REVIEW

Endoscopic methods for the treatment of nonvariceal upper

gastrointestinal hemorrhage

Z.W. Li. M D. F. URRUTIA. MO, R. WENSEL, MD. FRC P. A. B.R. T HOMSON. M D. PHO, FRC PC, FACP

ABSTRACT: In the l970s, diagnostic fibreoptic endoscopy became part of the standard practice for evaluation of gastrointestinal disease. In the 1980s, thera­peutic fibreoptic endoscopy is emerging as standard therapy for many gastroin­testinal diseases. As che already sophisticated technology continues co blossom, it promises to become even more a part of the management of an increasing number of gasrroenrcrological problems. Endoscopy can provide both a specific diagnosis as well as an identification of the high risk subgroup of patients with either active bleeding, or a non b leeding visible vessel that might benefit from endoscopic treat­ment. At endoscopy, patients with active ulcer bleeding have either arterial spurt­ing, oozing or oozing beneath an overlying clot. T hese have poor outcomes: for example, when a non bleeding visible vessel is identified, the chances for rebleeding are approximately 50% during the period of that hospitalization . With an over­lying clot withou t oozing, where dark spots are noted, there is less than a 10% chance of rebleeding. There are certain limitations for endoscopic hemostatic therapy and there are a few bleeding ulcers with an artery too large to expect endoscopic success. T he kind of treatmen t chosen will be dictated by the avail­ability of the therapeutic modalities and the skill of the surgeon. Can J Gastroenterol 1988;3(2):72-76

Key Words: Diagnosis, Fibreopcic endoscopy, Therapeutic endoscopy, Upper gastro­incestinal hemorrhage

Methodes endoscopiques et traitement de l'hemorragie non~ variqueuse des voies gastrointestinales hautes

RESUME: Dans le diagnostic des annees 1970, l'examen fibroscopique est deven u partie integrale des pratiques d 'evaluation des maladies gascrointestinales. Au cours de la decennie suivanre, !'examen fibroscopique cherapeutique emerge com me la cherapie standard de nombreux desordre gascrointcscinale. Au fur ec a

Nuiricwn and Metabolism Research Gro11/J, D1111 s1o11 of Gasiroenrcrology. Dc/}(mmenr of Medicme, Univermy of A lberrd, Edmonron, A Iberra

Corres/,ondence and reprinrs· Dr A B. R. Thom,011. Division o/ Gastroenccrology. 519 Roberr Newron Research B111ldi111l, Un11,ers1 r)' of Alhcrca, Edmonron, Alherca T6G 2C2

Rcccit-ed for p11blica1io11 February I, 1988. Acceprcd February 15. 1988

72

A MAJOR ADVANC'r IN THL MANAtiE,

me n t of gastroen terological prob­lems has been in the treatment of patients with up per gastroin teMinc1l tract bleed­ing. Recent reviews have consid ered the ma nagement of va riceal hemorrhage Va rio us ap proachc~ to nonvariceal bleeding include tissue contact by rlec­trocoagulacion , both monopolar and b ipo lar e lectrodes or heater probt's. A second approach. without tissue contact, consists o f laser phococoagulation with e ithe r ch e a rgon or ch e ncod ynium ytt rium alu m in u m garne c( Nd:YAGJ laser. The thi rd approc1ch is an injccuon therapy of known bleed ing lesion~ with a lcoho l, sclerosan ts or ad re naline. All of these therapeutic methods arc rcla· cively safe and effective in controlling b leeding a n d avoidi n g emergencv su rgery.

LASER PHOTOCOAGULATION In 197 l. Goodale and co-workers (I)

reported the first stu d ies using a carbnn d ioxide laser co con trol b leeding b1ons in animals. Curren tl y th e <l: YAG and argon lasers are used co treat gascrom­cestlnal b leeding. The relative merit~ of the Nd: YAG and argon lasers for the therapy of acute upper gastro intestinal b leeding arc as fo llows: when applied endoscopically. both lasers e ffectively produce in itial hemostasis in many pa·

