Endoscopic Stigmata Of Recent Haemorrhage Research Articles

Comparison of the performance of risk scoring systems for tumor bleeding in patients with inoperable gastric cancer.

The Glasgow - Blatchford bleeding score (GBS) and admission and full Rockall scores are widely used risk scoring systems to stratify risk and determine the need for intervention in patients with upper gastrointestinal bleeding. We evaluated the performance of these risk scoring systems in patients with gastric cancer and tumor bleeding. This retrospective study included patients with inoperable gastric cancer who presented with tumor bleeding at the National Cancer Center, Korea, between 2001 and 2015. The GBS, and admission and full Rockall scores were calculated. Primary outcome was the performance of the risk scoring systems in predicting the need for urgent interventions (endoscopic therapy, transarterial embolization, and surgery). The risk factors associated with urgent intervention were analyzed. Of 357 patients with tumor bleeding, 118 (33.1 %; 116 endoscopic therapy, 2 trans-arterial embolization) required urgent intervention. The full Rockall score was better at predicting the need for urgent intervention (area under the receiver operating characteristic curve = 0.78; P < 0.001) than the GBS (0.56) and admission Rockall score (0.56). Hemostatic intervention was not performed in patients with a full Rockall score ≤ 6 (103 patients, 28.9 %). On multivariate analysis, endoscopic stigmata of recent hemorrhage of Forrest classes Ia - IIb were significant factors associated with urgent intervention. The full Rockall score was superior to the GBS and admission Rockall score in predicting the need for urgent intervention for tumor bleeding. Thus, endoscopic evaluation is required to determine the need for urgent intervention in patients with gastric cancer and tumor bleeding.

Management of non-variceal upper gastrointestinal bleeding in the Gaza Strip: survey of evidence-based practice

BackgroundEarly recognition, comprehensive assessment, and evidence-based care are crucial to reduce morbidity and mortality due to non-variceal upper gastrointestinal bleeding (UGIB). The aim of this study was to compare the present treatment of non-variceal UGIB in Gaza hospitals with the best available, evidence-based recommendations. MethodsWe distributed 47 questionnaires to doctors in medical departments of three hospitals (Naser Hospital, Alshifa Hospital, and the European Gaza Hospital) about current management strategies for non-variceal UGIB in two hospitals in the Gaza Strip—the European Gaza Hospital and the Shifa hospital. The questions covered target haemoglobin for blood transfusion, duration of proton pump inhibitors (PPI) infusion after endoscopic therapy, use of nasogastric tubes, and use of endoscopic stigmata of recent haemorrhage for therapeutic decisions. Answers from both hospitals were compared with the best available evidence from guidelines by the American College of Gastroenterology (ACG), published in 2012. Findings47 questionnaires were completed and returned. Only ten (20%) of responders considered the ACG-reccommended 7 g/100 mL as the best threshold for transfusion (most used a higher dose), and only 12 (25%) followed the evidence with respect to the dose and duration of intravenous infusion of PPIs after endoscopic therapy. By contrast, 42 (90%) respondents complied with ACG recommendations of not to routinely use nasogastric tubes, and 38 (80%) used endoscopic stigmata of recent haemorrhage to guide treatment decisions for patients. Finally, only 25 (53%) respondents matched the ACG guidelines about the optimum time to reuse aspirin after non-variceal UGIB. InterpretationOverall, about half of the responses matched that stated in ACG guidelines, which suggests that only half of the decisions about treatment of non-variceal UGIB made by doctors in Gaza hospitals are based on the best available evidence. A potential limitation of our study was that our questionnaire only covered common and relevant aspects of management, not all aspects of therapy. FundingNone.

Rebleeding Risk Is Lower in Oozing Peptic Ulcers

The risk for rebleeding from peptic ulcers can be predicted by the presence of endoscopic stigmata of recent hemorrhage (SRH) as defined by the Forrest

Endoscopic management of tumor bleeding from inoperable gastric cancer.

Tumor bleeding is not a rare complication in patients with inoperable gastric cancer. Endoscopy has important roles in the diagnosis and primary treatment of tumor bleeding, similar to its roles in other non-variceal upper gastrointestinal bleeding cases. Although limited studies have been performed, endoscopic therapy has been highly successful in achieving initial hemostasis. One or a combination of endoscopic therapy modalities, such as injection therapy, mechanical therapy, or ablative therapy, can be used for hemostasis in patients with endoscopic stigmata of recent hemorrhage. However, rebleeding after successful hemostasis with endoscopic therapy frequently occurs. Endoscopic therapy may be a treatment option for successfully controlling this rebleeding. Transarterial embolization or palliative surgery should be considered when endoscopic therapy fails. For primary and secondary prevention of tumor bleeding, proton pump inhibitors can be prescribed, although their effectiveness to prevent bleeding remains to be investigated.

