current management peptic ulcer bleeding

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Summary and Introduction

Summary

Peptic ulcer bleeding is a common and potentially fatal condition. It is best managed using a multidisciplinary approach by a

team with medical, endoscopic and surgical expertise. The management of peptic ulcer bleeding has been revolutionized in

the past two decades with the advent of effective endoscopic hemostasis and potent acid-suppressing agents. A prompt

initial clinical and endoscopic assessment should allow patients to be triaged effectively into those who require active

therapy, versus those who require monitoring and preventative therapy. A combination of pharmacologic and endoscopic

therapy (using a combination of injection and thermal coagulation) offers the best chance of hemostasis for those with active

bleeding ulcers. Surgery, being the most effective way to control bleeding, should be considered for treatment failures. The

choice between surgery and repeat endoscopic therapy should be based on the pre-existing comorbidities of the patient and

the characteristics of the ulcer.

Introduction

Peptic ulcer bleeding is a common medical emergency, accounting for more than 300,000 hospital admissions annually in

the US.[1]

In a population-based UK audit, the incidence of peptic ulcer bleeding was 103 cases per 100,000 adults per

year.[2]

The condition is seen predominantly among the elderly: 68% of patients are over 60 years of age and 27% are over

80 years of age. Large cohorts have reported that 7-10% of patients die from the disease.[3]

This mortality rate has remained

unchanged for the past two decades. Death from peptic ulcer bleeding occurs almost exclusively among elderly patients with

significant comorbidities.

Approximately 80-85% of upper-gastrointestinal bleeding stops spontaneously and supportive therapy only is required. The

remaining 15-20% of upper-gastrointestinal bleeding continues or develops into recurrent bleeding; patients with continual or

recurrent bleeding constitute a high-risk group with substantially increased morbidity and mortality rates. Early

risk-stratification based on clinical and endoscopic criteria facilitates the delivery of the appropriate level of care to patients.Endoscopic therapy is well accepted as the first-line treatment in most management algorithms. The management of

patients with peptic ulcer bleeding requires a multidisciplinary approach, cooperation among gastroenterologists who are

skilled in endoscopic hemostasis and surgeons who are proficient in ulcer surgery.

Risk Assessment

Several validated risk-stratification schemes have been published; most are composite scoring systems incorporating both

clinical and endoscopic parameters. Such a scheme should aid in making clinical decisions, as to both the need for urgent

intervention and the prediction of continued or recurrent bleeding in the context of endoscopic therapy. The latter point is

important because alternative treatment strategies should be readily available to prevent recurrent bleeding. Each of the

published schemes has its own objective and clinical usage.

With the data generated from 4,185 admissions in the national UK audit, Rockall et al. derived a scoring scheme based on

admission and postendoscopy scores, and validated its ability to predict recurrent bleeding and death using data from 1,625

patients ( ).[4]

Their scoring system is based on age, comorbidities, the presence of shock, and endoscopic findings. A total

score of three or less is associated with an excellent prognosis, while a score of eight or more is associated with a high risk

of death. To date, the Rockall Score is the most widely used method for risk assessment and it has been validated by

independent studies.[5-7]

Table 1. The Rockall Risk Score Scheme[4]

Current Management of Peptic Ulcer BleedingJoseph Sung

Nat Clin Pract Gastroenterol Hepatol. 2006;3(1):24-32.

http://www.medscape.com/viewarticle/521

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Value

Score

0 1 2 3

Age (years) <60 60-79 >80 --

Shock No shock (systolic BP

≥100, pulse <100)

Tachycardia

(systolic BP ≥100,

pulse ≥100)

Hypotension (systolic BP

<100)

--

Comorbidity No major comorbidity -- Cardiac failure, ischemicheart disease, any major

comorbidity

Renal failure, liver failure, disseminated

malignancy

Diagnosis Mallory-Weiss tear, no

lesion identified and

no SRH

All other diagnoses Malignancy of upper

gastrointestinal tract

--

Major stigmata of

recent

hemorrhage

None or dark spot only -- Blood in upper

gastrointestinal tract,

adherent clot, visible or

spurting vessel

--

Maximum additive score prior to diagnosis = 7, maximum additive score following diagnosis = 11. BP, blood pressure; SRH,

stigmata of recent hemorrhage.

