October 23rd, 2014
Clip, Burn, Inject, or All Three? How Do You Treat Ulcer Bleeding?
As endoscopists, we have all sorts of tools to treat ulcer bleeding or other gastrointestinal bleeding, such as injection with epinephrine and thermal coaptive coagulation with heater probes or multipolar electrodes like the Gold probe. More recently, a myriad of clips have become available for use. It seems to me that both operator and ulcer characteristics determine what is used in any given situation.
Take the case of a duodenal ulcer that is actively oozing at the apex of the bulb.
- What approach would you take to control bleeding?
- What if it were spurting?
- What if it only had a visible vessel?
- What if it had an adherent clot?
- Would you take the same approach in treating a gastric ulcer?
I look forward to the dialogue.
3 Responses to “Clip, Burn, Inject, or All Three? How Do You Treat Ulcer Bleeding?”
M. Brian Fennerty, MD
Editor-in-Chief
NEJM Journal Watch Gastroenterology
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What approach would you take to control bleeding?
I will use diluted epinephrine injection therapy first to control bleeding
What if it were spurting?
I still will try to use diluted epinephrine injection therapy first to decrease bleeding amount first.
What if it only had a visible vessel?
I will use hemoclip for hemostasis.
What if it had an adherent clot?
I will remove the clot after epinephrine injection, followed by heat probe or hemoclip according to feasibility.
Would you take the same approach in treating a gastric ulcer?
It depends on the site, if applicable, i use hemoclip more often.
If it is spurting or oozing (forrest Ia/b), I firstly inject epinephrine around the lesion and then apply clip or thermal therapy (according to lesion -location, size etc-) for definitive treatment.
If it has a vissible vessel (forrest 2a), I apply clip or thermal therapy (according to lesion -location, size etc-).
If it has an adherent clot (forrest 2b), I firstly inject epinephrine around the lesion and then remove the clot by using snare or tripod. Thereafter, I apply clip or thermal therapy.
They are same in treating a gastric ulcer.
I would control bleeding with thermal coaptive coagulation with heater probes.