PWE-046 Early Clinical Experience of Endoclot™ in the Treatment of Acute Gastro-Intestinal Bleeding

IntroductionEndoClot™ is a new novel haemostatic powder for the treatment of gastrointestinal bleeding. We report our initial experiences of EndoClot™ as an adjunct haemostatic therapy. This is the first UK...

Effect of proton pump inhibitors on the outcomes of peptic ulcer bleeding: comparison of event rates in routine clinical practice and a clinical trial

Objective. To assess clinical outcomes in patients treated with proton pump inhibitors (PPIs) after endoscopic hemostasis in routine clinical care, and to compare these outcomes to those seen in a randomized controlled trial (RCT) of i.v. esomeprazole. Materials and methods. Patients with peptic ulcer bleeding and endoscopic stigmata of recent hemorrhage, who were treated with i.v. esomeprazole or pantoprazole ≥120 mg/day following therapeutic endoscopy, were identified from 12 hospitals in Spain (n = 539). Outcomes assessed included further bleeding, all-cause mortality and surgery. The results were compared to those of the RCT. Results. Overall, 9.1% (95% confidence interval [CI]: 6.7–11.5) of patients experienced further bleeding within 72 h following initial endoscopy, 14.3% (95% CI: 11.3–17.2) of patients had further bleeding within 30 days and 3.3% (95% CI: 1.8–4.9) of patients died within 30 days. In the RCT, the rate of rebleeding within 72 h was significantly lower in the esomeprazole arm (5.9%) than in the placebo arm (10.3%; p = 0.026). The further bleeding rate in patients treated with esomeprazole in routine clinical practice (7.8%; 95% CI: 4.6–11.1) was between these two values. Similar results were seen with the other outcomes studied. Conclusions. The proportion of patients treated with i.v. esomeprazole in routine clinical practice who experienced further bleeding following endoscopic treatment for peptic ulcer bleeding was between the rates observed in the esomeprazole group and the placebo group in the RCT.

Predictors of peptic ulcer rebleeding after scheduled second endoscopy: clinical or endoscopic factors?

In a previous study we demonstrated the efficacy of second-look endoscopy with therapy within 16 - 24 hours after index endoscopy in reducing major recurrent peptic ulcer bleeding. In this study, we sought to identify factors that might predict further rebleeding after this scheduled second-look endoscopy. We studied 249 patients (181 men, 68 women) with acute bleeding peptic ulcers who were treated at the United Christian Hospital, Hong Kong from 1999 to 2002 and who underwent a scheduled second endoscopy. Those patients who developed rebleeding after the second endoscopy were evaluated, and possible predictive factors for rebleeding were analyzed using a logistic regression model. Of the 249 patients who underwent scheduled second-look endoscopy, 17 patients (6.8 %) developed rebleeding: seven of these patients were treated by another endoscopic therapy; ten patients required surgery. The overall mortality rate was 3.1 %. A logistic regression analysis performed on the possible predictive factors for rebleeding found that the following factors were associated with a significant risk of further rebleeding after scheduled second endoscopy: American Society of Anesthesiologists (ASA) grade III or grade IV status (odds ratio 3.81, 95 % CI 1.27 - 11.44), ulcer size greater than 1.0 cm (odds ratio 4.69, 95 % CI 1.60 - 13.80), and a finding of persistent stigmata of recent hemorrhage at the scheduled second endoscopy (odds ratio 6.65, 95 % CI 2.11 - 20.98). Endoscopic factors, including large ulcer size and the persistence of endoscopic stigmata of recent hemorrhage are important predictors for recurrent bleeding after scheduled second endoscopy.

Clinical factors in the prediction of further haemorrhage or mortality in acute upper gastrointestinal haemorrhage.

