Acute Nonvariceal Upper Gastrointestinal Hemorrhage

Upper endoscopy to assess the risk of rebleeding in patients with nonvariceal upper gastrointestinal bleeding may be used for triage, allowing outpatient care of selected patients and leading to significant cost savings. Over the last 10 years, hospitalization days required for upper gastrointestinal bleeding have decreased significantly and the majority of patients with upper gastrointestinal bleeding undergo endoscopy within 24 hours of admission. Twenty percent to 35% of these endoscopies include endoscopic hemostatic therapy. Endoscopic treatment is recommended for actively bleeding (ie, spurting or oozing) visible vessels and nonbleeding visible vessels that are raised and cannot be washed off. Endoscopic methods can be divided into thermal (multipolar coagulation, heater probe, argon plasma coagulator, Nd:YAG laser) and nonthermal (eg, injection therapy); both types are effective. A combination of injection and thermal therapy with initial injection to slow the bleeding or "clear the field" followed by coagulation of the identified vessel is popular. Bleeding recurs in 15% of patients. A recent randomized controlled trial of repeat endoscopic treatment versus surgery for patients with recurrent ulcer bleeding concluded that endoscopic retreatment is superior to surgery. Most peptic ulcer rebleeding occurs within the first 3 days of presentation. A comparison of omeprazole and placebo therapy in high-risk ulcer patients with bleeding stigmata at endoscopy who were not treated endoscopically found that high-dosage omeprazole (40 mg twice a day) significantly lowered the rates of further bleeding and surgical intervention. Although unlikely to replace endoscopic therapy, this study demonstrated the efficacy of potent acid suppression, perhaps due to stabilization of clotting activity. A recent placebo-controlled trial of high-dosage parenteral omeprazole after endoscopic treatment of bleeding peptic ulcers demonstrated a substantial reduction in the risk of rebleeding.