Hemostasis For Bleeding Peptic Ulcers Research Articles

Risk factors for rebleeding in gastroduodenal ulcers.

Rebleeding after hemostasis of the gastroduodenal ulcer (GDU) is one of the indicators associated with death among GDU patients. However, there are few studies on risk score that contribute to rebleeding after endoscopic hemostasis of bleeding peptic ulcers. The aim of this study was to identify factors associated with rebleeding, including patient factors, after endoscopic hemostasis of bleeding gastroduodenal ulcers and to stratify the risk of rebleeding. We retrospectively enrolled 587 consecutive patients who were treated for Forrest Ia to IIa bleeding gastroduodenal ulcers with endoscopic hemostasis at three institutions. Risk factors associated with rebleeding were assessed using univariate and multivariate logistic regression analyses. The Rebleeding Nagoya University (Rebleeding-N) scoring system was developed based on the extracted factors. The Rebleeding-N score was internally validated using bootstrap resampling methods. Sixty-four patients (11%) had rebleeding after hemostasis of gastroduodenal ulcers. Multivariate logistic regression analysis revealed four independent rebleeding risk factors: blood transfusion, albumin <2.5, duodenal ulcer, and diameter of the exposed vessel ≧2mm. Patients with 4 risk factors in the Rebleeding-N score had a 54% rebleeding rate, and patients with 3 risk factors had 44% and 25% rebleeding rates. In the internal validation, the mean area under the curve of the Rebleeding-N score was 0.830 (95% CI = 0.786-0.870). Rebleeding after clip hemostasis of bleeding gastroduodenal ulcers was associated with blood transfusion, albumin <2.5, diameter of the exposed vessel ≧2mm, and duodenal ulcer. The Rebleeding-N score was able to stratify the risk of rebleeding.

Association between Hospital Volume and Outcomes of Elderly Patients with Hemorrhagic Peptic Ulcer in Japan: An Observational Study

Summary Background Little information is available on the relationship between case volume and the outcomes of elderly patients with bleeding peptic ulcers. This study investigated the effect of case volume on the outcomes of elderly patients with bleeding peptic ulcers, based on a national administrative database. Methods In total, 14,569 elderly patients (i.e., ≥ 80 years old) treated by endoscopic hemostasis for bleeding peptic ulcers were referred to 1073 hospitals from 2010 to 2012 in Japan. We compared in-hospital mortality (30-day and overall), length of hospital stay (LOS), and medical costs in relation to case volume. A hospital was categorized as a low-volume hospital (i.e., 9 cases/y). Results Multiple logistic regression revealed that HVHs did not have lower in-hospital mortality rates, compared to low- or medium-volume hospitals [for 30-day mortality: the odds ratio (OR) was 0.97 with a 95% confidence interval (CI) of 0.76–1.24; p = 0.831; for overall mortality: OR, 0.86; 95% CI, 0.70–1.07; p = 0.197]. However, multiple linear regression showed that HVHs had significantly shorter LOS and lower medical costs. The coefficient for LOS was −5.02 days (95% CI, from −6.04 days to −4.01 days; p p Conclusion This study demonstrated that a higher case volume was significantly associated with shorter LOS and lower medical costs among elderly patients with bleeding peptic ulcers. However, there was no significant effect of case volume on mortality in Japan.

Candidacy for Second-Look Endoscopy After Hemostasis for Bleeding Peptic Ulcers

Despite its observed benefits in selected patients, current guidelines do not recommend routine use of second-look endoscopy after endoscopic hemostasis. Investigators in Taiwan prospectively studied 316 patients with peptic ulcer bleeding requiring hemostasis to identify characteristics of patients most likely to benefit from second-look endoscopy. All patients were treated with a proton-pump inhibitor (PPI) infusion. Second-look endoscopy was performed on the …

Su1927 Gender Differences in GI Symptom Patterns Related to Clinically Significant Organic Diseases Are Detected in Japanese Patients

