointestinal hemorrhage.
Endoscopy.
1998;
30
774-777
-
31
Lau JY, Sung JJ, Lam YH, et al.
Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers.
N Engl J Med.
1999;
340
751-756
K. R. PalmerM.D.
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