Data collected prospectively from 326 admissions for acute upper gastrointestinal haemorrhage were examined to identify factors predicting further haemorrhage or mortality. Seven predictive factors were identified by univariate analysis for both further haemorrhage and/or mortality, but only age over 60 years, an admission haemoglobin less than 8 g/dl and the presence of endoscopic stigmata of recent haemorrhage were shown by stepwise logistic regression to have independent significance for further haemorrhage. An age over 60 years, the presence of clinical shock on admission and an episode of further haemorrhage following admission emerged as independently significant in the prediction of mortality.

Artificial Neural Network (ANN) Is Superior to the Pre-Endoscopic Rockall Score in Predicting Which Patients Will Benefit From Urgent EGD in Acute Upper GI Bleeding (UGIB)

Artificial Neural Network (ANN) Is Superior to the PreEndoscopic Rockall Score in Predicting Which Patients Will Benefit From Urgent EGD in Acute Upper GI Bleeding (UGIB) Ananya Das, Farees Farooq, Richard Wong, Tamir Ben-Menachem, Gregory Cooper, Amitabh Chak, Michael Sivak Introduction: In practice, not all patients with acute UGIB can receive urgent EGD (within 12 hours). A model for predicting need for urgent EGD based on nonendoscopic, clinical variables would be an important tool in patient triage. We have previously shown that ANN accurately predicts outcome in acute LGI bleeding (Lancet 2003;362:1261). Methods: We constructed an ANN to predict endoscopic stigmata of recent hemorrhage (SRH) and need for endoscopic therapy (ET) using prospectively collected data from 194 patients at an academic medical center who presented with acute UGIB over a 6-month period (training group). Confirmed variceal bleeding was excluded. The ANN model was a multi-layered perceptron network trained by back propagation using pre-endoscopic clinical input variables available at the time of triage. The trained ANN was applied to an internal validation (IV) group of 193 patients with UGIB during the same time period. The ANN was then applied to an external validation (EV) group of 200 patients at a tertiary care center in a different city over a 6-month period. The performance of the ANN was also compared to the widely used Rockall score. A pre-endoscopic Rockall score of 0 is considered low risk for adverse outcome. Results: The clinical characteristics of the EV group were different then the training and IV groups (increased men, CAD, cirrhosis, hematemesis, shock, ICU admit, rebleeding, and death). Using ANN, the areas under the ROC curve for predicting SRH and ETwere 0.94 & 0.84 in the IV group and 0.81 & 0.78 in the EV group, respectively. ANN had better specificity and predictive values than pre-endoscopic Rockall score in both validation groups and was comparable to total (post-endoscopic) Rockall score. Conclusions: ANN is an effective tool in the pre-endoscopic triage of patients with acute UGIB, even in a dissimilar external cohort. ANN is more specific than the preendoscopic Rockall score in identifying patients who may benefit from urgent EGD and may be used to exclude low risk patients.

Enhanced mucosal fibrinolytic activity in gastroduodenal ulcer haemorrhage and the beneficial effect of acid suppression.

The high mortality rate in patients with upper gastrointestinal bleeding appears to be particularly related to re-bleeding. The haemostatic mechanisms that may influence the re-bleeding of ulcers are largely unknown. We studied and analysed fibrinolytic activity in bleeding ulcer patients and the effect of acid suppression on this activity. Fibrinolytic activity was analysed in mucosal biopsies from 29 bleeding gastroduodenal ulcer patients and six controls. We analysed levels of D-Dimer, fibrin plate lysis area, plasminogen activator activity, plasminogen activator inhibitor activity, and plasmin antiplasmin complexes. Significantly more fibrinolytic activity was detected in biopsies from patients with bleeding ulcers compared to controls. Moreover, in patients with endoscopic stigmata of recent haemorrhage, mucosal fibrinolytic activity was higher compared to patients without stigmata of recent haemorrhage. In mucosal biopsies of patients that had used acid suppression before admission, a decreased fibrinolytic activity was found compared to patients without such therapy. This effect of acid suppression on fibrinolytic activity was confirmed in nine patients before and after a 24-h ranitidine infusion. Fibrinolytic activity is enhanced in patients with bleeding gastroduodenal ulcers. Acid suppressive therapy decreases this increased activity, which may be one of the mechanisms explaining the potential beneficial effect of this therapy.

