Endoscopic Interventions in Bleeding Duodenal Ulcer
For bleeding duodenal ulcers with high-risk stigmata (active bleeding or visible vessel), endoscopic hemostatic therapy with thermocoagulation or sclerosant injection is strongly recommended, with epinephrine injection never used alone but always combined with another method. 1
Risk Stratification and Timing
Perform early endoscopy within 24 hours of presentation for all patients admitted with acute upper gastrointestinal bleeding from suspected duodenal ulcer. 1
Pre-endoscopic PPI therapy may be considered to downstage the endoscopic lesion and decrease the need for endoscopic intervention, but should never delay endoscopy. 1
Do not delay endoscopy in patients receiving anticoagulants (vitamin K antagonists or DOACs), as endoscopic hemostatic therapy can be performed safely. 1
Endoscopic Treatment Algorithm Based on Stigmata
Low-Risk Stigmata (No Intervention Required)
- Endoscopic hemostatic therapy is NOT indicated for clean-based ulcers or nonprotuberant pigmented dots in the ulcer bed. 1
Adherent Clot (Controversial)
A clot in the ulcer bed warrants targeted irrigation attempting dislodgement, with appropriate treatment of any underlying lesion revealed. 1
The role of endoscopic therapy for adherent clots remains controversial—endoscopic therapy may be considered, though intensive PPI therapy alone may be sufficient. 1
High-Risk Stigmata (Intervention Mandatory)
- Endoscopic hemostatic therapy is mandatory for active bleeding or visible vessel in the ulcer bed. 1
Specific Endoscopic Techniques
Primary Recommended Methods (Strong Evidence)
Thermocoagulation (heater probe or bipolar electrocoagulation) or sclerosant injection are strongly recommended as first-line endoscopic therapy for high-risk stigmata, with demonstrated reduction in mortality and rebleeding compared to pharmacotherapy alone. 1
No single method of thermal coaptive therapy is superior to another (heater probe vs. bipolar electrocoagulation). 1
Hemoclips (Conditional Recommendation)
Through-the-scope clips are suggested as an alternative endoscopic therapy for high-risk stigmata, though the evidence quality is lower than for thermocoagulation. 1
Clips are superior to epinephrine injection alone for preventing rebleeding but not mortality. 1
Critical Pitfall: Epinephrine Injection
Epinephrine injection alone provides suboptimal efficacy and must always be combined with another method (thermocoagulation, sclerosant, or clips). 1
This is a common error—never use epinephrine as monotherapy. 1
TC-325 (Hemostatic Powder)
- TC-325 should be used only as temporizing therapy when conventional endoscopic therapies are unavailable or fail, not as a single therapeutic strategy. 1
Management of Rebleeding
Routine second-look endoscopy is NOT recommended in stable patients after successful initial hemostasis. 1
A second attempt at endoscopic therapy is generally recommended when rebleeding occurs after initial successful hemostasis. 1, 2
For hemodynamically stable patients with ulcers <2 cm, attempt repeated endoscopy first before considering surgery or angiographic embolization. 3
When to Abandon Endoscopic Therapy
Immediate Surgical Indications
Proceed directly to surgery without repeated endoscopy for patients with hypotension/hemodynamic instability at presentation OR ulcer size ≥2 cm at first endoscopy, as these are independent predictors of endoscopic retreatment failure. 3
Immediate surgery is indicated when arterial bleeding cannot be controlled at endoscopy. 4
High-Risk Features Predicting Endoscopic Failure
Ulcers ≥2 cm in diameter are more likely to fail repeat endoscopy and warrant early surgical consideration. 3, 2
Systolic blood pressure at admission, ulcer size, and Forrest classification independently influence recurrence rates. 5
Giant posterior duodenal ulcers with multiple bleeding points warrant semi-urgent surgery even after single rebleed due to high risk of further bleeding. 2
Adjunctive Pharmacologic Management
Following successful endoscopic therapy for high-risk stigmata, use IV PPI via loading dose followed by continuous infusion (strong recommendation, moderate-quality evidence). 1
H2-receptor antagonists (HRAs) are not recommended for acute ulcer bleeding. 1
Somatostatin and octreotide are not routinely recommended for acute ulcer bleeding. 1
Discharge Criteria
- Selected patients with acute ulcer bleeding who are at low risk for rebleeding based on clinical and endoscopic criteria (clean-based ulcer or flat pigmented spot) may be discharged promptly after endoscopy. 1
Common Pitfalls to Avoid
Never use epinephrine injection as monotherapy—always combine with thermal therapy, sclerosant, or clips. 1
Do not perform endoscopic therapy on low-risk stigmata (clean base, flat pigmented spot)—this provides no benefit and wastes resources. 1
Do not attempt repeated endoscopy in unstable patients or those with ulcers ≥2 cm—these require immediate surgery. 3
Do not delay endoscopy for promotility agents, as they do not increase diagnostic yield. 1