What is the next management step for a patient with a bleeding duodenal (D1) ulcer who continues to bleed despite initial endoscopic and angiographic interventions, with a dropping hemoglobin (Hb) level?

Management of Refractory Bleeding Duodenal Ulcer After Failed Endoscopic and Angiographic Intervention

Given the failure of both endoscopic therapy (injection and clipping) and angiographic intervention (gastroduodenal artery injection), with ongoing slow bleeding evidenced by a 1-unit hemoglobin drop, the next step is repeat endoscopy with combination hemostatic therapy, and if this fails, proceed directly to surgery rather than repeat angiography. 1, 2

Immediate Assessment and Monitoring

• Continue intensive hemodynamic monitoring with continuous vital signs (pulse, blood pressure, urine output) as this patient remains at high risk for decompensation despite current stability. 2, 3
• Maintain large-bore IV access (two 18-gauge or larger lines) and keep the patient NPO, as rebleeding risk remains substantial even with apparent cessation. 2, 4
• Monitor for clinical signs of active rebleeding including fresh melena, hematemesis, fall in blood pressure, rise in pulse rate, or further hemoglobin drops—these indicate need for urgent intervention. 3

Risk Stratification in This High-Risk Patient

This 77-year-old patient has multiple high-risk features that predict rebleeding and poor outcomes:

• Age >65 years 2, 4
• Multiple comorbidities (stable pneumonia, atrial fibrillation, acute kidney injury) 2
• Large posterior duodenal bulb ulcer (high-risk location) 5
• Already failed two therapeutic interventions (endoscopic and angiographic) 1
• Ongoing bleeding evidenced by hemoglobin drop 2

Repeat Endoscopic Intervention

Attempt one more endoscopic therapy session before proceeding to surgery, as guidelines support a second endoscopic attempt after initial failure. 1, 2, 6

• Perform repeat endoscopy urgently (within 12-24 hours) given the ongoing hemoglobin drop and high-risk features. 2, 4
• Use combination endoscopic therapy (injection plus thermal coagulation or clips) rather than single modality, as this is superior for high-risk lesions like large posterior duodenal ulcers. 4, 6
• Consider intraoperative endoscopy planning if surgical exploration becomes necessary, to facilitate localization of the bleeding site. 1

Critical Pitfall to Avoid

Do not perform routine scheduled follow-up endoscopy—only intervene if there are clinical signs of active rebleeding (fresh melena, hematemesis, hemodynamic instability). 3

Angiographic Re-intervention Considerations

Repeat angiography with embolization is NOT the preferred next step in this case for several reasons:

• The gastroduodenal artery has already been injected with adrenaline (not embolized), which is suboptimal therapy. 1
• If angiography is reconsidered, superselective embolization with microcoils should be performed in a distal-to-proximal fashion to reduce "back door" rebleeding through collaterals. 1
• However, given the posterior duodenal bulb location and already failed angiographic attempt, surgery is more definitive than repeat angiography. 1, 5

Surgical Intervention Threshold

Proceed to early elective surgery if:

• The second endoscopic attempt fails to achieve hemostasis 1, 6, 5
• Transfusion requirement exceeds 6 units of packed red blood cells 2
• Hemodynamic instability develops despite resuscitation 1, 2
• Severe bleeding recurrence occurs after the second endoscopic attempt 2

Early elective surgery is specifically recommended for high-risk patients with bleeding posterior duodenal bulb ulcers after primary endoscopic treatment fails, as this approach has demonstrated 0% mortality in specialized series. 5

Pharmacological Management

• Continue high-dose IV proton pump inhibitor: 80 mg bolus followed by 8 mg/hour continuous infusion for 72 hours, then transition to oral PPI twice daily for 14 days. 2, 4, 6
• Test for Helicobacter pylori and provide eradication therapy if positive to prevent recurrent bleeding. 2, 6

Management of Atrial Fibrillation and Anticoagulation

Given the patient's stable AF, anticoagulation management is critical:

• Do NOT restart anticoagulation until definitive hemostasis is achieved (either by successful repeat endoscopy or surgery). 2
• Once hemostasis is confirmed, restart anticoagulation within 7-15 days for low thrombotic risk, or consider low molecular weight heparin at 48 hours for high thrombotic risk. 2

Acute Kidney Injury Considerations

• The mild AKI may be prerenal from bleeding or contrast-induced from the angiography. 1
• Optimize renal function before any repeat contrast studies (CT angiography or repeat angiography). 1
• Avoid fluid overload during resuscitation, as this can impair clot formation and increase rebleeding risk. 1

Transfusion Strategy

• Maintain hemoglobin >7 g/dL during resuscitation, with a target of 7-9 g/dL, using a restrictive transfusion strategy. 1
• Avoid over-transfusion, as this can increase portal pressure and worsen bleeding in some contexts. 1

Definitive Algorithm for This Patient

1. Continue intensive monitoring with serial hemoglobin checks every 4-6 hours 2, 3
2. Perform repeat endoscopy with combination therapy (injection + thermal or clips) within 12-24 hours 2, 4, 6
3. If repeat endoscopy fails OR hemoglobin drops >2 units total OR transfusion requirement >6 units: Proceed directly to early elective surgery 1, 2, 5
4. Do NOT delay surgical consultation—involve surgery early given the high-risk features and already failed interventions 1, 5