CLINICAL SCORING SYSTEMS FOR DETERMINING THE PROGNOSIS OF GASTROINTESTINAL BLEEDING

The prognosis of GI bleeding depends upon many factors. Patients should be evaluated carefully for risk factors. To avoid complications from GI bleeding, triage should be performed promptly after patient presentation. The history and physical examination should emphasize analysis of risk factors for severe GI bleeding and mortality. Factors that increase the morbidity and mortality include: age greater than 60 years; underlying comorbidity such as pulmonary diseases, liver diseases, renal diseases, encephalopathy, or cancer; physiologic stress from major surgery, trauma, or sepsis; coexisting disease in three organ systems; low hematocrit; melena or hematochezia; and prolonged prothrombin time. Hospitalized patients who require more than five units of packed erythrocytes transfusion or who develop hypotension or hypovolemic shock are more likely to need surgery. Patients with a high APACHE II score, the presence of esophageal varices, active bleeding, or other endoscopic stigmata of recent hemorrhage are more likely to rebleed and undergo surgery. The proliferation of multivariable prognostic scales, as described herein, provides ample evidence that the goal of developing a single comprehensive multivariable scale to accurately assess severity of disease and to determine prognosis of GI bleeding is still not achieved. Yet significant progress has occurred in this field, leading to the hope of developing a universally applicable multivariable scale.

ACUTE GASTROINTESTINAL BLEEDING IN THE INTENSIVE CARE UNIT: The Intensivist's Perspective

Gastrointestinal (GI) hemorrhage is a common and potentially lethal medical emergency that is a common cause for intensive care unit admission. The intensivist plays an important role as a member of the medical team managing the patient with GI bleeding who is at high risk because of severe bleeding, comorbidity, or the presence of endoscopic stigmata of recent hemorrhage. This article presents the intensivist's approach to GI hemorrhage in initial patient assessment, triage, resuscitation, specialist consultation, diagnostic evaluation, and medical therapy. This article focuses on types of GI bleeding of particular concern to the intensivist, including esophageal variceal bleeding, stress-related GI bleeding, and GI bleeding associated with myocardial infarcation.

Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage

SummaryBackground Acute upper gastrointestinal haemorrhage is a common medical emergency and hospital admission has usually been regarded as obligatory until the risk of further haemorrhage has receded. This policy means that some patients at low risk stay in hospital for longer than is necessary especially when diagnostic endoscopy is delayed. We attempted to identify patients who had negligible risk of further bleeding or death and for whom early discharge or even outpatient management would be possible with no adverse effect on standards of care.Methods We used a validated risk scoring system based on age (score 0-2), presence of shock (0-2), comorbidity (0-3), diagnosis (0-2), and endoscopic stigmata of recent haemorrhage (0-2); the maximum possible score was 11. We studied patients identified through the UK National Audit of acute upper gastrointestinal haemorrhage; they had been admitted with upper gastrointestinal haemorrhage to hospitals in the UK during 4 months of 1993. This analysis was based on the 2531 patients from the national audit who underwent endoscopy after an acute admission.Findings 744(29·4%) of the 2531 patients scored 2 or less on the risk score. Of these patients only 32 (4·3% [95% Cl 3·0-6·0] rebled and only one (0·1% [0·006-0·75] died). Thus, the risk score identifies patients at low risk of rebleeding or death. The median hospital stay for these patients was 4 days; duration of hospital stay increased with risk score. Within risk score categories of 5 or less, there was a trend of increasing hospital stay as the time between admission and endoscopy increased.Interpretation Our risk score identifies a large proportion of patients with acute upper gastrointestinal haemorrhage who are at low risk of further bleeding or death. Early endoscopy and discharge of such patients could allow substantial resource savings.

Variation in outcome after acute upper gastrointestinal haemorrhage

Summary Hospital mortality after acute upper gastrointestinal haemorrhage varies widely. In a population-based, multicentre, prospective survey of the management and outcome of unselected cases of acute upper gastrointestinal haemorrhage, we have assessed the effect of risk standardisation on this variation. We collected data from 74 acute hospitals in four health regions in the UK on patients aged 16 years and over who presented with acute upper gastrointestinal haemorrhage during 4 months in 1993 (3981 cases) and 3 months in 1994 (1584 cases). The overall mortality was 14·3% (798/5565). Crude mortality in individual hospitals ranged from 0% to 29%, and differed significantly from the overall rate in eight. Risk-standardised mortality ratios were calculated with a risk score derived from well-established risk factors. Only two hospitals had standardised mortality ratios significantly different from the reference value. When hospitals were ranked in order of increasing mortality, risk standardisation for age, shock, and comorbidity resulted in 21 of the 74 hospitals changing ranks by ten or more places. After further standardisation for diagnosis, endoscopic stigmata of recent haemorrhage, and rebleeding, 32 hospitals moved ten or more places from their original rank; one hospital moved 45 places. Risk standardisation to correct for variation in case mix results in apparently significant differences in mortality rates becoming non-significant. The current state of routine data collection does not allow for anything but the most basic case-mix adjustment to be made. Simple league tables of crude mortality are misleading in this disorder and cannot be regarded as a reflection of the quality of health care.

