Hemorrhage

Gastrointestinal hemorrhage or bleeding affects 5 to 20 percent of ulcer patients and is more common in people with duodenal ulcers, or ulcers of the small intestine. Bleeding is the most common complication of peptic ulcer disease and occurs more often in men than in women. Hemorrhage from ulcers stops spontaneously in approximately 75 to 80 percent of cases. Approximately one fourth of all bleeding ulcers require an interventional procedure, however.

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Endoscopy, in which a flexible tube is inserted through the mouth or nasal passage, is the preferred way to diagnose and treat an upper gastrointestinal hemorrhage because of its accuracy and low complication rate. Endoscopy is able to accurately identify the bleeding source in more than 95 percent of patients with significant upper GI hemorrhage. The goal of endoscopic therapy is to "seal" the blood vessel involved and stop the bleeding. This may be accomplished in a variety of ways.

Several endoscopic methods of treatment rely on heat:

• Laser: A laser light can be focused on a bleeding point to induce rapid tissue heating, which leads to coagulation. Clinical trials of ulcer hemorrhage have confirmed that photocoagulation with a laser effectively seals bleeding and nonbleeding visible vessels at risk of future hemorrhage. Important considerations that limit emergency laser treatment include portability of the lasers and cost; the need for specific expertise by the endoscopist and technician as well as special electrical outlets and eye protection; and technical considerations such as the difficulty in aiming the laser beam.
• Electrocoagulation: Heat generated from high-frequency electrical current is capable of coagulating or cutting tissue. Thermal electrocoagulation is the classic treatment for bleeding during surgery and is now being used endoscopically to treat GI bleeding.
• Heater probe: The heater probe is a hollow aluminum cylinder with an inner coil that transfers heat to tissue when positioned. This probe may be passed through larger endoscopes and positioned on bleeding lesions to compress and heat them. Studies have shown the heater probe to be safe and effective for the treatment of ulcer bleeding and successful at significantly improving clinical outcomes.

Another endoscopic treatment uses chemical agents to seal ulcers:

Injection therapy, an alternative to heat therapy, is inexpensive, simple, and widely used. A catheter with a small retractable needle is passed through the endoscope, and vessels are treated with one or more of several different chemical agents.

A combination of injection and thermal treatment has theoretical advantages in the treatment of bleeding ulcers. Injection with the drug epinephrine constricts the blood vessels and activates platelet coagulation, reducing blood flow and facilitating thermal therapy. Recent studies have shown combination therapy (epinephrine injection and heater probe) to be more effective than either individual therapy alone.

Surgery may be necessary if other methods fail to stop the bleeding or if bleeding recurs, or to rule out cancer.