• GOCHA CHANKSELIANI Tbilisi State Medical University image/svg+xml
  • AVTANDIL GIRDALADZE Tbilisi State Medical University image/svg+xml
  • OMAR GIBRADZE Akaki Tsereteli State University image/svg+xml
  • PAATA MESHVELIANI Akaki Tsereteli State University image/svg+xml



peptic ulcer, hemorrhage, ligament, Treitz, therapeutic endoscopy


            Acute hemorrhage is a common medical emergency that ranges from minor, uncontrollable bleeding to potentially life-threatening bleeding. The site of bleeding can be located anywhere in the gastrointestinal tract, which makes it difficult to determine its exact location in the gastrointestinal tract. Patients with upper gastrointestinal bleeding usually have hematemesis or melena with the bleeding point proximal to the ligament of Treitz, while patients with lower gastrointestinal bleeding usually have melena or hematochezia with the bleeding point distal to the ligament of Treitz. Endoscopy is a first-line diagnostic procedure with 100% sensitivity to detect upper gastrointestinal bleeding; However, it has only 60% sensitivity for diagnosing lower gastrointestinal bleeding. Therapeutic options for treating acute GI bleeding include conservative treatment, therapeutic endoscopy, transcatheter embolization, and surgery. Transcatheter embolization and surgery are both options for recurrent GI bleeding.


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Chey WD, Wong BC. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. 2007 Aug. 102(8):1808-25.

Javid G, Zargar SA, U-Saif R, et al. Comparison of p.o. or i.v. proton pump inhibitors on 72-h intragastric pH in bleeding peptic ulcer. J Gastroenterol Hepatol. 2009 Jul. 24(7):1236-43.

Lai KC, Lam SK, Chu KM, et al. Lansoprazole for the prevention of recurrences of ulcer complications from long-term low-dose aspirin use. N Engl J Med.2002 Jun 27. 346(26):2033-8.

Lai KC, Lam SK, Chu KM, et al. Lansoprazole reduces ulcer relapse after eradication of Helicobacter pylori in nonsteroidal antiinflammatory drug users-a randomized trial. Aliment Pharmacol Ther. 2003 Oct 15. 18(8):829-36.

Sung JJ, Tsoi KK, Ma TK, Yung MY, Lau JY, Chiu PW. Causes of mortality in patients with peptic ulcer bleeding: a prospective cohort study of 10,428 cases. Am J Gastroenterol. 2010 Jan. 105(1):84-9.

Pietroiusti A, Luzzi I, Gomez MJ, et al. Helicobacter pylori duodenal colonization is a strong risk factor for the development of duodenal ulcer. Aliment Pharmacol Ther. 2005 Apr1. 21(7):909-15

Laine L, Curtis SP, Cryer B, Kaur A, Cannon CP. Risk factors for NSAID-associated upper GI clinical events in a long-term prospective study of 34 701 arthritis patients. Aliment Pharmacol Ther.2010Nov.32(10):1240-8.

Ruigomez A, Johansson S, Nagy P, Martin-Perez M, Rodriguez LA. Risk of uncomplicated peptic ulcer disease in a cohort of new users of low-dose acetylsalicylic acid for secondary prevention of cardiovascular events. BMC Gastroenterol. 2014 Dec 10. 14:205.

ReStore, National Centre for Research Methods. Geographical referencing learning resources: Townsend deprivation index. Available at

Vergara M, Catalan M, Gisbert JP, Calvet X. Meta-analysis: role of Helicobacter pylori eradication in the prevention of peptic ulcer in NSAID users. Aliment Pharmacol Ther. 2005 Jun 15. 21(12):1411-8.

Berezin SH, Bostwick HE, Halata MS, Feerick J, Newman LJ, Medow MS. Gastrointestinal bleeding in children following ingestion of low-dose ibuprofen. J Pediatr Gastroenterol Nutr. 2007 Apr. 44(4):506-8.