Laser Photocoagulation Versus Ethanol Injection Therapy after Preinjection with Epinephrine in the Treatment of Bleeding Peptic Ulcers

Abstract: A prospective, randomized trial was performed to compare the efficacy of Nd: YAG laser photocoagulation (LP) and absolute ethanol injection therapy (AEIT) in the treatment of peptic ulcer bleeding. Of 396 patients who underwent endoscopy for acute gastrointestinal hemorrhage over a 18‐month period, 185 were found to have peptic ulcers. The patients who had an ulcer with active bleeding (n = 25) or with a nonbleeding visible vessel (n = 35) were randomized to receive either LP (n = 29) or AEIT (n = 31). The two treatment groups were comparable in terms of age, severity of bleeding, site of ulcer, and endoscopic stigmata of recent hemorrhage. There were no significant differences between the LP and AEIT groups in terms of their transfusion requirements after treatment (0.6 ±1.0 vs. 0.5±0.9 unit), rate of initial hemostatic failure or rebleeding (13.8 vs. 9. 7%), emergency surgery (0 vs. O%), median hospital stay (6 us. 8 days), and mortality (0 us. 6.5%). All of the seven patients who rebled received a second session of endoscopic therapy with the other modality and bleeding was controlled. The cause of death in the two expired patients was not related to bleeding. We concluded that LP and AEIT are equally effective in the treatment of peptic ulcer bleeding but AEIT may be preferred over LP because of its simplicity and lower cost.

Etiology and course of acute bleeding esophageal ulcers.

Twenty (2%) of 1,140 patients with acute gastrointestinal bleeding had esophageal ulcers. Patients with esophageal ulcers most commonly had either melena (40%) or melena and hematemesis (40%). Fifty percent had orthostatic hypotension, and 80% required transfusions. Ulcers were associated with nonsteroidal anti-inflammatory drugs (NSAIDs) use in 50%, hiatal hernia in 60%, and esophagitis in 40%. Endoscopic stigmata of recent hemorrhage consisted of oozing blood (35%) and adherent clot (25%). Six patients had multiple ulcers. The majority of ulcers (90%) were in the distal esophagus. Nine patients were endoscopically treated without complications except for rebleeding in 1 patient. Endoscopic therapy was associated with decreased duration of hospitalization. Overall mortality was 45% in these patients, but no deaths were related to bleeding. Although uncommon, esophageal ulcers are a cause of significant acute gastrointestinal bleeding that appears to respond to endoscopic treatment.

Hypotension and endoscopic stigmata of recent haemorrhage in bleeding peptic ulcer: risk models for rebleeding and mortality.

Clinical and endoscopic data were collected prospectively in 1050 patients with bleeding peptic ulcer admitted between September 1985 and July 1989 to the care of one surgical team. Seventy-nine patients underwent therapeutic endoscopy soon after admission and in 129 patients either immediate or early elective surgery was performed. Eight hundred and forty-two patients, in whom therapeutic endoscopy was not performed at any stage, underwent initial conservative management and data from this latter group are now presented. Shock on admission was defined as systolic blood pressure (BP) less than or equal to 100 mmHg on presentation. There were 10 deaths of 147 shocked patients (6.8%) compared with only 25 deaths of 695 patients (3.6%) not in shock (P less than 0.08). Bleeding recurred in 30 patients (20.4%) shocked on presentation but in only 96 (13.8%) with a BP greater than 100 mmHg (P less than 0.05). Twenty-one of 358 patients (5.9%) with endoscopic stigmata of recent haemorrhage (ESRH) died, but only 14 of 484 patients (2.9%) without such stigmata (P less than 0.05) died. In shocked patients rebleeding was evident in 21 of 73 (28.8%) cases with ESRH but in only 9 of 74 (12.2%) patients in whom ESRH were absent (P less than 0.02). In the absence of fresh blood at endoscopy rebleeding occurred in 22 of 124 (17.8%) shocked patients and only 74 of 629 (11.8%) of those not shocked on presentation (P less than 0.07). When ulcer size was documented rebleeding rates for ulcers less than or equal to 1 cm, less than or equal to 2 cm and greater than 2 cm in size were 54 of 485 (11.1%), 30 of 142 (21.2%) and 12 of 44 (27.3%) respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Endoscopic injection sclerosis: effective treatment for bleeding peptic ulcer.