[Introduction] Endoscopic therapy has been demonstrated to be effective in achieving hemostasis for bleeding peptic ulcers. Thermal coagulation is one of the most commonly used methods with a high success rate. Recently, endoscopic submucosal dissection for early gastric carcinoma was developed and hemostasis with soft coagulation using hemostatic forceps was introduced. We applied endoscopic hemostasis with soft coagulation to gastroduodenal ulcer bleeding and reported that initial and final hemostatic rates were 95% and 100%, respectively. The aim of this study was to compare the hemostatic effects of soft coagulation with those of heater probe thermocoagulation for peptic ulcer bleeding. [Methods] Patients who visited our hospital with hematemesis or melena and required life-saving endoscopic treatment were recruited. Inclusion criteria in this study were that they presented with an actively bleeding ulcer, a nonbleeding visible vessel, or an adherent clot. Patients were excluded if they were unwilling to give written informed consent or had bleeding gastric malignancy. Patients were randomized to receive endoscopic hemostasis with soft coagulation (Group S) or heater probe thermocoagulation (Group H). In Group S, endoscopic hemostasis with soft coagulation was performed using a monopolar hemostatic forceps (FD410LR, Olympus) and an electrosurgical unit (ICC-200, ERBE) at 70W. In Group H, a heater probe unit (HPU-20, Olympus) was used and pulses of 20 to 30 J were given. When the allocated treatment failed to achieve hemostasis, the other method was applied. If hemostasis was not obtained using thesemethods, intervention radiology or surgical treatment was applied. Initial hemostasis was declared when hemostasis was obtained by the single allocated method and second-look endoscopy revealed no bleeding from ulcers. The primary endpoint was the initial hemostasis rate and secondary endpoints were the rebleeding rate, complications and the procedure time. [Results] Between May 2010 and February 2012, a total of 111 patients (89 gastric ulcers and 22 duodenal ulcers) were enrolled. There were no significant differences in the background characteristics between Groups S and H. Initial hemostasis was achieved in 54 patients (96%) in Group S and 37 patients (67%) in Group H (p , 0.0001). Rebleeding occurred in 4 patients in Group H and none in Group S. Of these patients, urgent surgery was performed in one patient. Perforation occurred in two patients in Group H, which were managed conservatively. The duration of endoscopic therapy was shorter in Group S than in Group H, although not significantly (P = 0.10). [Conclusions] For patients with gastroduodenal ulcer bleeding, soft coagulation using a monopolar hemostatic forceps provides an advantage in achieving hemostasis compared with heater probe thermocoagulation.

Su1923 A Prospective, Randomized Trial of Soft Coagulation Versus Heater Probe Thermocoagulation for Peptic Ulcer Bleeding

