Bleeding peptic ulcers

Bleeding peptic ulcers

The epidemiology of bleeding peptic ulcers mirrors that of perforated ulcers. In recent years, the population a ff ected has become older and bleeding is commonly associated with the ingestion of NSAIDs. Diagnosis can normally be made endoscopically , although occasionally the nature of the blood - loss precludes accurately identifying the lesion. However, the more experienced the endoscopist, the less likely this is to be a problem. Medical and minimally interventional treatments - Medical treatment has limited e ffi cacy . All patients are commonly started on either an H antagonist or a proton 2 pump inhibitor, and recent evidence confirms the benefit of PPI administration to prevent rebleeding after endoscopy . Meta-analysis of studies suggests that tranexamic acid, an inhibitor of fibrinolysis, may reduce overall mortality . Therapeutic endoscopy can achieve haemostasis in approx - imately 70% of cases, with the best evidence supporting a combination of adrenaline injection with heater probe and/or clips. Therapeutic endoscopy will probably never be e ff ective

80 Pulse >100 /uni00A0 bpm Systolic BP <100 /uni00A0 mmHg Circulatory failure/coronary Renal failure artery disease Liver failure Disseminated malignancy Blood/adherent clot/visible or spurting vessel gastrointestinal tract

the majority of the mortality is associated. In patients where the source of bleeding cannot be identi fied or in those who rebleed after endoscopy , angiography with transcatheter embolisation may o ff er a valuable alternative to surgery in expert centres. The risk of significant ischaemia fol lowing embolisation is low because of the rich collateral blood supply of the stomach and duodenum. The surgeon should be mindful that rescue surgery after failed embolisation is associ ated with poor outcome and it may be advantageous to pro ceed directly to sur gery . Surgical treatment Patients who continue to bleed require surgery except in expert centres with experience of angiographic embolisation where attempts may be made to arrest bleeding and avoid surgery . The surgical team should be immediately available, and an operation should not be delayed if bleeding persists. Patients with a visible vessel in the ulcer base, a spurting vessel or an ulcer with a clot in the base are likely to require surgical treatment. Frail and elderly patients are more likely to die as a result of bleeding than younger patients; thus, paradoxically , they should have early surgery . In general, a patient who has required more than six units of blood needs surgical treatment. The aim of the operation is to stop the bleeding. Preop erative endoscopy can usually identify the site of bleeding, which is most often from a peptic ulcer in the duodenum. At operation it is important that the duodenum is fully mobilised before it is opened as it makes the ulcer much more accessible and also allows the surgeon’s hand to be placed behind the gastroduodenal artery , which is commonly the source of major bleeding. Following mobilisation, the duodenum, and usually the pylorus, is opened longitudinally as in a pyloroplasty . This allows good access to the ulcer, which is usually found posteri orly or superiorly . Accurate haemostasis is important and can be achieved initially by direct pressure. It is the vessel within the ulcer that is bleeding and this should be controlled using well-placed sutures on a small round-bodied needle that under- run the v essel. The pyloroplasty is then closed with interrupted sutures in a transverse direction in the usual fashion. In the case of a large ulcer, the first part of the duodenum may be destroyed, making primary closure impossible. In this circum stance one should proceed to distal gastrectomy with Roux en-Y reconstruction. The duodenal stump may then be closed with T-tube drainage or around a drain to create a controlled fistula. The management of bleeding gastric ulcers is essentially the same. The stomach is opened at an appropriate site ante rior ly and the vessel in the ulcer under-run. Consideration is then given to local excision of the ulcer. If the ulcer is not e xcised, the ulcer margins must be biopsied to exclude malig nancy . Gastrectomy for b leeding is associated with a high perioperative mortality , even if the incidence of recurrent bleeding is less. Bearing in mind that most patients nowadays are elder and unfit, the minimum surgery that stops the bleeding is prob ably optimal (damage control surgery). Acid can be inhibited Georges Dieulafoy , 1851–1919, physician and surgeon, Hôtel-Dieu de Paris, Paris, France, later President of the French Academy of Medicine (1910). ap y will prevent ulcer recurrence. Definite acid-lowering sur - - gery is not now required. Patients on long-term NSAIDs can be managed as outlined in Treatment of peptic ulceration . -