## Clinical Scenario Analysis This is a **bleeding peptic ulcer with a visible vessel** — a high-risk lesion requiring urgent endoscopic intervention. ### Key Features Identifying High-Risk Ulcer **Key Point:** Visible vessel (Forrest Ia–Ib) is the strongest predictor of rebleeding (>50% if untreated). This patient has: - Active or recent bleeding (positive FOB, anaemia) - NSAID-induced ulcer (chronic aspirin use) - Anterior duodenal wall location (higher risk of perforation and bleeding from gastroduodenal artery) ### Management Algorithm for Bleeding PU ```mermaid flowchart TD A[Bleeding PU on endoscopy]:::outcome --> B{Forrest grade?}:::decision B -->|Ia-Ib: Visible vessel| C[Endoscopic haemostasis]:::action B -->|IIa-IIb: Clot/flat spot| D[Consider haemostasis]:::decision B -->|III: Clean base| E[Medical management alone]:::action C --> F[Adrenaline injection ± thermal/mechanical]:::action F --> G[High-dose PPI infusion]:::action G --> H[H. pylori serology/CLO test]:::action H -->|Positive| I[Triple/quadruple therapy]:::action H -->|Negative| J[Continue PPI, stop NSAIDs]:::action I --> K[Repeat endoscopy if rebleeding]:::decision K -->|Yes| L[Rescue PCI or surgery]:::urgent ``` ### Endoscopic Haemostasis Technique **High-Yield:** First-line is **adrenaline (epinephrine) 1:10,000 injection** (4–6 mL aliquots around the vessel). Success rate ~80–90%. Can combine with: - Thermal coagulation (heater probe, argon plasma coagulation) - Mechanical clips (increasingly preferred) ### Post-Haemostasis Medical Management | Intervention | Rationale | |---|---| | **High-dose PPI infusion** | Omeprazole 80 mg bolus, then 8 mg/hr infusion for 72 hrs | Raises gastric pH >6, stabilizes clot | | **H. pylori testing** | Serology, CLO test, or stool antigen | Eradication prevents recurrence | | **NSAID withdrawal** | Stop aspirin permanently | Remove ulcerogenic agent | | **Repeat endoscopy** | Only if clinical rebleeding (haematemesis, melena, haemodynamic instability) | Rescue PCI or surgery if fails | **Clinical Pearl:** Aspirin for secondary prevention (post-MI, stroke) may be restarted after 4–6 weeks on PPI, but chronic NSAID use for arthritis should be replaced with paracetamol or selective COX-2 inhibitor (with PPI cover). ### Why Surgery Is NOT First-Line **Key Point:** Surgical antrectomy + vagotomy is reserved for: - Failed endoscopic haemostasis (rebleeding despite 2 attempts) - Perforation - Intractable ulcer unresponsive to PPI (now rare) With modern endoscopy and PPIs, surgery is needed in <5% of bleeding PU cases. [cite:Harrison 21e Ch 297]
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