Gulmez SE, Lassen AT, Aalykke C, et al. Spironolactone use and the risk of upper gastrointestinal bleeding: a population-based case-control study. Br J Clin Pharmacol. 2008 Aug. 66(2):294-9.

Lewis JD, Strom BL, Localio AR, et al. Moderate and high affinity serotonin reuptake inhibitors increase the risk of upper gastrointestinal toxicity. Pharmacoepidemiol Drug Saf. 2008 Apr. 17(4):328-35.

Aldoori WH, Giovannucci EL, Stampfer MJ, Rimm EB, Wing AL, Willett WC. A prospective study of alcohol, smoking, caffeine, and the risk of duodenal ulcer in men. Epidemiology. 1997 Jul. 8(4):420-4.

Sonnenberg A, Muller-Lissner SA, Vogel E, et al. Predictors of duodenal ulcer healing and relapse. Gastroenterology. 1981 Dec. 81(6):1061-7.

Koivisto TT, Voutilainen ME, Farkkila MA. Effect of smoking on gastric histology in Helicobacter pylori-positive gastritis. Scand J Gastroenterol. 2008. 43(10):1177-83.

Schubert ML, Peura DA. Control of gastric acid secretion in health and disease. Gastroenterology. 2008 Jun. 134(7):1842-60.

Yuan XG, Xie C, Chen J, Xie Y, Zhang KH, Lu NH. Seasonal changes in gastric mucosal factors associated with peptic ulcer bleeding. Exp Ther Med. 2015 Jan. 9(1):125-30.

Lanas A, Chan FKL. Peptic ulcer disease. Lancet. 2017 Aug 5. 390(10094):613-24.

Peptic ulcer. OMICS International. Available at Accessed: August 1, 2019.

Malik TF, Gnanapandithan K, Singh K. Peptic ulcer disease. StatPearls [Internet]. 2021 Jan.

Sung JJ, Kuipers EJ, El-Serag HB. Systematic review: the global incidence and prevalence of peptic ulcer disease. Aliment Pharmacol Ther. 2009 May 1. 29 (9):938-46.

Cai S, Garcia Rodriguez LA, Masso-Gonzalez EL, Hernandez-Diaz S. Uncomplicated peptic ulcer in the UK: trends from 1997 to 2005. Aliment Pharm. Ther. 2009Nov15.30(10):1039-48

Azhari H, Underwood F, King J, et al. The global incidence of peptic ulcer disease and its complications at the turn of the 21st century: a systematic review. J Can Assoc Gastroenterol. 2018 Feb. 1(2):61-2.

Leontiadis GI, Sreedharan A, Dorward S, et al. Systematic reviews of the clinical effectiveness and cost-effectiveness of proton pump inhibitors in acute upper gastrointestinal bleeding. Health Technol Assess. 2007 Dec. 11(51):iii-iv, 1-164.

Bardou M, Toubouti Y, Benhaberou-Brun D, Rahme E, Barkun AN. High dose proton pump inhibition decrease both re-bleeding and mortality in high-risk patients with acute peptic ulcer bleeding [abstract]. Gastroenterology. 2003. 123(suppl 1):A625.

Bardou M, Youssef M, Toubouti Y, et al. Newer endoscopic therapies decrease both re-bleeding and mortality in highrisk patients with acute peptic ulcer bleeding: a series of meta-analyses [abstract]. Gastroenterology. 2003. 123:A239.

Gisbert JP, Pajares R, Pajares JM. Evolution of Helicobacter pylori therapy from a meta-analytical perspective. Helicobacter. 2007 Nov. 12 suppl 2:50-8.

Svanes C, Lie RT, Svanes K, Lie SA, Soreide O. Adverse effects of delayed treatment for perforated peptic ulcer. Ann Surg. 1994 Aug. 220(2):168-75.

Sengupta TK, Prakash G, Ray S, Kar M. Surgical management of peptic perforation in a tertiary care center: a retrospective study. Niger Med J. 2020 Nov-Dec. 61(6):328-33.

