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Treatment of Patients at High Risk for Recurrent Bleeding from a Peptic Ulcer

Dennis M. Jensen, MD
[+] Article, Author, and Disclosure Information

From David Geffen UCLA School of Medicine, CURE, and Veterans Affairs Greater Los Angeles Healthcare Center, Los Angeles, CA 90073-1003.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Dennis M. Jensen, MD, CURE/Veterans Affairs Greater Los Angeles Healthcare Center, 11301 Wilshire Boulevard, Building 115, Room 318, Los Angeles, CA 90073-1003.

Ann Intern Med. 2003;139(4):294-295. doi:10.7326/0003-4819-139-4-200308190-00012
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The management of patients with severe ulcer hemorrhage is rapidly changing. A decade ago, physicians called a general surgeon for upper gastrointestinal hemorrhage. Now, they call an endoscopist (usually a gastroenterologist) to assist in initial management (1). Although some use clinical criteria, such as Rockall scores (2), to triage patients to different levels of hospital care, the current standard of care is early panendoscopy to establish a specific diagnosis, identify predictors of more bleeding, and perform concurrent endoscopic hemostasis if high-risk stigmata are present. The stigmata of high-risk bleeding have traditionally included actively bleeding and nonbleeding visible vessels. On the basis of evidence from randomized, controlled trials (34), two different groups (including mine) have recommended adding “clot adhering to an ulcer” to this list. In those trials, patients with clots had a higher rebleeding rate (34% to 35%) if treated medically with food and oral proton-pump inhibitors (PPIs), 20 mg twice per day, than with combined medical and endoscopic hemostasis (epinephrine and thermal coaptive coagulation) (0% to 4%).

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