Peptic Ulcers - Medications

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• The doctor first places a thin, flexible plastic tube called an endoscope into the patient's mouth and down the esophagus into the stomach.
• The doctor passes a probe through an endoscope and applies electricity, heat, or small clips to coagulate the blood and stop the bleeding. This procedure also causes fluid buildup, which 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 PPI (usually omeprazole or pantoprazole) significantly prevents rebleeding. (Oral PPIs are also effective, but studies are needed to compare their effectiveness versus IV PPIs.) A PPI may also be useful for initial bleeding episodes when endoscopy is unsuccessful, inappropriate, or unavailable.

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Endoscopy is effective at controlling bleeding in most people who are good candidates for the procedure. If rebleeding occurs, a repeat endoscopy is effective in about 75% of patients. Those who fail to respond will need to have major abdominal surgery. The most serious complication from endoscopy is perforation of the stomach or intestinal wall.

Other Medical Considerations. Certain medications may be needed after endoscopy:

• Patients who harbor the H. pylori bacteria should be treated with antibiotic therapy to eliminate the bacteria. Most patients who are infected with the bacteria need triple therapy, which includes antibiotics, to eliminate H. pylori immediately after endoscopy.
• Somatostatin (a hormone used to prevent bleeding in cirrhosis) is also useful for reducing persistent peptic ulcer bleeding or the risk of recurrence. Researchers are investigating adding other therapies, such as fibrin glue (a blood clotting factor). To date, no therapy has been proven more effective than current treatments.

Major Abdominal Surgery

Major abdominal surgery for bleeding ulcers is now generally performed only when endoscopy fails or is not appropriate. Certain emergencies may require surgical repair, such as when an ulcer perforates the wall of the stomach or intestine, causing sudden intense pain and life-threatening infection.

Surgical Approaches. The standard major surgical approach (called open surgery) uses a wide abdominal incision and standard surgical instruments. Laparoscopic techniques use small abdominal incisions, through which are inserted miniature cameras and instruments. Laparoscopic techniques are increasingly being used for perforated ulcers. Research finds that laparoscopic surgery for a perforated peptic ulcer is comparable in safety with open surgery, and results in less pain after the procedure.