Thorsen K, Soreide JA, Soreide K. Long-term mortality in patients operated for perforated peptic ulcer: factors limiting longevity are dominated by older age, comorbidity burden and severe postoperative complications. World J Surg. 2017 Feb. 41(2):410-8.

Hung KW, Knotts RM, Faye AS, et al. Factors associated with adherence to Helicobacter pylori testing during hospitalization for bleeding peptic ulcer disease. Clin Gastroenterol Hepatol. 2020 May. 18(5):1091-1098.e1.

Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori infection. Am J Gastroenterol. 2017 Feb. 112(2):212-39.

Early DS, Lightdale JR, Vargo JJ 2nd, et al, for the ASGE Standards of Practice Committee. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2018 Feb. 87(2):327-37.

Ramakrishnan K, Salinas RC. Peptic ulcer disease. Am Fam Physician.2007 Oct 1.76(7):1005-12.

Ford AC, Marwaha A, Lim A, Moayyedi P. What is the prevalence of clinically significant endoscopic findings in subjects with dyspepsia? Systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2010 Oct. 8(10):830-7, 837.e1-2.

Zullo A, Hassan C, Campo SM, Morini S. Bleeding peptic ulcer in the elderly: risk factors and prevention strategies. Drugs Aging. 2007. 24(10):815-28.

Udd M, Miettinen P, Palmu A, et al. Analysis of the risk factors and their combinations in acute gastroduodenal ulcer bleeding: a case-control study. Scand J Gastroenterol. 2007 Dec. 42(12):1395-403.

Jensen DM, Eklund S, Persson T, et al. Reassessment of rebleeding risk of Forrest IB (oozing) peptic ulcer bleeding in a large international randomized trial. Am J Gastroenterol. 2017 Mar. 112(3):441-6.

Wang HM, Hsu PI, Lo GH, et al. Comparison of hemostatic efficacy for argon plasma coagulation and distilled water injection in treating high-risk bleeding ulcers. J Clin Gastroenterol. 2009 Nov-Dec. 43(10):941-5.

Khodadoostan M, Karami-Horestani M, Shavakhi A, Sebghatollahi V. Endoscopic treatment for high-risk bleeding peptic ulcers: A randomized, controlled trial of epinephrine alone with epinephrine plus fresh frozen plasma. J Res Med Sci. 2016. 21:135.

Larssen L, Moger T, Bjornbeth BA, Lygren I, Klow NE. Transcatheter arterial embolization in the management of bleeding duodenal ulcers: a 5.5-year retrospective study of treatment and outcome. Scand J Gastroenterol. 2008. 43(2):217-22.

Travis AC, Wasan SK, Saltzman JR. Model to predict rebleeding following endoscopic therapy for non-variceal upper gastrointestinal hemorrhage. J Gastroenterol Hepatol. 2008 Oct. 23(10):1505-10.

Elmunzer BJ, Young SD, Inadomi JM, Schoenfeld P, Laine L. Systematic review of the predictors of recurrent hemorrhage after endoscopic hemostatic therapy for bleeding peptic ulcers. Am J Gastroenterol. 2008 Oct. 103(10):2625-32; quiz 2633.

Chiu PW, Ng EK, Cheung FK, et al. Predicting mortality in patients with bleeding peptic ulcers after therapeutic endoscopy. Clin Gastroenterol Hepatol. 2009 Mar. 7(3):311-6; quiz 253.

Kikkawa A, Iwakiri R, Ootani H, et al. Prevention of the rehaemorrhage of bleeding peptic ulcers: effects of Helicobacter pylori eradication and acid suppression. Aliment Pharmacol Ther. 2005 Jun. 21(2):79-84.

Gisbert JP, Calvet X, Feu F, et al. Eradication of Helicobacter pylori for the prevention of peptic ulcer rebleeding. Helicobacter. 2007 Aug. 12(4):279-86.

Boparai V, Rajagopalan J, Triadafilopoulos G. Guide to the use of proton pump inhibitors in adult patients. Drugs. 2008. 68(7):925-47.

