Endoscopic Hemostasis for Peptic Ulcer with Adherent Clot

Initial Management Approach

• Vigorous irrigation is the critical first step when encountering an adherent clot in an ulcer bed, and should be attempted for at least 5 minutes using water pump irrigation to dislodge the clot and expose underlying stigmata, with successful dislodging occurring in 26-43% of cases, revealing high-risk stigmata in 70% of those cases 1, 2, 3
• If underlying stigmata are exposed after irrigation, they should be treated according to standard protocols for high-risk lesions, as recommended by the American College of Gastroenterology 1, 2

Endoscopic Therapy Decision-Making

• High-risk patients, such as those with serious concurrent illness, hemodynamic instability, or ongoing NSAID use, should receive endoscopic therapy, as it reduces rebleeding from 24.7% to 8.2% (number needed to treat = 6.3), according to the American College of Gastroenterology 1, 2
• The WSES advocates a cautious approach to clot dislodgment, with individual endoscopist judgment until further evidence emerges, and recommends against aggressive mechanical dislodgment, preferring cautious irrigation-based approaches 3, 4

Endoscopic Technique for Adherent Clots

• Dual-modality therapy, which combines mechanical therapy (clips or thermal coagulation) with epinephrine injection, is superior to monotherapy, reducing rebleeding (OR 0.19, 95% CI 0.07-0.52) and need for surgery (OR 0.10, 95% CI 0.01-0.50), as recommended by the American Society for Gastrointestinal Endoscopy 1, 2, 3
• Epinephrine injection alone is inadequate and should never be used as monotherapy, as it provides suboptimal efficacy and must be combined with mechanical or thermal therapy, according to the American College of Gastroenterology 1, 2

Post-Endoscopic Management

• After successful endoscopic hemostasis, high-dose PPI should be administered as an 80 mg bolus followed by 8 mg/hour continuous infusion for 72 hours, which reduces rebleeding from 10.3% to 5.9% (p=0.03), as recommended by the World Society of Emergency Surgery 4
• PPI therapy should be continued for 6-8 weeks following endoscopic treatment, according to the American College of Gastroenterology 4

Common Pitfalls

• Avoid mechanical dislodgment without preparation, as it can increase the risk of rebleeding and perforation, and instead use cautious irrigation-based approaches, as recommended by the WSES 3, 4
• Don't use epinephrine injection alone, as it provides suboptimal efficacy and must be combined with mechanical or thermal therapy, according to the American College of Gastroenterology 1, 2
• Don't skip Doppler assessment if available, as Doppler probe-guided hemostasis reduces 30-day rebleeding rates with a number needed to treat of 7, though availability limits widespread use, as recommended by the World Society of Emergency Surgery 4

Forrest Classification and Management of Bleeding Peptic Ulcers

Classification and Risk Stratification

• The Forrest classification is an endoscopic scoring system that categorizes bleeding peptic ulcers based on their appearance and predicts the risk of rebleeding, need for intervention, and mortality, as reported by the World Journal of Emergency Surgery 5, 6
• Forrest Ia ulcers have the highest risk of rebleeding, with spurting arterial bleeding, according to the World Journal of Emergency Surgery 6
• Forrest Ib ulcers have oozing bleeding, with a lower risk of rebleeding compared to IIa and IIb, as stated in the World Journal of Emergency Surgery 5
• Forrest IIb ulcers have an adherent clot, with the World Journal of Emergency Surgery recommending non-aggressive clot irrigation rather than mechanical dislodgment 5

Management Implications

• Endoscopic hemostasis is strongly recommended for Forrest Ia, Ib, and IIa ulcers, as advocated by the World Journal of Emergency Surgery 6, 7
• The WSES recommends non-aggressive clot irrigation rather than mechanical dislodgment for Forrest IIb ulcers, while the Asia-Pacific Working Group suggests vigorous target irrigation for at least 5 minutes, as reported in the World Journal of Emergency Surgery 5
• Dual modality endoscopic hemostasis is preferred over single modality for high-risk lesions, with mechanical therapy combined with epinephrine injection significantly reducing rebleeding and need for surgery, according to the World Journal of Emergency Surgery 5, 8

