What is the management approach for a patient with a gastric ulcer and bleeding?

Management of Gastric Ulcer with Bleeding

The management of a bleeding gastric ulcer requires prompt endoscopic intervention as first-line therapy, followed by proton pump inhibitor therapy, Helicobacter pylori testing and eradication if positive, and careful consideration of surgical options for refractory bleeding. 1

Initial Assessment and Stabilization

• Assess hemodynamic status immediately:

  • Check vital signs, particularly for hypotension (systolic BP <100 mmHg)
  • Calculate shock index (heart rate/systolic BP) - a value >1 indicates hemodynamic instability
  • Evaluate for signs of active bleeding (hematemesis, melena, hematochezia)

• Laboratory workup:

  • Complete blood count
  • Coagulation profile (PT, PTT)
  • Blood typing and cross-matching
  • Serum electrolytes, BUN, creatinine
  • Liver function tests

• Resuscitation measures:

  • Establish large-bore IV access (two lines)
  • Implement restrictive transfusion strategy (hemoglobin threshold of 70 g/L for most patients, 80 g/L for those with cardiovascular disease) 2
  • Maintain mean arterial pressure >65 mmHg while avoiding fluid overload

Endoscopic Management

• Urgent endoscopy is the cornerstone of management for bleeding gastric ulcers 1

• Endoscopic therapy should be performed for high-risk stigmata:

  • Active bleeding (spurting or oozing)
  • Non-bleeding visible vessel
  • Adherent clot

• Endoscopic treatment options:

  • Injection therapy (adrenaline/epinephrine)
  • Thermal coagulation
  • Mechanical methods (hemoclips)
  • Combination therapy is more effective than single modality

• Risk factors for endoscopic treatment failure 3:

  • Hypovolemic shock (OR 2.38)
  • Active bleeding at endoscopy (OR 2.98)
  • Ulcer location high on lesser curvature (OR 2.79)
  • Ulcer size larger than 2 cm (OR 3.64)

Pharmacological Management

• Start high-dose proton pump inhibitor (PPI) therapy:

  • IV bolus followed by continuous infusion for 72 hours after successful endoscopic therapy
  • Transition to oral PPI therapy once patient is stable and able to tolerate oral intake 4

• Test all patients with bleeding gastric ulcers for Helicobacter pylori 1

  • Note that tests may have increased false-negative rates during acute bleeding
  • Consider confirmatory testing if initial results are negative
  • Provide eradication therapy if H. pylori positive

• Discontinue ulcerogenic medications:

  • NSAIDs
  • Aspirin (if used for primary prevention)
  • For patients requiring continued antiplatelet therapy, consider less damaging agents with PPI co-therapy

Management of Refractory Bleeding

For patients with persistent or recurrent bleeding after endoscopic therapy:

1. Repeat endoscopy - For stable patients with ulcers <2 cm in diameter 1

2. Angiographic embolization - Consider as second-line therapy when:

   • Endoscopic retreatment fails
   • Patient is stable enough to undergo the procedure
   • Expertise is available 5, 6

3. Surgical intervention - Indicated when:

   • Endoscopic and angiographic treatments have failed
   • Patient has hemodynamic instability
   • Ulcer size ≥2 cm with heavy bleeding 1
   • Ulcer location makes endoscopic treatment difficult

Surgical Approach

• Open surgery is recommended over laparoscopic approach for refractory bleeding 1

• Intraoperative endoscopy helps locate the bleeding site

• Surgical options depend on ulcer location and characteristics:

  • For gastric ulcers: excision or partial gastrectomy (especially if malignancy is suspected)
  • For duodenal ulcers: oversewing of the bleeding vessel
  • Consider vagotomy/drainage procedures which may have lower mortality than local procedures alone

• Damage control surgery should be considered for patients with:

  • Hemorrhagic shock
  • Severe physiological derangement
  • Need for rapid ICU admission 1

Follow-up Care

• Continue PPI therapy for 6-8 weeks

• For gastric ulcers, perform repeat endoscopy after 6 weeks to:

  • Confirm ulcer healing
  • Exclude malignancy (biopsy if not done initially) 1

• For patients requiring continued NSAID therapy:

  • Use the least damaging agent (ibuprofen)
  • Co-prescribe a PPI
  • Consider COX-2 selective inhibitors 1

Key Pitfalls to Avoid

1. Delaying endoscopy in actively bleeding patients
2. Failing to test for H. pylori
3. Underestimating large ulcers (>2 cm) which have higher failure rates with endoscopic therapy
4. Neglecting to consider surgical consultation early for high-risk ulcers
5. Missing gastric malignancy (always biopsy gastric ulcers)
6. Restarting ulcerogenic medications without protective strategies

By following this algorithmic approach, the management of patients with bleeding gastric ulcers can be optimized to reduce morbidity and mortality.