Peptic Ulcer Hemorrhage

• • History of—or risk factors for—peptic ulcer disease (PUD)

  • Acute hemorrhage: Hematemesis or hematochezia perhaps with shock

  • Chronic hemorrhage: Anemia with melena or trace amounts of blood in stool

Epidemiology

• • Most common cause of massive upper GI hemorrhage

  • 20% of patients with PUD will have a bleeding episode, accounting for 40% of deaths from PUD

  • Chronic gastric and duodenal ulcers have about the same tendency to bleed, more severe bleeding with gastric ulcers

  • Bleeding duodenal ulcers are usually located on the posterior surface of the duodenal bulb and erode into the gastroduodenal artery

  • Rebleeding in the hospital has been attended by a death rate of about 30%

  • Gastric ulcer rebleed 3 times more commonly than duodenal ulcers

  • Most instances of rebleeding occur within 2 days from the time the first episode has stopped

Symptoms and Signs

• • Epigastric pain

  • Abdominal tenderness

  • Acute hemorrhage:

  • -Hematemesis or hematochezia

    -Hypotension or shock

  • Chronic hemorrhage:

  • -Weakness

    -Anemia

    -Fecal occult blood

Laboratory Findings

• • Acute hemorrhage: Hct may not be reflective of blood lost

  • Chronic hemorrhage: Anemia

  • Obtain blood for type and cross

  • Prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR) to evaluate for coagulopathy

  • Platelet count to evaluate for thrombocytopenia

  • Serial Hct to follow adequacy of transfusion and ongoing requirements

Imaging Findings

• • Upper GI endoscopy: Bleeding ulcer, visible vessel, ulcer with adherent clot

• • Diagnosis and treatment should be simultaneous

  • Upper GI endoscopy should be performed immediately in cases of acute hemorrhage for diagnosis and possible treatment

Rule Out

• • Other causes of upper GI bleeding than PUD:

  • -Esophageal varices

    -Gastritis

    -Mallory-Weiss syndrome

    -Gastric cancer

• • Acute hemorrhage:

  • -Admission to ICU

    -NG lavage

    -Laboratory tests (CBC, type and cross, PT, PTT, INR)

    -Upper GI endoscopy

  • Chronic hemorrhage:

  • Laboratory tests (CBC, PT, PTT, INR)

  • Urgent endoscopy (upper and lower if source unclear)

When to Admit

• • All patients with obvious GI bleeding should be admitted

• • Replace blood loss with crystalloid and blood products

  • NG lavage

  • Endoscopy for localization and possible treatment

Surgery

Indications

• • Massive hemorrhage with shock

  • Ongoing transfusion requirements

  • Recurrent hemorrhage

  • Excise ulcer (gastric) or oversew vessel (duodenal) and vagotomy

Medications

• • H2 blockers, proton pump inhibitors (may reduce risk of rebleed)

Treatment Monitoring

• • Twice-daily CBC

  • Treatment of PUD after bleeding episode

Complications

• • Rebleeding: Repeat endoscopic therapy for first rebleeding episode if patient is stable

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