Endoscopic Cauterization for Peptic Ulcer Bleeding
For actively bleeding peptic ulcers (Forrest Ia/Ib) or those with a nonbleeding visible vessel (Forrest IIa), use combination therapy with epinephrine injection plus either thermal coagulation (bipolar electrocoagulation or heater probe) or mechanical clips—never use epinephrine alone. 1
Endoscopic Therapy Indications
Endoscopic hemostatic therapy is mandatory for high-risk stigmata 1:
- Forrest Ia: Active spurting bleeding
- Forrest Ib: Active oozing bleeding
- Forrest IIa: Nonbleeding visible vessel
Do not perform endoscopic therapy for low-risk lesions (clean-based ulcer or flat pigmented spot) 1.
Recommended Cauterization Methods
First-Line Combination Therapy
The strongest evidence supports combination therapy over monotherapy 1, 2:
- Epinephrine injection (1:10,000) PLUS one of the following:
- Bipolar electrocoagulation (thermal contact)
- Heater probe (thermal contact)
- Through-the-scope clips
- Sclerosant injection (absolute ethanol)
Critical pitfall: Epinephrine injection alone provides suboptimal efficacy and should never be used as monotherapy 1. This reduces further bleeding by only 58% compared to other monotherapies, whereas combination therapy reduces it by 66% 2.
Thermal Coagulation Specifics
No single thermal method is superior to another 1. Options include:
- Bipolar electrocoagulation
- Heater probe
- Soft monopolar electrocoagulation
- Argon plasma coagulation
All thermal contact methods (heater probe, bipolar) reduce further bleeding by 56% compared to no therapy (NNT=4) 2.
Alternative First-Line Options (Newer Evidence)
The 2026 ESGE guideline 3 suggests over-the-scope (OTS) clips as monotherapy may be used as an alternative to combination therapy for high-risk stigmata, showing lower rebleeding rates than standard therapy. However, the 2019 international consensus 1 only conditionally recommends through-the-scope clips with very low-quality evidence.
Hemostatic forceps with soft coagulation may also be used as monotherapy per 2026 guidelines 3, though this represents emerging rather than established practice.
Special Situations
Adherent Clot (Forrest IIb)
This remains controversial 1. Two approaches:
- Intensive PPI therapy alone may be sufficient
- Clot removal with treatment of underlying lesion if the endoscopist has technical competence 3
Attempt targeted irrigation to dislodge the clot; treat the underlying lesion if high-risk stigmata are revealed 1.
Refractory Bleeding
If standard hemostasis fails 3:
- Consider topical hemostatic agents (TC-325) or OTS clips
- Proceed to transcatheter angiographic embolization (TAE)
- Surgery only if TAE unavailable or unsuccessful
Important: TC-325 hemostatic powder should be used as temporizing therapy when conventional methods fail, but not as single therapeutic strategy versus conventional therapy 1.
Recurrent Bleeding
For rebleeding after initial hemostasis 3, 4:
- OTS clips should be considered for second attempt
- If second endoscopic attempt fails → TAE → surgery
Adjunct Pharmacologic Therapy
High-dose intravenous PPI therapy is mandatory after successful endoscopic hemostasis 1, 4:
- Bolus followed by continuous infusion for 72 hours
- Then transition to twice-daily oral PPI for 2 weeks
Pre-endoscopy PPI may downstage lesions but should not delay endoscopy 1, 3.
Timing Considerations
Perform endoscopy within 24 hours of presentation 1. Do not perform emergent endoscopy (≤6 hours) unless the patient remains hemodynamically unstable despite adequate resuscitation 3.
Erythromycin infusion (or metoclopramide if unavailable) before endoscopy improves visualization in severe/active bleeding 3, 4.
Quality of Evidence Note
The thermal coagulation and combination therapy recommendations carry strong recommendation with low-quality evidence 1, while clips carry only conditional recommendation with very-low-quality evidence. The consistency across multiple international guidelines (2010,2019,2021,2026) strengthens confidence despite individual study limitations.