28 Peptic Ulcer Disease and Bleeding, Including Duodenal Ulcer
Moe Kyaw, James Lau, and Joseph Jao Yiu Sung
In peptic ulcer disease and bleeding, endoscopy has both a diagnostic and therapeutic role—diagnosis of peptic ulcer, exclusion of malignancy, identifying bleeding focus, hemostatic treatment, assessing risk of rebleeding, and prevention of further rebleeding. A variety of endoscopic therapeutic modalities for peptic ulcer bleeding have evolved which are classified into injection, thermal, mechanical, and topical. This review provides a summary of commonly used modalities and techniques to maximize their effectiveness. In addition, the role of newer therapeutic modalities such as over-the-scope clips (OTSC), and endoscopic suturing devices is discussed.
28.2 Diagnosis of Peptic Ulcer Disease and Bleeding
Signs and symptoms of peptic ulcer disease include dyspepsia, anemia, bleeding, and gastric outlet obstruction. Endoscopy is advisable for new-onset dyspepsia in patients older than age 50 or those with alarm features. 1 In uncomplicated peptic ulcer disease (absence of bleeding, obstruction, or perforation), the role of endoscopy is to provide a diagnosis and exclude malignancy. In the past, biopsies of all gastric ulcers were recommended—this was based on old data suggesting up to 11% gastric ulcers represented malignancy. 2 There are no recent data to guide recommendation to biopsy all gastric ulcers. The American Society for Gastrointestinal Endoscopy (ASGE) suggested individualized approach directed by patient symptoms and endoscopic appearance of ulcers. 3 Thus, in a young patient taking nonsteroidal anti-inflammatory drug (NSAID), with endoscopic findings of NSAID-associated ulcer appearance (shallow ulcers, with erosions), routine biopsy may not be required. Because of its very low risk of malignancy with duodenal ulcers, routine biopsy is not recommended. When endoscopic appearance of gastric ulcer does suggest malignancy, multiple biopsies should be taken from both the base and edges of ulcer. All patients confirmed with peptic ulcer disease should have endoscopic testing for Helocobacter pylori.
Despite unclear results on efficacy, and cost-effectiveness, plus without published recommendations, routine endoscopic surveillance of gastric ulcer continues to be a common practice due to the fact that gastric ulcers may initially appear benign on endoscopy appearance and histology. The ASGE suggested an individualized approach that might be more effective—a young patient with endoscopic appearance of benign ulcer confirmed on histology with an identifiable cause (NSAID, H. pylori) may not require surveillance endoscopy. 3 A second-look endoscopic surveillance for duodenal ulcer is only recommended in patients with persistent symptoms.
Endoscopy is essential for management of peptic ulcer bleeding. Endoscopy allows the identification of the bleeding focus, classification of risk of rebleeding, and treatment to halt the bleeding. Using the Forrest classification, the endoscopic appearance of ulcer can be used to identify the risk of persistent bleeding, rebleeding, and mortality (▶Table 28.1). Those ulcers classified as FI or FIIa are at high risk for rebleeding and endoscopic therapy is advised in these patients. 4 , 5 , 6 For ulcers classified as FIIb, endoscopic treatment remains controversial. 7 , 8 The most recent meta-analysis did not show significant benefit of endoscopic therapy on ulcers classified as FIIb. 9 Rebleeding is rare for ulcers classified as FIIc or FIII, thus endoscopic therapy is not beneficial. 10 , 11
Risk of recurrent bleeding (%)
Nonbleeding visible vessel
There are also other endoscopic diagnostic findings which are not described in the Forrest classification that can be used to predict rebleeding: ulcer size greater than 2 cm, blood in the gastric lumen, location of ulcer (posterior duodenal wall; proximal lesser curvature of stomach). 12 , 13 , 14
