Sun28November0440PM 22

A 55-year-old male is admitted with a large haematemesis. Three weeks ago he underwent bilateral inguinal hernia repair and has been taking analgesia. The following image was noted on endoscopy.

What is the most appropriate next step in the management of this patient?

(Please select 1 option)

Intravenous glypressin therapy

Oral proton pump inhibitor therapy

Endoscopic adrenaline injection and heater probe application Correct

Surgery

Endoscopic adrenaline injection

Explanation

The endoscopy shows a bleeding duodenal ulcer (approximately in the 9 o'clock position). The most appropriate initial step in the management of this patient is adrenaline injection and heater probe application. Peptic ulceration with stigmata of recent haemorrhage should be treated with two modalities to achieve haemostasis - this has been demonstrated to be significantly superior to use of only a single modality (ie adrenaline injection only) in preventing rebleeding. There is no evidence to suggest the superiority of any combination of two modalities over any other.

Studies have suggested that optimal treatment would now be to commence IV PPI for 72 hours post injection of ulcer. In particular, Lau et al. showed a decrease in recurrent bleeding, although no decrease in mortality.

Reference:

Lau JY, Sung JJ, Lee KK, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Engl J Med. 2000;343:310-6.

Answer Statistics

1

3%

2

14%

3

41%

4

3%

5

41%

Times answered: 273