CAN j G.~STROENHROI VOL 1 Nol APRIi 1%9

mcsure que la tcchnologie d 'avant garde progrcssc, cette prrnique confirme la place qu'elle occupe dans le craitement de certains problcmcs gastrointcstinaux Un progrcs majcur a ninsi etc realise dnns le traitemcnt des pnticnts Souffrant de sa1gnements des voies gastrointestmales Parmi !cs approches divcrses, ii faut inclure Ir contact tissulairc par electrocoagulation. qui comprcnd !'usage des electrodes unipola1res e t bipolaires ou les sondcs thermiqucs. La seconde approche sans contact avcc les tissus consiste a utiliser la phorocoagulation au laser argon o u ~d:YAG (done le milieu actif est un cristal d 'yttrium et d 'aluminium dope au nfodyme ). La troisiemc approchc est une thcrapie d'injections des lesions saignanres connues. Ccs trois mcthodes sont si'.1 rcs ct efficaces clans le trattemcnt des hemorragics ct cllcs permettent d'cviter lcs interventions d'urgence L'endoscopie rcut serv1r a la fois a CtabJir un diagnostic prccis Cl a identifier Je SOUS•groupe de patients ,'i haut risque qui one des saignements acnfs. ou a rcconnattrc !cs vaisseaux qui ne saignent pas mais qui bcneficicraient d 'un traitement endoscopique . Au moment de l'cndoscopie, Jes patients souffrant de sa1gnements d 'ulceres en

evolution ont soit des giclcments arteriau'(, des suitemencs, o u des suitements ,ous des caillots sus-jacents. Dans ccs cas parciculiers, les rcsultatssont mcdiocres. Par example, quand un vaisseau visible sans saignement est idcnufie, Jes chances

de rcsaignements sont de 50'\ , durant l'hospitalisauon Dans le cas d'un ca11lots sus-jacent sans suicemcnt, ou l'on remarque des rnchcs sombres, ii ya moins de IO'\;, de possibilitcs de resaignement.

uents; the Nd:YAG laser is tech111c:11l y

easier to use because distance from the bleeding lesion is not quite so critic.ii and coaxial gas flow requires carbon dioxide m a nonconc::ict mod e; and the risk of perforation is theorenrnlly less wnh the argon laser becaus·e the depth of tissue penetration is le,.,, At present che Nd YAG lnser is used most commonly.

The principle of endoscopic lasers is 1hc same as for a ll types of laser. There are acorn molecules in a laser medium of liquid, gas o r solid in a normal or

grounded energy state Thermal. clcc­mcal o r optical e nergy gives a higher energy rate to atom molecules existing

m the medi um The laser energy must be absorbed by the tissues to have any effect and each tissue has n particular absorption spectra, Jcpendmg on the amou nt of tissue chromophores (hemo­

globin, mclan111, c.irmcne. water, pro-

1eins). Once absorbed. laser light energy 1sconverced into hear energy producmg either coagulation, cu mng or abrasion.

Wavelength. which varies in different

n•pcs of laser, is im portant in the pro­ducuon of the tissue response The argon laser ndmits energy through nrgon gas, prod ucing light 111 the blue-green spec­

trum with .1 wavelength of 488 to 514 nm. The carbon dioxide laser admits

energy in the middle of the infrared spec­trum ar 10,600 nm. Unfortunntely, this

has limited w,c 111 gastwenterology, pri­marily because of poor trnnsm1ssil,n of infrared light by optical fibres

The Nd .YAG lnser is thL' m,1111 form of laser treatment in gastroenterology It produces infrared light with ;i wnve­

length of 1064 nm and has a greater abil-1tv to coagulme blood vessels. T he Nd: YAG laser can be used in eithe r a con­tact or nonconract mode, however, ,n

practice rhere is no advantage of one techrnque over the other

The firs t reports of endoscopic laser

therapy 111 humans were from uncon­trolled studies in the mid-1970s In 1979. Kicfhaber (2) reviewed the enti re inter­

n:uional experience from 17 centres with laser therapy of upper gasrr01ntest111al tract bleeding in 1729 patients. Success­ful 111itinl hemostas1s was achieved 111 H6";, ( range 70 ro 100'';,) of 196 parients treated

m seven centres with argon lasers and in 90'\,(range 74 to 100";,)of 1531 patients treated at 31 centres with the Nd:YAG laser. The largest experience 1s that of Kiefhaber (2). from 1975 ro 19H2. 994 acute bleeding incidents in 62 5 patients were treated at h b cen tre in Munich

All pauen ts. ie. an unselected group. were com,idered . Lesions included vari­

ccs. Mallory-Weiss tears. ulcers, erosions. vnscular anomalies and tumours. The overall succe'>s rate of initial hemostasis was 94'\,. Kie01aber claimed n reduced

Therapeutic endoscopy

mortality for acute and chrome ulcer bleed mg treated with laser as comp.ired to the experience 111 Munich before laser therapy wns available However, this sur­vey did not address the incidence of rebleeding. and this sem•s of pmients wns

nor randomized Reports of h igh success rates for laser therapy of uppergastrrnn­

testina l b leeding must be evnluated with the perspective that ,1 p prox1matcly 70''., of all episodes are sclf-lim,ted and resolw without specific the rapy.

