Current management of acute gastrointestinal bleeding

Endoscopic therapy is now the first-line treatment for the management of acute ulcer bleeding. Of the many endoscopic methods available, combination treatment using adrenaline injection to arrest the active bleeding, followed by thermal or electrical coagulation to seal the vessel, is currently the most popular. Endoscopic ulcer haemostasis is technically demanding, and indiscriminate extrapolation of results of published trials without reference to the expertise available locally may be dangerous. The cost-effectiveness of a routine second-look endoscopy has not been established, but repeat treatment in those who have rebled has shown good results in experienced hands. Current evidence supports the use of a proton-pump inhibitor to prevent acid-pepsin digestion of the blood clot plugging the eroded blood vessel. Interplay between acid, Helicobacter, NSAID and 'stress' results in peptic ulceration. Eradication of Helicobacter is an important measure in the secondary prevention of ulcer bleeding. The inability to measure blood flow in the eroded artery before and after treatment, to reliably seal a large blood vessel and to detect rebleeding before significant blood loss are limiting factors in the current management of ulcer bleeding.