Endoscopic Hydrogen Peroxide Spray May Facilitate Localization of the Bleeding Site in Acute Upper Gastrointestinal Bleeding

Abstract

A major problem encountered in the emergency endoscopic management of acute upper gastrointestinal (UGI) bleeding is poor localization of the bleeding site, which can be obscured by blood or clots. Traditional attempts to overcome this problem have been by physical methods, which have usually proved unsatisfactory. The aim of this prospective study was to show that hydrogen peroxide can be used as a dissolution agent, resulting in an alteration of the characteristics of blood clots and allowing a clearer visual field. Twenty patients with acute UGI bleeding (13 male, seven female) were included in the study. The suspected site of bleeding was initially sprayed with 200 ml of saline and then with 25-175 ml of 3 % H2O2. Pictures of the visual field were taken before and after irrigation with both saline and H2O2. These pictures were evaluated by three gastroenterologists and scored using the following visual clearance scoring system: -3, marked worsening of visual field; -2, moderate worsening; -1, slight worsening; 0, no change; +1, slight improvement; +2, moderate improvement; + 3, marked improvement. In cases of active oozing or spurting, after initial hemostasis was achieved the bleeding point was injected with pure ethanol or cauterized with a heater probe. In order to assess the safety of 3 % H2O2 endoscopic biopsies of the antrum and the duodenal bulb were performed before and 30 minutes after its use and examined by a pathologist. There was a significant improvement in the mean visual clearance score after irrigation with H2O2 compared to irrigation with saline alone (2.13 vs. 0.43, P<0.001). During endoscopic examination there were 19 patients with active oozing from the ulcer base covered by an adherent blood clot; 12 of these (63.1%) achieved initial hemostasis after H2O2 spraying. Eleven of 18 (61.1 %) patients complained of a mild epigastric burning sensation during H2O2 irrigation. There was no clinically significant change in the histology of the antrum and the duodenal bulb after H2O2 therapy. We concluded that H2O2 is a safe and effective way to clear the visual field, facilitating the localization of the bleeding site during emergency endoscopy for acute UGI bleeding, with only mild side effects. In some cases H2O2 therapy can also induce temporary hemostasis. We recommended the use of hydrogen peroxide to improve endoscopic visualization, especially in cases where an adherent blood clot covers the suspected bleeding site.