2. Endoscopic therapy
Endoscopic evaluation of the bleeding ulcer can decrease the
duration of the hospital stay by identifying patients at low risk for
rebleeding. Moreover, endoscopic therapy reduces the likelihood
of recurrent bleeding and decreases the need for surgery.
Patients can be stratified as having high or low risk for
rebleeding depending on the presence or absence of stigmata.
High-risk stigmata are the following:
•Active hemorrhage (90% risk of rebleeding)
•A visible vessel (50% risk of rebleeding)
•A fresh overlying clot (30% risk of rebleeding)
Ulcers with such stigmata require endotherapy, while ulcers with
a clean base need not be treated endoscopically.
3. • Injection therapy is performed with epinephrine in a
1:10,000 dilution or with absolute alcohol.
• Thermal endoscopic therapy is performed with a heater
probe, bipolar circumactive probe, or gold probe. Pressure
is applied to cause coagulation of the underlying artery
(coaptive coagulation)
• Combination therapy with epinephrine injection followed
by thermal coagulation appears to be more effective than
monotherapy for ulcers with a visible vessel, active
hemorrhage, or adherent clot.
4. • Hemoclips have been used successfully to treat an
acutely bleeding ulcer by approximating 2 folds and
clipping them together. Several clips may need to be
deployed to approximate the gastric ulcer folds. In treating
high-risk bleeding ulcers, combined therapy with
epinephrine and hemoclips seems to be more efficacious
than injection alone
5. Esophagogastroduodenoscopy
• Urgent esophagogastroduodenoscopy (EGD) is the
treatment of choice in the setting of a bleeding peptic
ulcer for diagnostic and therapeutic reasons.
• Endoscopy provides an opportunity to visualize the ulcer,
to determine the degree of active bleeding, and to attempt
hemostasis by direct measures.
• Primary endoscopic hemostatic therapy (EHT) is
successful in about 90% of patients; when this fails,
transcatheter embolization may be useful.
6. Medical Management
• Acid suppression is the general pharmacologic principle of
medical management of acute bleeding from a peptic
ulcer.
• Reducing gastric acidity is believed to improve
hemostasis primarily through the decreased activity of
pepsin
• Concomitant H pylori infection in the setting of bleeding
peptic ulcers should be eradicated, as this lowers the rate
of rebleeding
7. • Two classes of acid-suppressing medications currently in
use are: histamine-2 receptor antagonists (H2RAs) and
proton pump inhibitors (PPIs).
• Both classes are available in intravenous and oral
preparations.
• Examples of H2RAs include ranitidine, cimetidine,
famotidine, and nizatidine.
• Examples of PPIs include omeprazole, pantoprazole,
lansoprazole, and rabeprazole
8. • H2RAs are an older class of medications.
• Many gastroenterologists assert that intravenous PPI
therapy maintains hemostasis more effectively than
intravenous H2RA
• Parenteral PPI administration is indicated after successful
endoscopic therapy for ulcers with high-risk signs, such as
active bleeding, visible vessels, and adherent clots.
Parenteral PPI use before endoscopy is a common
practice.
9. 9
Surgery of bleeding duodenal ulcer
Truncal vagotomy Suture of bleeding duodenal ulcer
10. Finney pyloroplasty
• Pyloroplasty widens pyloric sphincter opening into the
duodenum.
• A pyloroplasty is performed to treat complications of
gastric ulcer disease, or when conservative treatment is
unsatisfactory.
• The longitudinal cut made in the pylorus is closed
transversely, permitting the muscle to relax. By
establishing an enlarged outlet from the stomach into the
intestine, the stomach empties more quickly.
• A pyloroplasty is often done is conjunction with a
vagotomy, a procedure in which the nerves that stimulate
stomach acid production and gastric motility (movement)
are cut. As these nerves are cut, gastric emptying may be
delayed, and the pyloroplasty compensates for that effect.
