bubble_chart Overview

Gastric and duodenal ulcers complicated by bleeding are one of the common causes of upper gastrointestinal hemorrhage. Bleeding occurs due to the erosion and rupture of blood vessels caused by the ulcer. When capillaries are damaged, occult blood is only detected during stool tests; when larger blood vessels are damaged, melena and hematemesis occur. Typically, symptoms worsen before bleeding, and upper abdominal pain diminishes or disappears after bleeding.

bubble_chart Etiology

Massive bleeding from an ulcer is the result of the ulcer eroding and rupturing the underlying blood vessels, mostly involving medium-sized arteries. Ulcers that cause significant bleeding are typically located on the lesser curvature of the stomach or the posterior wall of the duodenum. Bleeding from gastric ulcers on the lesser curvature often originates from branches of the right or left gastric arteries, while bleeding from duodenal ulcers usually stems from the superior pancreaticoduodenal artery or the gastroduodenal artery and their branches. Lateral wall rupture of a blood vessel is less likely to stop bleeding spontaneously compared to bleeding from a severed end. Sometimes, due to reduced blood volume and lowered blood pressure after massive bleeding, a clot forms at the site of the ruptured vessel, allowing the bleeding to stop on its own. However, about 30% of cases may experience a second episode of massive bleeding.

bubble_chart Clinical Manifestations

Most patients have a history of ulcers before bleeding, and about 10–15% of ulcer patients with massive bleeding do not exhibit ulcer symptoms before the hemorrhage. Once massive bleeding occurs, patients will show the following signs.

1. Tarry stool and hematemesis: In most cases of massive ulcer bleeding, the onset is sudden, and the bleeding is usually not accompanied by abdominal pain. Patients often first experience nausea, vertigo, and upper abdominal discomfort, followed by hematemesis or tarry stool, or both simultaneously. Hematemesis is mostly due to upper gastrointestinal bleeding in the duodenum, while tarry stool can occur in any part of the digestive tract. However, those with hematemesis will inevitably have tarry stool. In terms of ulcer disease, sudden massive hematemesis without black blood clots is often indicative of gastric ulcer bleeding, whereas tarry stool alone is more likely due to duodenal ulcer bleeding.
2. Shock: When blood loss reaches 400 milliliters, the compensatory phase of shock appears, characterized by pale complexion, thirst, rapid and strong pulse, and normal or slightly elevated blood pressure. When blood loss reaches 800 milliliters, obvious shock symptoms may occur, including cold sweating, thready and rapid pulse, shallow and rapid breathing, and decreased blood pressure.
3. Anemia: With massive bleeding, hemoglobin, red blood cell count, and hematocrit levels all decrease. In the early stages, due to hemoconcentration, the decrease may not be obvious. Therefore, short-term repeated measurements are necessary. Repeated testing can reveal the severity of the bleeding, whether it is still ongoing or has stopped, and whether the treatment is effective.
4. Other symptoms: For ulcer patients with massive bleeding in the shock phase, complex examinations are not advisable, but a quick and gentle physical examination is still necessary. The presence of peritoneal irritation signs may indicate concurrent ulcer perforation.

bubble_chart Auxiliary Examination

1. Fiberoptic gastroscopy has a positive detection rate of over 90%.
2. Selective celiac artery angiography may sometimes reveal contrast medium leaking from the bleeding point of an ulcer into the digestive tract.

bubble_chart Diagnosis

Symptoms

1. Small amounts of repeated bleeding, manifested as anemia and positive fecal occult blood test.
2. Massive bleeding, presenting with hematemesis and melena.
3. If the bleeding volume exceeds 400ml within a short period, circulatory compensation occurs; if it exceeds 800ml, shock may develop.

Sign

Epigastric tenderness and hyperactive bowel sounds.

bubble_chart Treatment Measures

1. Most patients with massive bleeding from ulcer disease can stop bleeding through general treatments such as blood transfusion, fluid replacement, gastric lavage with cold saline, endoscopic injection of epinephrine, laser coagulation, or selective stirred pulse injection of vasoconstrictors. However, about 5–10% of patients continue to bleed. Surgical treatment should be considered under the following circumstances:

1. Acute massive bleeding accompanied by shock, which is often caused by bleeding from larger vessels and is unlikely to stop spontaneously.
2. No improvement after transfusion of 600–1000 ml of blood within 6–8 hours, or temporary improvement followed by deterioration after stopping the transfusion.
3. A history of similar massive bleeding in the recent past.
4. Massive bleeding occurring during medical hospitalization, indicating highly erosive ulcers that are unlikely to respond to non-surgical treatments.
5. Patients aged 50 or older or those with stirred pulse sclerosis, as bleeding is less likely to stop spontaneously.
6. Massive bleeding complicated by perforation or pyloric obstruction.

