What is the management approach for a patient presenting with a bleeding peptic ulcer?

Management of Bleeding Peptic Ulcer

For a patient presenting with bleeding peptic ulcer, immediate resuscitation targeting MAP ≥65 mmHg and hemoglobin >7 g/dL should be initiated simultaneously with urgent gastroenterology consultation for endoscopic hemostasis within 12 hours for high-risk patients, using dual-modality therapy (mechanical plus epinephrine injection) for Forrest Ia, Ib, and IIa lesions, followed by high-dose intravenous PPI (80 mg bolus then 8 mg/hour infusion for 72 hours). 1, 2

Initial Resuscitation and Stabilization

Hemodynamic targets:

• Perform rapid ABC (airway, breathing, circulation) assessment 1
• Target systolic blood pressure 90-100 mmHg using permissive hypotension strategy until bleeding is controlled—aggressive normalization may worsen bleeding 2, 3
• Maintain mean arterial pressure ≥65 mmHg 1
• Achieve urine output ≥0.5 mL/kg/hour 1
• Normalize lactate and base deficit 2, 3

Transfusion strategy:

• Maintain hemoglobin >7 g/dL using restrictive transfusion strategy, which demonstrates superior outcomes compared to liberal transfusion (Hb >9 g/dL) 2, 3
• Transfuse 1-2 units packed red blood cells at a time, then reassess 3
• Correct coagulopathy (target INR <1.5) 2

Fluid resuscitation:

• Administer crystalloid boluses of 20 mL/kg over 5-10 minutes, repeated as needed 3
• Initiate norepinephrine if hypotension persists despite adequate fluid resuscitation 3

Risk Stratification and Endoscopy Timing

Use Glasgow-Blatchford score to determine endoscopy timing: 2

• Score 0-1 (very low risk): Consider outpatient endoscopy 2
• Score 2-6 (low risk): Early inpatient endoscopy within 24 hours 2
• Score ≥7 (high risk): Urgent inpatient endoscopy within 12 hours 2, 3

High-risk features requiring urgent endoscopy (≤12 hours): 2, 3

• Hemodynamic instability or shock
• Ongoing hematemesis or melena
• Hemoglobin <8 g/dL
• Heart rate >100 bpm with signs of shock

Endoscopic Management

Indications for endoscopic hemostasis (Forrest classification): 1, 2, 4

• Forrest Ia (spurting arterial bleeding): Mandatory endoscopic therapy 2, 4
• Forrest Ib (oozing bleeding): Mandatory endoscopic therapy 2, 4
• Forrest IIa (visible vessel, non-bleeding): Mandatory endoscopic therapy 2, 4
• Forrest IIb (adherent clot): Perform vigorous irrigation for at least 5 minutes to dislodge clot; if underlying high-risk stigmata exposed, treat accordingly 2, 4
• Forrest IIc (flat pigmented spot) and Forrest III (clean base): No endoscopic therapy needed, medical management only 4

Endoscopic technique:

• Use dual-modality therapy combining mechanical therapy (clips or thermal coagulation) with epinephrine injection—this reduces rebleeding (OR 0.19,95% CI 0.07-0.52) and need for surgery (OR 0.10,95% CI 0.01-0.50) 1, 4
• Never use epinephrine injection alone as monotherapy—it provides suboptimal efficacy 4
• For Forrest IIb lesions, use cautious irrigation-based approaches rather than aggressive mechanical dislodgment to avoid perforation 4
• Consider intraoperative endoscopy if bleeding site cannot be localized during surgery 1

Pharmacologic Management

Proton pump inhibitor (PPI) therapy:

• Administer high-dose IV PPI: 80 mg bolus followed by 8 mg/hour continuous infusion for 72 hours after successful endoscopic hemostasis—this reduces rebleeding from 10.3% to 5.9% 2, 4
• Continue oral PPI 40 mg once daily for 6-8 weeks following endoscopic treatment 2, 4
• Initiate PPI therapy as soon as possible, ideally before endoscopy 4

H. pylori management:

• Test all patients for H. pylori and eradicate if positive 2, 4
• Repeat negative tests obtained during acute bleeding, as false-negative rates reach 25-55% during active hemorrhage 4
• Confirm eradication after treatment 2, 4

Management of Rebleeding

If rebleeding occurs after initial successful hemostasis: 1, 2

1. First rebleeding: Perform second endoscopic hemostasis attempt 1, 2

2. After two failed endoscopic attempts, choose between:

   • Angiographic embolization for hemodynamically stable patients or those at high surgical risk 1, 2
   • Immediate surgery for hemodynamically unstable patients 1, 2

Predictors of endoscopic retreatment failure requiring upfront surgery: 1

• Hypotension at presentation (p=0.01)
• Ulcer size ≥2 cm (p=0.03)
• Hemodynamic instability despite resuscitation

Surgical Management

Indications for surgery: 1

• Failure of repeated endoscopy (after two attempts)
• Hypotension and/or hemodynamic instability with ulcer >2 cm at first endoscopy
• Rapidly exsanguinating hemorrhage refractory to endoscopic control

Surgical approach:

• Open surgery is recommended over laparoscopy for refractory bleeding 1
• Use intraoperative endoscopy to localize bleeding site if needed 1
• Choose procedure based on ulcer location and vessel characteristics 1

Surgical procedures by location:

• Gastric ulcers: Resect or at minimum biopsy to exclude malignancy 1
• Duodenal ulcers: Most requiring surgery are large posterior lesions with gastroduodenal artery bleeding; perform triple-loop suturing via duodenotomy due to collateral blood supply 1
• Vagotomy/drainage is associated with significantly lower mortality than simple ulcer oversew for intractable bleeding 1

Critical Pitfalls to Avoid

• Do not delay gastroenterology consultation while attempting to "stabilize" the patient—endoscopy is part of stabilization and delays increase mortality 2
• Do not aggressively normalize blood pressure before bleeding control—permissive hypotension (SBP 90-100 mmHg) is preferred 2, 3
• Do not use epinephrine injection alone—always combine with mechanical or thermal therapy 4
• Do not aggressively dislodge adherent clots mechanically—use cautious irrigation for at least 5 minutes 4
• Do not rely solely on initial hemoglobin to determine urgency—clinical signs of shock are more important as hemoglobin may not reflect acute blood loss for several hours 2
• Do not skip H. pylori testing—eradication is mandatory and superior to PPI maintenance alone 2, 4

Follow-up Management

• Perform follow-up endoscopy at 6 weeks to confirm ulcer healing and exclude malignancy in gastric ulcers 2
• Discontinue NSAIDs; if continuation necessary, use ibuprofen (least damaging) with concomitant PPI 2
• In patients on antiplatelet therapy, reiniciate aspirin as soon as cardiovascular risk exceeds bleeding risk 2