ASGE Annual Postgraduate Course: Clinical Challenges and Real-Time Decision Making in GI Endoscopy (Live and Virtual)

Das_UGI Bleeding

Pdf Summary

This video case discussion focuses on a 60-year-old man with recurrent melena, hemorrhagic shock, and multiple duodenal ulcers. The patient had previously received treatment with TTS endoscopic clip placement during his current hospital admission.<br /><br />During the repeat EGD, the following findings were observed: clean based, Forest III, clipped ulcers in the duodenal bulb, a ~1.5cm Forrest 1a/1b ulcer in the second portion of the duodenum, across from the ampulla. To address the bleeding, 3cc of 1:100,000 epinephrine was injected at the base of the duodenal ulcer, resulting in a slowing of bleeding and mucosal blanching.<br /><br />The Forrest classification of peptic ulcers was discussed. The options for further intervention were also explored. These options included repeat attempts at bipolar cautery, choosing between 10Fr and 7Fr, increasing wattage, using a coagulation grasper, clipping, using TTS, considering OTSC location, applying hemostatic powder, or considering vascular intervention.<br /><br />The decision-making process continued with considerations of whether the current intervention was enough or if adjunctive clip placement was needed. The risk of rebleeding was also discussed.<br /><br />Further management considerations included the use of PPI, the duration, route, and frequency of administration, resumption of anticoagulation, timing of resumption, future NSAID use, PPI prophylaxis, and the approach to rebleeding.<br /><br />Overall, this video case discussion provides valuable insights into the treatment and management options for a patient with recurrent melena and duodenal ulcers. It highlights the importance of accurate classification, appropriate interventions, and post-bleed management strategies to minimize the risk of rebleeding.

Keywords

60-year-old man

recurrent melena

hemorrhagic shock

multiple duodenal ulcers

TTS endoscopic clip placement

EGD

Forrest classification

bipolar cautery

hemostatic powder

PPI prophylaxis