Blatchford et al. used simple clinical and biochemical parameters to derive a score that predicts the need for intervention to

control bleeding ( ).[8]

Without incorporating endoscopic parameters, the Blatchford score was modelled on the clinical

process rather than treatment outcome. The risk markers -- elevated blood urea nitrogen, reduced hemoglobin, a drop in

systolic blood pressure, raised pulse rate, the presence of melena or syncope, and evidence of hepatic or cardiac disease --

are assigned numerical values that are easy to remember. The full score can be used to determine the required level of care

on admission and to identify those patients who need urgent treatment.

Table 2. Blatchford Admission Risk Markers

Admission risk marker Score component value

Blood urea (mMol/l)

6.5-8.0 2

8.0-10.0 3

10.0-25.0 4

>25 6

Hemoglobin (g/l) for men120-130 1

100-120 3

<100 6

Hemoglobin (g/l) for women

100-120 1

<100 6

Systolic blood pressure (mm Hg)


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100-109 1

90-99 2

<90 3

Other markers

Pulse >100 per min 1

Presentation with melena 1

Presentation with syncope 2

Hepatic disease 2

Cardiac failure 2

Reproduced with permission from reference 8 © (2000) Elsevier.

The Baylor Group developed and validated the Baylor Bleeding Score to identify patients who might require early surgical

intervention.[9]

By assessing simple pre-endoscopic (age; number and severity of concurrent medical illnesses) and

postendoscopic parameters (site and stigmata of bleeding ulcers), Saeed et al. showed that this scoring system might beable to predict patients at risk of rebleeding after successful endoscopic therapy of bleeding ulcers.

In the Canadian Consensus Conference Statement published in 2003, Barkun et al. reviewed studies over the previous

decade that used multivariate analyses, and formulated their own risk scoring scheme.[10]

Like the authors of most other

scoring systems, they concluded that advanced age, poor health status or comorbid illness, continued or recurrent bleeding,

fresh hematemesis or hematochezia, and the onset of bleeding in hospitalized patients (i.e. those admitted for reasons other

than upper-gastrointestinal bleeding) predicted poor prognosis and death. Endoscopic factors including active bleeding,

major stigmata of recent hemorrhage, ulcers greater than 2 cm in diameter, and the location of ulcers in proximity to large

arteries, were also identified as factors that predict recurrent bleeding.

Pharmacologic TherapyPlatelet aggregation is impaired in acidic environments, and hence blood clots that form on the surface of peptic ulcers are

unstable.[11]

In the stomach, an almost complete shutdown of gastric secretion is required to facilitate platelet aggregation

and clot formation.

H2-Receptor Antagonists

With the advent of potent acid-suppressing agents, attempts have been made to halt ulcer bleeding using pharmacologic

control. Unfortunately, H2-receptor antagonists (H

2RAs) are relatively weak acid suppressors. No single study has

convincingly demonstrated an overall benefit of using H2RAs in the cessation of acute peptic ulcer bleeding. In a recent

meta-analysis, Levine et al. pooled data from 30 randomized studies comprising 3,786 patients.[12]

They showed that the

use of H2RAs was beneficial only in patients with gastric ulcers, giving a modest reduction in the rate of recurrent bleeding,

the need for surgery and in mortality rate. There was no demonstrable benefit even with a high-dose infusion of H2RA.

These findings are remarkably similar to those reported by Collins and Langman.[13]

The use of H2RAs is therefore not

generally recommended in the management of bleeding peptic ulcers.

Proton-Pump Inhibitors

Proton-pump inhibitors (PPIs) have a more potent acid-suppressing effect in the stomach than H2RAs. In the first large-scale

study of intravenous omeprazole for the treatment of peptic ulcer bleeding, 1,174 patients with overt signs of upper-

gastrointestinal bleeding were randomly assigned to receive placebo or omeprazole 80 mg intravenous bolus followed by 40


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mg every 8 hours or placebo. Disappointingly, no differences in recurrent bleeding or mortality rates were observed

between the two treatment groups. In this particular trial, patients were randomized on admission and before endoscopic

confirmation of the diagnosis; the timing of endoscopy was not standardized. The decision to perform endoscopic therapy

and guidelines on how endoscopy was performed were not uniform among participating endoscopists. There were

indications, however, that endoscopic stigmata of bleeding were seen less frequently during endoscopy among patients

given omeprazole. This study suggests that omeprazole might hasten the resolution of endoscopic stigmata of bleeding.