Of more recent studies cvaluaung Nd:YAG laser therapy for all bleeding from ulcers, ..everal suggest that laser con­fers a benefit to the patient. However, some reports differ in their results and suggest no benefit. The study of Swain

and collengues (3) de::.erves a more de­ta iled discussion. Of 465 patients with upper gastrointest111al bleedmg, 2 32 had pep1ic ulcers and 147 of the ulcers were e1ther bleeding or showed stigmata of recent hemorrhage. Of 122 patients

111cluded m the study, 62 were treated with Nd:YAG laser while 61 served as

controls. In the laser treated group b lced­i ng \\'as more effective ly controlled ( P < 0. 02) and the morta Ii ty was less ( P < L1.05) than in the control group. In

those patients with acnvc bleeding from visible vessels . the laser group fared better

Macleod and colleagues (4) reported rhar of 184 patients found at endoscopy w be bkTding from peptic ulcers, 20 were bleeding from arte ries. Eight of these were allocated to placdx) treatment and nll latcr underwent emergency sur­

gery for further hemorrhage Of the 12 patients who underwent laser treatment, eight had surgery, but of these only one was still bleeding and actually required

surgery. These differences were statlsti­

cally significant. The authors concluded that lnser treatment was a snfc and effec­tive method of reducing the incidence of further bleeding and emergency sur­gery but the techn ique was difficult and

not applicnhle to all paucnts H:i lp ri n and co-authors ('i) usl'd Nd

YAG laser coagulation to treat H sen­ou:,Jy di pntients with massive or pro­longed gastrointesttnal bleeding An avernge of 7.5 units of hlood was given

prior co Nd YAG laser treatment Twl'nty patienrs showed no evidencl' of contin-

Lt er al

ueJ or recurrenr bleeding aftt.!r laser ther­apy. four patients rebbJ after 48 h, three patients rebled within 48 h, one rarient continued to bleed despi te the laser treat­ment but died of an unrelated cause. one patient required immediate surgery because of inability m control bleeding and one patient d1cJ several hours after control of the hlced1ng. Although six patients d1eJ within 10 weeks. no pati­ents cxsangumated. Thus, Nd:YAG laser 1re,1tment was a u~cful modaliry for con­trolling scwre gastrointestinal bleeding 111 the seriously ill patient.

In aprroximatcly 70",, of otherwise healthy patienrs. upper gastrointestinal bkeding will stop spontaneously. How­ever, 111 those patients with an identifi­able bleeding vessel the likelihood of rebleeding or continued bleeding is as high as 90 to 100'\,. About 50'\, of non­bleeding visible vessels will later re bleed. Numerous studies have shown an in­creased mortality from upper gastroin­testinal bleeding in the aged and in patients with above average transfusion requirements. These patients. as well as those with continued or recurrent bleed­ing, may i.,e ideal candidates for Nd: YAG coagulation of bleeding sites.

However. some studies of Nd :YAG laser therapy suggest no benefit. For example, Krejsand co-workers(6)scud­ied, over 4 3 months, 174 selected patients with either active bleeding (n = 32) or stigmata of recent bleeding (n = 142) due to peptic ulcers who were randomly assigned during endoscopy to either stan­dard treatment with laser phorocoagu­lation or therapy without photocoagu­lation. There was no significant dif­ference in outcome between grours. Continued bleedrng or n::bleeding was observed in 22''(, of the l,1ser treated group and in ZO"o of che control group. Urgent surgery was necessary in 16'\, of the laser treated patients and in 17"/, of the controls. Laser treated patients spenr a mean of 41 h in the intensive care unit, compared with 32 h for control patients. The mean hospital stay was 12 days in the laser treated group and 11 Jays in the control group. One death occurred in each group

When patients with active bleeding were analyzed separately, there was no significant difference 1n outconH:: be-

74

tween laser treated and control groups even though laser photocoagulation ini­tially stopped active bleeding in 88°0 of cases. Among patients with visible ves­sels, rebleeding occurred in five of 14 ( 36°,~) who received laser rrearment and two of 15 ( 13''.~) controls. Laser treatment rrecip1tated bleeding in four patients and duodenal perforation in one. The au­thors concluded that Nd:YAG laser pho­tocoagulation did not benefit patients with acute upper gastrointestinal bleed­ing from peptic ulcers. However. it should be emphasized that Krejs elim111ated many patients who were hemodynami­cally Lmsrable from the study, thereby drawing a major criticism of the paper.

