DIFFERENT ENDOSCOPIC TREATMENT OPTIONS

• Injection therapy• Thermal coagulation• Mechanical devices• Combination therapy

– Decrease the frequency of recurrent rebleeding and the rate of surgical intervention

Injection therapy

• In high-risk cases, the doctor may inject diluted epinephrine (1:10,000) directly into the ulcer to enhance the effects of the heating process.

• All that is needed is a sclerotherapy needle and the technique is simple

• Epinephrine activates the process leading to blood coagulation, narrows the arteries, and enhances blood clotting.

Thermal devices

• Contact types (heater probe, monopolar and bipolar electrocoagulation)

• Noncontact types (laser treatment, argon plasma coagulation [APC])

Mechanical devices

• have been used for the treatment of variceal hemorrhage, but rarely in the treatment of peptic ulcer disease

• Use of HEMOCLIPS – efficacy seems to be limited by its difficulty of successful application

• The deployment of hemoclips on fibrotic ulcer floors can be difficult, however, particularly when they are used tangentially or with the endoscope in a retroflexed position

Combined Therapy

• injection of diluted epinephrine precedes thermal coagulation

• In actively bleeding ulcers, an injection can diminish or even stop bleeding, allowing a clear view of the bleeding vessel, which in turn facilitates accurate thermal coagulation

• The cessation of blood flow can also prevent dissipation of thermal energy, so that tissue injury can be minimized

• Intravenous (IV) administration of a PPI (usually omeprazole or pantoprazole) significantly prevents rebleeding and appears to be cost-effective.

• A PPI may also be useful for initial bleeding episodes when endoscopy is unsuccessful, inappropriate, or unavailable.

RISKS/ COMPLICATIONS

• Complications can arise prior to, during, or after endoscopy

• Complications prior to endoscopy: - aspiration (especially in a sedated, combative, or encephalopathic patient)

- hypoventilation (related to oversedation), - hypotension (due to inadequate volume replacement or transfusions in addition to sedation with narcotics)

RISKS/ COMPLICATIONS

• Endoscopic complications are usually related to endoscopic hemostasis therapy and include precipitation and worsening of bleeding and perforation.

• Overly aggressive and repeated applications of thermal or injection therapy rarely increase the hemostasis rate but may increase the risk of treatment-induced complications.