What is the procedure for managing a bleeding pyloric ulcer?

Management of Bleeding Pyloric Ulcer

For a bleeding pyloric ulcer, endoscopic therapy is the first-line treatment, with surgical intervention reserved for cases refractory to endoscopy or for patients with hemodynamic instability, hypotension, or ulcers larger than 2 cm. 1

Initial Management Algorithm

1. Endoscopic Management (First-Line)

   • Indicated for all patients with active bleeding
   • Especially effective for Forrest 1a, 1b, and 2a lesions 2
   • Options include:
     • Injection therapies
     • Thermal therapies
     • Mechanical clips
     • Hemostatic sprays
     • Endoscopic suturing

2. Medical Management (Adjunctive)

   • High-dose proton pump inhibitors (PPIs) starting prior to endoscopy and continuing for 72 hours 1
   • H. pylori testing and eradication if positive 3
   • Discontinuation of NSAIDs if applicable

Surgical Management Indications

Surgery is indicated in the following scenarios:

• Failure of endoscopic treatment (refractory bleeding after repeated endoscopy)
• Hemodynamic instability or hypotension at presentation
• Ulcers larger than 2 cm (consider direct surgical approach without repeated endoscopy) 1
• Perforation (surgical emergency)
• Gastric outlet obstruction

Surgical Approach and Procedure

1. Approach:

   • Open surgery is recommended over laparoscopic approach for refractory bleeding peptic ulcer 1
   • Intraoperative endoscopy is advised to facilitate localization of the bleeding site 1

2. Procedure Selection:

   • For gastric ulcers: Resection or at least biopsy (to rule out malignancy) 1, 3

     • Antrectomy with truncal vagotomy for lesser curvature ulcers 3
     • Gastric resection with Roux-en-Y reconstruction for ulcers >2 cm 3

   • For duodenal/pyloric ulcers: 1

     • Via duodenotomy, identify and oversew the bleeding vessel
     • Triple-loop suturing for gastroduodenal artery bleeding
     • Vagotomy + drainage or vagotomy + antrectomy (lower recurrence rates) 4

3. Critical Surgical Steps:

   • Adequate margins (at least 5 cm beyond ulcer) for antrectomy 3
   • Complete truncal vagotomy to reduce acid production 3
   • Immediate or delayed biopsy to rule out malignancy 1, 3
   • Pathological examination of all resected specimens 3

Post-Procedure Management

1. Medical Therapy:

   • PPIs for 6-8 weeks following treatment 1
   • H. pylori eradication therapy if positive 1, 3

2. Follow-up:

   • Monitor for nutritional deficiencies (vitamin B12, iron, calcium) 3
   • Follow-up endoscopy to ensure complete healing 3

Important Considerations and Pitfalls

• Ulcer Location: Duodenal ulcers have higher 90-day mortality and re-operation rates compared to gastric ulcers 1

• Malignancy Risk: Always obtain biopsy of gastric ulcers to exclude malignancy (4.4% of pyloric ulcers may undergo malignant transformation) 5

• Recurrence Prevention: H. pylori eradication is more effective than antisecretory therapy alone in preventing recurrent bleeding 6

• Surgical Timing: Immediate surgery is crucial for unstable patients with refractory bleeding 1

• Surgical Expertise: Procedures should be performed by experienced surgeons, avoiding operations between midnight and 7 am if possible 3