The results of three argon studies are mixed (7-9) and argon lasers are seldom used at present.

ANGIODYSPLASIA The routine use of fibreoptic endo­

scopy in the evalumion of upper gastro­intestinal bleeding has demonstrated that angiodysplastic le ·ions in the upper tract may hemorrhage. Generally, bleeding from angiodysplastic lesions is self­limited but may be recurrent. If the bleeding lesion is within the reach of the endoscope, it 1s amenable to local therapy.

One of the several treatment modali­ties for angiodysplastic lesions is laser photocoagulation. There are several reports describing endoscopic oblitera­tion and clinical benefit with both argon and Nd:YAG laser therapy. Waitman et al ( 10) treated 50 patients with argon laser therapy; 3 3 had com piece cessation of bleeding with follow-up of six months co four years. The ocher 17 had mark­edly reduced bleeding. Bowers and Dixon ( 11) and Jensen and colleagues (9) reported decreased bleeding episodes and reduced transfusion requiremenb with argon laser therapy in patients with angiodysplasia and in a group with clas­sical hereditary tclangiectasia. Fleischer ( l2) reported similar benefits using the Nd:YAG laser. None of these studies incluJed perforation as a complication.

Laser use is nor free from problems. Commercially available lasers arc expen­sive and the machines arc not portable in the practical sense. Laser therapy is not free from risk, aside from usual risks

and complications of endoscopy and anesthesia. Major complications related co laser use itself occur in approximately 4°{, of patienrs including perforation, fis­tula to other organs and bleeding.

ENDOSCOPIC ELECTROCOAGULATION

Endoscopic eleca·ocoagulation appears co be an inexpensive. readily available technique for the control of massive bleeding. Endoscopic electrocoagulation may be performed using monopolar or bipolar electrodes, or by fulguration Electrocoagulation results as current flows through tissue near the electrode, hitting and desiccating the tissue ro form a layer broken down and condensed into a necrotic mass. With monopolar clec­rrocoagul:uion, current flows through the patient into a ground plate. In bipolar electrocoagulation rhe current dens1t:y 1s very concentratcJ at the bipolar clecrro­tip because the tissue contact completes a circuit between rwo wires only a few millimetres apart. This limits the nsk oi injury. which reduces the risk of per­foration.

Morcro and colleagues ( 13) report~d efficacy of monopolar clectrocoagulation in the treatment of bleeding gastric ulcers. In a controlled prospective fash­ion, the efficacy of monopolar clecrro­coagulation in the emergency trearmt'nt of bleeding gastric and stomnl ulcers was studied in 37 patients: 16 underwent electrocoagulation while the remaining 21 were treated by convenrional methods (conrrol group). Hemorrhage recurred 111 only one (6.2";,) of the patients in the elecrrocoagulation group, but bleeding recurred in 11 (52.4'~;, ) of the 21 control patients (P <0.05). with no significant dif­ference in mortali ty of the two groups.

Goff I 14) compared the efficacy of hi polar clectrncoagulation with Nd:YAG laser photocoagulation for upper ga,tro­intestinal bleed mg lesions. The total study group included 33 patients with soli­tary, actively blecd111g lesions, reblceding lesions or a lesion containmg a visible vessel in the upper gastrointestinal tract.

