Therapeutic endoscopy for control of upper gastrointestinal bleeding

The majority of patients with upper gastrointestinal hemorrhage will have bleeding that is self-limited, but approximately 20% will have persistent bleeding. Fiberoptic endoscopy is the procedure of choice for the evaluation of the patient with acute upper gastrointestinal bleeding, and in most cases the cause of bleeding can be determined. Despite improved diagnostic capabilities, the mortality rates for acute nonvariceal and variceal bleeding remain at 10 and 40%, respectively. One of the many factors contributing to this persistently high mortality is the risk associated with urgent or emergent surgery. In an effort to reduce morbidity and mortality, laboratory and clinical studies have been performed to assess endoscopic methods for the control of acute upper gastrointestinal bleeding. Several endoscopic methods have been evaluated in animals and humans for the treatment of nonvariceal bleeding. Topical treatments have been performed with tissue adhesives, clotting factors, collagen preparations, and ferromagnetic tamponade. A variety of pharmacologic agents have been injected at or around the bleeding site. Thermal therapy with electrocoagulation, laser photocoagulation, and heater probes has been evaluated. Electrocoagulation and laser therapy have been used the most extensively in humans for nonvariceal bleeding. Although laser therapy has been utilized for variceal bleeding, recent emphasis has been placed upon endoscopic sclerosis for that entity. Esophageal variceal sclerotherapy is fast becoming the procedure of choice, after failure of standard medical therapy, in the patient bleeding acutely from esophageal varices, in those patients in whom a decompressive shunt cannot be employed, and in the patients with marked impairment of liver function. Prospective studies are needed to define the long-term role of elective sclerotherapy versus conventional surgical or medical management in those patients with mild to moderate impairment of liver function. Recent technological advances have made it possible to evaluate a variety of endoscopic methods for the control of upper gastrointestinal bleeding. It is likely that other modalities will become available. The challenge to those involved in this area of therapeutic endoscopy is to determine which methods are safest and most effective for each specific lesion and to try to identify the group of patients who are most likely to benefit from endoscopic therapy as opposed to medical, radiological, or surgical treatment.