Argon Laser for Severe Ulcer Hemorrhage: Health and Economic Considerations

Abstract

Upper gastrointestinal (UGI) bleeding is a common and often serious medical and surgical problem (1, 2). Fortunately, most patients hospitalized for UGI bleeding have spontaneous hemostasis and do not rebleed or require urgent surgery. In spite of improvements in endoscopic diagnosis, and medical-surgical care, the mortality rate has not changed in the last 30 years and remains at 8–10% (1–3). Nevertheless, clinical prognostic factors have been identified such as old age, concomitant medical-surgical illness, shock, multiple transfusions of blood, varices, malignancy, active bleeding at endoscopy and rebleeding in the hospital (1–4). Also, for peptic ulcers that have bled, endoscopic major (active bleeding or non-bleeding visible vessel) and minor stigmata of recent hemorrhage (flat red or black spot, grey slough, oozing from granulation tissue and non-bleeding clots) have been identified and used in some studies to randomize patients admitted for UGI hemorrhage (5–9). In controlled clinical trials, the control groups with minor stigmata have had very low rates of rebleeding such as 15–22% for non-bleeding adherent clots and 5–7% for non-bleeding spots (5–9). No improvement in outcomes of such low risk patients has been documented when they are treated by endoscopic argon or YAG laser in controlled randomized trials (5–10). On the other hand, several different controlled studies either with argon laser (7), YAG laser (8, 9, 11), monopolar electrocoagulation (12), or bipolar electrocoagulation (BICAP — 13) have reported significant reductions in rates of continued bleeding-rebleeding or emergency surgery for patients with major stigmata such as active arterial bleeding (7, 8, 11), bleeding from under an adherent clot (9), or a non- bleeding visible vessel (7, 8).