Massive upper gastrointestinal bleeding caused by gastric and duodenal ulcers is characterized by hematemesis and large volumes of melena, leading to decreased red blood cell count, hemoglobin concentration, and hematocrit levels, along with symptoms such as rapid heart rate, reduced blood pressure, and in severe cases, shock.
Etiology and Pathology
Bleeding occurs due to the rupture of blood vessels eroded by inflammation at the base of the ulcer, most commonly resulting in arterial bleeding. Duodenal ulcer bleeding often involves branches of the gastroduodenal artery located in the posterior wall of the duodenal bulb, while gastric ulcer bleeding frequently occurs along the lesser curvature of the stomach.
Clinical Manifestations
Clinical presentations are related to the volume and rate of bleeding. Patients with small amounts of bleeding may only experience melena. Those with large and rapid bleeding may also present with hematemesis, with the vomitus appearing bright red. Symptoms such as dizziness, blurred vision, palpitations, or weakness are often reported before melena occurs. In more severe cases, syncope and shock may develop. Patients losing more than 800 mL of blood over a short time may exhibit irritability, a thready and rapid pulse, rapid breathing, and cold, clammy extremities. During bleeding episodes, abdominal symptoms are usually not prominent. Blood accumulation in the intestinal tract increases peristalsis, leading to hyperactive bowel sounds. Serial measurements of red blood cell count, hemoglobin concentration, and hematocrit levels assist in estimating the volume and rate of blood loss.
Diagnosis and Differential Diagnosis
The differentiation of ulcer-related bleeding requires distinguishing it from bleeding caused by esophagogastric variceal rupture, gastric cancer, or stress ulcers. Patients with ulcer-related bleeding often have a history of peptic ulcer disease. Those with esophagogastric variceal bleeding typically have a history of liver cirrhosis, with associated features such as dull facial complexion, visible superficial abdominal veins, and skin findings like spider angiomas. Stress ulcer bleeding is commonly associated with severe infections, trauma, or the use of corticosteroids or NSAIDs. Gastroscopy confirms the site and source of bleeding, while arterial angiography can also identify the bleeding site.
Treatment
Restoration of Circulating Blood Volume
Balanced salt solutions are rapidly infused, along with a cross-match for transfusion. Monitoring of vital signs, including heart rate, blood pressure, urine output, and peripheral circulation, is essential. When available, the placement of a central venous catheter allows for measurement of central venous pressure, guiding fluid replacement volume and speed to maintain adequate respiratory and renal function.
Nasogastric Tube Placement
Residual blood in the stomach is suctioned, and the stomach is irrigated until the aspirate is clear. A solution of 200 mL of 4°C saline containing 8 mg norepinephrine may be introduced via the tube, with the tube clamped for about 30 minutes. This process can be repeated every 4–6 hours as needed.
Medical Therapy
Hemostatic agents are administered either intravenously or intramuscularly. Intravenous H2 receptor antagonists or proton pump inhibitors reduce gastric acid secretion. The use of somatostatin analogs is also recommended.
Endoscopic Treatment
After confirming the bleeding site with gastroscopy, hemostasis can be achieved using techniques such as electrocautery, application of hemostatic powder, or placement of vascular clips.
Surgical Treatment
Approximately 10% of patients with gastric or duodenal ulcer bleeding require surgical intervention. Indications for surgery include:
- Failure of non-surgical hemostasis.
- Rapid bleeding with the onset of shock symptoms in the short term.
- Older patients with arterial sclerosis and a low likelihood of spontaneous cessation of bleeding.
- Recurrent bleeding expected in the short term despite temporary cessation of non-surgical bleeding.
Surgical options include:
- Transfixion Ligation of the Bleeding Site: For bleeding ulcers in the posterior wall of the duodenal bulb, the anterior wall may be incised to ligate the ulcer site. This approach is suitable for elderly or debilitated patients who cannot tolerate prolonged surgery.
- Partial Gastrectomy: For ulcers managed with partial gastrectomy, ligation of the ulcer site and management of surrounding blood vessels are required. This option addresses both the bleeding and the underlying ulcer disease.