[Introduction] Endoscopic therapy has been demonstrated to be effective in achieving hemostasis for bleeding peptic ulcers. Thermal coagulation is one of the most commonly used methods with a high success rate. Recently, endoscopic submucosal dissection for early gastric carcinoma was developed and hemostasis with soft coagulation using hemostatic forceps was introduced. We applied endoscopic hemostasis with soft coagulation to gastroduodenal ulcer bleeding and reported that initial and final hemostatic rates were 95% and 100%, respectively. The aim of this study was to compare the hemostatic effects of soft coagulation with those of heater probe thermocoagulation for peptic ulcer bleeding. [Methods] Patients who visited our hospital with hematemesis or melena and required life-saving endoscopic treatment were recruited. Inclusion criteria in this study were that they presented with an actively bleeding ulcer, a nonbleeding visible vessel, or an adherent clot. Patients were excluded if they were unwilling to give written informed consent or had bleeding gastric malignancy. Patients were randomized to receive endoscopic hemostasis with soft coagulation (Group S) or heater probe thermocoagulation (Group H). In Group S, endoscopic hemostasis with soft coagulation was performed using a monopolar hemostatic forceps (FD410LR, Olympus) and an electrosurgical unit (ICC-200, ERBE) at 70W. In Group H, a heater probe unit (HPU-20, Olympus) was used and pulses of 20 to 30 J were given. When the allocated treatment failed to achieve hemostasis, the other method was applied. If hemostasis was not obtained using thesemethods, intervention radiology or surgical treatment was applied. Initial hemostasis was declared when hemostasis was obtained by the single allocated method and second-look endoscopy revealed no bleeding from ulcers. The primary endpoint was the initial hemostasis rate and secondary endpoints were the rebleeding rate, complications and the procedure time. [Results] Between May 2010 and February 2012, a total of 111 patients (89 gastric ulcers and 22 duodenal ulcers) were enrolled. There were no significant differences in the background characteristics between Groups S and H. Initial hemostasis was achieved in 54 patients (96%) in Group S and 37 patients (67%) in Group H (p , 0.0001). Rebleeding occurred in 4 patients in Group H and none in Group S. Of these patients, urgent surgery was performed in one patient. Perforation occurred in two patients in Group H, which were managed conservatively. The duration of endoscopic therapy was shorter in Group S than in Group H, although not significantly (P = 0.10). [Conclusions] For patients with gastroduodenal ulcer bleeding, soft coagulation using a monopolar hemostatic forceps provides an advantage in achieving hemostasis compared with heater probe thermocoagulation.

Su1925 Characteristics of Gastric Polyps in African Americans and Hispanics

[Introduction] Endoscopic therapy has been demonstrated to be effective in achieving hemostasis for bleeding peptic ulcers. Thermal coagulation is one of the most commonly used methods with a high success rate. Recently, endoscopic submucosal dissection for early gastric carcinoma was developed and hemostasis with soft coagulation using hemostatic forceps was introduced. We applied endoscopic hemostasis with soft coagulation to gastroduodenal ulcer bleeding and reported that initial and final hemostatic rates were 95% and 100%, respectively. The aim of this study was to compare the hemostatic effects of soft coagulation with those of heater probe thermocoagulation for peptic ulcer bleeding. [Methods] Patients who visited our hospital with hematemesis or melena and required life-saving endoscopic treatment were recruited. Inclusion criteria in this study were that they presented with an actively bleeding ulcer, a nonbleeding visible vessel, or an adherent clot. Patients were excluded if they were unwilling to give written informed consent or had bleeding gastric malignancy. Patients were randomized to receive endoscopic hemostasis with soft coagulation (Group S) or heater probe thermocoagulation (Group H). In Group S, endoscopic hemostasis with soft coagulation was performed using a monopolar hemostatic forceps (FD410LR, Olympus) and an electrosurgical unit (ICC-200, ERBE) at 70W. In Group H, a heater probe unit (HPU-20, Olympus) was used and pulses of 20 to 30 J were given. When the allocated treatment failed to achieve hemostasis, the other method was applied. If hemostasis was not obtained using thesemethods, intervention radiology or surgical treatment was applied. Initial hemostasis was declared when hemostasis was obtained by the single allocated method and second-look endoscopy revealed no bleeding from ulcers. The primary endpoint was the initial hemostasis rate and secondary endpoints were the rebleeding rate, complications and the procedure time. [Results] Between May 2010 and February 2012, a total of 111 patients (89 gastric ulcers and 22 duodenal ulcers) were enrolled. There were no significant differences in the background characteristics between Groups S and H. Initial hemostasis was achieved in 54 patients (96%) in Group S and 37 patients (67%) in Group H (p , 0.0001). Rebleeding occurred in 4 patients in Group H and none in Group S. Of these patients, urgent surgery was performed in one patient. Perforation occurred in two patients in Group H, which were managed conservatively. The duration of endoscopic therapy was shorter in Group S than in Group H, although not significantly (P = 0.10). [Conclusions] For patients with gastroduodenal ulcer bleeding, soft coagulation using a monopolar hemostatic forceps provides an advantage in achieving hemostasis compared with heater probe thermocoagulation.

