61. Bleeding peptic ulcer

1. Definition

• Bleeding peptic ulcer → haemorrhage from a gastric or duodenal ulcer eroding a vessel in its base
• Upper gastrointestinal (UGI) bleeding → source proximal to the ligament of Treitz

2. Epidemiology

• Peptic ulcer → 36% of UGI bleeding (commonest cause)
• Mortality of ulcer bleeding → 5.8%; after surgery → 30%

3. Aetiology and risk factors

• Helicobacter pylori (H. pylori)
• Non-steroidal anti-inflammatory drugs (NSAIDs), aspirin
• Antiplatelet and anticoagulant drugs
• Elderly patients with comorbidity
• Stress ulcers → intensive care, burns, head injury

4. Pathogenesis

• Ulcer base erodes an artery:
  • Posterior duodenal ulcer → gastroduodenal artery (GDA)
  • Lesser curvature gastric ulcer → left gastric artery
• Anterior duodenal ulcers → ooze or perforate, rarely bleed massively
• Bleeding gastric ulcers → antrum or incisura (77%), higher lesser curve (15%)
• Acid (pH < 6) → impairs platelet aggregation and clot stability

5. Classification

Forrest classification (endoscopic)

1. Ia → spurting arterial bleeding
2. Ib → oozing
3. IIa → non-bleeding visible vessel
4. IIb → adherent clot
5. IIc → flat pigmented spot
6. III → clean base

Risk of further bleeding (without endoscopic therapy)

• Active bleeding → 55%
• Visible vessel → 43%
• Adherent clot → 22%
• Flat spot → 10%
• Clean base → 5%

Risk scores

• Glasgow-Blatchford score (GBS) → before endoscopy; predicts need for intervention; GBS 0 → safe discharge
• Rockall score:
  • Pre-endoscopy → age, shock, comorbidity
  • Full → adds diagnosis and stigmata of recent haemorrhage
  • Predicts mortality better than re-bleeding

6. Clinical picture

Symptoms

• Haematemesis → fresh blood; worse prognosis
• Coffee-ground vomiting → altered blood; not active bleeding
• Melaena → black tarry stool
• Haematochezia → massive UGI bleeding
• Syncope, dizziness
• History of dyspepsia, NSAID or anticoagulant use

Signs

• Tachycardia, hypotension, postural drop
• Pallor, cold peripheries
• Melaena on rectal examination
• Epigastric tenderness

7. Diagnosis

Laboratory

• Haemoglobin → poor guide to acute blood loss
• Urea → raised (digested blood)
• Clotting screen, platelets
• Crossmatch
• Liver function tests → suspected varices

Imaging

• Oesophagogastroduodenoscopy (OGD) → diagnosis and treatment
  • Unstable or ongoing bleeding → emergency OGD after resuscitation
  • Stable → within 24 h
• CT angiography → bleeding not found or not controlled at endoscopy
• Mesenteric angiography → localisation and embolisation

8. Differential diagnosis

• Oesophageal or gastric varices
• Mallory-Weiss tear
• Oesophagitis
• Gastritis, erosive duodenitis
• UGI malignancy
• Dieulafoy's lesion → within 6 cm of the cardia
• Aortoduodenal fistula → previous aortic surgery

9. Treatment

Conservative

• Resuscitation:
  • 2 large-bore cannulas
  • Crystalloid
  • Red cells when ≥ 30% blood volume lost
  • Platelets → keep > 50 × 10⁹/L
  • Fresh frozen plasma (FFP) → after > 1 blood volume lost
• Intravenous proton pump inhibitor (PPI) before endoscopy
• Endoscopic therapy → Forrest Ia, Ib, IIa; IIb after clot removal:
  • Dual therapy → adrenaline 1:10 000 injection + clip or thermal coagulation
  • Adrenaline alone → not adequate
  • Haemostatic powder → rescue
• After endoscopic therapy → high-dose PPI: omeprazole 80 mg bolus, then 8 mg/h for 72 h
• H. pylori → test, eradicate, confirm eradication
• Re-bleeding:
  • Repeat endoscopic therapy → controls 75%
  • Transarterial embolisation (TAE) → controls 64–91%; first choice after failed surgery
  • Surgery → ulcer > 2 cm with shock
• Endoscopic failure more likely:
  • Ulcer > 2 cm
  • Lesser curvature ulcer
  • Posterior or superior wall of the duodenal bulb

Surgical

• Indications:
  1. Massive bleeding not controlled at endoscopy
  2. Re-bleeding after 2 endoscopic attempts
  3. Re-bleeding with shock from an ulcer > 2 cm
  4. TAE not available or failed
• Bleeding duodenal ulcer:
  1. Kocher manoeuvre → mobilise the duodenum
  2. Longitudinal duodenotomy across the pylorus
  3. Control bleeding with finger pressure
  4. Under-run the GDA above and below the ulcer (0 or 1-0 suture)
  5. Medial U-stitch → transverse pancreatic artery
  6. No lateral stitch → common bile duct (CBD)
  7. Close as a Heineke-Mikulicz pyloroplasty
• Bleeding gastric ulcer:
  • Under-run or excise the ulcer, with biopsy
  • Distal gastrectomy → large or suspicious ulcer
• Vagotomy → no longer added; PPI and eradication replace it
• Giant posterior DU → distal gastrectomy with ulcer exclusion, controlled duodenostomy

10. Complications

• Re-bleeding
• Duodenal leak or stump blow-out
• CBD injury from deep stitches
• Pancreatitis
• Aspiration pneumonia
• Multi-organ failure
• Ischaemic events → myocardial infarction, stroke

11. Prognosis

• Mortality → 5.8% for all patients; 30% after surgery
• Rockall score → predicts death