Two multicenter trials from Scandinavia have subsequently evaluated the infusion of high-dose omeprazole (80 mg

intravenous bolus followed by 8 mg per hour for 72 h) in conjunction with endoscopic treatment.

[15,16]

Both trials, however,lacked discrete outcome variables. Instead, they used composite endpoints combining clinical and endoscopic outcomes in

the analysis, which makes the interpretation of efficacy difficult. In the trial by Hasselgren et al., the mortality rate at day 21

was, in fact, higher among those receiving active treatment.[16]

The first evidence showing a benefit of PPIs for the treatment of peptic ulcer bleeding came from a study performed in

India.[17]

220 patients were randomized to receive either oral omeprazole 40 mg twice daily or placebo for 5 days after

endoscopic confirmation of the presence of a bleeding peptic ulcer (defined as actively bleeding ulcers or ulcers with

non-bleeding visible vessels or clots).[17]

Patients whose ulcers had a nonbleeding visible vessel or a clot were less likely to

have further bleeding. A reduction in recurrent bleeding was not evident in those patients with ulcers with spurting or oozing

hemorrhage who were given oral omeprazole. In ulcers that stopped bleeding spontaneously, acid suppression again

seemed to prevent recurrent bleeding.

In their study, Lau et al. adopted a policy of early endoscopic triage and enrolled only patients with actively bleeding ulcers or

ulcers with nonbleeding visible vessels.[18]

In this double-blind, placebo-controlled trial, 240 patients were randomized to

receive either a high-dose omeprazole infusion (80 mg intravenous bolus followed by 8 mg per hour for 72 h) or an

equivalent placebo. The rate of recurrent bleeding at day 30 was 21.7% and 5.8%, respectively, for those assigned to

placebo and omeprazole infusion (RR 3.7, 95% CI 1.68-8.23). The study also demonstrated that there was a reduction in the

need for re-treatment and blood transfusion, as well as a trend towards fewer surgeries and deaths among those assigned

to omeprazole infusion. This trial provides convincing evidence to support the adjunctive use of high-dose PPI infusion after

endoscopic hemostasis.

Two studies have further evaluated the use of oral PPIs after endoscopic treatment. Javid et al. enrolled 166 patients with

peptic ulcers with signs of recent hemorrhage, confirmed by endoscopy.[19]

All patients received endoscopic injection

sclerotherapy using 1:10,000 epinephrine and 1% polidocanol, and were randomly assigned to receive omeprazole (40 mg

orally) every 12 h for 5 days, or placebo. Recurrent bleeding was reduced, and the hospital stay was shorter for those who

received the oral PPI. In a similar study, Kaviani et al. randomized 160 patients with bleeding ulcers after endoscopic

injection.[20]

The authors also showed that there was a lower rate of recurrent bleeding associated with the use of oral

omeprazole.

With the accumulation of conflicting data on the use of PPIs for the treatment of peptic ulcer bleeding, the Cochrane

Collaboration Group performed a systemic review on the subject.[21]

Twenty-one randomized, controlled trials with a total of

2,915 participants were identified in the literature. The pooled data showed that there was no significant difference in

mortality rates between patients receiving PPIs and control treatment (5.2% versus 4.6%, OR = 1.11, 95% CI 0.46-0.76). PPI

treatment did, however, significantly reduce the rate of recurrent bleeding and surgical intervention compared with control.

The result was independent of the route of administration of PPI -- oral or intravenous -- as long as a high dose was given.Post-hoc analysis showed that there was an interesting difference in patient outcome according to the geographic location of

trials. For European studies, mortality rates were significantly higher for PPI treatment than for controls, whereas data pooled

from Asian trials revealed that the mortality rate was significantly lower with PPI treatment (1.5%) than for controls (4.7%)

(OR = 0.35, 95% CI 0.16-0.74, P = 0.006). It is not clear why there is such a difference in outcome among different

geographic locations, but a possible explanation is variation in the rate of PPI metabolism and acid secretion capacity

among patients of different ethnic groups; these ideas require further investigation.

The benefit of PPI therapy has been further confirmed in a study comparing the use of intravenous pantoprazole versus

intravenous ranitidine in the prevention of peptic ulcer bleeding. Barkun et al. randomized more than 1,200 patients to

receive either of the two pharmacologic therapies for 72 h.[22]

Using a composite endpoint, including need for endoscopy,


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surgery and death, they showed that patients who received intravenous PPI had a lower rebleeding risk than those who

received an H2RA.

