What is the best course of treatment for a patient with an arterial bleed from a duodenal ulcer?

Management of Arterial Bleeding from Duodenal Ulcer

For arterial bleeding from a duodenal ulcer, endoscopic therapy is the first-line treatment, followed by surgical intervention (or angioembolization if immediately available) after endoscopic failure, with surgery being mandatory for hemodynamically unstable patients or those with ulcers >2 cm at first endoscopy. 1, 2

Initial Endoscopic Management

Endoscopy should be performed within 24 hours of presentation and serves as both diagnostic and therapeutic intervention. 2, 3

Endoscopic Therapy Techniques

• Combination therapy is superior to monotherapy for high-risk lesions with active bleeding or visible vessels. 2, 3
• Use bipolar electrocoagulation, heater probe, or injection of sclerosants combined with epinefrine (epinefrine alone is inadequate). 2, 3
• Endoscopic clips are an effective alternative hemostatic method. 2
• TC-325 hemostatic powder may serve as temporary therapy when conventional methods fail or are unavailable. 2

Post-Endoscopic Pharmacotherapy

• Administer IV proton pump inhibitors (PPI) with bolus followed by continuous infusion for 72 hours after successful endoscopic therapy for high-risk stigmata. 2, 3
• Transition to oral PPI twice daily for 14 days, then once daily thereafter. 2
• Patients should be hospitalized for at least 72 hours after endoscopic hemostasis for high-risk lesions. 2

Management of Endoscopic Failure

When to Abandon Endoscopy

Proceed directly to surgery (or angioembolization) without repeat endoscopy if: 1, 2

• Hemodynamic instability or hypotension persists
• Ulcer diameter exceeds 2 cm at initial endoscopy
• Active hemorrhagic shock is present

For rebleeding after initial successful endoscopy, attempt a second endoscopic treatment. 1, 2

Angioembolization as Alternative to Surgery

For recurrent bleeding after two failed endoscopic attempts, angioembolization is a feasible option in hemodynamically stable patients with appropriate resources available. 1, 2

Technical Considerations for Embolization

• Both celiac axis and superior mesenteric artery must be interrogated due to rich collateral blood supply in the duodenum. 4
• Perform superselective embolization in a distal-to-proximal fashion to prevent "back door" rebleeding through collaterals. 4
• Pre-procedural endoscopic clip placement at the ulcer site can guide angiographic localization. 1

Limitations of Angioembolization in Unstable Patients

Angioembolization should NOT be routinely used in hemodynamically unstable patients and should only be considered in highly selected cases at facilities with hybrid operating rooms or immediate proximity between angiography suite and operating room. 1 The appropriateness depends on timely availability of skilled interventional radiology, quality of resuscitation, and intensive care capabilities. 1

Comparative Outcomes: Angioembolization vs Surgery

Meta-analyses reveal nuanced trade-offs: 1

• Surgery reduces rebleeding rates more effectively than angioembolization
• Angioembolization shows trends toward lower mortality and fewer post-procedural complications
• Surgery demonstrates marginal trends toward increased mortality but better hemorrhage control

Surgical Management

Indications for Surgery

Open surgery is recommended when: 1, 2

• Repeated endoscopy has failed (typically after 2 attempts)
• Hemodynamic instability persists despite resuscitation
• Ulcer >2 cm at first endoscopy
• Evidence of ongoing bleeding with or without shock

Surgical Technique for Duodenal Ulcers

Large posterior duodenal ulcers typically erode into the gastroduodenal artery (GDA), the most common source of life-threatening bleeding requiring surgery. 4, 5

Critical Technical Points

• Perform triple-loop suturing of the GDA due to extensive collateral blood supply from transverse pancreatic arteries—single suture ligation is inadequate. 1, 4
• Access the bleeding vessel via duodenotomy to directly visualize and oversew the vessel on the ulcer floor. 1, 4
• Intraoperative endoscopy may facilitate localization when the bleeding source is not immediately apparent. 1, 4

Choice of Surgical Procedure

Vagotomy with drainage procedure is superior to simple ulcer oversewing alone for intractable bleeding ulcers, as it is associated with significantly lower mortality. 1 However, this must be balanced against the patient's physiological reserve and hemodynamic status.

• For most duodenal ulcers: oversew the bleeding vessel with triple-loop suturing of the GDA and right gastroepiploic artery. 1, 2
• Biopsy is not typically required for duodenal ulcers (unlike gastric ulcers where malignancy must be excluded). 1, 2

Damage Control Surgery

Consider damage control surgery for patients in hemorrhagic shock with severe physiological derangement to rapidly control bleeding and allow prompt ICU admission. 1 This approach prioritizes immediate hemorrhage control over definitive repair.

Prognostic Considerations

Duodenal ulcers have significantly higher 90-day mortality and reoperation rates compared to gastric ulcers, reflecting the anatomical complexity and involvement of major arterial structures. 1, 4

Post-Hemostasis Management

H. pylori Testing and Eradication

All patients must be tested for H. pylori and receive eradication therapy if positive. 1, 2 This is critical as H. pylori eradication reduces rebleeding rates from 26% to near zero. 1 Negative tests obtained during acute bleeding should be repeated as they may be falsely negative. 2

Antibiotic Therapy

Empirical antimicrobial therapy is NOT recommended for bleeding peptic ulcer (distinct from perforated ulcer). 1, 2

NSAID and Antiplatelet Management

• Discontinue NSAIDs; if resumption is necessary, use the least damaging agent (ibuprofen) with PPI. 2
• For patients on aspirin for cardiovascular disease, restart aspirin as soon as cardiovascular risk exceeds bleeding risk (ideally within 1-3 days, no later than 7 days). 2, 3
• Continue PPI therapy in patients requiring ongoing antiplatelet therapy. 2