What is the approach to managing a patient with suspected peptic ulcers or gastrointestinal bleeding?

Management of Suspected Peptic Ulcers or Gastrointestinal Bleeding

The management of suspected peptic ulcers or gastrointestinal bleeding requires immediate evaluation, adequate resuscitation, and early endoscopy within 24 hours as the primary diagnostic and therapeutic approach. 1, 2

Initial Assessment and Resuscitation

• Perform rapid evaluation of hemodynamic status using parameters from ATLS: heart rate, blood pressure, pulse pressure, respiratory rate, urine output, Glasgow Coma Scale score, and base deficit 1
• Obtain comprehensive medical history focusing on medications that affect coagulation (antiplatelets, anticoagulants), cardiac/pulmonary conditions that increase susceptibility to anemia, and neurological conditions that predispose to aspiration 1
• Perform blood tests including blood typing/cross-matching, hemoglobin, hematocrit, electrolytes, and coagulation assessment (INR >1.5 associated with increased mortality) 1
• Maintain hemoglobin level >7 g/dL (restrictive transfusion strategy) which has demonstrated better outcomes than liberal strategies 1, 2
• Maintain resuscitation targets similar to trauma patients with hemorrhage: systolic blood pressure 90-100 mmHg, normalization of lactate and base deficit 2

Risk Stratification

• Apply validated scoring systems to guide management decisions 1:
  • Rockall score to identify patients at risk of adverse outcomes 1
  • Glasgow-Blatchford score to identify patients needing interventions like blood transfusions or endoscopy 1, 2
• Stratify patients into risk categories to determine timing of endoscopy 2:
  • Very low risk: consider outpatient endoscopy 2
  • Low risk: early inpatient endoscopy (≤24 hours) 2
  • High risk: urgent inpatient endoscopy (≤12 hours) 2

Diagnostic Approach

• Perform gastroscopy as soon as possible, ideally within 24 hours of presentation, as it provides both effective therapy and prognostic information 1, 2
• Consider administering a prokinetic agent (erythromycin) before endoscopy to improve visualization 3
• When endoscopy is not available or not feasible, perform contrast-enhanced CT scan as an alternative diagnostic tool 1
• CT angiography is particularly useful for localizing small and large intestinal acute hemorrhage 1

Endoscopic Management

• Endoscopic therapy is indicated for ulcers with major stigmata of recent hemorrhage 2, 4:
  • Active bleeding in jet (Forrest 1a) 2
  • Oozing bleeding (Forrest 1b) 2
  • Non-bleeding visible vessel (Forrest 2a) 2
• Employ dual therapy (combination of two techniques) for endoscopic hemostasis 2, 4:
  • Options include: electrocoagulation bipolar, thermal probe, injection of sclerosants, or endoscopic clips 2, 4
• Dual endoscopic therapy by an experienced endoscopist reduces rebleeding risk, need for surgery, blood transfusions, and hospital stay 4

Pharmacological Management

• Administer proton pump inhibitors (PPIs) intravenously with loading dose followed by continuous infusion for 72 hours after successful endoscopic hemostasis 2, 5, 6
• PPI administration before endoscopy can downstage the bleeding lesion and reduce need for endoscopic therapy 6
• Lansoprazole 30mg has been shown to be effective for healing NSAID-associated gastric ulcers 5

Management of Rebleeding

• For recurrent bleeding after initial endoscopic therapy, attempt a second endoscopic treatment 2, 1
• If second endoscopic attempt fails, consider 1, 2:
  • Angioembolization in hemodynamically stable patients 1, 2
  • Surgical intervention in unstable patients 1, 2

Indications for Surgery

• Failure of repeated endoscopic therapy 1, 2
• Patients with hypotension and/or hemodynamic instability 1, 2
• Ulcers larger than 2 cm at first endoscopy 1
• Open surgery is recommended when endoscopic treatments have failed with evidence of ongoing bleeding 1

Surgical Considerations

• A consultant surgeon should be informed about possible need for surgery 1
• Timing of operation should avoid midnight to 7am if possible 1
• For bleeding duodenal ulcers, specific ligation of gastroduodenal and right gastroepiploic arteries reduces rebleeding rate 1
• Gastric ulcers are best excised or treated by partial gastrectomy depending on size and location 1
• For elderly patients in poor physical condition, perform the minimum operation to stop bleeding 1

Follow-up and Prevention

• Provide standard ulcer healing therapy 1, 2
• Test for Helicobacter pylori and eradicate if present, as rebleeding is extremely rare after successful eradication 1, 2, 7
• Discontinue NSAIDs if possible; if they must be continued, use the least damaging agent (ibuprofen) with a PPI 1, 2
• For patients with gastric ulcers, perform repeat endoscopy approximately six weeks after discharge to confirm healing and exclude malignancy 1, 2
• For patients on antiplatelets, restart aspirin as soon as cardiovascular risk exceeds bleeding risk 2

Common Pitfalls and Caveats

• Failure to recognize the significance of INR >1.5, which is associated with increased mortality 1
• Delaying endoscopy beyond 24 hours, which can increase morbidity and mortality 1
• Inadequate resuscitation before endoscopic or surgical intervention 1
• Overlooking the need for H. pylori testing and eradication in all patients with peptic ulcer bleeding 1, 7
• Using a liberal transfusion strategy (Hb >9 g/dL) rather than a restrictive strategy (Hb >7 g/dL), which has been shown to have worse outcomes 1, 2