A 48-year-old woman from Mumbai presents with a 6-month history of recurrent epigastric pain relieved by food and antacids. She reports dark tarry stools for the past 3 weeks and fatigue. She takes ibuprofen daily for arthralgia. On examination, she is pale with conjunctival pallor. Hemoglobin is 8.2 g/dL, MCV 72 fL. Fecal occult blood test is positive. Upper endoscopy reveals a 1.5 cm ulcer in the antrum with a visible vessel at the base. What is the most appropriate next step?

Explanation

## Clinical Diagnosis: Bleeding Peptic Ulcer with Visible Vessel **Key Point:** A visible vessel (Forrest Ia–Ib) at the base of a peptic ulcer is a high-risk stigma for rebleeding (40–50% if untreated) and requires immediate endoscopic hemostasis. **High-Yield:** NSAID-induced ulcers account for ~60% of peptic ulcer disease in developed countries. The presence of a visible vessel mandates endoscopic intervention; medical therapy alone is insufficient. ## Forrest Classification of Bleeding Ulcers | Forrest Grade | Appearance | Rebleeding Risk (untreated) | Management | |---|---|---|---| | Ia | Spurting arterial bleeding | 90% | Endoscopic hemostasis | | Ib | Oozing bleeding | 80% | Endoscopic hemostasis | | IIa | Visible vessel (no bleeding) | 50% | Endoscopic hemostasis | | IIb | Adherent clot | 30% | Consider hemostasis or PPI | | IIc | Flat pigmented spot | 10% | PPI monotherapy | | III | Clean ulcer base | 5% | PPI monotherapy | **Clinical Pearl:** A visible vessel is equivalent to an exposed artery and will rebleed in >40% of cases without intervention. Endoscopic hemostasis reduces rebleeding to <10%. ## Management Algorithm for Bleeding PU ```mermaid flowchart TD A[Bleeding PU on endoscopy]:::outcome --> B{Forrest grade?}:::decision B -->|Ia, Ib, IIa| C[Endoscopic hemostasis]:::action B -->|IIb, IIc, III| D[High-dose PPI]:::action C --> E[Epinephrine injection ± cautery/clip]:::action E --> F[High-dose PPI infusion]:::action D --> F F --> G[H. pylori serology/stool antigen]:::action G --> H{H. pylori positive?}:::decision H -->|Yes| I[Triple or quadruple therapy]:::action H -->|No| J[Continue PPI 8 weeks, NSAID cessation]:::action I --> K[Repeat endoscopy in 4 weeks if Forrest Ia/Ib]:::action J --> K ``` **Mnemonic: HEMOSTASIS for Visible Vessel — INJECT** - **I**njection (epinephrine 1:10,000, 0.5–2 mL aliquots) - **N**eed placement (4 quadrants around vessel) - **J**et coagulation or contact cautery (argon plasma or heater probe) - **E**valuation for rebleeding (observe 2–3 min) - **C**lip placement (optional second-line) - **T**herapy escalation (PPI infusion if rebleeds) ## Why This Answer Is Correct 1. **Endoscopic hemostasis:** Injection ± cautery/clip reduces rebleeding from 50% to <10% in visible vessel ulcers. 2. **High-dose PPI:** Omeprazole 40 mg IV BD (or equivalent) or 40 mg PO BD reduces gastric acidity, stabilizes clot, and prevents rebleeding. 3. **H. pylori testing:** Serology, stool antigen, or CLO test identifies H. pylori; if positive, eradication therapy is mandatory to prevent recurrence. 4. **NSAID cessation:** The patient must discontinue ibuprofen; consider gastroprotection if NSAID continuation is necessary. ## Why Other Options Are Wrong 1. **PPI monotherapy without hemostasis:** A visible vessel has 40–50% rebleeding risk. PPI alone is inadequate; endoscopic intervention is mandatory. Waiting 4 weeks risks massive hemorrhage and transfusion dependency. 2. **Immediate surgery:** Surgery (antrectomy/vagotomy) is reserved for failed endoscopic hemostasis (≥2 attempts) or recurrent bleeding despite PPI + H. pylori eradication. It is not first-line. 3. **Blood transfusion alone:** Transfusion addresses anemia but does not stop the bleeding source. The ulcer will continue to bleed without hemostasis, leading to further transfusion requirements and complications.