13. Role of surgery

in diameter), (c) difficulty to grasp fibrotic tissue, and (d) requirement of

Another clip called Ovesco clip is an over-the-scope clip used to stop peptic ulcer bleeding. The bleeding area is suctioned into a cup attached to the scope, and then

A combination of at least two modalities of endoscopic treatment (injection, thermal, or mechanical) is now the standard of care in the treatment of peptic ulcer

An ultrasound probe is passed through the endoscope channel and placed directly onto the area of bleeding. An audible sound is heard if there is blood flow. Arterial or venous blood flow can be detected. It is useful after endoscopic treatment to evaluate the presence of any residual blood flow which can increase the potential for rebleeding. It is also useful in Forrest IIc and III ulcers to find out any vascular signal. Doppler ultrasound-guided endoscopic hemostasis reduces 30-day

Hemospray or hemostatic nanopowder is an alternative approach to obtain hemostasis. The powder is delivered through a catheter which passes through the endoscope channel, and the powder is then sprayed over the bleeding site. The powder forms a stable mechanical barrier at the site of bleeding. Initial success rate in obtaining hemostasis is 75–100%, but rebleeding rate is 10–49% [70]. So hemospray should be used as a bridge therapy in massive peptic ulcer bleeding when standard

Endoscopic therapy can control acute peptic ulcer bleeding with high success. Primary hemostasis can be obtained in more than 90% of cases, but rebleeding can

Second-look endoscopy is not routinely recommended after initial endoscopy

Complications could be due to sedation, patients' comorbidities, and endoscopy itself. Sedation-related complications include hypoventilation, hypoxia, aspiration pneumonia, airway obstruction, arrhythmia, pulmonary embolism, myocardial infarction, phlebitis, and vasovagal attack [73]. The complications of endoscopic hemostasis include exacerbation of bleeding and perforation, but the overall incidence is <0.5%. The rate of perforation after contact thermal therapy could be as high as 2%. Following thermal therapy, induction or exacerbation of bleeding can

for the management of PU bleeding unless the endoscopist is concerned that suboptimal treatment was given in the first endoscopy or there was poor visualiza-

tion due to blood or food debris during the first endoscopy [72].

11. Complications of endoscopic treatment

occur in up to 15% of cases after therapeutic endoscopic procedure [71].

multiple clips [68].

Digestive System - Recent Advances

bleeding.

the clip is deployed like band ligation.

9. Endoscopic Doppler ultrasound

endoscopic treatment fails.

10. Role of second-look endoscopy

occur in up to 5% of cases [74].

14

rebleeding rate significantly and is also cost-effective [69].

Surgery is indicated if TAE fails to stop PU bleeding. Emergency surgery involves plication or oversewing of the ulcer with ligation of the bleeding artery and truncal vagotomy and pyloroplasty. Wong et al. compared surgery vs. TAE in bleeding PU patients who had failed endoscopic therapy. Surgery was associated with less recurrent bleeding but more complications when compared with TAE. There was no significant difference in the mean length of hospital stay, need for blood transfusion, and 30-day mortality between the two groups [76]. In practice, the surgical intervention continues to diminish, but the radiological intervention continues to increase in acute PU bleeding patients who have unsuccessful endoscopic therapy. Surgery is also recommended for (a) patients with perforation, (b) shock due to recurrent bleeding, (c) patients with hemodynamic instability despite adequate resuscitative measures needing more than three units of blood transfusion, and (d) unavailability of interventional radiology.

## 14. Prognosis of bleeding peptic ulcer

The outcome depends on successful endoscopic hemostasis without recurrent bleeding. The risk factors for recurrent bleeding include patients with renal failure on dialysis; elderly patients on NSAID, antiplatelet agents, and anticoagulants; patients with ulcer located on the posterior duodenal wall and lesser curve of the stomach; and patients with active bleeding ulcer during endoscopy. Despite the tremendous advances in technology, the mortality of acute PU bleeding remains about 10% [77].

## 15. Perforation

In patients with PUD, the lifetime prevalence of perforation is 5%. Patients generally present with acute abdomen. The triad of sudden onset of abdominal pain, tachycardia, and abdominal rigidity is highly suggestive of PU perforation. Smoking, NSAIDs, corticosteroids, old age, H. pylori infection, stress, and previous history of PUD are risk factors for perforation [78]. Upright chest X-ray is generally diagnostic, but it can miss free air under the diaphragm in 15% of cases. CT (computerized tomography) is very sensitive in detecting the presence and site of perforation [79]. CT with oral contrast may also show leak. Exploratory laparotomy with omental patch is the treatment of choice. PU perforation carries increased risk of morbidity and mortality if not treated early.

#### 16. Penetration

When the ulcer crater erodes through the gastric wall or intestinal wall into the surrounding structure but there is no free perforation or leakage of luminal contents into the peritoneal cavity, it is called penetration [80]. The pancreas is the commonest site of penetration. Other sites of penetration include the omentum, biliary tract, liver, colon, mesocolon, and blood vessels. Patients may notice change in pattern of abdominal pain, i.e., pain not being relieved by taking food or medication. Diagnosis is confirmed by CT with contrast which may show loss of fascial plane between the gastric wall or intestinal wall and the surrounding structure, band of soft tissue density between them, ulcer crater, sinus tract, and enlargement of head of the pancreas in case of penetration into the pancreas [81]. Treatment is surgical intervention.
