Is bleeding from a peptic ulcer site always continuous or can it be intermittent and stop spontaneously?

Peptic Ulcer Bleeding: Patterns and Spontaneous Resolution

Bleeding from peptic ulcers is typically intermittent rather than continuous, and can spontaneously stop or stabilize without intervention in many cases, particularly with smaller ulcers (less than 2 cm in diameter). 1

Bleeding Patterns in Peptic Ulcer Disease

• Peptic ulcer bleeding is rarely continuous and unrelenting
• The intermittent nature of bleeding is evidenced by:
  • Variable clinical presentations (from occult bleeding to massive hemorrhage)
  • The classification system used for ulcer bleeding (Forrest classification) which includes:
    • Active bleeding (Forrest 1a/1b)
    • Recent bleeding that has stopped (Forrest 2a/2b)
    • Ulcers with no signs of bleeding (Forrest 2c/3) 2

Factors Affecting Spontaneous Hemostasis

Ulcer Characteristics

• Ulcer size: Ulcers smaller than 2 cm in diameter are more likely to stop bleeding spontaneously 3
• Ulcer location: Duodenal ulcers, particularly posterior ones involving the gastroduodenal artery, are less likely to stop bleeding spontaneously and have higher mortality and re-operation rates 3
• Bleeding vessel characteristics: Larger exposed vessels are less likely to achieve spontaneous hemostasis

Patient Factors

• Hemodynamic status: Hypotension is an independent predictor of failed spontaneous hemostasis 3
• Medication use: Patients on antiplatelet or anticoagulant medications have higher risks of continued or recurrent bleeding 4
• Comorbidities: Severe medical comorbidities increase risk of continued bleeding 1

Evidence for Spontaneous Resolution

The World Journal of Emergency Surgery guidelines acknowledge that many bleeding peptic ulcers stop bleeding spontaneously, which is why endoscopic therapy is only indicated for specific high-risk lesions (Forrest 1a, 1b, and 2a) 3, 2.

The fact that proton pump inhibitor (PPI) therapy alone (without endoscopic intervention) is considered adequate management for some ulcers with adherent clots (Forrest 2b) further supports that many ulcers can stabilize without direct intervention 2.

Management Implications

• Initial approach: For stable patients with suspected peptic ulcer bleeding, medical management with high-dose PPI therapy can be initiated while awaiting endoscopy 1
• Endoscopic intervention: Reserved for high-risk lesions or unstable patients 3
• Surgical intervention: Only needed for refractory bleeding, particularly for:
  • Ulcers larger than 2 cm
  • Patients with hemodynamic instability
  • Failed endoscopic treatment 3

Important Caveats

• Despite potential for spontaneous resolution, peptic ulcer bleeding carries a mortality rate of 5-14% 4
• Even when bleeding stops spontaneously, recurrent bleeding is common without appropriate treatment
• Patients with alarm symptoms or older age should undergo prompt endoscopy regardless of apparent stabilization 5
• The risk of rebleeding can reach up to 300 cases per 1000 person-years in patients who continue taking medications like aspirin after an episode of bleeding 4

In summary, while peptic ulcer bleeding can be intermittent and may stop spontaneously, particularly with smaller ulcers, proper medical management and risk stratification remain essential to prevent rebleeding and reduce mortality.