Classification of peptic GI bleeding is based on Forrest classification (◘ Table 3.2). The classification differentiates between acute, recent (with risk of re-bleeding), and almost-healed ulcerations. The goal of the Forrest classification is the immediate judgment of the risk of re-bleeding and the need for endoscopic intervention (Forrest et al. 1974).

Active bleeding from the upper GI tract has to be considered as a medical emergency. Typical clinical signs are hematemesis and melena. Strong upper bleeding might lead to perianal bleeding with red color (hematochezia). Occult bleeding leads mainly to fatigue, dizziness, weakness, and cardiac symptoms (Peura et al. 1997).

The different scores are scientifically evaluated. However, they are not all embedded into clinical practice. Here, simple parameters can be used to judge the overall blood loss. Melena is associated with an average blood loss between 50 and 100 ml. Hypotension develops after blood loss between 10 and 25% of the overall blood volume. Stable vital signs are seen if less than 10% of the blood volume is lost.

Rapid pH elevation is mandatory for stabilization of blood coagulation and leads to reduced recurrence of GI bleeding. Cellular and plasmatic coagulation is only sufficiently active if pH values are between 4 and 5. There is inconsistency with regard to the route of administration of PPI (orally or intravenously) to be used. Oral administration may be sufficiently effective in patients with stable bleeding. Eradication of Helicobacter pylori if present is an additional benefit. The recurrence of ulcerations of the stomach and duodenum is accordingly reduced (less than 5%). Prokinetic agents such as erythromycin and metoclopramide can be of benefit in preparing for endoscopic diagnosis and therapy (Altraif et al. 2011). The stomach will be freed of blood clots by prokinetic therapy, and the visibility of blood lesions will be improved. In contrast, the vasoconstriction of the splanchnic vessels which can be achieved with somatostatin does not play a role in endoscopic bleeding management or therapy (Imperiale and Birgisson 1997).

Surgery does not play an important role in treatment of GI bleeding nowadays. Endoscopy, radiological interventions, and medical treatment have almost replaced surgical interventions. Resection methods such as Billroth were performed in the past but are no longer necessary. However, surgery is needed if recurrent bleeding is present. Complications such as perforation or stenosis still require surgery.

Co-medication with anticoagulation increases the risk of GI bleeding and can lead to more severe bleedings. However, cardiovascular mortality can be increased if anticoagulation is stopped based on GI bleeding. Thus, close interaction between cardiologists and gastroenterologists is needed to define optimal treatment of the patients.

It is mandatory to use two types of endoscopic therapy to sufficiently treat GI bleeding (Sung et al. 2007). Most commonly, injection therapy is combined with clipping.

The use of diluted epinephrine solution is most common. Several circumstances are in favor for this type of agent:

Injection with diluted epinephrine (1:10,000) is highly effective. The source of bleeding is treated by injecting several doses (1–2 ml) of epinephrine toward the bleeding vessel. Complication rates are below 1%. Bleeding control can be achieved in 75–90% of cases.

Technical note: The catheter covering the needle is gently passed over the working channel of the endoscope. The nurse moves the needle forward out of the catheter if the distal tip of the catheter becomes clearly visible. The syringe with the diluted epinephrine is connected with the catheter. The examiner moves the needle forward into the tissue. Ideally, injection is done within four quadrants surrounding the bleeding vessel. The nurse states aloud the amount of applied epinephrine and also whether the injection can be done easily or resistance occurs; the examiner can reposition the needle based on this information.

The diluted epinephrine can be further diluted, or pure saline can be used in patients with coronary heart disease to further minimize the risk for systemic side effects.

Injection therapy is an easy and basic endoscopic intervention and can be learned quickly. It can be performed also by less experienced examiners.

The mode of intervention is similar for polidocanol, alkyl cyanoacrylate, and fibrin glue. However, the preparation of compounds using components such as fibrin glue requires special attention. The eyes and mouth of the patient and the examiners should be protected.

Fibrin glue has been stated to be superior in single studies (compared to epinephrine injection). However, further studies and meta-analysis could not confirm this observation. Additional injection of sclerosing agents for peptic ulcer bleeding has no additional benefit. Indeed, it is associated with a higher complication rate due to risk of necrosis and is not recommended.

Combination of injection therapy and thermal ablation or treatment has also shown no convincing benefit. Mortality, risk of re-bleeding, and need for surgery were comparable. However, mechanical treatment (hemoclip) in combination with injection therapy has shown advantages. Here, re-bleeding is less frequent mainly because of the prolonged compression of the bleeding vessel.

◘ Figure 3.4 shows an 88-year-old patient with melena. The endoscopic examination revealed a continuously bleeding ulcer (Forrest I b) in the duodenal bulb. Hemostasis was done with two hemoclips ◘ Fig. 3.4b.

Furthermore, hemoclips have also proved themselves useful for marking (◘ Fig. 3.5) and for closure, for example, of small fistulas and perforations. All studies to date have demonstrated the significant superiority of hemoclips compared with injection methods with regard to primary hemostasis.