from early PPI use. An 80-mg intravenous bolus of omeprazole or pantoprazole followed by an infusion

at 8 mg/hr produces the most reliable acid suppression.110 All patients should be tested for Helicobacter

pylori (H. pylori) infection and treated if found. Treatment of the infection significantly reduces the

recurrence of hemorrhage when compared to no treatment or chronic antisecretory treatment alone.111

Interestingly H. pylori infection may be less common in patients with bleeding ulcers than in those with

nonbleeding ulcers.112

Endoscopic Treatment

The endoscopic appearance of a bleeding ulcer has important prognostic and therefore therapeutic

implications, as alluded to in Tables 65-6 and 65-7. A modification of the system employed by Forrest et

al.113 is shown in Table 65-8. In this system, category I findings are indicative of active bleeding while

category II findings provide evidence of recent hemorrhage. In general, only actively bleeding ulcers

(i.e., Forrest category I lesions) are treated endoscopically.

Table 65-8 Forrest Classification of Endoscopic Appearance of Bleeding Ulcers

A variety of endoscopic techniques are available to arrest hemorrhage from bleeding ulcers. The

precise method of treatment is less important than the correct selection of patients and the experience

of the endoscopist. Examples of methods typically include mechanical, thermal, or injection.

Mechanical ligation of bleeding vessels can be achieved with endoscopic ligation (banding),

endoscopic clipping, or endoloop ligation.114–116 Of these three methods, endoscopic clipping is the

method most commonly employed for bleeding ulcers.

Heater probes and monopolar and bipolar electrocoagulation probes can also effectively control UGI

hemorrhage. Monopolar probes apply high-frequency electrical current to the tissue, resulting in

localized heating to 100°C and sealing of the bleeding vessel by coagulation necrosis of the surrounding

tissue and vessel wall. Multipolar electrocoagulation (bicap) probes consist of three equally spaced pairs

of bipolar microelectrodes. This orientation of electrodes allows coagulation of tissue from tangential

approaches and eliminates some of the disadvantages of the monopolar probe, such as the unpredictable

depth of thermal injury, adherence of tissue, and clot dislodgement. Direct thermal coagulation of a

bleeding point can also be produced by applying a heater probe, consisting of an aluminum tip coated

with Teflon. The tip is rapidly heated to 250°C by an inner coil. The tip can be irrigated with a water jet

to prevent accumulation of debris and clot. Heat conducted from the probe produces tissue coagulation

to a depth of 1 to 5 mm.

Injection of epinephrine to induce vasoconstriction has been used successfully to control acutely

bleeding ulcers, particularly as an adjunct to electrocautery or mechanical hemostasis with clips. A

meta-analysis of 15 studies concluded that injection alone was inferior to either clips alone, or clips plus

injection.117 This study showed no difference between clips and thermocoagulation.

Although not commonly employed, the injection of sclerosants has been well described as a method of

treating esophageal varices and has been used for controlling nonvariceal bleeding. Sodium morrhuate

and ethanolamine oleate are most commonly used to treat esophageal varices, whereas ethanol and

polidocanol are most commonly used for nonvariceal sites. These agents act by thrombosing bleeding

vessels and causing necrosis and subsequent fibrosis of surrounding tissue. Clinical experience with

sclerosants has been similar to that obtained with electrocoagulation. In one large multicenter study of

332 actively bleeding patients or patients with stigmata of recent hemorrhage who underwent injection

of 98% alcohol around the lesions, less than 1% continued to bleed, 6% rebled, and only 3% required

emergency operative intervention.118

A meta-analysis of 25 randomized trials of endoscopic therapy for bleeding ulcers concluded that

endoscopic treatment methods have a beneficial effect on survival by reducing the rate of recurrent

hemorrhage. This analysis suggested that endoscopic therapy results in a relative reduction of 69% in

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recurrent bleeding, 62% in emergent surgery, and 30% in mortality rate, with the greatest benefit seen

in actively bleeding ulcers and ulcers with nonbleeding visible vessels.119 The effectiveness of early

aggressive endoscopic diagnosis and treatment is further supported by a report of 562 patients bleeding

from a variety of causes of whom only 2.5% required emergency operations to control hemorrhage.120

