Management of upper gastrointestinal bleeding

Abstract

Upper gastrointestinal bleeding secondary to ulcer disease is common and results in substantial patient morbidity and medical expense. After initial resuscitation to stabilize the patient, carefully performed endoscopy provides an accurate diagnosis and identifies high-risk ulcer patients who are likely to rebleed with medical therapy alone and will benefit most from endoscopic hemostasis. For patients with major stigmata of ulcer hemorrhage--active arterial bleeding, nonbleeding visible vessel, and adherent clot--combination therapy with epinephrine injection and either thermal coagulation (multipolar or heater probe) or endoclips is recommended. High-dose intravenous proton pump inhibitors are recommended as concomitant therapy after successful endoscopic hemostasis. Patients with minor stigmata or clean-based ulcers will not benefit from endoscopic treatment and should receive high-dose oral proton pump inhibitor therapy. Effective medical and endoscopic management of ulcer hemorrhage can significantly improve outcomes and decrease the cost of medical care by reducing rebleeding, transfusion requirements, and the need for surgery.

Gastric acid inhibition in the treatment of peptic ulcer hemorrhage

“…Endoscopic evaluation and therapy have been discussed in detail separately [2]. In this paper, we review peptic ulcer bleeding, stigmata of ulcer hemorrhage, risk of rebleeding, and medical management with an emphasis on inhibiting gastric acid secretion.…”

Injection and Cautery Methods for Nonvariceal Bleeding Control

“…The principle of injection therapy is to create a combination of hydrostatic pressure, tissue edema, vasoconstriction, and inflammatory changes in the region of the ulcer. [18][19][20][21][22] Injection needles are single-use or autoclavable, Teflon or stainless steel, 7-Fr catheter sheaths with retractile needles varying from 19 to 25 G. The length of the needle may vary from 4 to 6 mm, although recommended needle length is 4 mm (Fig. 2A).…”

“…2A). 21 The most commonly used injectates [18][19][20][21][22][23] for bleeding control are the following:…”

“…56 7 Also APC was significantly more effective than injection therapy in preventing recurrent bleeding. 19 Any method of contact thermal coagulation can be used in patients with high-risk lesions, alone or in combination with epinephrine injection. No single cautery method is superior to another and the choice depends essentially on the confidence that the operator has with the different devices.…”

An implantable wireless biosensor for the immediate detection of upper GI bleeding: a new fluorescein-based tool for diagnosis and surveillance (with video)

“…[13][14][15] Current clinical options for the detection of rebleeding include vital signs monitoring, serial hematocrit/ hemoglobin checks, and observation of clinical status (eg, melena, hematemesis). 16 However, these methods can be imprecise and often require clinical interpretation. 17,18 Furthermore, these methods usually do not indicate a re-bleeding event in real time and sometimes call attention to a rebleeding event after significant blood loss has occurred.…”