Treatment of Patients at High Risk for Recurrent Bleeding from a Peptic Ulcer

The management of patients with severe ulcer hemorrhage is rapidly changing. A decade ago, physicians called a general surgeon for upper gastrointestinal hemorrhage. Now, they call an endoscopist (usually a gastroenterologist) to assist in initial management (1). Although some use clinical criteria, such as Rockall scores (2), to triage patients to different levels of hospital care, the current standard of care is early panendoscopy to establish a specific diagnosis, identify predictors of more bleeding, and perform concurrent endoscopic hemostasis if high-risk stigmata are present. The stigmata of high-risk bleeding have traditionally included actively bleeding and nonbleeding visible vessels. On the basis of evidence from randomized, controlled trials (3, 4), two different groups (including mine) have recommended adding “clot adhering to an ulcer” to this list. In those trials, patients with clots had a higher rebleeding rate (34% to 35%) if treated medically with food and oral proton-pump inhibitors (PPIs), 20 mg twice per day, than with combined medical and endoscopic hemostasis (epinephrine and thermal coaptive coagulation) (0% to 4%).

The clinical rationale for early endoscopic diagnosis and treatment of patients with upper gastrointestinal hemorrhage rests on endoscopic classification of findings as high risk or low risk for recurrent bleeding (for example, flat spots or a clean ulcer base) and on the natural history of bleeding. The natural history reflects the presence of arteries that lie beneath the ulcer base when visible vessels are present. In a classic pathologic description, the mean diameter of arteries associated with visible vessels was less than 1 mm (5). Contact thermal techniques, such …