Endoscopic Therapy for Peptic Ulcer Bleeding

Abstract

Among the gastrointestinal emergencies, acute upper gastrointestinal bleeding (UGIB) remains a challenging clinical problem owing to significant patient morbidity and costs involved with management. Peptic ulcer bleeding (PUB) contributes to the majority of causes of UGIB with a growing concern of its impact on the elderly and the increasing use of NSAIDs as precipitating bleeding episodes. Apart from initial critical assessment and care, endoscopy remains as the preferred initial management of PUB. Early use of high-dose proton pump inhibitor therapy is cost-effective and reduces the need for endotherapy as well as rebleed rates. Current endoscopic modalities offer a wide range of choices in high-risk PUB (active arterial bleeding or non-bleeding visible vessel). A combination of injection (epinephrine) along with thermal or endoclips therapy offers the best strategy for overall successful clinical outcomes. The role of endotherapy for adherent clots is controversial. A second-look endoscopy may be beneficial in high-risk patients. A multidisciplinary team approach should be part of all treatment protocols for the ideal management of UGIB.Peptic ulcer bleeding (PUB) continues to account for 28-59% of all episodes of upper gastrointestinal bleeding (UGIB) [1]. Recent epidemiological estimates show incidence rates for UGIB of about 60 per 100,000 population [2]. Though the prevalence of ulcers related to Helicobacter pylori are steadily declining at least in the Western world, these have been overtaken by aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) as underlying causes of ulcer. The mortality rate from peptic ulcer disease has continued to rise progressively with age along with complications of perforation and hemorrhage [3]. Much of the increase in the frequency of peptic ulcer disease, particularly gastric ulcer, in the elderly is attributable to the high prevalence of NSAID use in this population. In addition to the use of NSAIDs for inflammatory conditions, increasing numbers of elderly patients take aspirin for cardiovascular and neurologic prophylaxis. Wilcox [4] reported that 65% of patients who had UGIB were taking aspirin or other NSAIDs, often administered without a prescription. In elderly patients, the risk of serious, adverse gastrointestinal events in patients taking non-selective NSAIDs is 5 times that of controls, whereas the risk in younger patients is slightly more than 1.5. Associated comorbidities in the older patient shifts the mortality rates upward approaching 7-10%, thus early diagnosis and treatment remains critical in such patients to best improve outcome [5].Endoscopy with hemostatic therapy has clearly been shown to aid in proper diagnosis, prognosticate requirement for blood transfusions and in the majority of instances obviates the need Downloaded by: Kainan University 203.64.11.45 -3/17/2015 2:36:59 AM Downloaded by: Kainan University 203.64.11.45 -3/17/2015 2:36:59 AMTotal score: A+B+C+D. Range of scores is from 0 to 23; maximum score is 23, high risk, >0. * Blo...

Therapeutic and interventional endoscopy for gastrointestinal bleeding

“…Clinical assessment will best determine the fluid requirement needed for hemodynamic stabilization [1,2]. A large-volume hemorrhage can have a major cardiovascular effect and signs and symptoms associated with blood loss may be present even before any clinically evident signs of bleeding.…”

“…Clues such as cold sweating, thirst, dry mucous membranes, non-distensible neck veins, and decreased urinary output also point towards significant intravascular volume depletion. Hypotension (systolic blood pressure less than 100 mmHg), tachycardia (greater than 100 beats/min), postural hypotension (blood pressure fall of 15 mmHg when the patient sits up from a recumbent position or a pulse increase of 15 beats/min) indicates a significant blood loss of at least 20-30% of blood volume [1][2][3][4][5][6][7]. Large-bore intravenous access, judicial use of crystalloids, plasma expanders, or packed red cells can be dictated by the clinical setting.…”

“…An important differential diagnosis is hemosuccus pancreaticus, often seen in trauma patients with pancreatic lacerations Commonly used forms of injection therapy include: (1) epinephrine mixed with saline (1:10,000), (2) non-constrictive agents, such as normal or hypertonic saline, 50% dextrose (these agents work by their local compressive action); and (3) other agents which include sclerosants, such as ethanol, polidocanol. However, these latter agents result in tissue necrosis and even perforation [1,2,13]. We want to emphasize that epinephrine alone is inadequate endoscopic therapy for hemostasis [15].…”

“…Several predictors for peptic ulcer re-bleeding by logistic regression analysis include: American Society of Anesthesiologists (ASA) grade III or grade IV status, ulcer size greater than 1.0 cm, and a finding of persistent stigmata of recent hemorrhage at the scheduled second endoscopy [1,2,13,17].…”

Antiulcer activity of hydroalcoholic extract of unripe fruit of carica papaya in experimental rats

“…Endoscopy therapy is also used now a days. 6 A combination of pharmacological and endoscopic therapy offers the best method of hemostasis to those with active bleeding ulcers. Ulcer due to asprin is more as compare to H pylori now a day.…”