In 2004, the American Society of Gastrointestinal Endoscopy recommended the use of PPIs in all patients with upper-

gastrointestinal bleeding that was severe enough to require endoscopic therapy, and in patients with suspected peptic ulcer

bleeding associated with hemodynamic instability.[23]

The recommendation endorsed systematic use of PPIs in upper-

gastrointestinal bleeding.

The benefit of pre-emptive PPIs in patients with upper-gastrointestinal bleeding is supported by the interim analysis of alarge-scale randomized study from Hong Kong.

[24] Patients with symptoms and signs of upper-gastrointestinal bleeding who

received intravenous PPIs were found to have less active bleeding on endoscopy, and hence were less likely to require

endoscopic therapy. This result needs to be confirmed by the final analysis of this study and validated by other clinical trials.

Which dose of intravenous PPI to use has been the subject of debate. While a high-dose regimen (80 mg bolus followed by

8 mg/h infusion) has been used in most studies, the optimal dose of PPI to achieve almost complete cessation of acid

secretion in the stomach in patients with upper-gastrointestinal bleeding has not been determined. Two studies suggested

that there might be room to reduce the infusion of intravenous omeprazole to the 'regular' dose of 20-80 mg per day.[25,26]

It

worthwhile pointing out that these studies included patients with low-risk ulcers who did not require endoscopic therapy. The

relatively small sample sizes might also limit the interpretation of these studies.

Endoscopic Therapy

Since the late 1980s, endoscopic hemostatic therapy has been widely accepted as the first-line therapy for upper-

gastrointestinal bleeding. Numerous clinical trials and two meta-analyses have confirmed the efficacy of endoscopic therapy

in this setting.[27,28]

Most clinical trials demonstrated a reduction in both recurrent bleeding and the need for surgical

intervention when endoscopic hemostasis was used.

Endoscopic therapy can be broadly categorized into injection therapy, thermal coagulation, and mechanical hemostasis.

When analyzed separately, injection therapy, thermal-contact devices, and laser treatment all decrease the frequency of

recurrent bleeding and rate of surgical intervention.

Injection Therapy

Injection with solutions of diluted epinephrine (1:10,000) is widely used because of its simplicity. All that is required is a

sclerotherapy needle, and the technique is simple. The principal mechanism of action by which diluted epinephrine solutions

work is a tamponade effect induced by the volume of solution injected. It is, therefore, logical that in a recent study, a large

volume (35-45 ml) epinephrine injection appeared to be more effective than a standard volume (15-25 ml) injection.[29]

Solutions of agents other than epinephrine, such as polidocanol, saline and even dextrose, can produce the same effect. In

spite of the large body of published literature, no single solution for endoscopic injection has been shown to be superior to

another in achieving hemostasis. The use of sclerosants (including absolute alcohol) in injection therapy for bleeding ulcers

should, however, be discouraged: extensive and uncontrolled tissue necrosis caused by sclerosants injected to the ulcer

base can result in ulcer perforation and complications relating to adjacent tissues.

Thermal Devices

Thermal devices can be divided into contact (heater probe, monopolar and bipolar electrocoagulation) and noncontact types

(laser treatment, argon plasma coagulation [APC]). While the hemostatic effects of contact probes are well established by

clinical trials, the use of APC in the treatment of peptic ulcer bleeding has only recently been reported. There has been only

one randomized, controlled study comparing APC with heater-probe coagulation, and it suggested that APC is equally as

safe and effective.[30]

In both groups of patients, epinephrine injection was administered before thermal treatment. Of 185

cases analyzed, 97 were in the heater-probe group and 88 in the APC group. No significant differences were detected in

terms of initial hemostasis at index endoscopy, frequency of recurrent bleeding, requirement for emergency surgery, number

of units of blood transfused, length of hospital stay, and mortality rate. To summarize, no single method of endoscopic

thermal coagulation therapy is superior to the others.


