A 30 year old male patient presents with a peptic ulcer in the posterior duodenum with a bleeding vessel at the base. The bleeding is not controlled endoscopically. On examination his heart rate is 100/min, BP is 110/76 mm of Hg and Hb is 10 gm/dl after transfusion. Next step in his management will be:
|A||Proton pump inhibitors|
|B||Duodenotomy with controlled bleeder and pyloroplasty|
|C||Duodenotomy with controlled bleeder and truncal vagotomy with antrectomy|
|D||Partial gastrectomy involving the bleeding ulcer|
Indications for Surgery in Gastrointestinal Hemorrhage
a. The first priority at operation is control of the hemorrhage. After this is accomplished, a decision must be made regarding the need for a definitive acid-reducing procedure.
b. Each of these steps varies depending on whether the lesion is a duodenal or gastric ulcer.
c. The first step in the operation for duodenal ulcer is exposure of the bleeding site. Because most of these lesions are in the duodenal bulb, longitudinal duodenotomy or duodenal pyloromyotomy is performed. Hemorrhage can typically be controlled initially with pressure and then direct suture ligation with nonabsorbable suture.
d. When ulcers are positioned anteriorly, typically four-quadrant suture ligation suffices. A posterior ulcer eroding into the pancreaticoduodenal or gastroduodenal artery may require suture ligature of the vessel proximal and distal to the ulcer.