Curr Gastroenterol Rep (2011) 13:525–531 results, and should thus be repeated in case they give no evidence of H. pylori infection [10 ]. A total of 1 month after antimicrobial therapy, patients should be reassessed for successful eradication, as persistent H. pylori infection is associated with a more than 50% risk of recurrent ulcer disease within 2 years, and thus, with a significant risk for recurrent ulcer complications including bleeding [34]. Patients who develop PUB while on NSAID therapy, should be considered for permanent withdrawal of such therapy. If this is not feasible, they should preferentially switch to the combination of a selective COX2-inhibitor together with PPI gastroprotection since a COX2-inhibitor alone, as well as a conventional NSAID with a PPI are both associated with a persistent rebleeding risk [10 , 35]. The need for adequate adherence to the gastroprotective PPIs should be stressed, as various studies have now shown that even moderate lack of adherence significantly increases the risk of events [36, 37]. In patients who develop ulcer bleeding while on low dose aspirin, the need for this therapy should also be reassessed. In many, low dose aspirin is given for secondary prevention of cardiovascular disease. In these patients, continuation of antiplatelet treatment during the bleeding episode may increase rebleeding but reduces all-cause mortality rates. This was concluded by a recent RCT including 156 low-dose aspirin users for secondary cardio- vascular prophylaxis. After endoscopic treatment for peptic ulcer bleeding, these patients were randomly assigned to either continue aspirin or receive placebo, both in combi- nation with 72 h high dose IV PPI followed by an oral PPI for 8 weeks. The 30-day rebleeding rate was not signifi- cantly higher in the aspirin than in the placebo group (10.3 vs. 5.4%; Δ 4.9% [95% CI −3.6–13.4]), but the all-cause mortality (1.3% vs. 12.9%; Δ 11.6% [CI, 3.7–19.5%]) and the mortality rates attributable to cardiovascular, cerebro- vascular or gastrointestinal complications (1.3% vs. 10.3% Δ 9% [CI, 1.7–16.3%]) were significantly lower in the aspirin group [38 ]. Until now, no prospective studies have been performed to study shorter intervals of discontinuation of aspirin. The optimal period of discontinuation is thus not yet defined. For now, guidelines recommend to restart aspirin 3 to 5 days after endoscopic therapy, provided that the patients hemodynamic condition is stable [29]. Patients with idiopathic ulcer disease, ie those in whom adequate assessment does not reveal an underlying cause, should also be treated with PPI maintenance therapy as they are at considerable risk for recurrent ulcer formation and bleeding [39]. Future Research In the past 2 decades, major developments took place in the management of peptic ulcer bleeding. Proton pump inhib- 529 itors were introduced, H. pylori was recognized as an important risk factor for the development of peptic ulcers, and endoscopic therapy had become the main therapy for the majority of patients with peptic ulcer bleeding. Despite these valuable new discoveries, PUB incidence remained stable and probably will even rise in the near future due to aging of the population accompanied by increasing use of medication and comorbid illness. Therefore, there is a pressing need for studies to elucidate the optimal time to endoscopy, the optimal approach to patients with adherent clots, the most effective endoscopic techniques and the best alternative for patients refractory to endoscopic therapy. In addition, development of an appropri- ate risk stratification scorings system and safe transfusion policy will be important topics for future research. Conclusions Peptic ulcer bleeding is the most frequent emergency condition in gastroenterology practice. It is associated with significant morbidity and mortality. Endoscopy is the main- stay in the modern management of PUB. Ideally endoscopy should be performed within 24 h of presentation. Combination therapy of epinephrine injection plus another hemostatic technique or the use of another hemostatic technique alone is more effective than epinephrine alone. Hemospray is a new promising endoscopic therapy. Patients with high-risk stigma- ta should receive continuous IV PPI administration for 72 h after endoscopy. After the acute phase, the underlying cause of the ulcer should be verified and treated when possible. Disclosure Ernst J. Kuipers has been an advisory board member, consultant and grant recipient for AstraZeneca; Ingrid L. Holster reported no potential conflicts of interest relevant to this article. Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which per- mits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. References Papers of particular interest, published recently, have been highlighted as: Of importance Of major importance 1. van Leerdam ME, Vreeburg EM, Rauws EA, et al. Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000. Am J Gastroenterol. 2003;98:1494–9.