Question 9#

The optimal initial management of a patient hospitalized for a bleeding peptic ulcer is:

a. Ulcer oversew
b. Vagotomy and pyloroplasty
c. Distal gastrectomy
d. Intravenous PPIs

Correct Answer is D


The management of bleeding peptic ulcer is summarized in the algorithm in Fig. below. All patients admitted to hospital with bleeding peptic ulcer should be adequately resuscitated and started on continuous IV PPI. Seventy-five percent of patients will stop bleeding with these measures alone, but 25% will continue to bleed or will rebleed in hospital. Among the high risk group, endoscopic hemostatic therapy is indicated and usually successful. Only then should surgical intervention be considered, with indications including massive hemorrhage unresponsive to endoscopic control and transfusion requirement of more than four to six units of blood, despite attempts at endoscopic control. Long-term maintenance PPI therapy should be considered in all patients admitted to hospital with ulcer complications.

 Algorithm for the treatment of bleeding peptic ulcer:

ASA = acetylsalicylic acid; EGO = esophagogastroduodenoscopy; IV = intravenous; OR = operating room; PPI = proton pump inhibitor; PRBC = unit of packed red blood cells; PT = prothrombin time; PTI = partial thromboplastin time; Rx = treatment.