Clinical Endoscopy

Endoscopic Management of Peptic Ulcer Bleeding: Recent Advances: Philip WY Chiu; Clin Endosc 2019;52(5):416-418. Published online August 13, 2019; DOI: https://doi.org/10.5946/ce.2018.182

Bleeding peptic ulcers remained as one of the commonest causes of hospitalization worldwide. While endoscopic hemostasis serves as primary treatment for bleeding ulcers, rebleeding after endoscopic hemostasis becomes more and more difficult to manage as patients are usually poor surgical candidates with multiple comorbidities. Recent advances in management of bleeding peptic ulcers aimed to further reduce the rate of rebleeding through—(1) identification of high risk patients for rebleeding and mortality; (2) improvement in primary endoscopic hemostasis and; (3) prophylactic angiographic embolization of major arteries. The technique and clinical evidences for these approaches will be reviewed in the current article.

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A Case of Extensive Necrosis of the Gastric Mucosa Following Ethanol Injection Therapy: Su Min Jang, M.D., Jung Sik Choi, M.D., Hyun Seok Ryu, M.D., Jae Nam Lee, M.D., Sung Hoo Park, M.D., Sang Yong Lee, M.D. and Sang Ho Lee, M.D.; Korean J Gastrointest Endosc 2008;36(3):154-158. Published online March 30, 2008

Abstract PDF: A bleeding peptic ulcer is the most common cause of upper gastrointestinal bleeding as well as for hospitalization and death. Many endoscopic methods of treating bleeding peptic ulcers are currently being studied and developed. Among them, the endoscopic pure ethanol injection therapy is favored because of its high efficacy, low cost, and rapid administration. Pure ethanol is an excellent agent to stop bleeding and manifests itslef by inducing tissue dehydration, fixation and vessel compression, which in turn causes arterial coagulation and tissue necrosis. However, an excessive injection volume may bring about extensive mucosal necrosis; hence, caution should be taken when deciding upon the injection volume and depth. We report a case of extensive necrosis of the gastric mucosa following endoscopic ethanol injection therapy of a bleeding peptic ulcer along with a review of the relevant literature. (Korean J Gastrointest Endosc 2008;36:154-158)

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Is Routine Second-Look Endoscopy Necessary for All Bleeding Peptic Ulcers?: Eun Ju Lee, M.D., Sang Won Lee, M.D., Tae Dong Kim, M.D., Kook Hyun Kim, M.D.,; Korean J Gastrointest Endosc 2003;26(1):1-7. Published online January 30, 2003

Abstract PDF: Background
/Aims: Second-look endoscopy is generally performed to prevent rebleeding in patients with bleeding peptic ulcers. However, considering recent technologic advances of endoscopic hemostasis and decreasing rate of rebleeding, a small benefit with second-look endoscopy is suggested. Prospective study was carried out to evaluate the efficacy of second-look endoscopic examinations. Methods and Results: One hundred thirty six patients with bleeding from peptic ulcer were included. Emergency endoscopic treatments consisting of the injection of hypertonic saline- epinephrine (HSE), band ligation and/or clipping were performed in patients with Forrest class I-IIb. They were scheduled to receive second-look endoscopy in 48 hours after initial endoscopy. Nine patients (6.6%) received endoscopic retreatment during second-look endoscopy and emergency endoscopic retreatment was required before scheduled endoscopy in six patients (4.4%) because of the evidence of rebleeding. Factors influencing retreatment were Forrest classification of initial endoscopy and methods of hemostasis. None of the patients with Forrest class IIb-III and the patients receiving endoscopic band ligation or clipping on initial endoscopy required retreatment during follow-up endoscopy. Conclusion: Routine second-look endoscopy may not be recommended after initial successful endoscopic treatment of peptic ulcer bleeding, especially in case of Forrest class IIb, IIc or III and in the patients treated with band ligation or clipping. (Korean J Gastrointest Endosc 2003;26:1⁣7)

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출혈성 소화성 궤양의 장기 재발률 (Long-Term Recurrent Bleeding Rate of Bleeding Peptic Ulcer): Korean J Gastrointest Endosc 1999;19(2):186-192. Published online November 30, 1998

