Curr Gastroenterol Rep (2011) 13:525–531 DOI 10.1007/s11894-011-0223-7 STOMACH AND DUODENUM (JOSEPH R. PISEGNA, SECTION EDITOR) Update on the Endoscopic Management of Peptic Ulcer Bleeding Ingrid Lisanne Holster & Ernst Johan Kuipers Published online: 15 September 2011 # The Author(s) 2011. This article is published with open access at Springerlink.com Abstract Upper gastrointestinal bleeding is the most common gastrointestinal emergency, with peptic ulcer as the most common cause. Appropriate resuscitation followed by early endoscopy for diagnosis and treatment are of major importance in these patients. Endoscopy is recommended within 24 h of presentation. Endoscopic therapy is indicated for patients with high-risk stigmata, in particular those with active bleeding and visible vessels. The role of endoscopic therapy for ulcers with adherent clots remains to be elucidated. Ablative or mechanical therapies are superior to epinephrine injection alone in terms of prevention of rebleeding. The application of an ulcer-covering hemospray is a new promising tool. High dose proton pump inhibitors should be administered intravenously for 72 h after endoscopy in high-risk patients. Helicobacter pylori should be tested for in all patients with peptic ulcer bleeding and eradicated if positive. These recommendations have been captured in a recent international guideline. Keywords Peptic ulcer . Ulcer bleeding . Endoscopy . Management . Pharmacotherapy . Review I. L. Holster (*) Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands e-mail: i.holster@erasmusmc.nl E. J. Kuipers Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands e-mail: e.j.kuipers@erasmusmc.nl E. J. Kuipers Department of Internal Medicine, Erasmus MC University Medical Centre, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands Introduction Upper gastrointestinal bleeding (UGIB) is the most common gastrointestinal emergency, with peptic ulcer bleeding (PUB) responsible for 31% to 67% of all cases, followed by erosive disease (7% to 31%) and variceal bleeding (4% to 20%). Less frequent causes are oesophagitis, Mallory Weiss tears and neoplasm [1–6]. Peptic ulcer bleeding is associated with considerable morbidity and mortality, which in various series range between 5% and 13% [5]. The risk of mortality strongly depends on age, the presence of comorbidity, the severity of the bleed, and the occurrence of rebleeding [6]. Comorbidity as risk determinant explains why in-patients with a bleeding episode have higher mortality rates than out- patients presenting at the emergency unit. Endoscopy and pharmacotherapy have become the mainstay in the manage- ment of PUB. Endoscopy allows both identification of the bleeding focus, classification of the risk of rebleeding, and application of treatment in the same session, whereas pharmacotherapy in particular aims at clot stabilization and ulcer healing by profound acid suppression. This review provides an update on the endoscopic management of peptic ulcer bleeding. Risk Assessment and Pre-Endoscopic Management Pre-Endoscopic Resuscitation Immediate evaluation and initiation of appropriate resuscita- tion by means of administration of IV fluids, oxygen and blood transfusion when needed are of major importance in patients presenting with UGIB. Red blood cell transfusions are, depending on the underlying condition and clinical presenta- tion generally administered once the hemoglobin level drops below 70 g/L, but the impact of transfusion on rebleeding and