A 48-year-old woman on chronic aspirin (500 mg BD) for secondary stroke prevention presents with acute onset epigastric pain, vomiting, and black tarry stools. On examination, blood pressure is 95/60 mmHg, heart rate 110/min, and she appears pale. Haemoglobin is 8.5 g/dL (baseline 12 g/dL). Upper GI endoscopy reveals a 2 cm ulcer on the posterior wall of the first part of the duodenum with a visible vessel at the base. H. pylori serology is negative. What is the most appropriate next step in management?

Explanation

## Clinical Presentation: Bleeding Peptic Ulcer This patient has **acute upper GI bleeding from a duodenal ulcer** with haemodynamic instability (hypotension, tachycardia) and significant anaemia. The visible vessel on endoscopy indicates **high risk of rebleeding** and requires urgent haemostasis. ## Management Algorithm for Bleeding Peptic Ulcer ```mermaid flowchart TD A[Upper GI bleeding + haemodynamic instability]:::outcome --> B[Resuscitation: IV access, fluids, cross-match]:::action B --> C[Urgent endoscopy]:::action C --> D{Visible vessel or arterial spurting?}:::decision D -->|Yes| E[Endoscopic haemostasis]:::action E --> F[Adrenaline injection + clip/band]:::action F --> G[High-dose PPI infusion]:::action D -->|No| H[Conservative management + PPI]:::action G --> I[Cessation of offending agent]:::action I --> J[Assess need for repeat endoscopy]:::decision J -->|Rebleeding| K[Repeat endoscopy or IR/surgery]:::urgent J -->|No rebleeding| L[Continue PPI, monitor]:::action ``` ## Endoscopic Haemostasis: Technique and Rationale **Key Point:** Endoscopic therapy is the gold standard for bleeding peptic ulcers with visible vessels or arterial spurting. Success rate: 85–95%. ### Two-Agent Approach | Agent | Mechanism | Indication | | --- | --- | --- | | **Adrenaline 1:10,000** | Vasoconstriction + platelet aggregation | First-line; injected around the vessel | | **Haemoclip or band** | Mechanical compression of vessel | Applied after adrenaline for definitive haemostasis | **High-Yield:** Combination therapy (adrenaline + clip) is superior to either agent alone; rebleeding risk drops to <10%. ## Post-Haemostasis Management 1. **High-dose PPI infusion:** Omeprazole 80 mg bolus, then 8 mg/hour continuous infusion for 72 hours - Maintains gastric pH >6, which optimizes platelet aggregation and clot stability - Reduces rebleeding risk by ~50% 2. **Cessation of aspirin:** Discontinue immediately in the acute phase - Aspirin is the likely culprit (NSAIDs cause 60% of non-H. pylori ulcers) - Restart only after haemostasis is secured and ulcer has healed (typically 4–6 weeks) 3. **H. pylori status:** Negative serology rules out H. pylori; no eradication therapy needed **Clinical Pearl:** In patients requiring long-term antiplatelet therapy (e.g., post-stroke), consider switching to a different antiplatelet agent (e.g., clopidogrel) or adding PPI prophylaxis once ulcer heals. ## Why Other Options Are Incorrect **Warning:** Delayed endoscopy (24 hours) is inappropriate in a haemodynamically unstable patient with a visible vessel. Rebleeding risk is high; intervention must be immediate. Surgery is now reserved for: - Failure of endoscopic haemostasis (2 attempts) - Massive transfusion requirement (>6 units in 24 hours) - Patient refusal of endoscopy - Rare cases of recurrent rebleeding despite repeat endoscopy Conservative management without endoscopy is contraindicated when a visible vessel is present — this carries unacceptable rebleeding risk.