What is the next step in managing a patient with peptic ulcer disease and gastrointestinal bleeding who has undergone endoscopy with findings of large clots in the stomach and a duodenal ulcer with no active bleeding?

Management of Bleeding Peptic Ulcer with Gastric Clots and Duodenal Ulcer

The next step in management for this patient with peptic ulcer disease who has undergone endoscopy showing large clots in the stomach and a duodenal ulcer without active bleeding should be a repeat endoscopy with clot removal and endoscopic therapy of the underlying lesion. 1, 2

Initial Assessment and Stabilization

• Continue resuscitation measures with hemodynamic monitoring (pulse, blood pressure, urine output) as the patient has already shown signs of hemodynamic instability (tachycardia, tachypnea) and massive bleeding (hematemesis, hematochezia) 3
• Maintain systolic blood pressure 90-100 mmHg and hemoglobin >7 g/dL (restrictive transfusion strategy) 1
• Correct any coagulopathy, as INR >1.5 is associated with increased mortality 3

Repeat Endoscopy for Clot Management

• The presence of large clots in the stomach that could not be dislodged during the initial endoscopy warrants a repeat endoscopic procedure 3, 2
• Adherent clots (Forrest IIB) are associated with significant risk of rebleeding if left untreated 2, 4
• Endoscopic therapy should include:
  • Injection of epinephrine at the base of the clot 2
  • Mechanical removal of the clot to expose the underlying lesion 2, 4
  • Application of thermal therapy (bipolar electrocoagulation or heater probe) to achieve hemostasis 1, 2

Pharmacological Management

• Administer high-dose intravenous proton pump inhibitor therapy:
  • 80 mg IV bolus followed by continuous infusion of 8 mg/hour for 72 hours 3
  • This regimen has been shown to reduce rebleeding rates, blood transfusion requirements, and hospital stay 3

Monitoring for Rebleeding

• Continue close monitoring for signs of rebleeding (fresh hematemesis, melena, hemodynamic instability) 3
• The risk of rebleeding is highest within the first 24-72 hours 5
• Patients with duodenal ulcers, hemodynamic instability, and high-risk endoscopic stigmata (as in this case) have up to 24% risk of rebleeding 5

Management if Rebleeding Occurs

• If rebleeding occurs, a second attempt at endoscopic therapy should be performed 3
• If the second endoscopic attempt fails:
  • For hemodynamically stable patients: consider angioembolization 3
  • For hemodynamically unstable patients: urgent surgical intervention 3

Surgical Considerations

• Surgical consultation should be obtained early in the course of management given the severity of bleeding and high risk of rebleeding 3
• Indications for surgery include:
  • Failure of repeated endoscopic therapy 3
  • Persistent hemodynamic instability despite resuscitation 3
• Patients who rebleed within 8 days of initial endoscopy are more likely to require surgery (82%) compared to those who rebleed later (33%) 6

Prevention of Recurrence

• Once the acute bleeding is controlled:
  • Test for H. pylori and eradicate if positive 3
  • Continue PPI therapy for 6-8 weeks to allow mucosal healing 3
  • Discontinue NSAIDs if possible 1

Pitfalls to Avoid

• Delaying repeat endoscopy when large clots are present, as this increases rebleeding risk 2, 4
• Failing to recognize the high-risk features in this patient (duodenal ulcer location, hemodynamic instability, large clots) that predict higher rebleeding rates 5
• Waiting for clinical evidence of rebleeding before considering repeat endoscopy, as preventive clot removal and treatment of underlying lesions improves outcomes 2