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September 8, 1989

Therapeutic Endoscopy and Bleeding Ulcers

JAMA. 1989;262(10):1369-1372. doi:10.1001/jama.1989.03430100103037

Peptic ulcer disease is a major health problem in the United States that affects more than 4 million people each year. Bleeding is one of the most dread complications of peptic ulcer. Upper gastrointestinal bleeding is a common cause of emergency hospitalization in the United States. It has been estimated that more than 100 000 patients with peptic ulcer disease bleed each year. Morbidity and mortality from ulcer bleeding remain significant despite major improvements in the accurate diagnosis of peptic ulcer disease and the use of H2-receptor antagonist drugs and other pharmacologic agents. The mortality rate from bleeding ulcers has averaged between 6% and 10% during the past 30 years despite advances in diagnosis and treatment.

During the past decade, there has been a remarkable transition of the application of the endoscope from solely a diagnostic tool to a therapeutic modality. With the advent of this therapeutic role, there has been much enthusiasm about using endoscopie techniques in managing high-risk patients. A variety of approaches for endoscopie management of bleeding have evolved and there has been continuing improvement over the past decade, resulting in considerable interest in evaluating the various treatment options for managing patients with bleeding ulcers. Unfortunately, there have been limited and conflicting clinical studies on the efficacy and safety of the various hemostatic modalities available for treating these ulcers. In an effort to define the role of these methods, the National Institute of Diabetes and Digestive and Kidney Diseases and the Office of Medical Applications of Research of the National Institutes of Health sponsored a Consensus Development Conference on therapeutic endoscopy and bleeding ulcers. The conference brought together research clinicians and other health professionals and representatives of the public on March 6 through 8, 1989. Following 2 days of presentations and discussion by the invited experts and the audience, members of a consensus panel drawn from the health care and medical communities weighed the scientific evidence in formulating a statement in response to several questions:

  1. Which patients with bleeding ulcers are at risk for rebleeding and thus emergency surgery?

  2. How effective is endoscopie hemostatic therapy?

  3. How safe is endoscopie hemostatic therapy?

  4. Which bleeding patients should be treated?

  5. What further research is required?

It is important that certain limitations be considered when applying the findings of this conference to a particular bleeding patient. The conference was charged to address specifically the question of therapeutic endoscopy for the treatment of bleeding peptic ulcer. Other causes of upper gastrointestinal bleeding, including gastric and esophageal varices, diffuse erosive gastritis, and Mallory-Weiss tears, were necessarily excluded from consideration. It should be noted that the conclusions reached should not be extrapolated to those diseases excluded from consideration. Moreover, a striking finding from the review of available clinical trials of therapeutic endoscopy was the selective inclusion of only a small proportion (10% to 25%) of the total population of patients who presented with upper gastrointestinal bleeding. In addition to patients with the above diagnoses, many other patients were also excluded, quite appropriately, owing to hemorrhage too massive or too little to justify prudent therapeutic endoscopy.

In this conference, the need for emergency surgery was taken as one indicator of inadequately controlled bleeding. Although many patients treated with surgery do well, they are subjected to additional discomfort and cost and to approximately a 10% risk of mortality when the surgery must be performed under such emergency conditions. On the other hand, when temporary hemostasis achieved by endoscopie therapy allows resuscitation and hemodynamic control of a patient whose condition is unstable, considerable benefit may be realized even if surgery must be performed ultimately. Fora variety of reasons, a surgeon should be involved from the outset in the team caring for the patient with bleeding peptic ulcer.