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Peptic ulcer bleeding — ESEGH MCQ

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ModerateGI BleedingPeptic ulcer bleedingESEGH

A 73-year-old man presents with haematemesis. After resuscitation, he is haemodynamically stable. Index oesophagogastroduodenoscopy shows a 15-mm posterior duodenal bulb ulcer with a non-bleeding visible vessel (Forrest IIa), but no active bleeding. What is the most appropriate next management?

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Correct answer: B — Endoscopic haemostatic therapy followed by proton pump inhibitor therapy

A non-bleeding visible vessel is a Forrest IIa lesion and remains a high-risk stigma despite the absence of active bleeding. It requires endoscopic haemostasis, using an appropriate mechanical or thermal modality, followed by proton pump inhibitor therapy to reduce rebleeding. Adrenaline, if used, should not be the sole haemostatic modality. PPI therapy alone and observation leave the exposed artery untreated, while omitting post-endoscopy acid suppression increases rebleeding risk. A posterior duodenal ulcer may involve the gastroduodenal artery and warrants particular vigilance; however, transcatheter arterial embolisation is not first-line treatment before attempted endoscopic haemostasis in this stable patient. It is principally a rescue option after failed endoscopic treatment, although prophylactic embolisation may be considered after haemostasis in selected exceptionally high-risk cases.

Reference: NICE. Acute upper gastrointestinal bleeding in over 16s: management (CG141), recommendations 1.4.1–1.4.4. Published 2012, updated 2016. https://www.nice.org.uk/guidance/cg141/chapter/Recommendations