Effect of High Dose Oral Rabeprazole On Recurrent Bleeding After Endoscopic Treatment of Bleeding Peptic Ulcers: A Preliminary Report

Background: Patients with major bleeding and endoscopic evidence of an ulcer with stigmata of recent hemorrhage are at a high risk for rebleeding and should receive endoscopic treatment. Although hemostasis can usually be obtained with endoscopic treatment, rebleeding occurs in 10% to 30% of these patients. Intravenous proton pump inhibitors (IV PPI) decrease rebleeding following endoscopic hemostasis of bleeding peptic ulcers. Oral PPI may be equally efficacious in reducing rebleeding. However, there has not yet been prospective, randomized study to compare the efficacy of oral vs IV PPI in the patients with bleeding peptic ulcers. The aim of this study was to evaluate the effect of high dose oral rabeprazole on rebleeding after endoscopic treatment of bleeding peptic ulcers. Methods: We planned originally a prospective, randomized study to enroll 224 patients with bleeding peptic ulcers. 45 patients were enrolled after they underwent endoscopic therapy within 24 hours. All patients were randomly assigned to receive oral rabeprazole (20 mg BID for 3 days) or IV omeprazole (80 mg IV bolus and 8 mg/hr infusion for 3 days). Results: Twenty-four (53%) patients had gastric ulcer, 16 (36%) had duodenal ulcer and 5 (11%) had gastric and duodenal ulcer. In 6 (13%) patients the ulcers showed arterial spurting, in 13 (29%) there was active oozing, in 16 (36%) there were nonbleeding, visible vessels, in 10 (22%) there were adherent clots. Twenty-three patients were randomized to the oral rabeprazole group and 22 to the IV omeprazole group. The mean hospital stays were 8.3 ± 6.2 days and 6.5 ± 2.2 days in the oral rabeprazole and IV omeprazole groups, respectively (P = 0.200). The mean amounts of blood transfused were 2.4 ± 1.2 and 2.2 ± 0.9 units in the oral rabeprazole and IV omeprazole groups, respectively (P = 0.578). Rebleeding occurred in 1 (4%) of 23 patients in the oral rabeprazole group and 1 (5%) in the IV omeprazole group (P = 1.000). One patient in the oral rabeprazole group needed surgery to control their bleeding and this patient died one month later as sepsis after surgery. No patient in the IV omeprzole group needed surgery and died, respectively (P = 1.000 and P = 1.000). Conclusions: We conclude that in this preliminary report, the effect of high dose oral rabeprazole was similar to that of IV omeprazole in decreasing rebleeding, the hospital stay and the need for blood transfusion after endoscopic treatment of bleeding peptic ulcers.

Intravenous Versus High-Dose Oral Proton Pump Inhibitor Therapy After Endoscopic Hemostasis of High-Risk Lesions in Patients with Acute Nonvariceal Upper Gastrointestinal Bleeding

Intravenous proton pump inhibitors (IV PPIs) decrease rebleeding following endoscopic hemostasis of bleeding peptic ulcers. Oral PPIs may be equally efficacious and may significantly reduce health care costs. This study aimed to compare outcomes in patients receiving oral versus IV PPI therapy following endoscopic hemostasis in patients with acute nonvariceal upper gastrointestinal bleeding (ANVUGIB). We performed a retrospective review of all patients who received PPI therapy following endoscopic hemostasis for ANVUGIB. The primary outcome was the adverse gastrointestinal event rate. One hundred sixty-two patients met the entry criteria (72 oral PPIs, 90 IV PPIs). The difference in the rate of adverse gastrointestinal events between the two groups was 1% (P = 0.85). Postendoscopic IV PPI use was associated with an odds ratio of 1.01 for developing an adverse outcome versus oral PPIs (95% CI: 0.44-2.33). We conclude that oral PPIs are probably equivalent to IV PPIs for preventing rebleeding in ANVUGIB patients.