The patients selected for this study were heavily weighted rowarJ high risk i,troups for rebleeding. Altogether. 11 patients unJerwent 37 coagulation sessions, 19 of the patients were randomized (eight

CA~ J GAsTRlll STIROl V,,1 l No 2 Al'l\11 IQ~9

laser, ll bipolar). In the randomi:cd grour, 4 7.4"., haJ no rebleedmg after therapy (laser 37 5'\,, bipolar 54.5''.,, P<O. l ). The 14 nonranJom1zed racients were primarily treated with bipolnr coag­

ulation because they wt.'rl' felt to be too unstable to transfer to tht.· laser unit ,lt

University Hospital. 58 6'';, had no fur­ther b leed111g. Eleven ( 13".,) of the pa­

tient, required surgery but no rnuent dted from bleeding or complications relmed to the study Thu,, there was no

significant difference in the frequency of rehlceding nfrcr cndoscc1p1c trcatmem of upper gastr()lntcstinal hemcirrhage

from various sources, using e11lwr Nd YAG laser phmoco,1gulauon or bipolar

dectrocoagu In tion Rurgeens t.'i al ( 15) studied NJ YAG

laser phorocm1gulatinn versus mulupo­lar elecirocongulation for the trt.',Hmcnt

of severely bleed mg ulcer,. A random­ized trtal comparmg the efficacy of Bl­

CAP clecrrocoagulation and Nd YAG laser photocoagu latton was earned out m 100 panents presenttng ilt endoscopy with a spurting or oozing vessel. or a

nonbleed111g ,•cssd Fifty patients were enrolled rn each treatmt.'ni group. All

lesions were pretreated \\'Ith an 1111ect1on of adrenaline I: 10,000. Subsequently, the lesions were treated with I to 2, pulses of electrocoagulauon of 2 5 watt

BICA Pat a setting of 10. The 10 F Bl CAP probe was al\\'ays useJ. Definitive lwnw­stasb after one treatment anwunted tc, 12"o 111 both the la,er and tn the BICAP group After two sessions the cumul.1-rive success race \\'ns ~W'., 111 the la:,er group and 80'';, 111 the BICAP group. Emergency surgery and mmcalir) were also comparable One perforation oc­curred in each treatment group and both pacicnts were operated upon ,,·nhout complications. le was concluded that horh ~d: YAG laser and BI CAP were t.•qually highly effecrive in the rrcmmcnt of severe bleed mg from pepuc ulcers Tl11S stud) stres:,ed the impormncc of repcateJ trent­ment session, 111 order ro ohram opcimal rcsu Its.

From chest' data and others 111 chc lit­erature. it is condut.kd rhar the Nd YACi laser and bipolar rnagulauon arc equally

effecuvc for the trearmt.·nt of solitary upper gastroincesunal bleeding lesions Prcsenrly, an Nd YAG laser unit costs

20 co 2 5 times more than a bipolar coag­ulator. The Nd: YAG is generally not port­able so the patient must be transporred to the laser unit, whereas the bipolar cm1gulator can be taken easily to the patient's bedside Consequently, mosc authors now recommend that the hi po­lar coagulator he used 111 preference to

the Nd. Y AG laser. Smee the heater probe

may be more effectiw and cheaper chan the Nd:YAG laser, it is ,1lso potcnually preferable Wlwthcr the heater probe is

more efficaciou:, chan the bipolar coag­ulator re maim co be dccermmed

THE H EATER PROBE The he;itcr probe 1, a device that ,:an

s1mulcaneously give heat and pressure lt com1:,ts of ;i hollc)\\ aluminum cylm­der with ;in inner hear coil anJ an outer w,1ting of Teflon The alummum ha, high

thermal conducuv1ry which prcw1des uniform d1smbut1on of the ht.'at. Storey ( 16) reporced cm 15 patients with ;i gas­trn: ulcer, mean age of 60 years and mean pretreatment blood transfusion require­ment of (1 6 L. created wirh the hemer probe All but one of the 15 patients avoiJed immedime operation and only two oi the remaming pat1enr, had de­layed bleeJ111g, one of which required upcration There were no Jeaths 111 this group

Over the ,ame period there were 10 panents wnh duodenal ulcer wnh a mean agl' of 62 years anJ mt•an pretrearment blond transfusion requirement cif 5 L. Operation wns .1vo1Jed 111 only t\\'O pai1l'nt:., of whom cmt.• had a smnll de­layed hemorrhage which was treated con­,t.'n auvely Of the rt.'st, the technique foiled in three hecause ,1ccess was impns­s1hle owmg to bleeding, concnct \\'as po,­sihk but unsucce~sful 111 three patients and there were two patten ts wnh 1111ual success follom•d hy delnycd ht.·morrhagc

l\l'Cess1tating operation Threl' pauents died durmg th,H aJm1ss1on Perhnp, th 1,

technique can well replace emergency operauon tn panents w11h hlcedmg gns­Lril ulcers, but kss n,mmonly in thnsc

wnh duodenal ulcer Johnston and co-workers t 17 J com­

pared hearer probe and Nd YAG laser 111 endoscopic treatment of mnJor bleed­ing from peptic ulcers The ulr1mate ht·mo,tanc success wa:, achieved 111 19 of

