Editing Peptic ulcer disease (section)

===Bleeding===
[[Image:GU with clip.jpg|right|thumb|Endoscopic clipping placed on a gastric ulcer at risk for bleeding]]
For those with bleeding peptic ulcers, [[fluid replacement]] with [[crystalloid solution|crystalloids]] is sometimes given to maintain volume in the blood vessels. Maintaining haemoglobin at greater than 7 g/dL (70 g/L) through restrictive blood transfusion has been associated with reduced rate of death. [[Glasgow-Blatchford score]] is used to determine whether a person should be treated inside a hospital or as an outpatient. [[Intravenous]] PPIs can suppress stomach bleeding more quickly than oral ones. A neutral stomach pH is required to keep platelets in place and prevent clot lysis. [[Tranexamic acid]] and [[antifibrinolytic]] agents are not useful in treating peptic ulcer disease.<ref name="Angel 2017"/>

Early endoscopic therapy can help to stop bleeding by using [[cautery]], [[endoclip]], or [[epinephrine]] injection. Treatment is indicated if there is active bleeding in the stomach, visible vessels, or an adherent clot. Endoscopy is also helpful in identifying people who are suitable for hospital discharge. [[Prokinetic agent]]s such as [[erythromycin]] and [[metoclopramide]] can be given before endoscopy to improve endoscopic view. Either high- or low-dose PPIs are equally effective in reducing bleeding after endoscopy. High-dose intravenous PPI is defined as a bolus dose of 80&nbsp;mg followed by an infusion of 8&nbsp;mg per hour for 72 hours—in other words, the continuous infusion of PPI of greater than 192&nbsp;mg per day. Intravenous PPI can be changed to oral once there is no high risk of rebleeding from peptic ulcer.<ref name="Angel 2017"/>

For those with [[hypovolemic shock]] and ulcer size of greater than 2&nbsp;cm, there is a high chance that the endoscopic treatment would fail. Therefore, surgery and angiographic embolism are reserved for these complicated cases. However, there is a higher rate of complication for those who underwent surgery to patch the stomach bleeding site when compared to repeated endoscopy. [[Angiographic embolisation]] has a higher rebleeding rate but a similar rate of death to surgery.<ref name="Angel 2017"/>