Barkun A, Bardou M, Marshall JK, for the Nonvariceal Upper GI Bleeding Consensus Conference Group. Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2003 Nov 18. 139(10):843-57.

Cote GA, Howden CW. Potential adverse effects of proton pump inhibitors. Curr Gastroenterol Rep. 2008 Jun. 10(3):208-14.

Laine L, Shah A, Bemanian S. Intragastric pH with oral vs intravenous bolus plus infusion proton-pump inhibitor therapy in patients with bleeding ulcers. Gastroenterology. 2008 Jun. 134(7):1836-41.

Chan WH, Khin LW, Chung YF, Goh YC, Ong HS, Wong WK. Randomized controlled trial of standard versus high-dose intravenous omeprazole after endoscopic therapy in high-risk patients with acute peptic ulcer bleeding. Br J Surg. 2011 May. 98(5):640-4.

Andriulli A, Loperfido S, Focareta R, et al. High- versus low-dose proton pump inhibitors after endoscopic hemostasis in patients with peptic ulcer bleeding: a multicentre, randomized study. Am J Gastroenterol. 2008 Dec. 103(12):3011-8.

Sari YS, Can D, Tunali V, Sahin O, Koc O, Bender O. H pylori: treatment for the patient only or the whole family? World J Gastroenterol. 2008 Feb 28. 14(8):1244-7.

Konno M, Yokota S, Suga T, Takahashi M, Sato K, Fujii N. Predominance of mother-to-child transmission of Helicobacter pylori infection detected by random amplified polymorphic DNA fingerprinting analysis in Japanese families. Pediatr Infect Dis J. 2008 Nov. 27(11):999-1003.

Singh V, Mishra S, Maurya P, et al. Drug resistance pattern and clonality in H. pylori strains. J Infect Dev Ctries. 2009 Mar 1. 3(2):130-6.

Ram M R, Teh X, Rajakumar T, et al. Polymorphisms in the host CYP2C19 gene and antibiotic-resistance attributes of Helicobacter pylori isolates influence the outcome of triple therapy. J Antimicrob Chemother. 2019 Jan 1. 74(1):11-6.

[Guideline] Lanza FL, Chan FK, Quigley EM, for the Practice Parameters Committee of the American College of Gastroenterology.

Guidelines for prevention of NSAID-related ulcer complications. Am J Gastroenterol. 2009 Mar.104(3):728-38.

Chan FK, Hung LC, Suen BY, et al. Celecoxib versus diclofenac and omeprazole in reducing the risk of recurrent ulcer bleeding in patients with arthritis. N Engl J Med. 2002 Dec 26. 347(26):2104-10.

Yang M, He M, Zhao M, et al. Proton pump inhibitors for preventing non-steroidal anti-inflammatory drug induced gastrointestinal toxicity: a systematic review. Curr Med Res Opin. 2017 Jun. 33(6):973-80.

Chan FK, Ching JY, Hung LC, et al. Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding. N Engl J Med. 2005 Jan 20. 352(3):238-44.

Lai KC, Chu KM, Hui WM, et al. Esomeprazole with aspirin versus clopidogrel for prevention of recurrent gastrointestinal ulcer complications. Clin Gastroent Hepatol. 2006 Jul. 4(7):860-5.

Hsu PI, Lai KH, Liu CP. Esomeprazole with clopidogrel reduces peptic ulcer recurrence, compared with clopidogrel alone, in patients with atherosclerosis. Gastroenterology. 2011 Mar. 140(3):791-8.

[Guideline] Talley NJ, Vakil N, for the Practice Parameters Committee of the American College of Gastroenterology. Guidelines for the management of dyspepsia. Am J Gastroenterol. 2005Oct. 100(10):2324-37.

Tajima A, Koizumi K, Suzuki K, et al. Proton pump inhibitors and recurrent bleeding in peptic ulcer disease. J Gastroenterol Hepatol. 2008 Dec. 23 (2):S237-41.

