## Clinical Scenario Analysis This patient presents with **acute peptic ulcer bleeding** (hematemesis/melena, anemia, hemodynamic stress) with endoscopic evidence of a **visible vessel** — a Forrest Ia/Ib lesion indicating **active or imminent rebleeding**. ### Key Findings | Feature | Significance | |---------|-------------| | Visible vessel at ulcer base | High rebleeding risk (>50% without intervention) | | Negative urease test | Rules out *H. pylori* as immediate cause; suggests NSAID or stress etiology | | Hemoglobin 8.2 g/dL | Significant blood loss requiring transfusion threshold | | Hemodynamic stability (BP 110/70) | Allows time for endoscopic therapy but not for observation alone | ### Management Algorithm ```mermaid flowchart TD A[Peptic ulcer bleeding]:::outcome --> B{Endoscopic findings?}:::decision B -->|Visible vessel/Spurting| C[High-risk lesion]:::urgent B -->|Flat spot/Clot| D[Low-risk lesion]:::outcome C --> E[Immediate endoscopic hemostasis]:::action E --> F[IV PPI: Omeprazole 40 mg BD or Pantoprazole 80 mg stat + infusion]:::action D --> G[PPI monotherapy]:::action F --> H[Eradicate H. pylori if positive]:::action G --> H ``` ### Rationale for Correct Answer **Key Point:** Visible vessel = **endoscopic emergency**. Requires immediate hemostasis (injection, thermal, or mechanical) + high-dose IV PPI. **High-Yield:** IV PPI dosing in bleeding ulcer: - **Omeprazole:** 40 mg IV bolus, then 8 mg/hr infusion (or 40 mg BD) - **Pantoprazole:** 80 mg IV bolus, then 8 mg/hr infusion - Goal: maintain intragastric pH > 6 to stabilize clot **Clinical Pearl:** The negative urease test does **not** negate the need for immediate hemostasis. Whether the ulcer is NSAID-induced or *H. pylori*-related, a visible vessel requires intervention now; eradication therapy comes after stabilization. [cite:Harrison 21e Ch 297]
Sign up free to access AI-powered MCQ practice with detailed explanations and adaptive learning.