Not all nonbleeding visible vessels have the same risk of recurrent bleeding; pale, protuberant vessels carry a higher risk than dark, flattened vessels. 15 And at times, it can be difficult to differentiate between a nonbleeding visible vessel and an adherent clot. For ulcers with adherent clot, removal of clot should be attempted to identify underlying ulcer base and exclude any visible vessels. However, even after the removal of the clot, it can be difficult to identify those vessels that are buried in the ulcer base. In such cases, the use of magnifying endoscopy has been suggested to improve exposure and characterization of visible vessels while differentiating between slightly protuberant vessels from clots and pigmented spots. 16 Doppler ultrasound at the ulcer base has also been suggested as a method to determine whether a vessel is present—a “Doppler positive” ulcer base was noted when the Doppler identified a vessel within 1 mm from the ulcer base. Both techniques are not used in common clinical practice due to cost and technical complexity. 17 , 18 However, recent publication has suggested the role of Doppler endoscopic probe (Vascular Technology Inc, Nashua, New Hampshire) in risk stratification for patients to determine rebleeding risk. The tip of the Doppler endoscopic probe was placed next to the ulcer pre- and postendoscopic treatment, and blood flow in the underlying ulcer base was confirmed by auditory sound. Those patients with residual blood flow after endoscopic treatment was suggested as a potential indicator for rebleeding. The authors concluded that the Doppler endoscopic probe combined with visual endoscopic assessment (of stigmata of recent hemorrhage) was more accurate than visual endoscopic assessment alone for risk stratification for ulcer rebleeding and as a new potential guide for definitive endoscopic hemostasis. 19
The role of early capsule endoscopy preformed prior to gastroscopy in patients with suspected acute upper gastrointestinal bleeding has been reported in a few case series. 20 , 21 , 22 Capsule endoscopy is usually performed within 6 hours of arrival into the emergency department. To date, risk stratification for patients presenting with upper gastrointestinal bleeding has been based on clinical judgment using validated Blatchford and Rockall scores. Capsule endoscopy may have a potential role as a triage tool for early diagnosis of upper gastrointestinal bleeding, or avoiding unnecessary admissions for a gastroscopy in those with negative findings. In addition, it can be used as alternative diagnostic tool for nonendoscopists, such as emergency care physicians, who can be trained to perform capsule endoscopy and interpret the findings to achieve an earlier diagnosis. 22
28.3 Choice of Instrument for Peptic Ulcer Bleeding
Endoscopy in bleeding patients should always be carried out in adequately equipped settings. In high-risk patients with hemodynamic instability, endoscopy in intensive care unit (ICU) settings is recommended. The development of mobile endoscopic travel cart equipped with all the necessary accessories has resulted in avoidance of unnecessary transfer of unstable patients.
The choice of endoscope depends on the severity of the bleeding and location of the ulcer site. In patients with significant bleeding, the use of a therapeutic gastroscope can be of advantage. Olympus (Olympus Corporation, Tokyo, Japan) provides two types of therapeutic gastroscopes, a single-channel (GIF-1TH190) and a double-channel therapeutic gastroscope (GIF-2TH180). The single-channel therapeutic gastroscope has a 3.7-mm working channel allowing an improvement in lavage and use of large accessories such as 10-F heater probe. The double-channel therapeutic gastroscope with 2.8- and 3.7-mm diameter channels can accommodate two endoscopic devices simultaneously.
With peptic ulcers in unfavorable locations, a change of endoscope will provide better access to target for therapy. In patients with ulcers located in the posterior wall of duodenum or stomach, the use of a colonoscope with the working channel positioned on the right side may provide more accurate approach to the ulcer. 23 A side-viewing duodenoscope can be useful in ulcers located at the junction of the first and second parts of the duodenum or on the lesser curvature of the stomach. In certain cases, using a regular gastroscope with a smaller diameter provides more flexibility in those difficult-to-reach areas.
28.4 Therapeutic Modalities for Peptic Ulcer Bleeding
The goal of therapeutic endoscopy in patients with peptic ulcer bleeding is to prevent continued bleeding or rebleeding. Endoscopic hemostasis can be achieved with injection, thermal, mechanical, and topical modalities (▶Table 28.2).