Therapeutic endoscopy

20 (95"o) ukers treated \\·1th the heata

probe, compared with 24 ot 35 t69'\,) YAG1asertreatcdulcer'>IP <005) The heater probl' was cmployl'd w1th recent design change:,, includmg Sdvasmne 'nonst1ck · coaung liver the probe 11 p Also, a computer regulated mn,1mal

internal probe ( 1 2 mm in d1amett.·r) wa,

u:;ed preferentially with the GIF-lT endoscope (although in two mst,1111:es tlw small probe [2.4 mm] was used) Both probes included water 1mi.:ation In casl'' of bmk ulcer bleeding, the inactivated

heater probe was applteJ with moder­ntc force, either directly or ci rcumferen­tially around the bleeding site, to fmd a

pren'>e pomt rhat ramponaded hleedmg Upon successful vessel ramponade, water

1 rngauon rrod uced rapid clea rt ng of blond from the ulcer bas<.' At that junc turt.·, several continuous hearer probe.• pulses (each 30 J) were applied to rher­malh seal the compressed vessel If hlcedmg recurred after miual hemostatic success. a second endoscopic heater probl' treatment was performed 1mme­diatdy This study indicated that hemer probe treatments were more effective, casin and quicker than laser therapy

Johnston l't al f 18) compared YAG la,er, argon laser, monopolar and bipolnr elec­trowagulat1l,n, elcctrofulguration and heater probe 111 coagulation of canll1l' arteries They concluded that the most efft.'ctl\'l' way w coagulate medium s1;:e mcsentertc nrtent.·s was vessel occlusion hv rompres-.1on followed hy heat nppli­cation to ~cal 1t Overall hemostatic rank mg ,,·as heater pro he, bipolar, monopolar. YAG. argon. electrofulguracion These

data\\ ill he useful to clinicinns plannmg endo,cop1c therapy 0f arterial blced111g future concrolled clm1cal studies com paring heater probe, BICAP and YAG laser \\'di he of 111teresr

The maior disadvantage for mono· polar electrocoagulauon mclude, pocen­u,11 probe ad herencc to the t1~sut.' The risk l)f perforation has ht·en as high a, 1.6''., 111 some stud 1es. The heatl'r pro ht.• and RICAP were t.k s1gncd so that thl're 1, n(> potennal for acure ussut.· t.'n1s1(111

No perforauon~ hnvt.' been reported to

datt' with these mstrunwnts Some dis­advantages of the RICAP un,r 111clude subopnmal probe stiffness 111 design, lack of prox1m;1l wnter 1rnga11on and a hcmn·

75

Li et al

static bond strength which is significantly

less than the heater probe. The main dis­advan tage of the heater probe is long pu l­sation, during which time the probe must

be kept in d irect con tact with the targer.

SUMMARY The field of endoscopic hcmostatic

therapy attracts m uch interest ( 19,20). There arc certain limimtions for endo­scopic hemostatic therapy including inex-

REFERENCES GouJalc R. OkaJa A. Gnn:alc:, R. ct al RapiJ cnJo,copic control of bleed mg gastnc erosions by laser radmnon. Arch Surg 1970.1.0l.llH

2. Kicfhabcr P lntcrnm11rn:il <'Xpcricnc<.' with lasers for ga,trointe~tin.11 bleeding Proceeding, of the lnternntional Laser Congrt'ss. Detroit, 1972

1. Swain C. Bown S. Sal mun P. et al. Controlled trial of NJ YAG laser photocoagulation 111 hlccJmg peptic ulcer,. La,ers Surg Med 198 >; "1- 11

4 Made0d IA. Mills PR. Macken:ic JF. ct al. Nec>dymium ytmum alu1111num garnet la,cr phococoagul,1uon fur rnaJor haemorrhage from reptic ulcers and single vessels A ,ingk blind controlled swdy. Br Med J 1981,286: 3-! 5-R.

