Endoscopic dual therapy for giant peptic ulcer hemorrhage

Abstract

Upper gastrointestinal bleeding (UGIB) is a common condition with an incidence of 40 − 150 cases per 100 000 inhabitants per year [1, 2]. Peptic ulcer represents the most common cause of UGIB and dual therapy seems to be the best treatment [3]. Chronic ulcerated lesions have a greater chance of severe bleeding and may lead to shock within a few minutes [3-5]. Often, owing to lesion size and the presence of fibrosis, the use of endoscopic clips is not possible and other methods are necessary for dual treatment. To illustrate this, we describe the case of a patient with UGIB caused by a chronic peptic ulcer with active bleeding, which re-bled just after the first endoscopic treatment. We propose a waiting period of a few minutes after achieving initial hemostasis in order to check for rebleeding, especially in cases with a high risk of rebleeding (▶ Video 1). Video 1 Dual therapy with electrocoagulation and epinephrine injection was performed for active bleeding of a chronic giant peptic ulcer located in the incisura angularis. Owing to the size of the ulcer and the presence of fibrosis, endoscopic clips would not be successful. The importance of review time after the first therapy is emphasized in order to check for rebleeding. ▶ Fig. 1 Bleeding peptic ulcer in the incisura angularis (Forrest IA). a Clot adherent to the ulcer. b Spurting hemorrhage. c Electrocoagulation in the vascular stump. d Treatment failure 1 minute later. e Injection of epinephrine into the vascular stump. f Final view of the ulcer.

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