This document summarizes the management of acute bleeding from peptic ulcers. The majority of acute upper GI bleeding is caused by peptic ulcers. Presenting signs include hematemesis and melena. Priority is given to assessing hemodynamic status, resuscitation, NG tube placement, and early endoscopy within 24 hours. Endoscopy allows classification of ulcers and identification of those with high-risk stigmata requiring endoscopic hemostasis treatment. Patients with high-risk ulcers are admitted and treated with IV PPIs. Those with low-risk ulcers may be discharged after endoscopy if stable, with oral PPI treatment. Surgery or radiology are considered if rebleeding occurs despite

1. Management of Acute Bleeding from a Peptic Ulcer August 28, 2008;359:928-937 Review Article

2. Epidemiology The vast majority of acute episodes of upper GI bleeding (80 to 90%) have nonvariceal causes, with gastroduodenal peptic ulcer accounting for the majority of lesions. The mortality associated with acute bleeding from a peptic ulcer remains high (5 to 10%).

3. Clinical Presentation Hematemesis and melena are the most common presenting signs of acute upper gastrointestinal hemorrhage. Resting tachycardia (HR >100 bpm), hypotension (SBP <100 mm Hg), or orthostatic changes (HR ↑20 bpm or a SBP ↓20 mm Hg on standing).

4. Priority in Treatment Assess hemodynamic status (pulse and blood pressure, including orthostatic changes). Obtain CBC, electrolytes (including BUN and creatinine), INR, blood type, and cross-match. Initiate resuscitation (crystalloids and blood products, if indicated) and use of supplemental oxygen. Consider NG-tube placement and aspiration; no role for occult-blood testing of aspirate. Perform early endoscopy (within 24 hours after presentation).

5. Priority in Treatment Consider initiating treatment with an intravenous PPI (80-mg bolus dose plus continuous infusion at 8 mg per hour) while awaiting early endoscopy; no role for H 2 blocker. Consider giving a single 250-mg intravenous dose of erythromycin 30 to 60 minutes before endoscopy. Perform risk stratification; consider the use of a scoring tool (e.g., Blatchford score or clinical Rockall score) before and (e.g., complete Rockall score) after endoscopy.

6. Nasogastric Tube and Acute Upper Gastrointestinal Bleeding The insertion of a NG tube may be helpful in the initial assessment of the patient (specifically, triage). The presence of blood in the NG aspirate is an adverse prognostic sign that may be useful in identifying patients who require urgent endoscopic evaluation. The absence of bloody or coffee-ground material does not definitively rule out ongoing or recurrent bleeding, since approximately 15% of patients without bloody or coffee-ground material in NG aspirates are found to have high-risk lesions on endoscopy. The use of a large-bore OG tube with gastric appears to improve only the visualization of the gastric fundus on endoscopy and has not been documented to improve outcome.

9. FORREST - classification of upper gastrointestinal hemorrhage Acute hemorrhage Forrest IA Active spurting hemorrhage Forrest IB Oozing hemorrhage Signs of recent hemorrhage Forrest IIA Non-bleeding visible vessel Forrest IIB Adherent clot Forrest IIC Hematin on ulcer base Lesions without active bleeding Forrest III Clean-base ulcers

10. Endoscopic Stigmata of Bleeding Peptic Ulcer, Classified as High Risk or Low Risk Spurt blood (grade IA) Ooze blood (grade IB) Nonbleeding visible vessel (grade IIA) Adherent clot (grade IIB) Flat, pigmented spot (grade IIC) Clean base (grade III)

11. High-risk — active bleeding or nonbleeding visible vessel (Forrest grade IA, IB, or IIA) Perform endoscopic hemostasis using contact thermal therapy alone, mechanical therapy using clips, or epinephrine injection, followed by contact thermal therapy or by injection of a second injectable agent. Epinephrine injection as definitive hemostasis therapy is not recommended. The endoscopist should use the most familiar hemostasis technique that can be applied to the identified ulcer stigma. Admit the patient to a monitored bed or ICU setting. Treat with an intravenous PPI (80-mg bolus dose plus continuous infusion at 8 mg per hour) for 72 hours after endoscopic hemostasis; no role for H 2 blocker, somatostatin, or octreotide. Initiate oral intake of clear liquids 6 hours after endoscopy in patients with hemodynamic stability. Transition to oral PPI after completion of intravenous therapy. Perform testing for Helicobacter pylori; initiate treatment if the result is positive.

12. High-risk — adherent clot (Forrest grade IIB) Consider endoscopic removal of adherent clot, followed by endoscopic hemostasis (as described above) if underlying active bleeding or nonbleeding visible vessel is present. Admit the patient to a monitored bed or ICU setting. Treat with an intravenous PPI for 72 hours after endoscopy, regardless of whether endoscopic hemostasis was performed; no role for H 2 blocker, somatostatin, or octreotide. Initiate oral intake of clear liquids 6 hours after endoscopy in patients with hemodynamic stability. Transition to an oral PPI after completion of intravenous therapy. Perform testing for H. pylori; initiate treatment if the result is positive.

13. Low-risk — flat, pigmented spot or clean base (Forrest grade IIC or III) Do not perform endoscopic hemostasis. Consider early hospital discharge after endoscopy if the patient has an otherwise low clinical risk and safe home environment. Treat with an oral proton-pump inhibitor. Initiate oral intake with a regular diet 6 hours after endoscopy in patients with hemodynamic stability. Perform testing for H. pylori; initiate treatment if the result is positive.

14. After Endoscopy If there is clinical evidence of ulcer rebleeding, repeat endoscopy with an attempt at endoscopic hemostasis, obtain surgical or interventional radiologic consultation for selected patients.

15. Predictors of failure of endoscopic treatment history of peptic ulcer disease, previous ulcer bleeding, presence of shock at presentation, active bleeding during endoscopy, large ulcers (>2 cm in diameter), large underlying bleeding vessel (2 mm in diameter), ulcers located on the lesser curve of the stomach or on the posterior or superior duodenal bulb.

16. Repeat Endoscopy Repeat endoscopy may be considered on recurrent bleeding or if there is uncertainty regarding the effectiveness of hemostasis during the initial treatment. Planned second-look endoscopy that is performed within 24 hours after initial endoscopic therapy is generally not recommended.

18. Surgery Surgery remains an effective and safe approach for treating uncontrolled bleeding (i.e., those in whom hemodynamic stabilization cannot be achieved through intravascular volume replacement using crystalloid fluids or blood products) or patients who may not tolerate recurrent or worsening bleeding. For persistent ulcer bleeding or rebleeding, a second attempt at endoscopic hemostasis is often effective, and is the recommended management approach. Exceptions may include patients with ulcers that are more than 2 cm in diameter and those who have hypotension associated with a rebleeding episode.

19. Interventional Radiology Angiography with transcatheter embolization is reserved for patients in whom endoscopic therapy has failed, especially if such patients are high-risk surgical candidates. Primary rates of technical success range from 52 to 94%, with recurrent bleeding requiring repeated embolization procedures in approximately 10% of patients.