'i Halprin!'\, Anselm K NJ:YAG la~er 111

treatment of seriously ill parienr, with gastrointesunal blced111g G.1,tro111tcst EnJ,1sc 198(); 32 199-201

6 Krej, CiJ. Lndc KH. Westergaard H. <'t al Laser phorocoagulanon for the treatmcnr of acute pepnc ulcer bleeding N EnglJ Med 1987.25: 161K-21.

7 Vallon AG. Cotton PB. Laurence BN. <'l al Randum1: cd tnal 1if argon la,er phtltocoagulatton in bleeding peptic ulcers Gut 198l.Z2.12ts- 3"1

76

rericnced endoscopic therapists, severe concomitan t medical disease that will increase mortality, lack of endoscopic

access to the bleeding point. large un­movable clots and b leeding from the

posterior wall of the cap which will reduce the effectiveness of therapeutic endoscopy.

Finally. there are few bleeding ulcers with an artery too large co expect endo­scopic success. Presently, many impor-

8. Swam CP. Storey OW. NonhficlJ TC. <'t al Concmllt:d trial of mgon la,cr photocoagulanon m bleeding rep11c ulcers. Lancet 1981 :n. 1313-6.

9 Jcn,en OM. i\lachicadl> GA. Topia JR. ct al l::.ndoscop1c argon I.i,cr photocoagul:rnon of patients wtth ,everc gastrointestinal blecJmg Ga,trc,intc,t Endosc 1982:28: l5l

10. Waitman AM. Grand DZ, Chatcau F Argon la,cr photocoagul::nion treatment of patients with acute and chronic bleeding secondary to telangicctasia. Gasrroinrest Enclose 1982;28· 15,

11. Bowcr, JM, OixonJ. Argon la,cr photocoagulaunn of va,cular malformations in the GI tract. Ga,trointest Endosc 1982.W 126

12. Fb1cher DE. Nd YAG laser photo­coagulation for UGI ::mgiodysplasia Gastro1ntest Enc.lose 1981,26: 122.

I l Morcto /vi , Zab.ula M. !bane: S. ct al. Efficacy of rnonopolar elcctrncoagula­tilll) in the trcatm.:nt of bleeding gm,tric ulcer : A controlled mal. EnJoscopy 1987, 19 54-6

14. Goff JS Bipolar electwcuagulation 1•,'rsus Nd-YAG l,1,cr photocoagulation for upper gastrointestinal hleeding lesions Dig Dis Sci 1986. 31 906- 10

tant issues ::ibour rhcr::ipeu tic endoscopy remain unresolved ::ind the kind of treat­ment chosen will be d ictated by the avail­ability of therapeutic modalities and the ski ll of the operator. No one rypc of treat­mcn r is best for all instances. lt can be

concluded that. for nonvariceal bleed­ing, injection therapy. electTOcoagulation, laser photocoagulation and heater probe are reasonable considerations for endo­scopic therapy.

15 Rurgccn, P. Vantrappen G. Hoc>t<'gcm V, ct al Neoc.lym1um-YAG la,er phomco.igulm1on ver,u, mulupolar electrocoagul:rnon for the trcatm<·n1 ot ~cvcrely bleed111g ulcer,; A randonmtJ compari,011 Ga,tmintt',t l::.ndo,c 1987,H 199-202.

16 Storey OW Endoscopic control of pep11c ulcer haemorrhage ustng rhc "heater probe" Gut 1910:24:967-8

17. Johnston JH , SonesJQ. Ll>ng BW. ct al Compamon uf h<'atc•r prob<' and YAG laser 111 endo:,01pic treatment of mai,ir bleeding from pepttc ulcers G.1stmintc,t Endosc 1%5,31. 175-80

18 John,tonJ,Jcn,en D.Jacbon DA . real Compari:mn of cnJm,copic lasers. ckctrosurgcry and the heater prc,he 111

coagulauon of canine arteries Gawointcst Endosc 1986, 3l\ 154

19 Fleischer D Endoscopic thcra py of upper gastrointestinal bleeding 111

human,. Gasrrocntcmll,g·y 1986,9(\ 217- 34

20. Rutgccrt, P, Van Compel F. Gchncs K, V.1ntr::ippcn G, Brocckacn L. Corcman~ G. Lung-term results of trcatmcnt l>f va,cular malformauons of the gastrointestinal tract by Neodymium Yag la~cr rhowcoagulauon Gut i9tl5 ,26: 586-9 l

CAN J GAqRL)ENTrROI Vm ~ No 2 APRIL 1989

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