Effect of Repeated Bolus Injection, Low- or High-Dose Continuous Infusion of Omeprazole on Intragastric pH in Patients With Bleeding Peptic Ulcer via Dose-Titration Study

Effect of Repeated Bolus Injection, Low or High Dose Continuous Infusion of Omeprazole on Intragastric pH in Patients With Bleeding Peptic Ulcer v a Dose-Titration Study Philip Wai Y., Simon Kin Hung Wong, Justin Chi Yuen Wu, Man Yee Yung, Wilfred Mui, Enders Kwok Wai Ng, James Yun Wong Lau, Joseph Sung Aim: From our previous study, we have shown that the adjunctive use of high dose omeprazole infusion reduced the rate of recurrent bleeding after endoscopic hemostasis for bleeding peptic ulcers. The appropriate dose of omeprazole to achieve optimal pH profile for clot stability is unknown. The aim of this study is to define the gastric acid suppression profile among various regimens of adjunctive omeprazole. Patients and Method: We included patients that presented with bleeding peptic ulcers and had endoscopic stigmata of either red dot or clean base that do not required endoscopic treatment. We excluded those that received regular antisecretory medications, NSAID/aspirin users, previous gastric surgery and moribund patients. All patients were randomly assigned to receive various dosage protocol of proton pump inhibitor for 24 hours, including 1. Omeprazole 80 mg bolus, then 8 mg/hr infusion (192 mg/d); 2. Omeprazole 80 mg bolus, then 4 mg/hr infusion (96 mg/d); or 3. Omeprazole intravenous 40 mg bolus 6 hourly (160 mg/d). We measured the 24 hour fasting gastric pH with the electrode positioned at 10 cm below the gastroesophageal junction. We collected the median pH, % time pH O 4 and % time pH O 6 at intervals of 1 hour, 4 hour, 12 hour and 24 hours after the start of therapy. We also analyzed the time needed to attain pH O 4 and pH O 6. Results: We included 30 patients with bleeding peptic ulcers that had endoscopic stigmata of either red dot or clean base. 11 patients received omeprazole 40 mg every 6 hourly, 10 patients received omeprazole 4mg/hr and 9 patients received omeprazole 8 mg/hr. The three groups were comparable in terms of age, body weight, ulcer size, initial blood pressure and hemoglobin level. There was no difference in the % time pH O 4 or 6 at 1, 4, 12 and 24 hours between the three groups. However, we found that those patients receiving omeprazole 8 mg/hr could reach pH O 4 in a significantly shorter time (Kruskal-Wallis test p Z 0.04) (Figure 1). Conclusion: Patients receiving a regime of high dose omeprazole infusion at 8mg/hr attained an intragastric pH profile of more than 4 in a significantly shorter period of time. A high dose regimen may be more effective in prevention of early recurrent rebleeding by early clot stabilization.

Effect of Repeated Bolus Injection, Low or High Dose Continuous Infusion of Omeprazole on Intragastric pH in Patients With Bleeding Peptic Ulcer v a Dose-Titration Study