28.4.1 Injection Therapy
Injection therapy with dilute epinephrine in saline (1:10,000) is widely used as the initial method for hemostasis due to its ease of use and availability. It can be an effective initial hemostatic modality in large ulcer bleeding where the views are obscured and application of other modalities will be difficult. It is delivered through a 25-gauge retractable catheter with increments of 0.5 to 1.5 mL in all four quadrants around the ulcer base, with or without injection into ulcer base. The catheter can be positioned in tangential or en face position. Epinephrine injection achieves hemostasis through a combination of a pressure effect by local tamponade, vasospasm, and induction of thrombosis. Although epinephrine injection is effective in achieving primary hemostasis, its effect resolves after 20 minutes, thus it is recommended that a second endoscopic modality should be applied to reduce the risk of rebleeding. 24 , 25 Epinephrine injection should be used to slow down or stop bleeding in order to obtain a clearer view of the vessel before a second endoscopic modality is applied. Epinephrine injection can potentially cause tachycardia, hypertension, cardiac arrhythmias, and angina, but they generally do not clinically manifest if less than 12 mL of epinephrine is used. 26
Other Injection Agents
Alternative injection agents to epinephrine include sclerosants (polidocanol, ethanolamine, ethanol), fibrin sealant, N-butylcyanoacrylate. Sclerosants are no longer used due to local side effects, and limited benefits over epinephrine. 27 Although fibrin sealant was originally shown to be more effective than sclerosants (polidocanol), it is not used in clinical practice due to requirement of multiple therapies. 28 N-butylcyanoacrylate is commonly used in treatment of variceal bleeding, and it has been used in rare cases of refractory peptic ulcer bleeding. 29
Thermal therapies can be divided into contact thermal and non-contact thermal modalities, with the former being more commonly used in peptic ulcer bleeding. Contact thermal devices include electrocautery probes, heater probes, and hemostatic grasper (▶Table 28.3). Noncontact thermal modalities include argon plasma coagulation (APC) and laser phototherapy (Nd: YAG laser).
Contact Thermal Modalities
Electrocautery probes can be monopolar, bipolar, or multipolar. A monopolar electrocautery probe supplies only one electrode to the bleeding ulcer; an electrical grounding pad is attached to the skin to complete the circuit. As electricity flows through the body from the probe to the grounding pad, there is a risk of scatter injury, thus the use of monopolar coagulation has now become obsolete. Bipolar probes contain two electrodes on the probe tip, and electricity travels from one electrode to the other. The electric circuit terminates locally at the tip of the probe and the electrical intensity decreases as the target tissue desiccates with electrocautery, limiting the depth of penetration and reducing the risk of perforation. 30 Bipolar devices have been replaced by multipolar probes, which consist of alternating arrays of positive and negative electrodes. This allows multipolar probes to be effective in both tangential or en face positions, whereas bipolar probes have to be applied en face for maximum effectiveness.
When using either bipolar or multipolar probes, the optimal technique involves using a large-diameter probe (10 F, 3.2 mm) and applying high constant pressure of low-energy (15 W) electrocoagulation for 10 to 12 seconds. This will occlude and achieve a tamponade effect on the vessel of the bleeding ulcers. The application of mechanical pressure together with electric current or heat to coagulate the vessel is known as “coaptive coagulation” (▶Fig. 28.1). A footprint effect on the ulcer base will be seen after achievement of hemostasis with thermal therapy (▶Fig. 28.2). For optimal coaptive coagulation, long-duration (10–12 seconds) and low-energy (15 W) electrocoagulation is preferred than escalating of the watts; because of an ensuing increase in impedance, escalation of watts does not increase coagulation. 31 , 32
Gold Probe (Boston scientific, Natick, Massachusetts, United States) and Injection Gold Probe (Boston scientific, Natick, Massachusetts, United States) are multipolar electrocautery probes, both available in two sizes, 7 F (2.3 mm) and 10F (3.2 mm), requiring a minimum of 2.8- or 3.7-mm working channels, respectively. Thus, a therapeutic gastroscope is required for the 10-F probes. Injection Gold Probe offers simultaneous capability of injection, electrocoagulation, and irrigation by one device.