What is the role of endoscopy in the treatment of upper gastrointestinal bleeding (UGIB)?

Updated: Aug 12, 2019
  • Author: Bennie Ray Upchurch, III, MD, FACP, AGAF, FACG, FASGE; Chief Editor: BS Anand, MD  more...
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Answer

For several decades, endoscopy has been the primary method of evaluating and managing upper gastrointestinal (GI) bleeding (UGIB). [129]

Several observational studies, randomized clinical trials, and meta-analyses have demonstrated and supported the idea that early endoscopic hemostatic therapy significantly reduces the rates of recurrent bleeding, the need for emergent surgery, and mortality in patients with acute nonvariceal UGIB. This effect has been more evident in higher-risk patients. [106, 115, 130, 131, 132, 133]

Challenges, such as increasing patient age and comorbidity, the extremely effective antithrombotic or anticoagulant agents, and significant side-effect concerns of the most effective therapeutic agents for ulcer disease, have fortunately been balanced with various endoscopic technological developments and dissemination of evidence-based treatment pathways. Yet the mortality from peptic ulcer bleeding has changed very minimally over this time. [97, 134]

Three significant technological advances have been developed: (1) endoscopic application of Doppler probes to evaluate arteries in the ulcer base, (2) endoscopic application of hemostatic powders, and (3) over-the-scope clips, with enhanced capability over the standard endoclips.

Aside from ulcer hemorrhaging, other causes of GI bleeding, including mucosal tears in the esophagus or upper stomach due to vomiting (Mallory-Weiss tears), venous blebs, and vascular ectasias, can also be treated with endoscopic coagulation.

The bleeding from gastric cancers and ulcers in leiomyomas does not usually respond to endoscopic therapy; surgical or radiologic intervention is needed.

Much debate has focused on the significance of the nonbleeding visible vessel (ie, color, size, diagnostic characteristics, risk of rebleeding) in ulcer hemorrhage. These matters became clarified after the characteristics and significance of the visible vessel in the ulcer crater were defined and the evidence for endoscopic therapy was established, demonstrating that patients requiring therapy to control bleeding or rebleeding could be diagnosed and treated at the time of the upper endoscopy.

The use of Doppler probes to evaluate the arterial flow in the base of ulcers to assess for the rebleeding risk and adequacy of hemostasis may prove to be more accurate than the visual assessment of bleeding stigmata.

Patients should be considered for upper endoscopy if blood loss from the upper GI tract is suspected.

The patient should undergo upper endoscopy prior to any operative intervention in order to diagnose and localize the bleeding site. Most patients (85%-90%) respond to endoscopic therapy.

During the endoscopy, the patient is monitored according to the analgesia and sedation guidelines formulated by the American Society of Anesthesiology. The characteristics of the bleeding lesion are noted, and appropriate therapy is applied when necessary for high-risk lesions or active bleeding.


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