Page 17 - Gastrointestinal Bleeding (Xuất huyết tiêu hóa)

CHAPTER 20 Gastrointestinal Bleeding 291

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A B C

D E F

G H

Fig. 20.13 A, Endoscopic treatment of a duodenal ulcer with an adherent clot. B, The clot was injected with
epinephrine, followed by piecemeal snare polypectomy to trim away the clot (C-E), after which an underlying
vessel was revealed (F [arrow]). G and H, Two endoscopic hemoclips were placed across the visible vessel.

Clean-Based Ulcers Over-the-Scope Hemoclip
Patients with a clean-based ulcer (Forrest III) at endoscopy have A large over-the-scope (OTSC) hemoclip (OVESCO Endoscopy
a rebleeding rate of less than 5% and do not require endoscopic AG, Tübingen, Germany) has been reported in a randomized
therapy. If the patient has a clean-based gastric ulcer, biopsies controlled trial to significantly reduce rebleeding rates compared
of the ulcer edge and gastric muscosa should be considered to with standard hemostasis in patients with recurrent ulcer bleed-
exclude underlying malignancy (see Chapter 53). These patients ing. Case series have also reported good results using the OTSC
can be fed after the endoscopy and treated with oral acid suppres- hemoclip as primary treatment, but no randomized controlled tri-
sion medication; they do not require continued hospitalization als of ulcer bleeding have been reported to demonstrate whether
unless indicated for other medical problems. OTSC hemoclipping is superior to standard hemostasis as initial
therapy. We have documented that, when successfully applied,
Newer Endoscopic Techniques OTSC hemoclipping more effectively obliterates underlying arte-
rial blood flow in the peptic ulcer base with high-risk SRH than
Hemospray standard hemostasis with through-the-scope hemoclips or MPEC.
Hemospray has been reported to stop active bleeding both from
nonvariceal UGI lesions, varices, and tumors, but hemospray does Testing for Hp Infection
not treat underlying arterial or variceal blood flow. Therefore the
risk of rebleeding is high, and definitive hemostasis with standard In a patient with a bleeding gastric or duodenal ulcer, endoscopic
techniques is usually required in patients with varices or ulcers mucosal biopsy specimens of the normal-appearing antrum and
with major stigmata. Current guidelines recommend utiliza- mid-body greater curvature should be obtained to assess for the
tion of hemospray as a stopgap or adjunct technique. 116 Further presence of Hp infection. Biopsy specimens can be obtained safely
studies, including randomized controlled trials, are required to after successful endoscopic hemostasis, but bleeding reduces the
determine the efficacy and role of hemospray in the clinical man- sensitivity of rapid urease testing. Therefore stool antigen and
agement of GI bleeding. other tests for Hp infection are recommended (see Chapter 52).