Upper gastrointestinal (UGI) bleeding secondary to peptic ulcer disease is a common medical condition that results in high patient morbidity and medical care costs. While the majority of patients with bleeding peptic ulcers will stop bleeding spontaneously and not rebleed during hospitalization, a subgroup of patients is at high-risk for recurrent hemorrhage and requires endoscopic therapy to decrease this risk . If endoscopic therapy fails, interventional angiography or surgery may be required.
Despite advances in pharmacologic and endoscopic therapy, mortality rates have not improved. In a Danish study of 13,498 patients with peptic ulcer bleeding studied between 2004 and 2011, rates for successful endoscopic therapy were higher in 2010 to 2011 than in 2004 to 2006 (94 versus 89 percent) . In addition, rebleeding rates were lower (13 versus 18 percent). However, 30-day mortality did not improve (11 percent for both groups), though there was a trend toward decreased mortality after adjusting for potential confounders (adjusted relative risk 0.89, 95% CI 0.78-1.00).
The pharmacologic and endoscopic management of UGI bleeding due to peptic ulcer disease will be reviewed here. The discussion that follows is consistent with a multidisciplinary international consensus statement published in 2010, a 2012 guideline issued by the American Society for Gastrointestinal Endoscopy, and a 2012 guideline issued by the American College of Gastroenterology [3-6]. A general approach to patients with UGI bleeding, general treatment of patients with peptic ulcer disease, an overview of the complications of peptic ulcer disease, a detailed discussion of the tools used for endoscopic hemostasis, and detailed discussions of angiographic and surgical management of patients with peptic ulcer disease are discussed separately. (See "Approach to acute upper gastrointestinal bleeding in adults" and "Overview of the natural history and treatment of peptic ulcer disease" and "Overview of the complications of peptic ulcer disease" and "Contact thermal devices for the treatment of bleeding peptic ulcers" and "Angiographic control of nonvariceal gastrointestinal bleeding in adults" and "Surgical management of peptic ulcer disease".)
APPROACH TO THE PATIENT
The initial evaluation of a patient with upper gastrointestinal (UGI) bleeding starts with assessing hemodynamic stability and determining the need for fluid resuscitation and/or blood transfusion. This part of the evaluation is discussed in detail elsewhere. (See "Approach to acute upper gastrointestinal bleeding in adults".)
Patients with clinically significant UGI bleeding (ie, signs of active UGI bleeding including hematemesis, melena, or hematochezia, with or without hemodynamic instability or blood transfusion requirement) should be started on an intravenous proton pump inhibitor while undergoing their initial evaluation. Once the patient is stabilized, endoscopy is performed to diagnose high-risk lesions (table 1) . Ulcers that are actively bleeding and most nonbleeding ulcers that are at high-risk for recurrent bleeding based upon the presence of stigmata of recent hemorrhage require endoscopic therapy. Ulcers that lack high-risk stigmata can be managed acutely with acid suppression alone.