Question

A 65-year-old woman with a known duodenal ulcer being treated with H2 blocker therapy is admitted with upper gastrointestinal bleeding. After blood replacement is begun, the next step in her management should be

• A. Institute anti-H. pylori treatment
• B. Repeated gastric lavage
• C. Endoscopy and coagulation of the bleeding vessel
• D. Pyloroduodenotomy and oversewing of the bleeding vessel

Hint:

Think about what step both diagnoses the source and can stop the bleeding in the same sitting.

Answer 1

The Correct Option is C

Step 1: Understanding the Question:
The question asks what should be done next in a patient with an upper GI bleed from a known duodenal ulcer, once resuscitation with blood has already been started.

Step 2: Key Concept or Approach:
Once a bleeding patient has been resuscitated enough to be stabilised, the priority is to identify the exact bleeding point and, where possible, achieve haemostasis using the least invasive effective method before considering surgery. Upper GI endoscopy is both diagnostic and therapeutic in this setting.

Step 3: Working Through the Options:
Starting anti-H. pylori treatment may help long-term ulcer healing and reduce the chance of recurrence, but it does nothing to control active bleeding and H. pylori status has not even been established yet, so it is not the next step. Repeated gastric lavage was once used to clear the stomach and gauge whether bleeding was ongoing, but it does not by itself stop the bleeding and is not considered the definitive next step in current practice. Surgery, such as pyloroduodenotomy with oversewing of the bleeding vessel, is reserved for when endoscopic control fails, bleeding recurs after endoscopic therapy, or the patient remains unstable despite adequate resuscitation, so it is not the immediate step here. Endoscopy allows the bleeding ulcer to be seen directly and, in the same sitting, treated with injection, thermal coagulation, or clipping to achieve haemostasis, which makes it the correct next step once resuscitation is underway.

Step 4: Conclusion:
The next step should be endoscopy with coagulation of the bleeding vessel.