Bleeding Ulcers Pharmacological Therapy and Injection Techniques

■ Pharmacological Therapy of Bleeding Ulcers

Hemostasis cannot be achieved with medical therapy alone. PPI ►

are used, but their benefit is still unproved. If H. pylori is de- ►

tected, eradication therapy should be performed. This can expe- ►

dite healing and lower the risk of recurrence. NSAIDs should be ► discontinued.

■ Endoscopic Techniques

The treatment of choice is endoscopic hemostasis (injection therapy, hemoclips, thermal methods).

■ Injection Therapy

Key Characteristics

► Epinephrine

- Therapy of choice

- Safe, economical, can be used to treat rebleeding after prior hemostasis with polidocanol

► Polidocanol

- Very effective, especially after initial use of epinephrine

- Problem: enlarges tissue lesion, should not be used to treat rebleeding

- Agent of second choice

- Two components (fibrin and thrombin) form a fibrin clot when mixed together. They are mixed at the time of injection.

- Excellent tissue compatibility; very costly, laborious technique

- Very effective for rebleeding

► Physiological saline solution, glucose, ethanol

- Very rarely used today as a solitary treatment

Materials

Endoscope Suction pumps Water jet

Single-lumen injection needles for epinephrine and polido-canol, double-lumen needles for fibrin glue Epinephrine 1:10000 in physiological saline solution, 1% polidocanol, fibrin glue

Technique

Epinephrine (Fig. 4.21)

- Make several injections of 1 mL each around the bleeding ulcer.

- Then inject 1-2 mL into the bleeding site at the ulcer base.

Polidocanol

- Inject 1 mL of polidocanol into the bleeding site.

- Caution: Inject no more than 2 mL per ulcer; more could cause a substantial tissue lesion.

Fibrin glue

- Preflush the needle with physiological saline solution.

- Inject 2 mL of both components into the bleeding site through a double-lumen needle.

- Then flush the needle with physiological saline solution.

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