In the United States, about 150,000 patients per year are admitted to the hospital with gastrointestinal bleeding due to peptic ulcer disease. 19 Factors predicting death include large initial bleed, continued or recurrent bleeding, older age, and comorbid illness. 19 The mortality rate is 2 to 3 percent for the 80 to 85 percent of patients who do not rebleed, compared to 20 percent or greater for those who do bleed while hospitalized. 19 Shock, low initial hematocrit, red blood in the emesis or stool, and failure of blood to clear with lavage all predict further bleeding. 19
Treatment for ulcer bleeding should focus on restoring hemodynamic stability by intravenous administration of isotonic saline solution and packed red blood cells. Appropriate blood work should be performed, including a complete blood count and type and crossmatching for several units of packed red cells. Two large-bore intravenous lines should be started and the patient placed on oxygen and a cardiac monitor. A nasogastric tube should be inserted and lavaged with water until clear. This does not slow bleeding but allows monitoring of ongoing bleeding and clears the stomach for endoscopy. An H 2RA or PPI can be started, but there is no proof that either reduce rebleeding rates.
Most patients should undergo upper gastrointestinal endoscopy for diagnostic, prognostic, and treatment purposes. An actively bleeding vessel seen on endoscopy heralds a 35 percent chance of emergency surgery and an 11 percent mortality rate, with decreasing morbidity and mortality rates with findings of a nonbleeding visible vessel; an adherent clot; a flat, pigmented spot; and a low of 0.5 percent emergency surgery and a 2 percent mortality rate if a clear base is found. 19 Treatment through endoscopy includes injection therapy with epinephrine, alcohol, or combinations; heat probe or bipolar electrical coagulation; or laser therapy. All of these treatments stop bleeding, prevent recurrences, and decrease transfusion rates and length of hospital stay. The technique chosen depends on the equipment available and the experience of the endoscopist.192,0,
The rebleeding rate after endoscopic therapy is about 20 percent and can be treated by repeat endoscopy or emergency surgery. Surgery is also indicated if bleeding cannot be controlled by initial endoscopy. Angiography with arterial vasopressin or embolization can be considered if endoscopy has failed and surgery is thought to be very high risk.19
Hospitalization in an intensive care setting is indicated for all patients with significant upper gastrointestinal bleeding due to peptic ulcers. If clinical and endoscopic features suggest a low risk of rebleeding, a ward bed may be acceptable.
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