One hundred and nine patients presenting with severe haemorrhage from benign peptic ulcers were randomised to either endoscopic injection sclerotherapy using a combination of 1:100,000 adrenaline and 5% ethanolamine or to conservative treatment. Only high risk patients with active bleeding or endoscopic stigmata of recent haemorrhage and accessible ulcers were considered. The two groups were well matched for age, shock, haemoglobin concentration, endoscopic findings, and consumption of non-steroidal anti-inflammatory drugs. The group treated endoscopically had a significantly reduced rebleeding rate (12.5% v 47%, p less than 0.001). Rebleeding was successfully treated in some patients by injection sclerotherapy, other patients underwent urgent surgery. While there was a tendency towards a lower operation rate and lower transfusion requirements in the treated group, this failed to achieve statistical significance. The use of injection sclerotherapy in the conservatively treated group after rebleeding undoubtedly reduced the number of surgical operations. Endoscopic injection sclerotherapy is effective in the prevention of rebleeding in these patients.

Bleeding Duodenal Ulcer

There were 12 hospital deaths in 433 patients (2.8%, 1.6% at 30 days) presenting with bleeding duodenal ulcer. Excluding patients who underwent immediate operation or early elective surgery, where ulcer size was measured at initial endoscopy rebleeding was evident in 40/288 patients (13.9%) and was associated with an increased mortality (0.4% v 12.5%) (p less than 0.0001). Rebleeding rates for ulcers less than or equal to 1 cm and greater than 1 cm were respectively 28/239 (11.7%) and 12/49 (24.5%) (p less than 0.02). Rebleeding occurred in 13/186 patients (7.0%) in whom endoscopic stigmata of recent haemorrhage were absent and in 27/102 (26.5%) with such stigmata (p less than 0.0001). The mortality rate for patients without stigmata was 3/186 (1.6%) whilst mortality figures for patients with ulcers less than or equal to 1 cm and greater than 1 cm in size were respectively 0/77 and 3/25 (12.0%) when stigmata were identified. Ulcers greater than 1 cm were more frequent in the greater than 60 year age group, more likely to have stigmata and carried an increased risk of rebleeding and mortality.

Bleeding peptic ulcer: A prospective evaluation of risk factors for rebleeding and mortality

Clinical, endoscopic, and laboratory data were collected prospectively in 701 patients with bleeding peptic ulcer. The overall rebleeding rate was 16.1% and increased the risk of a fatal outcome by 17 fold (1.2% versus 20.6%, p less than 0.001). Rebleeding was documented in more than 75% of the group who did not survive following initial conservative management. Rebleeding was more likely (24.1% versus 14.2%, p less than 0.02) when shock was present on admission and the risk of a rebleed was doubled in patients over 60 years of age (22.1% versus 10.9%, p less than 0.001). Ulcers greater than 1 cm in size carried twice the risk of rebleeding (23.9% versus 12.4%, p less than 0.002). Concomitant medical illness had a significant adverse effect on outcome (p less than 0.05). Shock on admission was associated with a doubling of mortality figures (9.5% versus 3.7%, p less than 0.01). The identification of endoscopic stigmata of recent hemorrhage (ESRH) tripled the risk of mortality (7.5% versus 2.4%, p less than 0.002), ESRH were more frequently encountered when ulcer size was larger than 1 cm (61.4% versus 39.8%, p less than 0.001). Respective mortality rates for ulcers less than or equal to 1 cm and greater than 1 cm in size were 1.6% and 12.5% (p less than 0.001), corresponding mortality figures for patients over 60 years of age being 4.4% and 16.4% (p less than 0.002). The risk of a rebleed tripled (6.7% versus 2.6%, p less than 0.02) when ESRH were evident. There was a 6-fold increase in mortality following emergency surgery when compared with conservative management of patients in whom no surgical intervention was necessary (2.6% versus 14.9%, p less than 0.001). In summary, age over 60 years, previous medical illness, shock on admission, large ulcer size, and ESRH were each associated with an increased risk of rebleeding and mortality.