High gastric ulcer

[Gastrointestinal hemorrhage--hemorrhage from the upper digestive system]

Upper gastrointestinal (GI) bleeding represents the commonest emergency managed by gastroenterologists utilizing substantial clinical and economic resources. Manifestations of GI bleeding depend uppon its localization, magnitude and co-morbidity. Although endoscopic haemostasis has significantly improved the outcome of patients with upper GI bleeding, in some cases patients continue to bleed or rebleed after initial control requiaring early elective surgery in order to decrease mortality. Despite recent advances in, both, endoscopic and surgical therapy, mortality rates have remained essentialy unchanged at 6-15%.

Surgery in the acute management of bleeding peptic ulcer

The management of bleeding peptic ulcers is an increasing challenge in an ageing population. Endoscopic therapy reduces the need for emergency surgery in bleeding peptic ulcers, and ulcers that fail endoscopic therapy are often 'difficult' ulcers, highly demanding for most gastric surgeons. Mortality in patients requiring eventual salvage surgery is high. Planned urgent surgery is preferable to emergency surgery in elderly patients. Initial endoscopic control offers an opportunity for selecting high-risk ulcers for early surgery. Such a logical approach has, however, not been supported by evidence in the literature. At surgery, an aggressive approach is recommended. Post-operative bleeding is more common after lesser surgery, and this complication is often fatal. When re-bleeding occurs, a selective approach is suggested as emergency surgery carries with it a substantial mortality. Large chronic ulcers with exigent bleeding are less likely to respond to endoscopic re-treatment. Expedient surgery is advised for these patients.

Mechanical endoscopic methods of haemostasis for bleeding peptic ulcers: a review

Re-bleeding following endoscopic therapy for gastrointestinal bleeding remains common probably because injection and thermal methods for treating bleeding are of limited efficacy, especially in the presence of a large bleeding artery. This chapter reviews mechanical methods of endoscopic haemostasis. The design of clips, which can be delivered through flexible endoscopes, is reviewed with experimental and clinical data of their efficacy. The need for improvements in clip design is stressed. Experimental studies and preliminary clinical data where available on a variety of other mechanical methods of haemostasis are presented, including band ligation, endoloops, sewing machines, stapling machines, ulcer clamps, corkscrews, balloon tamponade and ferromagnetic tamponade. New, less invasive, surgical methods which might have a place in ulcer haemostasis, including transgastric endoluminal surgery and flexible endoscopic ulcer excision with wound closure, are discussed. Mechanical methods offer the best prospect for improvements in security of endoscopic haemostasis for bleeding peptic ulcer. More development is required if the results are to improve.

Clinical courses and predictors for rebleeding in patients with peptic ulcers and non-bleeding visible vessels: a prospective study

Detailed characterisation of non-bleeding visible vessels in terms of colour, size evolution, and time of rebleeding is important in determining the natural history of these lesions. The colour and size of non-bleeding visible vessels were observed endoscopically every day for three days and then every other day until rebleeding or flattening of visible vessels occurred in 140 patients. Rebleeding happened in 61 (44%) patients. Of them, 59 (97%) rebled within 72 hours. Flattening of visible vessels happened in 79 (56%) patients and 77 of 79 (98%) had flattening of visible vessels within 72 hours. Rebleeding rate increased with increasing length of exposed vessels (r = 0.96, p < 0.001). Coffee ground fluid or blood retention in the stomach and ulcer size > or = 2.0 cm were independent predictors for rebleeding using multivariate analysis. It is suggested that patients with non-bleeding visible vessels and independent predictors for rebleeding may need early aggressive treatment.

Gastroduodenal disease in the elderly patient

Benign and malignant diseases of the stomach and duodenum are common in the elderly. Atypical presentations frequently are seen, making early diagnosis difficult. Aggressive surgical and medical management regimens are usually possible, giving cure rates comparable to those seen in the younger population.

Peptic ulcer disease in the elderly

The elderly are a growing minority; they comprise approximately 12% of the population but consume an increasing proportion of health care resources. Disease in the aged is unique in many ways, demanding special attention and study. This is particularly evident with regard to peptic ulceration, which is a more serious disorder in the elderly than in younger individuals, often presenting in an atypical manner and having a greater propensity to complications. Management traditionally tends to be conservative, enthusiasm often being tempered by the presence of frailty and associated disease. Despite technologic and pharmacologic advances, the elderly continue to account for a disproportionate number of deaths from this disorder. This paper will review the peculiarities of peptic ulcer disease of the elderly and examine currently emerging trends which may influence evolving management policies.