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Mechanical Devices

Mechanical devices have been used for the treatment of variceal hemorrhage, but rarely in the treatment of peptic ulcer

disease. Hemoclips have gained popularity in the past few years. Initial enthusiasm for the use of hemoclips was generated

by a study by Cipolleta and colleagues,[31]

in which they compared hemoclips with heater probe thermocoagulation. They

reported a significantly lower rate of recurrent bleeding with the use of hemoclips (1.8% versus 21%). The deployment of

hemoclips on fibrotic ulcer floors can be difficult, however, particularly when they are used tangentially or with the endoscope

in a retroflexed position. Indeed, two subsequent trials yielded conflicting results on the use of hemoclips. Lin and colleagues

compared hemoclips with heater probe coagulation, and in 6 out of 40 patients the hemoclips could not be applied.[32]

Gevers et al. randomly assigned patients with bleeding ulcers to treatment with hemoclips, injection, or both.[33] They

reported a failure rate of 13 out of 35 patients with the hemoclips compared with 5 out of 34 patients with injection and 8 out

of 32 patients with combined therapy. The efficacy of hemoclips seems to be limited by difficulty of successful application.

With improvements in design, this technical problem might be overcome. More studies are required to give a fair verdict on

the effectiveness of hemoclips.

Combined Therapy

Many endoscopists favor combined therapy, in which the injection of diluted epinephrine precedes thermal coagulation. In

actively bleeding ulcers, an injection can diminish or even stop bleeding, allowing a clear view of the bleeding vessel, which

in turn facilitates accurate thermal coagulation. The cessation of blood flow can also prevent dissipation of thermal energy,

so that tissue injury can be minimized. In theory, this all sounds very promising.

In a prospective randomized trial, 134 patients with actively bleeding ulcers who received epinephrine alone were compared

with 136 patients who received the combined therapy of epinephrine injection followed by heater-probe coagulation.[34]

There was no difference in the outcome of the two treatment strategies as measured by rebleeding, the need for surgery,

requirement for repeated endoscopic hemostasis, length of hospital stay, mortality rate, or healing at 4 weeks. When the

subgroup of patients with spurting ulcers was analyzed separately, however, there was less rebleeding in the combined

group. A lesser need for surgery was seen in the combined treatment group (8 out of 27 patients versus 2 out of 31 patients

in the injection group, P = 0.03). For the severe form of spurting hemorrhage, combined therapy therefore seems to be

beneficial.

The benefit of combination therapy has been evaluated in many trials and confirmed by meta-analysis. In a systematic

review that aimed to determine whether the addition of a second hemostatic procedure immediately after epinephrineinjection improves efficacy of hemostasis or patient outcomes, a total of 16 randomized studies involving 1,673 patients were

analyzed.[35]

The addition of a second procedure reduced the rate of recurrent bleeding from 18.4% to 10.6% (OR 0.53,

95% CI 0.40-0.69) and that of emergency surgery from 11.3% to 7.6% (OR 0.64, 95% CI 0.46-0.90). The mortality rate fell

from 5.1% to 2.6% (OR 0.51, 95% CI 0.31-0.84). Eleven studies used injected substances (such as a sclerosant, tissue

adhesive, or thrombin), two studies added hemoclips, and three studies evaluated the added use of thermal coagulation

devices. Pooled data revealed that combined therapy is the treatment of choice for high-risk bleeding peptic ulcers. The

meta-analysis also confirmed a greater risk of the significant complications of perforation and gastric-wall necrosis in the

combined therapy group (6 out of 558 patients) than in the epinephrine alone group (1 out of 560 patients). Furthermore,

improvement in prognosis seems to be more evident in those with active bleeding. The caveat of this meta-analysis is that

some of the studies included are relatively old, and acid suppression therapy using a high-dose PPI was not included.

Currently, the standard therapy most widely used is injection with diluted epinephrine, followed by thermocoagulation with a

3.2 mm heater probe.

Second-Look Endoscopy

Despite the effectiveness of endoscopic hemostasis, rebleeding occurs in 10-25% of cases, irrespective of the method of

treatment. The benefit of a routine 'second-look' endoscopy after the initial hemostasis is disputed. In a meta-analysis of four

studies comparing systematic second-look endoscopy and re-treatment versus expectant treatment, Marmo et al. showed

that the risk of recurrent bleeding with the former approach was reduced by 6.2%, but risk reductions for surgery and

mortality were insignificant.[36]

The authors concluded that appropriate selection of patients for second-look endoscopy is

crucial. The selective use of second-look endoscopy and re-treatment has been supported by a single-center trial that


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included only Forrest I and IIa ulcers; patients were treated by a standardized endoscopic therapy in combination with

intravenous omeprazole.[37]

A scheduled second-look endoscopy the day after initial endoscopic hemostasis was found to

prevent recurrent bleeding (relative risk 0.33, 95% CI 0.1-0.96).

