Therapeutic endoscopy for acute upper gastrointestinal bleeding

Abstract

Endoscopy is the primary diagnostic and therapeutic tool for upper gastrointestinal bleeding (UGIB). The performance of endoscopic therapy depends on findings of stigmata of recent hemorrhage (SRH). For peptic ulcer disease—the most common etiology of UGIB—endoscopic therapy is indicated for findings of major SRH, such as active bleeding, oozing, or the presence of a nonbleeding visible vessel, but not indicated for minor SRH, such as a pigmented flat spot or a simple ulcer with a homogeneous clean base. Endoscopic therapies include injection, ablation, and mechanical therapy. Monotherapy reduces the risk of rebleeding in patients with peptic ulcer disease with major SRH to about 20%. Combination therapy, especially injection followed by either ablation or mechanical therapy, is generally recommended to further reduce the risk of rebleeding to about 10%. Endoscopic dual hemostasis by an experienced endoscopist reduces the risk of rebleeding, the need for surgery, the number of blood transfusions required, and the length of hospital stay. This Review article comprehensively analyzes the principles, indications, instrumentation, techniques, and efficacy of endoscopic hemostasis.

Key Points

  • Esophogastroduodenoscopy is the prime diagnostic and therapeutic procedure for acute upper gastrointestinal bleeding (UGIB), which accounts for nearly 400,000 admissions to hospital annually in the US

  • The performance of endoscopic therapy for acute UGIB for peptic ulcer disease largely depends on findings of stigmata of recent hemorrhage (SRH); major SRH generally mandate endoscopic therapy, whereas minor SRH or absence of SRH generally require no endoscopic therapy

  • Endoscopic therapies include injection therapy, ablative therapy, and mechanical therapy; combination therapy (usually injection therapy followed by ablative therapy or mechanical therapy) is performed to maximally reduce the risk of rebleeding

  • Combined therapeutic endoscopy can reduce the risk of ongoing or recurrent bleeding from 80% to 15% for an actively bleeding ulcer and from 50% to 10% for an ulcer with a nonbleeding visible vessel

  • Although originally designed for peptic ulcer disease, endoscopic therapeutic techniques and protocols have increasingly been adapted for other etiologies of UGIB and for many types of lower gastrointestinal bleeding

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Figure 1: Endoscopic argon plasma coagulation therapy for extensive gastric antral vascular ectasia.
Figure 2: Stigmata of variceal hemorrhage and endoscopic band ligation.

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Acknowledgements

Charles P. Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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Cappell, M. Therapeutic endoscopy for acute upper gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol 7, 214–229 (2010). https://doi.org/10.1038/nrgastro.2010.24

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