Aim: From our previous study, we have shown that the adjunctive use of high dose omeprazole infusion reduced the rate of recurrent bleeding after endoscopic hemostasis for bleeding peptic ulcers. The appropriate dose of omeprazole to achieve optimal pH profile for clot stability is unknown. The aim of this study is to define the gastric acid suppression profile among various regimens of adjunctive omeprazole. Patients and Method: We included patients that presented with bleeding peptic ulcers and had endoscopic stigmata of either red dot or clean base that do not required endoscopic treatment. We excluded those that received regular antisecretory medications, NSAID/aspirin users, previous gastric surgery and moribund patients. All patients were randomly assigned to receive various dosage protocol of proton pump inhibitor for 24 hours, including 1. Omeprazole 80 mg bolus, then 8 mg/hr infusion (192 mg/d); 2. Omeprazole 80 mg bolus, then 4 mg/hr infusion (96 mg/d); or 3. Omeprazole intravenous 40 mg bolus 6 hourly (160 mg/d). We measured the 24 hour fasting gastric pH with the electrode positioned at 10 cm below the gastroesophageal junction. We collected the median pH, % time pH > 4 and % time pH > 6 at intervals of 1 hour, 4 hour, 12 hour and 24 hours after the start of therapy. We also analyzed the time needed to attain pH > 4 and pH > 6. Results: We included 30 patients with bleeding peptic ulcers that had endoscopic stigmata of either red dot or clean base. 11 patients received omeprazole 40 mg every 6 hourly, 10 patients received omeprazole 4mg/hr and 9 patients received omeprazole 8 mg/hr. The three groups were comparable in terms of age, body weight, ulcer size, initial blood pressure and hemoglobin level. There was no difference in the % time pH > 4 or 6 at 1, 4, 12 and 24 hours between the three groups. However, we found that those patients receiving omeprazole 8 mg/hr could reach pH > 4 in a significantly shorter time (Kruskal-Wallis test p = 0.04) (Figure 1). Conclusion: Patients receiving a regime of high dose omeprazole infusion at 8mg/hr attained an intragastric pH profile of more than 4 in a significantly shorter period of time. A high dose regimen may be more effective in prevention of early recurrent rebleeding by early clot stabilization.

Intravenous pantoprazole versus ranitidine for prevention of rebleeding after endoscopic hemostasis of bleeding peptic ulcers

The role of intravenous pantoprazole in treatment of patients with high-risk bleeding peptic ulcers following endoscopic hemostasis remains uncertain. We therefore conducted the pilot prospective randomized study to assess whether intravenous pantoprazole could improve the efficacy of H(2)-antagonist as an adjunct treatment following endoscopic injection therapy for bleeding ulcers. Patients with active bleeding ulcers or ulcers with major signs of recent bleeding were treated with distilled water injection. After hemostasis was achieved, they were randomly assigned to receive intravenous pantoprazole or ranitidine. One hundred and two patients were enrolled in this prospective trial. Bleeding recurred in 2 patients (4%) in the pantoprazole group (n = 52), as compared with 8 (16%) in the ranitidine group (n = 50). The rebleeding rate was significantly lower in the pantoprazole group (P = 0.04). There were no statistically significant differences between the groups with regard to the need for emergency surgery (0% vs 2%), transfusion requirements (4.9+/-5.9 vs 5.7+/-6.8 units), hospital days (5.9+/-3.2 vs 7.5+/-5.0 d) or mortality (2% vs 2%). Pantoprozole is superior to ranitidine as an adjunct treatment to endoscopic injection therapy in high-risk bleeding ulcers.

Endoscopic hemostasis of a bleeding marginal ulcer: hemoclipping or dual therapy with epinephrine injection and heater probe thermocoagulation.

Endoscopic hemoclipping and dual therapy with epinephrine injection and heater probe thermocoagulation have been proven effective in the hemostasis of bleeding peptic ulcers. However, the hemostatic efficacy has not been investigated in bleeding marginal ulcers. The aim of this study is to investigate the hemostatic efficacy of endoscopic hemoclipping and dual therapy with epinephrine injection and heater probe thermocoagulation in bleeding marginal ulcers. From November 1997 to July 2000, 50 patients with active marginal ulcer bleeding underwent either hemoclipping (20 patients) or dual therapy (30 patients) for hemostasis. The demographic data, clinicopathological characteristics, endoscopic findings, initial hemostatic rates, rebleeding rates, amount of blood transfusion, the need of surgery, and mortality rates were collected and analyzed. Marginal ulcers were located at the anastomotic site (64%), saddle portion (22%), efferent loop (10%), or at the afferent loop (4%). The bleeding stigmata were classified into spurting artery (32%), oozing vessel (38%), visible vessel (20%), and blood clot adhesion (10%). The overall therapeutic results in 50 patients were initial hemostasis (100%), rebleeding rate (22%), need for surgery (4%), and hospital mortality rate (4%). There was no significant difference in demographic data and clinicopathological characteristics between the two modes of treatments, whereas recurrent bleeding developed in 5% in the hemoclipping group and 33% in the dual therapy group. No complication related to the procedure occurred in either mode of therapy. The hospital mortality rates were 0 and 6.7%, respectively. Endoscopy is effective in achieving initial hemostasis from bleeding marginal ulcers. However, the rebleeding rate remains high and repeated endoscopy may be needed to arrest the hemorrhage.

