1. DIFFERENT ENDOSCOPIC TREATMENT OPTIONS Injection therapy Thermal coagulation Mechanical devices Combination therapy –Decrease the frequency of recurrent rebleeding and the rate of surgical intervention

2. Injection therapy In high-risk cases, the doctor may inject diluted epinephrine (1:10,000) directly into the ulcer to enhance the effects of the heating process. All that is needed is a sclerotherapy needle and the technique is simple Epinephrine activates the process leading to blood coagulation, narrows the arteries, and enhances blood clotting.

3. Thermal devices Contact types (heater probe, monopolar and bipolar electrocoagulation) Noncontact types (laser treatment, argon plasma coagulation [APC])

4. Mechanical devices have been used for the treatment of variceal hemorrhage, but rarely in the treatment of peptic ulcer disease Use of HEMOCLIPS – efficacy seems to be limited by its difficulty of successful application The deployment of hemoclips on fibrotic ulcer floors can be difficult, however, particularly when they are used tangentially or with the endoscope in a retroflexed position

5. Combined Therapy injection of diluted epinephrine precedes thermal coagulation In actively bleeding ulcers, an injection can diminish or even stop bleeding, allowing a clear view of the bleeding vessel, which in turn facilitates accurate thermal coagulation The cessation of blood flow can also prevent dissipation of thermal energy, so that tissue injury can be minimized

6. Intravenous (IV) administration of a PPI (usually omeprazole or pantoprazole) significantly prevents rebleeding and appears to be cost-effective. A PPI may also be useful for initial bleeding episodes when endoscopy is unsuccessful, inappropriate, or unavailable.

7. RISKS/ COMPLICATIONS Complications can arise prior to, during, or after endoscopy Complications prior to endoscopy: - aspiration (especially in a sedated, combative, or encephalopathic patient) - hypoventilation (related to oversedation), - hypotension (due to inadequate volume replacement or transfusions in addition to sedation with narcotics)

8. RISKS/ COMPLICATIONS Endoscopic complications are usually related to endoscopic hemostasis therapy and include precipitation and worsening of bleeding and perforation. Overly aggressive and repeated applications of thermal or injection therapy rarely increase the hemostasis rate but may increase the risk of treatment-induced complications.