McConnell DB, Baba GC, Deveney CW. Changes in surgical treatment of peptic ulcer disease within a veterans hospital in the 1970s and the 1980s. Arch Surg. 1989 Oct. 124(10):1164-7.

Gisbert JP, Calvet X, Cosme A, et al, for the H. pylori Study Group of the Asociacion Espanola de Gastroenterologia (Spanish Gastroenterology Association). Long-term follow-up of 1,000 patients cured of Helicobacter pylori infection following an episode of peptic ulcer bleeding. Am J Gastroenterol. 2012 Aug. 107(8):1197-204.

[Guideline] Tarasconi A, Coccolini F, Biffl WL, et al. Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg Surg. 2020. 15:3.

Berne TV, Donovan AJ. Nonoperative treatment of perforated duodenal ulcer. Arch Surg.1989Jul.124(7):830-2.

Donovan AJ, Berne TV, Donovan JA. Perforated duodenal ulcer: an alternative therapeutic plan. Arch Surg. 1998 Nov. 133(11):1166

Wangensteen OH. Non-operative treatment of localized perforations of the duodenum. Proc Minn Acad Med. 1935. 18:477-80.

Strand DS, Kim D, Peura DA. 25 years of proton pump inhibitors: a comprehensive review. Gut Liver. 2017 Jan 15. 11(1):27-37.

Kajihara Y, Shimoyama T, Mizuki I. Analysis of the cost-effectiveness of using vonoprazan-amoxicillin-clarithromycin triple therapy for first-line Helicobacter pylori eradication. Scand J Gastroenterol. 2017 Feb. 52(2):238-41.

Ng JC, Yeomans ND. Helicobacter pylori infection and the risk of upper gastrointestinal bleeding in low dose aspirin users: systematic review and meta-analysis. Med J Aust. 2018 Sep 1. 209(7):306-11.

Mirabella A, Fiorentini T, Tutino R, et al. Laparoscopy is an available alternative to open surgery in the treatment of perforated peptic ulcers: a retrospective multicenter study. BMC Surg. 2018 Sep 25. 18(1):78.

Havens JM, Castillo-Angeles M, Nitzschke SL, Salim A. Disparities in peptic ulcer disease: A nationwide study. Am J Surg. 2018 Dec. 216(6):1127-8.

[Guideline] Satoh K, Yoshino J, Akamatsu T, et al. Evidence-based clinical practice guidelines for peptic ulcer disease 2015. J Gastroenterol. 2016 Mar. 51(3):177-94.

Lau JY, Sung J, Hill C, Henderson C, Howden CW, Metz DC. Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion. 2011.84:102-13.

Sonnenberg A. Temporal trends and geographical variations of peptic ulcer disease. Aliment Pharmacol Ther. 1995. 9(2):3-12.

Mohamed WA, Schaalan MF, Ramadan B. The expression profiling of circulating miR-204, miR-182, and lncRNA H19 as novel potential biomarkers for the progression of peptic ulcer to gastric cancer. J Cell Biochem. 2019 Aug. 120(8):13464-77.

Sanaii A, Shirzad H, Haghighian M, et al. Role of Th22 cells in Helicobacter pylori-related gastritis and peptic ulcer diseases. Mol Biol Rep. 2019 Dec. 46(6):5703-12.

Charbonnet P, Toman J et al: Treatment of gastrointestinal hemorrhage. Abdom Imaging, 2005; 30: 719-26.

Cherian MP, Mehta P, Kalyanpur TM, Hedgire SS, Narsinghpura KS: Arterial interventions in gastrointestinal bleeding. Semin Intervent Radiol, 2009; 26: 184-195.

Sheth R, Someshwar V, Warawdekar G: Treatment of acute lower gastrointestinal hemorrhage by superselective transcatheter embolization. Indian J Gastroenterol, 2006; 25: 290-294.

Rozycki GS, Tremblay L, Feliciano DV, etal: Three hundred consecutive emergent celiotomies in general surgery patients. Ann Surg, 2002; 235: 681-689.