Nonbleeding Ulcers With an Adherent Clot or Protuberant Vessel

The role of pharmacologic and endoscopic treatments for nonbleeding peptic ulcers with adherent clots is not well defined.

One concern with endoscopic manipulation is the possibility of provoking bleeding while elevating the clot. Two recent

randomized, controlled studies supported the lifting of clots overlying an ulcer floor, followed by endoscopic therapy. Jensenet al. randomized 32 patients (17 to medical treatment and 15 to endoscopic therapy) and found that endoscopic therapy

completely abolished recurrent bleeding, whereas 35.3% of patients on medical therapy alone experienced rebleeding.[38]

Bleau et al. randomized 56 patients (35 to medical therapy and 21 to endoscopic therapy) and reported similar results.[39]

It

is worth emphasizing, however, that both trials recruited only small numbers of patients. These trials also differed in their

definition of an adherent clot. Jensen et al. defined an adherent clot as greater than 6 mm in diameter, red in color, and

amorphous in its texture. By contrast, Bleau et al. defined an adherent clot as a red, maroon, or black protuberance greater

than 3 mm in diameter, that could not be dislodged by forceful irrigation with water.

Combined endoscopic treatment and the adjunctive use of PPI infusion has been compared with the use of PPI infusion

alone in the treatment of ulcers with nonbleeding visible vessels or clots.[40]

In those assigned to the combined treatment,

recurrent bleeding was seen in 1 out of 70 patients, which occurred on day 14 after treatment. In those given an intravenous

PPI infusion alone, the rate of recurrent bleeding was 11% at day 30. While the results clearly showed that combined therapy

was superior in the control of bleeding, the low rate of recurrent bleeding in the PPI infusion alone group would suggest that

acid suppression does have a therapeutic role in the treatment of ulcers with nonbleeding visible vessels and clots.

Recurrent Bleeding After Initial Hemostasis

At the time of recurrent bleeding, the dilemma often faced by physicians is whether to repeat endoscopic treatment or to

refer the patient directly to surgery. Lau et al. conducted a randomized trial in patients who experienced recurrent bleeding

after initial endoscopic control of their bleeding ulcers.[41]

Of 48 patients who underwent endoscopic re-treatment, long-term

hemostasis was achieved in 35 patients. Ulcer perforation occurred in two patients, in association with repeated thermal

coagulation. Of 44 patients assigned to surgery, 22 underwent gastrectomy, which was associated with greater morbidity.

The two groups did not, however, differ in regard to mortality rate. In a logistic regression analysis, ulcers larger than 2 cm indiameter and hypotension at the time of rebleeding were two independent factors that predicted failure of endoscopic

retreatment. The findings of Lau et al. suggest that, in the management of patients with recurrent bleeding after initial

endoscopic control, a selective approach can be adopted based on the local characteristics of the ulcer and the pre-existing

comorbidities of the patients. Large chronic ulcers should probably be treated by expeditious surgery if recurrent bleeding

ensues. Those who are poor surgical candidates might benefit from repeated endoscopic treatment.

Eradication of Helicobacter Pylori

There is ample evidence to prove that, for bleeding related to Helicobacter pylori infection, when patient is not using aspirin

or nonsteroidal anti-inflammatory drugs, curing the infection with a 1 or 2 week course of triple therapy obviates the risk of

ulcer recurrence and ulcer rebleeding. This therapy is even more reliable than maintenance therapy with H 2RA because thecompliance of patients for taking long-term medication will no longer be required.

[42-44] The economic impact of this strategy,

especially in young ulcer patients, cannot be over-emphasized.

Conclusions

Peptic ulcer bleeding is best managed using a multidisciplinary approach, as outlined in Figure 1. A prompt initial clinical and

endoscopic assessment should allow the effective triaging of patients who require active therapy versus those who need

monitoring and preventive therapy. A combination of pharmacologic and endoscopic therapy (i.e. injection and thermal

coagulation) offers the best method of hemostasis to those with active bleeding ulcers. Those patients with an adherent clot

and/or a protuberant vessel should probably receive the same therapy to reduce the risk of recurrent bleeding. Rebleeding


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despite initial hemostasis can be effectively handled by repeating endoscopic therapy or surgery. The choice between the

two options should be made at the discretion of the physician, based on the pre-existing comorbidities of the patient.

Figure 1.

Clinical algorithm for the management of peptic ulcer bleeding adopted at the Prince of Wales Hospital, Hong Kong.

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