From the Guidelines
A repeat esophagogastroduodenoscopy (EGD) should be performed in patients who rebleed after an initial period of clinical stability following a bleeding duodenal ulcer, to confirm further bleeding and assess the need for repeat endoscopic therapy or surgical intervention. This approach is supported by the guidelines for non-variceal upper gastrointestinal haemorrhage, which recommend repeat endoscopy in patients who rebleed after an initial period of stability 1. The decision to perform a repeat EGD is based on clinical judgment and takes into account the patient's age, comorbidity, and endoscopic findings. For example, a giant posterior duodenal ulcer with multiple bleeding points is at high risk of further bleeding and may require semi-urgent surgery, while a lesser curve gastric ulcer in a younger patient with little comorbidity may be managed with an expectant policy 1.
In terms of follow-up, patients who have bled from ulcers should receive standard ulcer healing therapy, which typically involves Helicobacter eradication and proton pump inhibitor (PPI) therapy 1. While endoscopic confirmation of duodenal ulcer healing following H. pylori eradication is probably not necessary, repeat endoscopy may be considered in patients who need to continue non-steroidal anti-inflammatory drugs (NSAIDs) while receiving ulcer healing therapy 1. The use of NSAIDs should be avoided indefinitely or used with gastroprotection, and patients should discontinue anticoagulants and antiplatelets if possible before the procedure.
Key considerations for the management of patients with bleeding duodenal ulcers include:
- Repeat EGD in patients who rebleed after an initial period of clinical stability
- Standard ulcer healing therapy, including Helicobacter eradication and PPI therapy
- Avoidance of NSAIDs or use with gastroprotection
- Discontinuation of anticoagulants and antiplatelets before the procedure, if possible
- Consideration of semi-urgent surgery in high-risk patients, such as those with giant posterior duodenal ulcers with multiple bleeding points.
From the Research
Indications for Repeat Esophagogastroduodenoscopy (EGD)
- Rebleeding after initial endoscopic treatment is a common indication for repeat EGD, with a reported recurrence rate of 33% in patients with bleeding gastric and duodenal ulcers 2
- Patients with high-risk stigmata of bleeding, such as those with duodenal ulcers, are at increased risk of rebleeding and may require repeat EGD 3
- Hemodynamic instability and failure of initial endoscopic therapy are also indications for repeat EGD or consideration of alternative treatments such as surgery or transcatheter arterial embolization 4, 3
Timing of Repeat EGD
- Repeat EGD may be considered within 24 hours of the initial procedure in patients with low-risk profiles, while those with high-risk profiles may require earlier intervention 5
- Patients who rebleed within 8 days of the index endoscopy are more likely to require surgery, while those who rebleed after 8 days may be effectively treated with repeat endoscopic therapy 2