Medical Health Encyclopedia

Such features include the following:

• Low-risk (5% to 15%) for bleeding: flat dot; a clean or white base.
• High-risk (30% to 50%) for bleeding. Swollen but nonbleeding blood vessels; blood clots that adhere to ulcers.
• According to one study, if patients with these high-risk features are untreated, their risk for rebleeding after endoscopy ranges from about 10% in the first day after endoscopy to about 3% by the third day. Identifying and treating patients with high-risk features in the ulcers (referred to as stigmata) can reduce these risks. (Other factors that increase the risk for rebleeding include have bleeding disorders, very low blood pressure, other serious medical conditions, and bleeding that started after hospitalization.)

Endoscopy as Treatment. Endoscopy is usually employed to treat bleeding from ulcers with visible blood vessels that are less than 2 mm in diameter. This approach also appears to be very effective in preventing rebleeding in patients whose ulcers are not bleeding but have high-risk features (swollen blood vessels or clots adhering to ulcers).

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The following is a typical endoscopy procedure in many patients:

• The surgeon passes a probe through an endoscopic tube and applies electricity, heat, or small clips to coagulate the blood and stop the bleeding. It also causes fluid build-up that helps to compress the blood vessels.
• In high-risk cases, the doctor may inject epinephrine (commonly known as adrenaline) directly into the ulcer to enhance the effects of the heating process. Epinephrine activates the process leading to blood coagulation, narrows the arteries, and enhances blood clotting.
• Intravenous (IV) administration of a proton-pump inhibitor--most likely omeprazole or the newer PPI pantoprazole--significantly prevents rebleeding and appears to be cost effective. In one major study, the use of IV proton-pump inhibitors reduced the risk for bleeding from 23% without the agent to 7% with a PPI. (Oral PPIs are also effective, but studies are needed to compare their effectiveness with IV PPIs. A proton-pump inhibitor may also be useful alone for initial bleeding episodes if endoscopy is unsuccessful, inappropriate, or unavailable.)