A 30 yr old male patient presented with massive haemetemesis. Upper GI endoscopy shows a 2x2 cm ulcer on the posterior aspect of the first pa of the duodenum. Bleeding vessel is seen, but could not be controlled endoscopically. Patient's pulse rate is 100, BP 110/70, Hb 10 gms% after blood transfusion. What will be the next line of management is:
Duodenotomy, with ligation of bleeding vessel, truncal vagotomy with pyloroplasty. The surgical treatment for peptic ulcer disease has changed dramatically. The elective operations for peptic ulcer disease have been viually eliminated! Antibiotics have become primary anti-ulcer therapy with the realization that in most cased, peptic ulceration is an infectious disease. Operative interventions are now reserved for complications of the ulcer disease. 3 complications are most common: - hemorrhage - perforation - obstruction For gastric ulcers, surgical indications also include intractability or nonhealing of the ulcer because of the risk of cancer. Management of hemorrhage: Upper gastrointestinal endoscopy is the intial diagnostic test if peptic ulcer is suspected, following resuscitation. Endoscopy is able to identify the site and source of bleeding in over 90 % of patients. First line of treatment for bleeding ulcer is endoscopic hemostasis. Methods of endoscopic therapy include: -Thermal coagulation by bipolar electrocoagulation or - Direct application of heat through a heater probe or - Injection of epinephrine into the base of the bleeding peptic ulcer Operative intervention is required when -The endoscopic treatment fails - There is massive hemorrhage leading to shock or cardiovascular instability - Prolonged blood loss requiring continuing transfusion - Recurrent hemorrhage requiring hospitalization Emergent operative therapy consists of duodenotomy with direct suture ligagtion of the bleeding vessel in the ulcer base. Post operatively patients are given antibiotic therapy against H. pylori. According to Maingot- role of acid reducing surgeries like vagotomy have decreased significantly. But steps like vagotomy combined with pyloroplasty or antrectomy are still being performed depending on individual preferences to cure the ulcer. Here this patient not controlled by endoscopic methods should undergo emergent surgery consisting of only duodenotomy and bleeding vessel ligation. But since this is not one of the options we would choose the one with the least morbidity. As mentioned above another indication for surgery in gastric ulcer is failure of a recurrent ulcer to respond to medical therapy. This is because of the risk of cancer in nonhealing gastric ulcer (there is no such risk in duodenal ulcer). For benign gastric ulcer, the elective operation of choice is usually a distal gastrectomy including the ulcer with either gastroduodenal (Billroth I) or gastrojejunal (Billroth 11) anastomosis.
IV pantoprazole
Paial gastrectomy including the bleeding segment
Duodenotomy, with ligation of bleeding vessel, truncal vagotomy with pyloroplasty
Duodenotomy, ligation of bleeding vessel with truncal vagotomy, antrectomy