Review of Endoscopic Thermal Treatment of Peptic Ulcer Hemorrhage

Abstract

Peptic ulcer hemorrhage is still an important cause of emergency surgery and death. The overall mortality is around 10% from gastrointestinal bleeding, and most of the preventable deaths occur in elderly patients with continued or recurrent bleeding from peptic ulcers. An effective nonsurgical method of hemostasis has long been recognized to be desirable. However it was only when the 'visible vessel' was recognized as the important risk factor for further bleeding that studies capable of testing new modalities adequately could be performed. Careful washing of the ulcer crater is essential for identification of these visible vessels. An effective endoscopic method was first demonstrated in 1981 in patients with visible vessels treated with argon laser. Many groups have now shown excellent efficacy of neodymium:yttrium-aluminum-garnet (NdYAG) laser in preventing further hemorrhage from ulcers with bleeding and nonbleeding visible vessels. Two controlled prospective studies have demonstrated efficacy of the heater probe, but one well designed study did not. Similar studies with both bipolar and monopolar electrocoagulation have shown significant reductions in rebleeding in patients with visible vessels treated using the chosen modality. More recent studies have achieved excellent results by pre-injection with adrenaline and one repeat endoscopic treatment for rebleeds. A few groups have now reported equally good results with injection alone. Long term follow-up of patients with peptic ulcer hemorrhage has confirmed prolonged hemostasis in groups treated with two thermal modalities and in controls.