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Bleeding Peptic Ulcer

  • Mortality is high – increases with age and associated systemic disease
  • Precipitating factors – NSAIDs, H.pylori infection, coagulopathy, anticoagulation drugs

1. ANATOMY

Branches of the celiac trunk

Sites of gastric and duodenal ulcer bleeding

2. BLEEDING DUODENAL ULCER

  • Risk of bleeding in chronic duodenal ulcer increases if patient hasn’t taken anti-H.pylori therapy and PPIs
  • A posterior ulcer is more likely to bleed
  • Sources of bleeding
    • Small vessels in the ulcer wall – less severe
    • Erosion into the gastroduodenal artery – severe bleeding, needs early surgical intervention

Classification – Forrest Classification

Type I – active haemorrhage

  • Type Ia – spurting and bleeding
  • Type Ib – oozing

Type II – signs of recent haemorrhage

  • Type IIa – visible vessel
  • Type IIb – nonbleeding ulcer with clot overlying
  • Type IIc – ulcer with haematin base

Type III – no signs of haemorrhage

  • Type III – clean base ulcer (no clot, no vessel)

Clinical features

  • Haematemesis and melaena
  • Shock – pallor, tachycardia, sweating, hypotension, dry tongue, cold peripheries
  • History of pain and tenderness in epigastric region which has recently increased in intensity

Investigations

  • Gastroscopy is confirmative
    • Flat clear based ulcer is less likely to rebleed
    • Active ulcer/fresh clot/large ulcer are more likely to rebleed
  • Celiac angiogram
  • Hb% and hematocrit
  • Blood group and cross matching
  • Serum electrolyes, blood urea, serum creatinine, platelet count

Treatment

  • Correct the shock – foot end elevation, IV fluids, CVP line, sedation, catheterisation, blood transfusion
  • Stomach wash – adrenaline in saline through nasogastric tube
  • IV ranitidine (H2 antagonist)
  • IV pantoprazole (PPI)
  • Endoscopic cauterisation of small vessels
  • Sclerotherapy – with ethanolamine oleate or distilled water
    • Cause tamponade, vasoconstriction and sclerosis to control the bleeding

Surgery

  • Bleeding site is identified during laparotomy
  • Under-running of the ulcer base with sutures and ligation of the gastroduodenal artery

Further treatment

  • During discharge patients are advised to take anti-H.pylori triple therapy (omeprazole, clarithromycin, amoxicillin)
  • Healing can be confirmed by gastroscopy after 6-12 wks

2. BLEEDING GASTRIC ULCER

  • Similar to duodenal ulcer bleeding
  • Severe bleeding is due to erosion into the left gastric artery
    • Bleeding more severe than in DU
  • Commonly present with severe hematemesis and shock
  • Surgery is the main treatment
    • Under-running of the ulcer base
    • Partial gastrectomy with Billroth I anastomosis (gastroduodenostomy)
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