Efficacy of Argon Plasma Coagulation for Bleeding Gastroduodenal Ulcers

Background: Argon plasma coagulation (APC) can achieve an effective coagulation of large areas with a relatively shallow but well-controlled and uniform coagulation depth. There are only a few reports of APC therapy applied to bleeding peptic ulcers, especially ulcers with exposed vessels. Methods: The aim of this study is to evaluate the usefulness of APC as a means of achieving endoscopic hemostasis for bleeding gastroduodenal ulcers. Thirty-nine patients having these ulcers were treated with APC. Results: The success rates for initial hemostasis and complete hemostasis with APC are 87% and 97.4%, respectively. These results are almost equal to those of injection therapy and hemoclip. Six cases that re-bled after other hemostatic procedures obtained complete hemostasis finally with APC. In one ineffective case of APC, complete endoscopic hemostasis was achieved with hemoclip. Conclusion: Argon plasma coagulation therapy is an effective therapeutic alternative in endoscopic hemostasis for bleeding peptic ulcers.

CURE multicenter randomized, prospective trial of gold probe vs. Injection & gold probe for hemostasis of bleeding peptic ulcers

CURE multicenter randomized, prospective trial of gold probe vs. Injection & gold probe for hemostasis of bleeding peptic ulcers

Systemic absorption of epinephrine after endoscopic submucosal injection in patients with bleeding peptic ulcers.

Epinephrine injection is an effective, simple, and economical method of endoscopic hemostasis for bleeding peptic ulcers. We measured catecholamine levels in 18 patients with actively bleeding ulcers (8 gastric ulcers and 10 duodenal ulcers) treated by endoscopic injection. Injection of epinephrine (1:10,000 IU) was given until bleeding from the ulcers stopped. Catecholamine levels were assayed by high-pressure liquid chromatography. Immediately after the injection the plasma level of epinephrine rose by four to five times above the basal level and returned to the baseline in 20 minutes. Norepinephrine levels were not significantly raised in these patients. No cardiovascular complications were seen. Although adverse cardiac events have not been recorded, it seems prudent to monitor these patients closely during and immediately after epinephrine injection.

Injection Therapy for Hemostasis of Bleeding Peptic Ulcers: Techniques and Results of Randomized Prospective Trials

One of the most serious sequelae of peptic ulcer disease is active gastrointestinal hemorrhage. Numerous endoscopic modalities have been developed to control bleeding. A simple, inexpensive, readily available means of treating hemorrhage is injection of the lesion with a sclerosant or other hemostatic agent. The authors review the current status, technique, and types of injectable agents and provide analysis of prospective trials on injections therapy for peptic ulcer disease.

Heater Probe for Endoscopic Hemostasis of Bleeding Peptic Ulcers

Endoscopic heater probe coagulation is a newer technique for hemostasis of ulcers and other nonvariceal lesions. For hemostasis of peptic ulcers, a standardized technique is recommended, which includes a large diameter probe (3.2 mm), firm tamponade directly on the active bleeding site or nonbleeding visible vessel, and coagulation with 120 J (four 30-J pulses) before changing the probe position. Coagulation with either the tip or side of the heater probe is feasible. Several randomized controlled studies have demonstrated that patients with major stigmata of ulcer hemorrhage have significantly better outcomes after endoscopic heater probe coagulation than with medical management.