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Upper GI bleeding — ABIM Board MCQ

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ModerateGastroenterology/HepatologyUpper GI bleedingABIM Board

A 66-year-old man presents with melena and lightheadedness. Blood pressure is 92/58 mm Hg, pulse is 118/min, and hemoglobin is 7.4 g/dL. He takes naproxen daily. After appropriate hemodynamic resuscitation, upper endoscopy reveals a duodenal ulcer with a nonbleeding visible vessel. Which of the following is the most appropriate management of this lesion?

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Correct answer: D — Endoscopic clip or thermal hemostasis followed by high-dose proton pump inhibitor therapy for 72 hours

A nonbleeding visible vessel is a high-risk endoscopic stigma with a substantial risk of recurrent hemorrhage. It requires endoscopic hemostasis, such as clip placement or contact thermal coagulation, followed by high-dose proton pump inhibitor therapy continuously or intermittently for 72 hours. PPI therapy alone is insufficient for a visible vessel. Epinephrine injection should not be used as definitive monotherapy because its hemostatic effect is temporary. Transcatheter arterial embolization is generally used when endoscopic therapy fails, and surgery is reserved for bleeding that cannot be controlled by endoscopic and, when available, angiographic treatment. Naproxen should subsequently be discontinued if possible, and the patient should be tested for and treated for Helicobacter pylori, but neither measure replaces immediate hemostasis.

Reference: American College of Gastroenterology. Laine L, et al. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. American Journal of Gastroenterology. 2021;116:899-917. https://pubmed.ncbi.nlm.nih.gov/33929377/