Bleeding Peptic Ulcer
Bleeding Peptic Ulcer
* Incidence: More common with posterior duodenal ulcer which is
related to gastroduodenal artery ( artery of hemorrhage ) .
* Predisposing Factors: Any factor leading to acute exacerbations
and inflammation of the ulcer e.g. NSAID, alcohol , nervousness and
stress ….etc.
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Bleeding Peptic Ulcer
* Pathology:
• Bleeding may be:
1. Mild: Due to erosion of the friable granulation tissue in the floor
of the ulcer.
2. Moderate: Due to erosion of a small vessel in the floor of the
ulcer.
3. Severe: Due to erosion of a large extra-gastric vessel
(gastroduodenal or splenic).
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Bleeding Peptic Ulcer
• Fate:
1. In young patient , recent ulcer or mild bleeding → in most of
these cases bleeding stops spontaneously due to clot
formation in the ulcer fioor obstructing the source of bleeding ,
therefore conservative treatment should be considered .
2. In old patient , marked chronicity or massive bleeding( arteries
are incapable to retract to stop bleeding due to fibrosis &
atherosclerosis ) → no spontaneous cessation of bleeding
, therefore surgical treatment should be considered .
* Complications: Hypovolaemic shock & respiratory complications.
* Clinical Picture:
1. There may be long history of ulcer dyspepsia or it may be the
1st. presentation.
2. Melaena:
▪ In mild cases (50- 100 c.c.) occurs alone the patient feels
faint & collapse then pass loose dark tarry offensive stools.
▪ In massive bleeding, red blood may pass with stool.
3. Haematemesis: In severe cases.
▪ Vomiting blood which is dark coffee ground (acid haematin) or
bright red in massive bleeding.
▪ It is always associated with melaena.
4. Manifestation of hypovolaemic shock: (Mention in short).
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Bleeding Peptic Ulcer
5. There may be local abdominal pain, tenderness & rigidity over
the ulcer.
6. Exclude: Portal hypertension & false haematemesis.
* Investigations:
1. Emergency endoscopy: to visualize the bleeding ulcer and to
exclude other causes of haematemesis specially oesophageal
varices.
2. HB% & Haematocrite estimation: Decrease in any haemorrhage
after few hours when haemodilution occur and progressively
decrease in any continuous hemorrhage .
* D.D.: Other causes of haematemesis (mention them).
* Treatment:
I) Consevative Treatment & resuscitation: ( main line of
treatment )
1. Hospitalization and ICU admission .
2. Anti-shock measures: Rest, sedative , oxygen by mask , I.V.
fluild & blood transfusion.
3. Ryle’s Tube:
♦ To detect the amount of bleeding.
♦ Instillation of food , antacids & cold adrenalised saline.
4. I.V. Omeprazol.
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Bleeding Peptic Ulcer
5. Feeding: Cold drinks and soft diet should be given after control
of bleeding.
6. Avoid Pulmonary complications: Prophylactic antibiotics &
chest physiotherapy.
7. Observation: For vital signs, urine output , CVP, haematocrite
& amount of bleeding ……..etc.
II) Once the general condition is stabilized, urgent upper GIT
endoscopy , which is the main line of treatment nowadays
if bleeding does not stop spontaneously ,is performed to
diagnose the cause of bleeding, detect site of bleeding before
the operation ( if open surgery is performed ) & to control
bleeding by :
▪ Laser photocoagulation .
▪ Injection of ulcer base by adrenaline or alcohol .
▪ Endoscopic haemostasis
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Bleeding Peptic Ulcer
III) Interventional Radiology
▪ Angiography with transcatheter embolization provides a
non‐operative option for patients in whom bleeding location has
not been identified or controlled by endoscopy.
IV) Surgical Treatment:
▪ Indications:
1. Failure of conservative treatment (continous bleeding &
progressive shock).
2. Severe initial bleeding ( 2000 ml or more )
3. Recurrent bleeding after endoscopic haemostasis.
4. Old patient .
5. Long standing chronicity.
6. Associated pathology requiring surgery e.g. perforation.
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Bleeding Peptic Ulcer
▪ Methods:
a) Bleeding duodenal ulcer:
▪ The pylorus and duodenum are opened longitudinally
to expose the bleeding ulcer .
▪ Control bleeding as follows :
a) Bleeding from the granulation tissue in the floor →
obliterate the ulcer by sutures.
b) Bleeding from a vessel in the floor → under run on
either side of the bleeding point .
c) Bleeding from large extra-gastric vessel → ligate
outside the stomach.
▪ The pylorus and duodenum are closed transversely thus
performing pyloroplasty .
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Bleeding Peptic Ulcer
b) Bleeding gastric ulcer:
▪ Most popular is control bleeding , obliterate or
remove the ulcer & biopsy to exclude malignancy .
After surgery , medical treatment is the rule for peptic ulcer .
