Treatment for Bleeding Ulcers

When a patient comes to the hospital with bleeding ulcers, in most cases, endoscopy is performed. This procedure is critical for all phases of bleeding ulcers, including diagnosis, determination of treatment options, and treatment itself.

In high-risk patients or those with evidence of bleeding, options include watchful waiting with medical treatments or surgery. The first critical steps for massive bleeding is to stabilize the patient and support vital functions with fluid replacement and possibly blood transfusions. People on NSAIDs should discontinue them if possible.

Depending on the intensity of the bleeding, patients can be released from the hospital within a day or kept up to three days after endoscopy. Bleeding stops spontaneously in about 70 - 80% of people, but about 30% of patients who come to the hospital for bleeding ulcers will need surgery. Endoscopy is the surgical procedure most often used for treating bleeding ulcers and for patients at high-risk for rebleeding. It is usually used in combination with medications, such as epinephrine and intravenous proton-pump inhibitors.

Between 10 - 20% of patients require more invasive procedures, usually major abdominal surgery. Such patients are usually bleeding.

Endoscopy for Treating or Preventing Bleeding Ulcers

Endoscopy is important for both diagnosing and treating bleeding ulcers. The doctor first places an endoscope (a thin, flexible plastic tube) into the patient's mouth and down the esophagus (food pipe) into the stomach.

Endoscopy Used for Diagnosing Bleeding Ulcers and Determining Risk for Rebleeding. Doctors are able to detect the signs of bleeding such as active spurting or oozing of blood from arteries. Endoscopy can also detect specific features in the ulcers referred to as stigmata, which indicate a higher or lower risk for rebleeding.

Such features include the following:

• Low risk (5 -15%) for bleeding: flat dot; a clean or white base.
• High risk (30 - 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 bleeding again 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).

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. This procedure also causes fluid buildup 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 PPI -- most likely omeprazole or the newer PPI pantoprazole -- significantly prevents rebleeding and appears to be cost effective. In one study, the use of IV PPIs 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 PPI may also be useful alone for initial bleeding episodes if endoscopy is unsuccessful, inappropriate, or unavailable.)

Intravenous H2 blockers are often used, but a major analysis reported no benefits from their use in bleeding duodenal ulcers--although they may be useful for gastric ulcers.

Endoscopy is effective in controlling bleeding in more than 85% of appropriate candidates. If rebleeding occurs, a repeat endoscopy performed by experienced doctors may be effective in about 75% of cases. Those who fail to respond require major abdominal surgery. The most serious complication from endoscopy is perforation of the stomach or intestinal wall, which occurred in about 1.4% of patients in one large 2002 study.

Other Medical Considerations. Certain agents may be warranted after endoscopy:

• Patients who harbor the H. pylori bacteria, even if NSAIDs caused the bleeding, should be treated with antibiotic therapy to eradicate the bacteria. Triple therapy, including antibiotics, to eradicate H. pylori immediately after endoscopy is warranted in most patients infected with the bacteria.
• 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 proven to be more effective than the 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 uses a wide abdominal incision and standard surgical instruments (called open surgery). Laparoscopic techniques employ small abdominal incisions and the insertion of tubes that contain miniature viewing tubes and instrument. Laparoscopic techniques are increasingly being used for perforated ulcers. Surgery is not effective for upper GI ulceration caused by chronic NSAID use.

Major Surgical Procedures. There are a number of surgical procedures aimed at long-term relief of ulcer complications.

Click the icon to see an illustrated series detailing a gastrectomy procedure.

• Vagotomy cuts the vagus nerve and interrupts messages from the brain that stimulate acid secretion in the stomach. This surgery may impair stomach emptying; a recent variation that cuts only parts of the nerve may reduce this complication.
• Antrectomy removes the lower part of the stomach, which manufactures the hormone responsible for stimulation of digestive juices.
• Pyloroplasty enlarges the opening into the small intestine so that stomach contents can pass into it more easily.

Antrectomy and pyloroplasty are usually performed with vagotomy.