Pennoyer WP, Vignati PV, Cohen JL: Management of angiogram positive lower gastrointestinal hemorrhage: long term follow-up of non-operative treatments. Int J Colorectal Dis, 1996; 11: 279-282.

Schuetz A, Jauch KW: Lower gastrointestinal bleeding: therapeutic strategies, surgical techniques and results. Langenbecks Arch Surg, 2001; 386: 17-25.

Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ: Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol, 2011; 66: 500-509.

Bjorkman DJ, Zaman A, Fennerty MB, Lieberman D et al: Urgent vs. electiveendoscopy for acute non-variceal upper GI-bleeding: an effectiveness study. Gastrointest Endosc, 2004; 60: 1-8.

Church NI, Palmer KR: Diagnostic and therapeutic endoscopy. Curr Opin Gastroenterol, 1999; 15: 504.

Yap FY, Omene BO, Patel MN, etal: Transcatheter embolotherapy for gastrointestinal bleeding: a single center review of safety, efficacy, and clinical outcomes. Dig Dis Sci, 2013; 58: 1976-1984.

DeBarros J, Rosas L, Cohen J, Vignati P, Sardella W, Hallisey M: The changing paradigm for the treatment of colonic hemorrhage: superselective angiographic embolization. Dis Colon Rectum, 2002; 45: 802-808.

Lewis BS: Small intestinal bleeding. Gastroenterol Clin North Am, 1994; 23: 67-91.

Jenson DM, Machicado GA, Jutabha R, Kovacs TO: Urgentcolonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med, 2000; 342: 78-82.

Zuccaro G: Management of the adult patient with acute lower gastrointestinal bleeding. Am J Gastroenterol, 1998; 93: 1202-1208.

Angtuaco TL, Reddy SK, Drapkin S, Harrell LE, Howden CW: The utility of urgent colonoscopy in the evaluation of acute lower gastrointestinal tract bleeding: a 2-year experience from a single center. Am J Gastroenterol, 2001; 96: 1782-1785.

Bloomfield RD, Rockey DC, Shetzline MA: Endoscopic therapy of acute diverticular hemorrhage. Am J Gastroenterol, 2001; 96: 2367-2372.

Eisen GM, Dominitz JA, Faigel D, etal; American Society for Gastrointestinal Endoscopy. Standards of Practice Committee: an annotated algorithmic approach to acute lower gastrointestinal bleeding. Gastrointest Endosc, 2001; 53: 859-863.

Zuckerman GR, Prakash C: Acute lower intestinal bleeding. Part I: clinical presentation and diagnosis. Gastrointest Endosc, 1998; 48: 606-617.

Fisher L, Krinsky ML, Anderson MA, etal: The role of endoscopy in the management of obscure GI bleeding. Gastrointestinal Endoscopy, 2010; 72: 471-479.

Funaki B, Kostelic JK, Lorenz J, etal: Superselective microcoil embolization of colonic hemorrhage. Am J Roentgenol, 2001; 177: 829-836.

Funaki B: Superselective embolization of lower gastrointestinal hemorrhage: a new paradigm. Abdom Imaging, 2004; 29: 434-438.

Barkun AN, Bardou M, Kuipers EJ, et al: International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med, 2010; 152: 101-113.

Weldon DT, Burke SJ, Sun S, Mimura H, Golzarian J Interventional management of lower gastrointestinal bleeding. Eur Radiol, 2008; 18: 857-867.

Jay A Yelon, DO, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American Burn Association, American College of Surgeons, American Trauma Society, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Pan American Trauma Society, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress

National Centre for Research Methods. Geographical referencing learning resources: Townsend deprivation index. Available at Accessed: December 20, 2018.

M, Catalan M, Gisbert JP, Calvet X. Meta-analysis: role of Helicobacter pylori eradication in the prevention of peptic ulcer inNSAID users. Aliment Pharmacol Ther. 2005 Jun 15. 21(12):1411-8.




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