Curr Gastroenterol Rep (2011) 13:525–531 528 Author, year Marmo 2007 [23] Sung 2007 [24] Yuan 2008 [26] Laine 2009 [19] Barkun 2009 [25] Table 1 Recent meta-analyses comparing endoscopic techniques for treatment of peptic ulcer bleeding No. trials included No. patients included Compared techniques Conclusion 20 15 12 65 41 2472 1156 699 6237 4261 Epinephrine injection +other injection or thermal or mechanical method vs. monotherapy with one of these methods Hemoclips vs. injection/thermocoagulation Hemoclips vs. other endoscopic techniques Thermal devices, sclerosant, hemoclips, fibrin glue and epinephrine Pharmacotherapy, injection, thermocoagulation, clips or combinations Dual endoscopic therapy is superior to epinephrine injection alone, but not to thermal or mechanical monotherapy Hemoclip placement is superior to injection alone but comparable to thermocoagulation Hemoclip placement is not superior to other endoscopic modalities Thermal devices, sclerosant, clips and fibrin glue are comparable. Epinephrine monotherapy is inferior to other interventions. All endoscopic therapies are superior to pharmacotherapy alone. Thermal therapy or clips alone or in combination with injection are comparable barrier, covering the bleeding site. In a very recent prospective pilot study on 20 adults with confirmed PUB (Forrest 1a or 1b), acute hemostasis was achieved in 95%. Rebleeding occurred in two patients (shown by hemoglobin drop), but no active bleeding was seen during repeat endoscopy in these patients. No mortality or adverse events were reported during 30-day follow-up [28 ]. Further studies on the effectiveness of hemospray, also for other causes of UGIB, are ongoing. Second Look Endoscopy Few data support the overall benefit of a routine repeat endoscopy after endoscopic hemostasis. Those studies which did report a benefit from routine second look were in part of older date and did not include the use of PPIs or modern endoscopic haemostatic techniques. Therefore, second look endoscopy is not routinely recommended, however it may be beneficial in selected patients at high risk of rebleeding [10 , 29, 30]. Post-Endoscopic Management Surgery or Angiographic Embolization Although endoscopic therapy is highly effective, sometimes bleeding cannot be stopped or recurs. In case of recurrent bleeding a second attempt at endoscopic treatment is generally recommended [10 ]. With persistent or renewed bleeding, emergency surgery and selective transcatheter arterial embo- lization (TAE) of the bleeding artery are rescue modalities. In a retrospective analysis of 70 cases with refractory PUB, no differences were found between patients treated with TAE versus surgery in the incidence of recurrent bleeding (29% vs. 23.1%), need for additional intervention (16.1% vs. 30.8%), or death (25.8% vs. 20.5). The lack of difference and the fact that the patients in the TAE group were older (75 year vs. 63 year, P < 0.001) and had more comorbidity, suggests a slight advantage of TAE [31]. There is a pressing need for randomized controlled trials to prospectively compare these two techniques. Acid Suppressive Therapy High dose intravenously administered PPI therapy (80 mg bolus, followed by 8 mg/h continuous infusion for 72 h) is recommended to reduce rebleeding in PUB patients with high- risk stigmata at endoscopy. This guideline recommendation is supported by a meta-analysis in which high dose IV PPI therapy significantly improved outcome compared with placebo/no therapy (RR, 0.40 [95% CI, 0.28-0.59]; NNT, 12 [95% CI, 10-18]) [19 ]. In Asian patients, this beneficial effect has been achieved with different PPIs [32]. In Caucasian patients, who on average, have higher acid output, a significant effect on major outcome parameters such as rebleeding has only been achieved with high-dose continu- ous esomeprazole infusion [33]. Patients at low risk can be fed within 24 h and early discharged with oral PPI therapy. Further Measures In all patients, oral treatment with a PPI is generally recommended for 4 weeks, as this is sufficient to heal nearly all ulcers and address the underlying cause of the bleeding ulcer. Helicobacter pylori infection and the use of non- steroidal anti-inflammatory drugs (NSAIDs) are the main risk factors for the development of peptic ulcer disease. Therefore, every patient with a PUB should be tested for H. pylori and receive eradication therapy if applicable. Invasive tests obtained in the acute setting may yield false-negative