Jeffrey M. Marks

Introduction

Surgery for bleeding duodenal ulcers is required less often now as a result of advances in endoscopic and interventional radiology techniques and acid suppression agents. When these measures fail to control a bleeding ulcer, however, surgical exposure of the intraluminal posterior wall of the duodenum is required to provide hemostasis.

Principles of Treatment

Patients with upper gastrointestinal bleeding (UGIB) may have either hematemesis or melena/hematochezia, depending on the volume and briskness of the bleeding. Multiple sources for UGIB are well described, including esophageal or gastric varices, gastritis or gastric ulcers, and duodenal ulcers. Comorbid diseases such as portal hypertension, renal failure, and chronic pancreatitis, as well as chronic nonsteroidal antiinflammatory drug (NSAID) use, may help to predict the etiology.

Patients who are seen with symptoms of UGIB initially require full clinical assessment and hemodynamic stabilization. Depending on the amount of blood loss, this may include multiple blood transfusions, medical support of blood pressure, and endotracheal intubation. In patients seen with blood per rectum, placement of a nasogastric tube and aspiration of gastric contents may help confirm an upper GI source for bleeding if clear, nonbloody bile is seen. A nonbloody and nonbilious aspirate does not exclude a postpyloric source of bleeding.

Duodenal ulcers that result in bleeding are usually positioned in the posterior duodenal bulb (Fig. 9-1, A). There are numerous submucosal arterial vessels around the duodenum, but invasion of the gastroduodenal artery is the predominant source for massive duodenal ulcer bleeding (Fig. 9-1, B).

After stabilization of the patient, the first diagnostic (and often therapeutic) intervention is upper endoscopy (Fig. 9-1, C). Multiple endoscopic adjuncts for providing hemostasis are available, including clips, cautery, and injection of sclerotherapy agents. If these endoscopic approaches are unsuccessful and the patient continues to have evidence of bleeding from an identified duodenal ulcer, radiologic interventions are typically used. The gastroduodenal artery is accessed with transarterial catheters through the celiac trunk, and the site of bleeding is then identified and treated with a combination of intraluminal coils, foams, and autologous clots. Vasoactive medications can also be delivered by a subselective catheter left in place with its tip into the gastroduodenal artery to assist in hemostasis.