Hallal Mahmoud
The worldwide approach to upper GI bleeding is becoming uniform, both medical and endoscopic management. It is evident that in the most of cases high dose PPI should be startedto downstage the endoscopic lesion and decrease the need for endoscopic intervention, but should not delay early endoscopy (within 24h). Endoscopic hemostatic therapy is indicated for pts with high-risk stigmata and no single method of endoscopic thermal coagulative therapy is superior to another. Clips, thermocoagulation or sclerosant agents should be used in pts with high risk lesions alone or in combination with epinephrine injection. When there is no active bleeding but a red protuberance is seen in the center of an ulcer, most would inject with epinephrine, and in addition, use APC, heat probe, or clips. Epinephrine injection alone provides suboptimal efficacy and should be used in combination with another method IV erythromycin will help but should not delay the decision of urgent endoscopy; when oozing is seen from an ulcer site, injection with epinephrine, and or the argon plasma coagulator used, followed by ethanolamine. Other endoscopic modalities can be used including hemospray, rubber band ligations. Patients admitted to the hospital whose GI bleeding requires therapeutic endoscopy, but they do not take a second look on the day after the endoscopic examination unless active bleeding recurs. None of the International Board members would perform any therapeutic measures if melena was the presenting symptom and a clean ulcer base was present in the duodenum. Biopsy specimens for Helicobacter are usually taken if hemostasis has been achieved. All skills have a learning curve and we recommend use what you are expert in stopping bleeding. The GI endoscopist should achieve their skills based on workshops and hands-on training to be certified in therapeutic endoscopic management.
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