Abstract PDF: Background
/Aims: Bleeding from a peptic ulcer is one of the common and serious complications associated with the rate of reported mortality, which ranges from 5% to 10%. Endoscopic therapy is effective in controlling active bleeding and reducing the emer-gency surgery, the immediate mortality rate and the incidence of early rebleeding. But few recent studies have documented the long-term recurrent bleeding rate after discharge in patients with bleeding peptic ulcers. The aim of this study was to determine the long-term recurrent bleeding rate and factors predisposing to recurrent bleeding. Methods: Eighty-eight patients with bleeding peptic ulcers discharged after medical treatment between Dec. 1990 and Jul. 1992 were included in this study and retrospectively followed up with medical records and telephone interviews. The end point of follow-up was recur-rent hemorrhage, surgery for treatment of ulcer complication, or death. Results: By July 1997, retrospective follow-up was available in 76 patients. Recurrent bleeding occurred in 23 patients (30.3%) with bleeding peptic ulcers and the median follow-up period was 69 months (range, 1 ∼79 months). The estimated cumulative recurrent bleeding rate after 1, 2, 3, 4, 5 and 6 years was 11.8%, 14.5%, 19.9%, 24.2%, 27.2% and 34.2%, respectively. There was no difference between the recurrent bleeding group and the non-recurrent bleed-ing group according to age, sex, prior NSAIDs use, previous history of bleeding or pepticulcer, site of ulcer, stigmata of recent hemorrhage at initial examination, method of treatment and amount of transfusion. Conclusion: Recurrent bleeding occurred in one-third of patients with bleeding peptic ulcers after 6 years of follow-up and one-third of recurrent bleeders rebled within 1 year. The factors predisposing to recurrent bleeding in the long-term follow-up could not be found. Therefore, further studies designed to identify factors predisposing to recurrent bleeding are needed and the evaluation of Helicobacter pylori status in bleeding peptic ulcer is needed because Helicobacter pylori is an important factor of peptic ulcer recurrence. (Korean J Gastrointest Endosc 19: 186 ∼192, 1999)

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원저 : 식도 위장관 ; 소화성궤양 출혈 환자에서 다양한 내시경적 국소 주입 요법과 Hemoclip 요법의 치료효과 비교 ( Original Articles : Esophagus , Stomach $ Intestine ; Comparison of Various Endoscopic Injection Therapy and Hemoclipping for Bleeding Peptic Ulcers ): Korean J Gastrointest Endosc 1998;18(6):817-824. Published online November 30, 1997

Abstract PDF: Background
/Aims: Widely practiced endoscopic methods for hemastasis of bleeding peptic ulcer include thermal application (laser, heater probe) and local injection (epi- nephrine, fibrine-glue or various sclerosing agents). Studies evaluating these modalities have presented high success rates for achieving initial hemostasis. Recently, endoscopic hemoclipping is considered to be a safe and effective hemostatic method for upper gas- trointestinal bleeding. The aim of this study was to compare various hemostatic modalities for bleeding peptic ulcer. Methods: Over a three year period between June 1994 and October 1997, a total of 133 patients with bleeding peptic ulcer were included in this study, We have conducted clinical trials and a retrospective analysis. All of the patients we selected had either active bleeding or a nonbleeding visible vessel on endoscopy. Endoscopy was performed on an emergency basis within 12 hours of hospital arrival. (Korean J Gastrointest Endosc 18: 817-824, 1998) (continue)

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원저 : 식도 위장관 ; 소화성궤양 출혈 환자에서 내시경적 Hemoclip 요법 , Hypertonic Saline Epinephrine ( HSE ) 국소 주입 요법과 병합요법의 치료효과 ( Original Articles : Esophagus , Stomach & Intestine ; Hemostatic Effect of Endoscopic Hemoclip Method , Hypertonic Saline Epinephrine Injection Method and Their Combined Method for Bleeding Peptic Ulcer ): Korean J Gastrointest Endosc 1997;17(3):335-345. Published online November 30, 1996

Abstract PDF: Background
Bleeding peptic ulcer is the most common cause of upper gastrointestinal bleeding. Various different endoscopic hemostatic methods were introduced to treat bleeding peptic ulcer. Many studies reported the efficacy and comparision of various methods. Endoscopic injection therapy is the most comman method among them because it is inexpensive and easy in use. Complications of injection therapy such as aggravation of bleeding, tissue neerosis and perforation were repoted rarely. Recently endoscopic hemoclipping method is considered to be safe and effective hemostatic method for upper gastrointestinal bleeding, Methods: During the period between January 1993 and August 1996, we have conducted clinical trial and retrospective analysis among 100 patients in whom active bleeding or visible vessel was identified. (Korean J Gastrointest Kndosc 17: 335-345, 1997) (continue...)

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