Management of Patients with Rebleeding

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Key points

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    Rebleeding after endoscopic hemostasis is a major risk factor for mortality.

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    Risk factors for rebleeding should be recognized to identify high-risk patients.

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    Newly developed devices, such as TC-325 (Hemospray; Cook Medical, Bloomington, IN) and Over-The-Scope Clip (Ovesco Endoscopy AG, Tübingen, Germany), might secure hemostasis on recurrent bleeding.

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    If further rebleeding recurs after a second endoscopic attempt, transarterial angiographic embolization or surgery should be considered.

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    Definitive

Risk Stratification

The first step in managing patients with upper gastrointestinal bleeding is clinical evaluation and risk stratification. The aim is to determine the severity of bleeding and, hence, the priority and timing of different therapies. Patients with exsanguinating hemorrhage and unstable hemodynamics require immediate resuscitation and intensive monitoring. Prompt fluid and red cell replacement can be life saving in this situation. Nevertheless, overzealous transfusion in otherwise stable patients

Recurrent peptic ulcer bleeding

Rebleeding after initial endoscopic control occurs in up to 15% of cases. It is a major risk factor for peptic ulcer–related mortality. A cohort study based on 3000 patients with peptic ulcer bleeding showed that rebleeding was an important factor contributing to mortality,4 along with other clinical prognostic factors, including age older than 70 years, medical comorbidity, hypotension, and need for surgery.

Summary

The past few decades have witnessed revolutionary changes in the management of peptic ulcer disease. Despite major breakthroughs, there is still a small proportion (5%–10%) of patients who have recurrent peptic ulcer bleeding after endoscopic hemostasis. Identifying such patients using a risk stratification scoring system or key risk factors should be adopted as a routine practice. In high-risk patients, a more aggressive approach including second-look endoscopy and preemptive endoscopic

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    • Disclosure statement: The authors declare no conflict of interest.

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