TREATMENT FOR BLEEDING DUODENAL ULCER

Endoscopic therapyEndoscopic evaluation of the bleeding ulcer can decrease the duration of the hospital stay by identifying patients at low risk for rebleeding. Moreover, endoscopic therapy reduces the likelihood of recurrent bleeding and decreases the need for surgery.Patients can be stratified as having high or low risk for rebleeding depending on the presence or absence of stigmata. High-risk stigmata are the following:

•Active hemorrhage (90% risk of rebleeding)•A visible vessel (50% risk of rebleeding)•A fresh overlying clot (30% risk of rebleeding)

Ulcers with such stigmata require endotherapy, while ulcers with a clean base need not be treated endoscopically.

• Injection therapy is performed with epinephrine in a 1:10,000 dilution or with absolute alcohol.

• Thermal endoscopic therapy is performed with a heater probe, bipolar circumactive probe, or gold probe. Pressure is applied to cause coagulation of the underlying artery (coaptive coagulation)

• Combination therapy with epinephrine injection followed by thermal coagulation appears to be more effective than monotherapy for ulcers with a visible vessel, active hemorrhage, or adherent clot.

• Hemoclips have been used successfully to treat an acutely bleeding ulcer by approximating 2 folds and clipping them together. Several clips may need to be deployed to approximate the gastric ulcer folds. In treating high-risk bleeding ulcers, combined therapy with epinephrine and hemoclips seems to be more efficacious than injection alone

Esophagogastroduodenoscopy• Urgent esophagogastroduodenoscopy (EGD) is the

treatment of choice in the setting of a bleeding peptic ulcer for diagnostic and therapeutic reasons.

• Endoscopy provides an opportunity to visualize the ulcer, to determine the degree of active bleeding, and to attempt hemostasis by direct measures.

• Primary endoscopic hemostatic therapy (EHT) is successful in about 90% of patients; when this fails, transcatheter embolization may be useful.

Medical Management• Acid suppression is the general pharmacologic principle of

medical management of acute bleeding from a peptic ulcer.

• Reducing gastric acidity is believed to improve hemostasis primarily through the decreased activity of pepsin

• Concomitant H pylori infection in the setting of bleeding peptic ulcers should be eradicated, as this lowers the rate of rebleeding

• Two classes of acid-suppressing medications currently in use are: histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs).

• Both classes are available in intravenous and oral preparations.

• Examples of H2RAs include ranitidine, cimetidine, famotidine, and nizatidine.

• Examples of PPIs include omeprazole, pantoprazole, lansoprazole, and rabeprazole

• H2RAs are an older class of medications.• Many gastroenterologists assert that intravenous PPI

therapy maintains hemostasis more effectively than intravenous H2RA

• Parenteral PPI administration is indicated after successful endoscopic therapy for ulcers with high-risk signs, such as active bleeding, visible vessels, and adherent clots. Parenteral PPI use before endoscopy is a common practice.

Surgery of bleeding duodenal ulcer

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Truncal vagotomy Suture of bleeding duodenal ulcer

Finney pyloroplasty• Pyloroplasty widens pyloric sphincter opening into the

duodenum.• A pyloroplasty is performed to treat complications of

gastric ulcer disease, or when conservative treatment is unsatisfactory.

• The longitudinal cut made in the pylorus is closed transversely, permitting the muscle to relax. By establishing an enlarged outlet from the stomach into the intestine, the stomach empties more quickly.

• A pyloroplasty is often done is conjunction with a vagotomy, a procedure in which the nerves that stimulate stomach acid production and gastric motility (movement) are cut. As these nerves are cut, gastric emptying may be delayed, and the pyloroplasty compensates for that effect.

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Finney pyloroplasty