Treatment Considerations

• Mechanical therapy combined with epinephrine injection reduces rebleeding (OR 0.19, 95% CI 0.07-0.52) and need for surgery (OR 0.10, 95% CI 0.01-0.50), as reported in the World Journal of Emergency Surgery 5
• Epinephrine with thermal therapy reduces rebleeding (OR 0.30, 95% CI 0.10-0.91), according to the World Journal of Emergency Surgery 5
• Doppler probe assessment can improve risk stratification beyond the Forrest classification, with Forrest Ia, IIa, and IIb lesions having higher Doppler flow compared to Forrest Ib, as stated in the World Journal of Emergency Surgery 5

Post-Endoscopic Management

• After successful endoscopic hemostasis, high-dose PPI as continuous infusion for the first 72 hours is recommended, as advocated by the World Journal of Emergency Surgery 5
• PPI therapy should be continued for 6-8 weeks following endoscopic treatment, according to the World Journal of Emergency Surgery 5

Management of Bleeding Peptic Ulcers

Initial Assessment and Resuscitation

• The World Journal of Emergency Surgery recommends early assessment of ABC (airway, breathing, circulation) and resuscitation targets, including systolic blood pressure 90-100 mmHg until major bleeding is controlled 9, 10
• Maintain hemoglobin > 7 g/dl (restrictive strategy) 9, 10
• Normalize lactate and base deficit 9, 10
• Correct/prevent coagulopathy 9, 10

Endoscopic Management

• For Forrest Ia, Ib, and IIa ulcers, endoscopic treatment is mandatory, with dual modality hemostasis (mechanical and injection therapy) 9, 10
• Perform urgent endoscopy within 12 hours of admission for high-risk patients 9, 10
• Apply combined therapy: mechanical (clips or thermal) plus epinefrin injection 9, 10
• Administer high-dose proton pump inhibitors (PPIs): 80 mg bolus followed by 8 mg/hour infusion for 72 hours 9, 10

Management by Forrest Classification

• Forrest IIb ulcers require vigorous irrigation to expose underlying stigmata, followed by standard treatment for high-risk lesions if stigmata are exposed 9, 10
• Forrest IIc and III ulcers have low risk of rebleeding and do not require endoscopic hemostasis, with management limited to medical therapy with PPIs 9, 10

Post-Endoscopic Management

• Repeat endoscopy with hemostasis if rebleeding occurs after initial successful treatment 9, 10
• Consider angiographic embolization or surgery if second endoscopic attempt fails 9, 10

Bleeding Ulcer Classification and Risk

Classification Systems

• The American College of Gastroenterology recommends using the Forrest classification system to stratify bleeding peptic ulcers based on endoscopic appearance, with rebleeding rates ranging from 5% for clean-based ulcers (Forrest III) to 55-59% for active arterial bleeding (Forrest Ia) 11
• The Forrest classification system is divided into three main categories: Forrest I (active bleeding), Forrest II (stigmata of recent bleeding), and Forrest III (clean base), with each category having different rebleeding rates and management strategies 11

Risk Stratification

• Patients with high-risk lesions (Forrest Ia, Ib, IIa) have a rebleeding rate of 43-55% and require endoscopic hemostasis, with a combination of mechanical and thermal therapy or epinephrine injection reducing rebleeding (OR 0.19, 95% CI 0.07-0.52) and the need for surgery (OR 0.10, 95% CI 0.01-0.50) 11
• The Rockall score, which includes age, shock, comorbidities, diagnosis, and endoscopic stigmata, predicts mortality better than rebleeding, with a score < 3 associated with excellent prognosis and a score > 8 associated with high risk of death 12
• A Rockall score ≥ 6 indicates increased risk of rebleeding (18.6% vs 2.9% for score < 6) in patients with Forrest IIc lesions at follow-up endoscopy 12
• The Glasgow-Blatchford score identifies patients with very low risk (score 0-1) who do not require early endoscopy or hospitalization, with a sensitivity of 99% for identifying high-risk patients 13

Management Strategies

• High-risk lesions (Forrest Ia, Ib, IIa) require endoscopic hemostasis with a combination of mechanical and thermal therapy or epinephrine injection, followed by high-dose PPI therapy, which reduces rebleeding from 10.3% to 5.9% 11
• Low-risk lesions (Forrest IIc, III) do not require endoscopic hemostasis and can be managed with medical therapy alone, including PPIs, with early discharge possible for patients with low-risk lesions and no comorbidities 11

