Endoscopic Hemostasis of Ulcer Hemorrhage with Injection, Thermal, and Combination Methods

Endoscopy by well-trained and skilled endoscopists yields a definitive diagnosis in over 95% of patients with upper gastrointestinal (UGI) bleeding, and endoscopic hemostasis can be applied in most patients with major stigmata of hemorrhage: active bleeding, nonbleeding visible vessels, or adherent clots. Based on these high rebleeding rates on medical therapy alone, we now recommend endoscopic treatment of all patients with active arterial bleeding, NBVV, and adherent clots. Persistent oozing without other stigmata is also included in this group, although rebleeding rates on medical therapy are substantially lower. In the last 15 years, ulcer hemorrhage has decreased in prevalence, whereas the prevalences of esophagogastric varices and erosive esophagitis have both increased. Heat energy applied through endoscopic probes coagulates tissue proteins, causes edema and vasoconstriction, activates intrinsic arterial (platelet) coagulation, and thereby obliterates the arterial lumen. These contact devices can be applied directly on the ulcer stigmata or the bleeding site to compress the underlying vessel with moderate appositional pressure before coagulation. The pressure on the stigmata interrupts blood flow through the underlying vessel and reduces the heat sink effect. Subsequent applications of low energy, long coagulation with MPEC or heater probe can weld the walls of mesenteric arteries up to 2.0 mm in diameter together for effective "coaptive coagulation" in the laboratory. Combination therapy combines the mechanisms of action for arterial hemostasis of two or more treatment methods. Both epinephrine injection and thermal coagulation activate platelet coagulation and cause tamponade of the vessel. In addition, epinephrine causes vessel constriction, and thermal coagulation probes result in secondary edema and coaptive coagulation. In two recent randomized trials, investigators reported that combination endoscopic treatment with epinephrine injection near the pedicle of the clot in the ulcer base, followed by mechanical shaving down of the clot to expose the underlying stigmata, and subsequent thermal coagulation with MPEC or heater probes, dramatically reduced rebleeding rates compared with medical therapy alone from about 34% to less than about 5%. Combination therapy with epinephrine injection followed by thermal therapies (eg, MPEC or heater probe) has reduced these ulcer rebleeding rates to 15% to 20% for active arterial bleeding and to about 10% for NBVV. In two recent randomized controlled trials, combination epinephrine and thermal therapy (multipolar probe) was also reported to have similar rebleeding rates to hemoclipping for hemostasis of active ulcer bleeding or NBVV. Combination therapy was better than hemoclipping for the subgroup of patients with tangential ulcers.