Epinephrine for the treatment of bleeding peptic ulcer was pioneered by Chung and colleagues (1988). We prefer epi-nephrine as the initial agent to stop active bleeding and give a clear view of the vessel. A four-quadrant injection of epinephrine 0.1 mg/mL (1:10,000 dilution) using a 23 gauge needle (Marcon-Haber, Wilson Cook) requires approximately 10 mL. We follow this with direct injection into the responsible vessel. Nonbleeding visible-vessels are managed the same way. Resistance to injection occurs commonly in chronic peptic ulcers with fibrotic bases and may require a metallic needle (NM-1K, Olympus). Epinephrine does not cause tissue damage, and cardiovascular effects are rare due to its extensive first pass metabolism in the liver. Despite adequately delivered epinephrine, the rate of recurrent bleeding from ulcers remains 15 to 20%. Thus, as discussed below, combining epinephrine with other hemo-static modalities has been studied extensively.
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