Clinical Factors

• Clinical factors such as age > 65 years, shock, comorbidities, low hemoglobin, and need for transfusion are independent predictors of rebleeding, and should be taken into account when managing patients with bleeding ulcers 11
• The American College of Gastroenterology recommends considering these clinical factors when stratifying patients according to risk, in addition to the Forrest classification system 13

Management of Bleeding Peptic Ulcers

Role of Forrest Classification in Guiding PPI Therapy

• The American College of Gastroenterology recommends that high-risk lesions (Forrest Ia, Ib, IIa, and IIb) require immediate endoscopic hemostasis followed by high-dose intravenous PPI, while low-risk lesions (Forrest IIc and III) require only standard oral PPI therapy without endoscopic intervention 14, 15

Forrest Classification Categories and Management

• High-risk lesions, such as Forrest Ib (Oozing bleeding), require endoscopic therapy and high-dose PPI, with a rebleeding risk of 10.3% reduced to 5.9% with high-dose IV PPI 14, 15
• Forrest IIa (Visible vessel) lesions have a high rebleeding risk and require endoscopic hemostasis and high-dose PPI, with Doppler studies showing higher arterial flow than Forrest Ib lesions 14, 15

PPI Regimen Based on Forrest Classification

• The European Society of Gastrointestinal Endoscopy recommends initiating PPI therapy as soon as possible, ideally before endoscopy, for high-risk lesions (Forrest Ia, Ib, IIa, IIb) 14, 15
• After successful endoscopic hemostasis, administering 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours reduces rebleeding risk and decreases the need for repeat endoscopy 14, 15

Critical Limitations of Forrest Classification

• Doppler probe assessment is superior to Forrest classification for predicting rebleeding risk, with Doppler-guided hemostasis reducing 30-day rebleeding rates 14, 15
• Forrest Ib lesions have a lower rebleeding risk than Forrest IIa and IIb despite representing active bleeding, highlighting the limitations of the classification 14, 15

Common Pitfalls to Avoid

• Cautious irrigation-based approaches should be used for at least 5 minutes to dislodge Forrest IIb clots, as aggressive dislodgment increases perforation risk 15

Upper GI Bleeding Management

Classification and Risk Stratification

• The Forrest classification is an endoscopic scoring system that categorizes bleeding peptic ulcers based on their appearance at endoscopy and directly predicts rebleeding risk, need for intervention, and guides management decisions, as recommended by the World Journal of Emergency Surgery 16
• The American College of Gastroenterology recommends combining the Forrest classification with the Blatchford score for comprehensive risk stratification, where very low risk (Blatchford 0-1) patients can undergo outpatient endoscopy, low risk (Blatchford 2-6) patients should have early inpatient endoscopy within 24 hours, and high risk (Blatchford ≥7) patients require urgent inpatient endoscopy within 12 hours 16

Management of High-Risk Lesions

• For Forrest Ia, Ib, and IIa ulcers, endoscopic hemostasis is mandatory and should utilize dual-modality therapy combining mechanical therapy (clips or thermal coagulation) with epinephrine injection, as recommended by the World Journal of Emergency Surgery 16
• The American Society for Gastrointestinal Endoscopy recommends performing urgent endoscopy within 12 hours for high-risk patients with hemodynamic instability, and applying dual-modality hemostasis, which reduces rebleeding (OR 0.19, 95% CI 0.07-0.52) and need for surgery (OR 0.10, 95% CI 0.01-0.50) 16

Management of Rebleeding

• If rebleeding occurs after initial successful hemostasis, the American College of Surgeons recommends performing repeat endoscopy with hemostasis as the first-line approach, and considering transcatheter angiographic embolization or surgery if endoscopic therapy fails 16
• The Society of American Gastrointestinal and Endoscopic Surgeons recommends seeking surgical consultation when endoscopic therapy fails 17

Essential Adjunctive Management

• All patients with peptic ulcer bleeding require H. pylori testing with eradication therapy if positive, and confirmation of eradication, as recommended by the American College of Physicians 17
• The Infectious Diseases Society of America recommends negative H. pylori tests in acute setting should be repeated, as false-negative rates reach 25-55% during active bleeding 18