Andrew W. Yen1,2 and Joseph W. Leung1,2 1 Sacramento VA Medical Center, VA Northern California Health Care System, Mather, CA, USA 2 University of California Davis School of Medicine, Sacramento, CA, USA Upper gastrointestinal (UGI) bleeding from peptic ulcer disease and other nonvariceal causes is a frequent cause of hospitalization (250 000–300 000 hospital admissions per year in the United States). Advances in endoscopic diagnosis and therapy have not substantially affected the overall mortality rate of this disorder, which remains in the range of 5–15% depending on age and comorbid medical conditions. Initial treatment should focus on vigorous volume resuscitation. A combination of clinical characteristics and endoscopic findings can predict the risk for rebleeding and mortality. This allows the level of care to be tailored to the risk for the individual patient. In the setting of bleeding peptic ulcers, the best predictor of persistent or recurrent bleeding, the need for surgical intervention, and mortality is the endoscopic appearance of the ulcer. Lesions with active bleeding or a visible vessel have a high likelihood of rebleeding (40–55%) and a mortality rate that exceeds 10%. On the other hand, lesions with a clean base have a very low risk of rebleeding (<5%) and a mortality rate that approaches 0%. Early endoscopic evaluation can, therefore, determine the optimal treatment approach for each patient. Endoscopic therapy is indicated for all lesions considered to have a high risk of rebleeding (active bleeding or visible vessel). Ulcers with adherent clots that obscure the underlying lesions may benefit from careful endoscopic therapy. Endoscopic therapies can be thermal (electrocoagulation, direct heat application, or laser therapy), involve injection with various agents, or employ mechanical compression of the bleeding site (hemostatic clips or bands). All of these methods have a high rate (90%) of success in stopping active bleeding, and significantly reduce the risk of rebleeding. Endoscopic therapy also reduces morbidity, mortality, transfusion requirements, and the costs of care. The technique of choice for a specific patient depends on the clinical situation, the location of the lesion, and the skill of the endoscopist. This chapter demonstrates some of the endoscopic findings predictive of the outcome of a bleeding lesion, some of the devices used to treat the lesions, and the results of therapy (Figures 81.1–81.16). Figure 81.1 Deep gastric ulcer with flat pigmented spots in the base. This lesion, despite its depth, has a low (<10%) risk of rebleeding and a mortality rate of less than 5%. Endoscopic therapy is not indicated for this lesion. Figure 81.2 A duodenal ulcer with a central smooth‐surfaced protuberance indicating a visible vessel. Despite the absence of active bleeding, the risk of rebleeding in this lesion is greater than 40% and the mortality rate is greater than 10%. Both of these figures can be considerably reduced by appropriate endoscopic therapy. Source: Dooley J, Sherlock S. Sherlock’s Diseases of the Liver and Biliary System, 12th edn. Oxford: Wiley‐Blackwell, 2011. Reproduced with permission of John Wiley & Sons. Figure 81.3 A large, deep duodenal ulcer with a visible vessel with bleeding is seen in the center of the base of the ulcer. The position of this lesion is ideal for direct application of thermal therapy to coagulate the vessel. Figure 81.4 This large ulcer at the apex of the duodenal bulb shows a visible vessel extending into the lumen. The risk of rebleeding from this lesion is very high without endoscopic therapy.
CHAPTER 81
Endoscopic diagnosis and treatment of nonvariceal upper gastrointestinal hemorrhage
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