High Risk Ulcer Bleeding: When Is Second-Look Endoscopy Recommended?

High Risk Ulcer Bleeding: When Is Second-Look Endoscopy Recommended?
Philip Wai Yan Chiu, Joseph Jao Yiu Sung

Affiliations
Reprint requests Address requests for reprints to: Professor Joseph J.Y. Sung, Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, NT, Hong Kong, China. fax: (852) 26467824
published online 01 February 2010.

Abstract
A 78-year-old gentleman with background history of is-chemic heart disease and diabetes mellitus, presents with passage of tarry stool for 2 days. He is taking regular aspirin 80 mg daily. Upon admission he has blood pressure of 90/60 and pulse rate of 120 beats per minute. An emergency upper endoscopy performed at 3 am by the on-call gastrointestinal fellow showed a visible vessel beneath a 2 cm gastric ulcer (Figure 1A). There was 500 ml of fresh blood in the fundus obscuring the endoscopic view. Endoscopic injection of epinephrine followed by application of hemoclips achieved hemostasis (Figure 1B and C). He is given intravenous omeprazole infusion 80 mg bolus followed by 8 mg per hour for 72 hours. A second endoscopy was scheduled and performed on the next day which showed persistent stigmata of visible vessel. Endoscopic therapy with further injection of epinephrine and heater probe is applied. Rapid urease test results are negative and the ulcer biopsy confirmed benign gastric ulcer. He sustained an episode of acute coronary syndrome with elevation of troponin on day 5 after the ulcer bleeding and aspirin was restarted. He is discharged from hospital 3 weeks afterward without rebleeding.

This article has an accompanying continuing medical education activity on page e87. Learning Objectives—At the end of this activity, the learner should be able to understand the risk factors for rebleeding and mortality from peptic ulcer disease and understand the clinical scenarios that might merit a second-look endoscopy.

Conflicts of interest The authors disclose the following: Joseph Sung served as an advisory committee member for AstraZeneca, and a speaker for AstraZeneca, Nycomed, Roche, BMS, and Given. Philip Chiu discloses no conflicts.

PII: S1542-3565(10)00070-4

doi:10.1016/j.cgh.2010.01.008

© 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.

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High Risk Ulcer Bleeding: When Is Second-Look Endoscopy Recommended?