A 52-year-old man with a 10-year history of duodenal ulcer disease presents with acute epigastric pain and haematemesis. He denies NSAID use and is H. pylori-negative on serology. On examination, he is haemodynamically stable with mild epigastric tenderness. Upper GI endoscopy reveals a 2 cm duodenal ulcer with a visible vessel at the base. What is the most appropriate immediate next step in management?

Explanation

## Clinical Scenario Analysis This patient presents with **acute upper GI bleeding from a duodenal ulcer with a visible vessel** — a Forrest class IIa lesion with high rebleeding risk (~50% without intervention). ### Forrest Classification of Bleeding Ulcers | Grade | Appearance | Rebleeding Risk | Management | |-------|-----------|-----------------|-------------| | Ia | Spurting artery | ~90% | Endoscopic haemostasis ± surgery | | Ib | Oozing artery | ~80% | Endoscopic haemostasis ± surgery | | IIa | Visible vessel | ~50% | **Endoscopic haemostasis + PPI** | | IIb | Adherent clot | ~30% | Endoscopic haemostasis + PPI | | IIc | Flat pigmented spot | ~10% | PPI alone | | III | Clean base | <5% | PPI alone | ## Management Algorithm ```mermaid flowchart TD A[Upper GI bleed + haemodynamic stability]:::outcome --> B{Endoscopy findings?}:::decision B -->|Forrest Ia-IIb| C[Endoscopic haemostasis]:::action B -->|Forrest IIc-III| D[High-dose IV PPI]:::action C --> E[High-dose IV PPI<br/>80 mg bolus + 8 mg/hr infusion]:::action E --> F[Repeat endoscopy at 24 hrs<br/>if rebleeding]:::decision D --> G[Clinical observation<br/>+ repeat endoscopy if rebleeding]:::action ``` ## Key Management Principles **Key Point:** Endoscopic haemostasis is the **gold standard** for Forrest class IIa–IIb lesions (visible vessel or adherent clot). Success rate is 80–90% with combined injection + thermal therapy. **High-Yield:** The combination of **endoscopic haemostasis + high-dose IV PPI** reduces rebleeding from ~50% to <10% in visible-vessel ulcers. **Clinical Pearl:** High-dose IV PPI regimen: - **Bolus:** 80 mg IV over 30 min - **Infusion:** 8 mg/hr continuous (or 40 mg IV Q6H) - **Duration:** 72 hours, then switch to oral PPI **Mnemonic: VISIBLE VESSEL = ENDOSCOPY** — Any Forrest IIa lesion mandates endoscopic intervention before relying on PPI monotherapy. ## Why PPI Alone Is Insufficient Here Although modern PPIs have dramatically improved outcomes, a **visible vessel carries inherent mechanical bleeding risk** that acid suppression alone cannot reliably prevent. The vessel requires direct haemostatic intervention (injection of epinephrine ± sclerosant, or thermal coagulation). ## Haemodynamic Stability Matters This patient is **haemodynamically stable** → endoscopy is safe and indicated. If he were unstable, resuscitation and ICU monitoring would precede endoscopy, but the next definitive step remains haemostasis. ## Surgical Referral Timing Surgery is reserved for: - **Failed endoscopic haemostasis** (rebleeding after 2 endoscopic attempts) - **Massive transfusion requirement** (>6 units in 24 hrs) - **Perforation** with peritonitis This patient has not yet failed endoscopic therapy, so surgery is premature.