Several other more recent studies have confirmed the critical role of endoscopy and control of UGI

hemorrhage.43,121,122 For most patients with evidence of persistent bleeding, a second attempt at

endoscopic hemostasis should be attempted because this can provide up to 75% of patients with durable

hemostasis. Exceptions may include patients with ulcers greater than 2 cm in diameter and those who

have hypotension associated with a rebleeding episode, since such patients may be at an increased risk

for failure of repeat endoscopic hemostasis.104,121,123

Operative Treatment

The successful use of endoscopic therapies has relegated operative procedures to a rescue role for those

cases in which endoscopy is unsuccessful in arresting hemorrhage. Numerous studies have attempted to

identify those patients at greatest risk of continued or recurrent bleeding. Of the many factors

examined, those associated with the highest risk of rebleeding included patients in hypovolemic shock

during the initial endoscopy, ulcers greater than 2 cm in diameter, and endoscopic stigmata of recent or

ongoing hemorrhage (Forrest type I and II lesions).123 Many studies have demonstrated the ability of

endoscopy to identify those patients at greatest risk of rebleeding. In one review, the presence of active

bleeding was associated with a 90% to 100% chance of continued or recurrent hemorrhage. A

nonbleeding visible vessel had a 40% to 50% chance, adherent clot 20% to 30%, oozing without visible

vessel 10%, flat spot 5% to 10%, and clean-based ulcer 1% to 2%.124 Even in those patients who rebleed

following initial endoscopic therapy, two-thirds may be successfully retreated endoscopically thus

avoiding operative intervention.90 Factors that must be considered in decisions regarding the timing of

operative intervention include the magnitude of the initial (or recurrent) hemorrhage, the physiologic

ability of the patient to withstand continued or recurrent hemorrhage, and the likelihood of recurrent or

continued hemorrhage. It is generally accepted that elderly patients and those with significant

concurrent medical problems should undergo operative intervention earlier during the course of the

hemorrhage since these individuals will poorly tolerate continued bleeding, recurrent hypotension, and

repeated transfusions.

The type of operation depends on the pathology encountered. For bleeding gastric ulcers, the

operation of choice depends on the patient’s condition and location of the ulcer. For favorably located

ulcers, excision of the ulcer with closure of the gastrotomy will suffice. If the ulcer is unfavorably

located, for example, near the gastroesophageal junction, simple oversewing of the vessel through the

base of the ulcer may adequately control bleeding.125 If a gastric ulcer is left in situ, follow-up

endoscopy is necessary 4 to 8 weeks later to either confirm healing or obtain tissue to rule out

malignancy. Extensive gastric resections such as antrectomy, subtotal or total gastrectomy are generally

not performed in these unstable patients.

For patients bleeding from duodenal ulcers, the type of surgery performed has changed since the

development of PPIs and treatment of H. pylori. Formerly, truncal vagotomy, pyloroplasty, and

oversewing of the bleeding vessel were the most widely used operation. However, the trend is now

more toward direct ligation of the bleeding vessel through the duodenotomy.126 When performed,

ligation should incorporate the gastroduodenal artery proximal and distal to the ulcer as well as the

transverse pancreatic artery. Despite the above noted trend, a recent study has shown vagotomy and

drainage may be superior to simple oversewing of the vessel.127

Angiographic Embolization

Of late, much has been written about the use of transcatheter embolization for peptic ulcer disease. In

general, angiographic embolization is used after failure of endoscopic treatment in patients who cannot

or will not undergo surgery. One large review (including nonulcer UGI indications) showed a high

technical success rate (i.e., localization of bleeding and deployment of the embolic agent) but a clinical

success rate of only 51%.128 Other reviews have shown higher success rates ranging from 69% to 100%

technical success rate and 63% to 97% clinical success rate.129 Significant ischemic complications can

occur however. While this technique has utility in select patients, it should not be considered as a firstline treatment option for bleeding peptic ulcers, but may have a role as a safe alternative to surgery for

ulcers refractory to endoscopic treatment.

Stress Gastritis

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