How do you manage a duodenal bleeding ulcer near the ampulla of Vater?

Management of Duodenal Bleeding Ulcer Near the Ampulla of Vater

For bleeding duodenal ulcers in relation to the ampulla of Vater, perform triple-loop suturing of the gastroduodenal artery via duodenotomy, with careful identification and preservation of the ampulla, as this location represents the most technically challenging and high-risk surgical scenario. 1

Initial Endoscopic Approach

• Attempt endoscopic hemostasis as first-line therapy for all bleeding duodenal ulcers, regardless of proximity to the ampulla 1
• Use combination therapy with injection and thermal coagulation or clips for optimal initial control 1
• If rebleeding occurs after initial endoscopic control, attempt repeat endoscopy once before proceeding to surgery or angioembolization 1
• Ulcers larger than 2 cm in diameter and patients with hypotension at presentation are more likely to fail repeat endoscopy and should be considered for early surgical intervention 1

Surgical Technique for Ampulla-Adjacent Ulcers

Operative Approach

• Perform open duodenotomy to directly visualize the bleeding vessel on the ulcer floor, as most posterior duodenal ulcers requiring surgery involve the gastroduodenal artery 1
• Use intraoperative endoscopy to facilitate precise localization of the bleeding site if the ulcer location is uncertain preoperatively 1

Critical Suturing Technique

• Execute triple-loop suturing of the gastroduodenal artery due to collateral blood supply from the transverse pancreatic arteries—single sutures are inadequate and lead to rebleeding 1
• Place sutures to ligate both the gastroduodenal artery proximally and the right gastroepiploic artery distally to achieve hemostasis comparable to gastrectomy 1

Ampulla Preservation

• When the ulcer is at or above the ampulla of Vater, identify and preserve the ampulla using transcystic or transpapillary tube placement 2
• For major D1-D2 perforations or bleeding ulcers in close proximity to the ampulla, pancreas-sparing, ampulla-preserving duodenectomy is feasible in experienced hands, though associated with significant morbidity 2

Alternative to Surgery: Transcatheter Arterial Embolization

• Consider angioembolization as an alternative to surgery when endoscopic therapy fails, particularly in elderly patients or those with significant comorbidities 3, 4
• Terminal muscular branch vessel embolization provides better long-term bleeding control than proximal gastroduodenal artery embolization (15/28 vs 8/29 patients) 4
• Be aware that terminal vessel embolization carries higher risk of duodenal stenosis (7/28 patients) compared to proximal gastroduodenal artery occlusion (2/29 patients) 4

Timing and Patient Selection for Surgery

• Proceed immediately to surgery for unstable patients with bleeding refractory to endoscopy and angioembolization 1
• For stable patients with first rebleed, attempt repeat endoscopy; for second rebleed, proceed to surgery or angioembolization based on patient age, comorbidity, and ulcer characteristics 1
• Giant posterior duodenal ulcers with multiple bleeding points warrant semi-urgent surgery even after single rebleed due to high risk of further bleeding 1

Common Pitfalls to Avoid

• Do not perform single-suture ligation of the gastroduodenal artery—always use triple-loop technique to account for collateral flow 1
• Avoid attempting complex definitive procedures in unstable patients; damage control with simple oversewing may be necessary in severely compromised patients 1
• Do not delay surgery attempting to normalize coagulation parameters indefinitely; administer fresh frozen plasma while preparing for urgent intervention 5
• Recognize that bleeding from the ampulla of Vater (hemobilia) after liver trauma suggests ruptured intrahepatic pseudoaneurysm, not peptic ulcer disease—this requires angioembolization, not duodenal surgery 1

Adjunctive Measures

• Perform biopsy of duodenal ulcers when feasible to exclude malignancy, though this is less critical than for gastric ulcers 1
• Vagotomy is no longer necessary in the era of potent proton pump inhibitors 1
• Minimize operative invasiveness in elderly patients with poor physiological reserve—perform only the minimum procedure necessary to achieve hemostasis 1