Endoscopic treatment of ulcer bleeding.

Upper gastrointestinal (UGI) bleeding secondary to ulcer disease occurs commonly and results in significant patient morbidity and medical expense. After initial resuscitation, carefully performed endoscopy provides an accurate diagnosis of the source of the UGI hemorrhage and can reliably identify those high-risk subgroups that may benefit most from endoscopic hemostasis. Large-channel therapeutic endoscopes are recommended. Endoscopists should be very experienced in management of patients with UGI hemorrhage, including the use of various hemostatic devices. For patients with major stigmata of ulcer hemorrhage--active arterial bleeding, nonbleeding visible vessel, and adherent clot--combination therapy with epinephrine injection and either thermal coaptive coagulation (with multipolar or heater probe) or endoclips is recommended. High-dose intravenous proton-pump inhibitors are recommended as concomitant therapy with endoscopic hemostasis of major stigmata. Patients with minor stigmata or clean-based ulcers will not benefit from endoscopic therapy and should be triaged to less intensive care and be considered for early discharge. Effective endoscopic hemostasis of ulcer bleeding can significantly improve outcomes by reducing rebleeding, transfusion requirement, and need for surgery, as well as reduce cost of medical care.