Video Endoscopic Sequence 1 of 14.

 Upper GI Bleeding due to a duodenal ulcer

 This is a 58 year-old man, that was under non steroids
 anti-inflammatory drugs and aspirin treatment.
 The patient had one week evolution of intermittent melena.
 At the time of arrival to the Emergency unit, showed signs
 of hipovolemic shock and his hemoglobin was 7.2 mg/dl.
 
 Emergency endoscopy revealed a duodenal ulcer with an
 active bleeding site.
                                           Medline.

Video Endoscopic Sequence 2 of 14.

 Injection therapy of bleeding duodenal ulcer.

 Immediately after the endoscopic diagnosis, we performed
 a combined an aggressive therapeutic procedure, consisting
 of sclerotherapy with absolute alcohol and then the
 placement of rubber bands.
 (Combined Therapeutical methods).

 After the first application of alcohol, we noticed the result,
 the bleeding was over.

 Due to the recent development of endoscopic hemostatic
 procedures, including clipping methods and absolute ethanol
 injection, the number of emergency operations for bleeding peptic
 ulcers has markedly declined.

Video Endoscopic Sequence 3 of 14.

 It is observed the sclerotherapy needle, injecting alcohol
 on the anterior wall of the duodenal bulb.

 Despite advances in medical management, gastrointestinal
 bleeding remains a substantial cause of morbidity and mortality.
 At risk are patients with history of the event, those taking
 nonsteroidal antiinflammatory agents, and those with active peptic
 ulcer disease. Endoscopy may be performed for diagnosis and
 treatment. Antisecretory therapy may be employed to control
 gastric acid secretion, treat active peptic ulcer disease, and
 control symptoms such as abdominal pain.

Video Endoscopic Sequence 4 of 14.

 After the injection of 0.5 cc alcohol, we removed the needle
 and planned three more shots.

Video Endoscopic Sequence 5 of 14.

The endoscopic procedure continues.

Video Endoscopic Sequence 6 of 14.

 The site of acute peptic ulcer bleeding was in the anterior
 wall of the duodenal bulb.

Video Endoscopic Sequence 7 of 14.

 On the image and video the ulcer can be seen, soon after
 the alcohol injections.

 And in order to rule out the possibility that bleeding
 was caused by an arterial branch with a big vessel, and
 therefore preventing another, we were a little more
 aggressive on the treatment, by placing a couple of rubbers
 bands.

Video Endoscopic Sequence 8 of 14.

 Endoscopic band ligation for control of acute peptic ulcer
 bleeding.
 After the hemostatic procedure with absolute ethanol
 injection, and in order to avoid the re-bleeding, the vessel,
 is suctioned into the banding apparatus.

Video Endoscopic Sequence 9 of 14.

 The use of endoscopic band ligation is being extended to
 treat various causes of upper and lower gastrointestinal
 bleeding.

 Endoscopic band ligation is currently considered to be the
 treatment of choice for esophageal variceal bleeding.

Video Endoscopic Sequence 10 of 14.

 At present time,there is no consensus as to the best
 treatment for non-variceal, non-ulcer gastrointestinal
 hemorrhage.

Video Endoscopic Sequence 11 of 14.

Combined Therapeutical methods.

 This treatment combines successfully the use of the
 sclerotherapy with absolute alcohol and the placement of
 rubber bands onto the bleeding site.

Video Endoscopic Sequence 12 of 14.

 Endoscopic follow-up examination

 To the sixth day of the therapeutic procedure, a new
 endoscopy was performed, observing the status post
 therapeutic treatment.

Video Endoscopic Sequence 13 of 14.

 More images and video clips of the status post
 therapeutic treatment.

 A second-look endoscopy is often performed to evaluate the
 efficacy of a prior injection therapy in patients with bleeding peptic
 gastric or duodenal ulcers.

Video Endoscopic Sequence 14 of 14.

Visible vessels are observed.

 It has been recommended that all visible vessels of peptic ulcers,
 irrespective of inactive bleeding, be treated by the endoscopic
 hemostatic procedure at the first endoscopy, if possible