Patients requiring surgical treatment should receive aggressive blood transfusion and anti-shock measures. Surgery is best performed within 24 hours of bleeding onset for better outcomes. Delaying until the condition becomes critical increases mortality. Elderly patients should undergo surgery as early as possible.

2. Surgical Treatment: Subtotal gastrectomy, including the ulcer, is widely used domestically. This not only removes the ulcer and stops bleeding but also treats the ulcer disease, making it an ideal surgical approach. If ulcer resection is difficult, the ulcer can be bypassed, but the bleeding stirred pulse or its main trunk at the ulcer base must be ligated. For critically ill patients unsuitable for subtotal gastrectomy, simple ligation for hemostasis may be performed. Recently, some have treated duodenal ulcer bleeding by ligating the bleeding stirred pulse followed by vagotomy and drainage.

1. Indications for Surgery
   1. No improvement or worsening of symptoms after 24–48 hours of non-surgical treatment.
   2. Rapid bleeding leading to shock (failure to maintain blood pressure and a sharp drop in hematocrit after transfusion of 600–800 ml of blood within 6–8 hours).
   3. Recurrent and frequent episodes of bleeding.
   4. Suspected malignancy.
   5. Age over 45 or presence of stirred pulse sclerosis.
2. Preoperative Management
   1. NPO (nothing by mouth), gastrointestinal decompression, fluid infusion, and blood transfusion if necessary.
   2. Administration of hemostatic medicinal such as vitamin K, p-aminomethylbenzoic acid, and adrenochrome.
   3. Close monitoring of vital signs, blood pressure, pulse, urine output, and volumes of hematemesis and hematochezia.
3. Surgical Methods
   1. Subtotal gastrectomy including the ulcer.
   2. If ulcer resection is difficult, Bancroft procedure may be performed, but the bleeding point must be ligated with silk sutures.

bubble_chart Differentiation

Patients with a typical ulcer history who experience hematemesis or tarry stools generally do not present diagnostic difficulties. However, for those accompanied by abdominal pain, the possibility of ulcer perforation should be considered. In patients without an ulcer history, identifying the bleeding site is more challenging. Often, barium meal examinations, endoscopy, and selective angiography can determine the nature of the lesion and the bleeding site. Massive bleeding from ulcer disease should be differentiated from various upper gastrointestinal bleeding conditions, such as massive bleeding due to portal hypertension, acute biliary tract bleeding, and stomach cancer bleeding.

Differential diagnosis of various upper gastrointestinal bleeding conditions

1. Gastroduodenal bleeding: History of chronic ulcer, possibly recent exacerbation; tenderness (+) at the ulcer site; barium meal or gastroscopy may reveal the ulcer; mostly presents with melena, gastric fluid mixed with small blood clots, rarely fresh hematemesis, usually small to moderate bleeding.
2. Portal hypertension, esophageal or gastric variceal bleeding: History of schistosomiasis or exposure, chronic hepatitis; history of hepatosplenomegaly; dilated abdominal wall veins; spider angiomas, scleral icterus; pancytopenia, especially thrombocytopenia and leukopenia; barium meal may show esophageal or gastric varices; mostly presents with hematemesis, often massive, fresh blood or clots, hematochezia usually follows hematemesis.
3. Stomach cancer bleeding: History of gastric disease, possible weight loss and anemia; epigastric pain often distending or stabbing, occasionally a palpable mass in the upper abdomen; barium meal or gastroscopy may reveal stomach cancer; hematemesis often dark brown or black-red gastric fluid, usually small bleeding.
4. Biliary tract bleeding: History of biliary tract infection or biliary ascariasis; chills and fever: cyclical bleeding, may accompany biliary colic or jaundice, followed by cold sweats and palpitations, then mostly melena, little or no hematemesis; liver often enlarged, gallbladder may be palpable, right upper quadrant tenderness; ultrasound may show gallbladder enlargement; duodenoscopy during bleeding may yield positive findings; mostly melena, hematemesis often dark blood or clots, usually self-limiting, cyclical with intervals of about 10–20 days.