o Urgent EGD is the treatment of choice in the setting of bleeding duodenal ulcer for both diagnostic and therapeutic reasons. Endoscopy provides an opportunity to visualize the ulcer, to determine the degree of active bleeding, and to attempt hemostasis by direct measures. See Surgical Care for a full discussion of endoscopic therapy. Medical management usually serves as an adjunct to direct endoscopic therapy.

o Acid suppression is the general pharmacologic principle of medical management of acute bleeding from a peptic ulcer. Reducing gastric acidity is believed to improve hemostasis primarily through the decreased activity of pepsin in the presence of a more alkaline environment. Pepsin is believed to antagonize the hemostatic process by degrading fibrin clots. By suppressing acid production and maintaining a pH above 6, pepsin becomes markedly less active.

o Two classes of acid-suppressing medications currently in use are H2RAs and PPIs. Both classes are available in intravenous or oral preparations. Examples of H2RAs include ranitidine, cimetidine, famotidine, and nizatidine. Examples of PPIs include omeprazole, pantoprazole, and lansoprazole and rabeprazole.

o H2RAs are an older class of medications, and their use in the setting of an actively bleeding duodenal ulcer has been largely superseded by the use of PPIs. Many gastroenterologists assert that intravenous PPI therapy maintains hemostasis more effectively than intravenous H2RA. Intravenous H2RA no longer has a role in the management of bleeding peptic ulcers (Barkun, 2003).

o Parenteral PPI is indicated after successful endoscopic therapy of ulcers with high-risk signs, such as active bleeding, visible vessels, and adherent clots. Parenteral PPI use before endoscopy is common practice, and evidence from a recent Canadian database (RUGBE) indicates some benefit in decreasing rebleed rates (Barkun, 2003). However, no randomized control trial has provided evidence to support its use in this setting.

o When indicated, intravenous pantoprazole or omeprazole is administered as an 80-mg bolus followed by a continuous 8-mg/h infusion for 72 hours. This treatment is changed to oral PPI therapy after 72 hours if no rebleeding occurs.

o Whether acid suppression improves therapeutic outcomes of peptic ulcers compared with placebo may be more important than the issues raised above. Many researchers have compared parenteral PPI therapy to placebo. Overall, the results demonstrate shorter bleeding and decreased incidence of rebleeding with PPI therapy. Some studies have demonstrated decreased need for emergency surgery and transfusion; however, evidence that parenteral PPI reduces mortality from ulcer bleeding is relatively recent (Bardou, 2003).
Endoscopic intervention is the primary mode of treating bleeding ulcers. Surgical management of duodenal ulcers is generally reserved for refractory ulcers and bleeding ulcers that fail to respond to medical management.

* Endoscopic therapy

o Endoscopic therapeutic intervention is indicated for bleeding duodenal ulcers with high-risk signs (active bleeding, visible vessels, and adherent clots).

o Several tools are available to the endoscopist to achieve hemostasis; these include bipolar cautery, use of a heater probe or hemoclips, argon plasma coagulation, and local injection of epinephrine and other agents.

+ Bipolar cautery and use of a heater probe both apply heat to the ulcer and cauterize the bleeding vessel. Hemoclip placement is a promising therapy but requires a skilled endoscopist and a lesion amenable to clip placement.

+ Injection with epinephrine achieves hemostasis through the vasoconstrictive effect of epinephrine. However, some physicians argue that it is effective mainly through the tamponade effect of local fluid injection. This is supported by the fact that injection of saline achieves comparable hemostasis.

+ Argon plasma coagulation uses heat to achieve hemostasis. One group compared argon plasma coagulation with heater probe and found no difference in incidence of rebleeding or the need for surgical intervention.

* Urgent surgical management

o The indications for urgent surgery include (1) failure to achieve hemostasis endoscopically, (2) recurrent bleeding despite endoscopic attempts at achieving hemostasis (many advocate surgery after 2 failed endoscopic attempts), and (3) perforation.

o In general, 5% of bleeding ulcers eventually require operative management. Most emergent surgical procedures involve simple oversewing of the ulcer to achieve hemostasis.

* Elective surgical management

o The indications for elective surgical management include (1) refractoriness to medical treatment, (2) intolerance to medications, and (3) noncompliance with medications.

o With the advent of improved antisecretory therapy and with the discovery of H pylori, elective surgical management of duodenal ulcer has become much less common in areas where such treatment is readily available.

* Elective surgical approaches

o Vagotomy

+ Vagotomy involves resection of the vagus nerve, which eliminates the autonomic stimulation of the parietal cells. Historically, a truncal vagotomy was performed; however, this led to gastric atony and subsequent stasis in as many as 20% patients. Currently, selective vagotomies are the procedures of choice.

+ Selective vagotomy preserves the celiac and hepatic branches of the vagus nerve, thus decreasing the incidence of gastric atony. However, a gastric drainage procedure (eg, pyloroplasty) remains an essential component of this surgical approach. Highly selective vagotomy results in denervation of the parietal cells but preserves nerves supplying the pyloroantral region.

+ The Billroth I and Billroth II are the 2 types of truncal vagotomy and antrectomy. These surgical approaches carry a mortality rate of approximately 1% and are currently performed much less frequently.

Consultations: Surgical consultation is recommended for all patients with bleeding ulcers, especially those at high risk of significant bleeding. Such ulcers include those that are causing hemodynamic instability, those that are actively bleeding, and those that are showing a visible vessel on endoscopy.

http://www.emedicine.com/MED/topic591.htm