What is the management for a pulsatile bleed from the lateral wall of the second part of the duodenum?

Management of Pulsatile Bleed from Lateral Wall of Second Part of Duodenum

Immediate open surgical exploration with duodenotomy and triple-loop suturing of the gastroduodenal artery is the definitive treatment for a pulsatile bleed from the lateral wall of the second part of the duodenum, as this anatomic location indicates gastroduodenal artery involvement requiring direct surgical control. 1

Immediate Resuscitation and Stabilization

• Hemodynamic status determines all subsequent management decisions - unstable patients (shock index >1) require immediate operative intervention without delay for additional diagnostic procedures 1
• Maintain systolic blood pressure 90-100 mmHg during resuscitation, avoiding over-resuscitation which can worsen bleeding 2
• Target hemoglobin >70 g/L with restrictive transfusion strategy (>80 g/L if cardiovascular disease present) 1, 2
• Correct coagulopathy with prothrombin complex if patient is anticoagulated 1, 2

Anatomic Significance of Lateral Wall Location

The lateral wall of the second part of the duodenum is the classic location for gastroduodenal artery (GDA) erosion from posterior duodenal ulcers - this is the most dangerous bleeding site in the duodenum with significantly higher 90-day mortality and re-operation rates compared to other locations 1, 3

• Pulsatile bleeding from this location indicates arterial involvement requiring surgical hemostasis 1
• The GDA has collateral blood supply from transverse pancreatic arteries, making simple oversewing inadequate 1

Surgical Approach

Operative Technique

• Perform open surgery via duodenotomy to directly visualize the bleeding vessel on the ulcer floor 1
• Execute triple-loop suturing of the GDA - this is critical due to collateral blood supply and prevents re-bleeding 1
• Place sutures proximally and distally to the bleeding point to control collateral flow 1
• Consider intraoperative endoscopy if bleeding source location is uncertain preoperatively 1

Additional Surgical Considerations

• For intractable ulcer bleeding, vagotomy/drainage is associated with significantly lower mortality than local oversew alone and should be performed 1
• Obtain biopsy of duodenal ulcers (immediate or delayed) to exclude malignancy 1, 3
• Place nasogastric tube for proximal decompression 1

When Endoscopic or Angiographic Approaches Fail

Endoscopic therapy is contraindicated as first-line treatment for pulsatile arterial bleeding from the lateral duodenal wall - while endoscopy may be attempted in stable patients with smaller ulcers (<2 cm), pulsatile bleeding indicates endoscopic failure and requires immediate surgery 1

• Repeated endoscopy is only appropriate for stable patients with ulcers <2 cm without pulsatile bleeding 1
• Angioembolization may be considered in stable patients if available within 60 minutes, but surgery should not be delayed in unstable patients 1, 2
• No patient should proceed to emergency laparotomy without attempting localization EXCEPT when hemodynamically unstable with active pulsatile bleeding 1

Damage Control Surgery Indications

Consider damage control approach (rapid hemostasis followed by ICU resuscitation and delayed definitive repair) only if: 1

• Hemorrhagic shock with severe physiological derangement (acidosis, hypothermia, coagulopathy)
• Multiple associated injuries requiring staged management
• Patient physiology does not permit definitive repair

Critical Pitfalls to Avoid

• Never perform simple oversewing of GDA bleeding - the collateral circulation will cause immediate re-bleeding; triple-loop suturing is mandatory 1
• Do not delay surgery for repeated endoscopic attempts in unstable patients or those with pulsatile bleeding 1
• Do not attempt laparoscopic approach for bleeding duodenal ulcers - open surgery is recommended 1
• Avoid pyloric exclusion procedures as they prolong operative time without improving outcomes and increase complications 1

Post-Operative Management

• Initiate intravenous proton pump inhibitor with loading dose followed by continuous infusion for 3 days 2
• Test for Helicobacter pylori and provide eradication therapy if present 3, 2
• Perform follow-up endoscopy at 6 weeks to confirm ulcer healing and exclude malignancy 3, 2
• Discontinue NSAIDs permanently; if antiplatelet therapy required, restart aspirin when cardiovascular risk exceeds bleeding risk 2