Duodenal Ulcer IV - The Gastrointestinal Atlas- gastrointestinalatlas.com
Gastrointestinal bleeding duodenal ulcer

Video Endoscopic Sequence 1 of 11.

Gastrointestinal tract bleeding from duodenal ulcer

This is a 72 year-old female who underwent an upper endoscopy due to abdominal pain and weight loss. A pseudo- diverticulum of the duodenal bulb because of a duodenal ulcer scar was found. The computer tomography detected an hepatoma. After that she underwent a liver surgery and was discharged from the hospital after six days. Ketorolac was prescribed for the post-operative period.
Then by herself, she decided to double the dose and then started bleeding from the digestive tract which manifested with melena and hematemesis.

Ketorolac is used for the short-term treatment of moderate to severe pain in adults. It is usually used before or after medical procedures or after surgery.

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Duodenal ulcer with active bleeding

Video Endoscopic Sequence 2 of 11.

Duodenal ulcer with active bleeding

At endoscopy the exact site of bleeding is identified. Endoscopy is helpful in defining the bleeding point.

Urgent endoscopy is indicated when patients present with hematemesis, melena, or postural changes in blood pressure. 

 

 

 

Gastrointestinal bleeding duodenal ulcer

Video Endoscopic Sequence 3 of 11.

Another image and video clip of a duodenal ulcer with active bleeding which emerges a blood clot.

In the patient who has an ulcer with an overlying clot, attempting to remove the clot by target washing is critical. Endoscopic removal of the clot by washing or cold snare has been demonstrated to be effective in reducing the recurrence of bleeding. (Cutting away the adherent clot is somewhat controversial but is recommended based on study results from experienced centers.

The findings under the clot (eg, bleeding vessel, visible vessel, clean base, examples of which are seen in the images below) help to determine the therapy needed and improve efficacy by allowing treatment to be applied directly to the vessel.

Urgent endoscopy is indicated when patients present with hematemesis, melena, or postural changes in blood pressure. 

Acute gastrointestinal bleeding is a potentially life-threatening abdominal emergency that remains a common cause of hospitalization. Upper gastrointestinal bleeding (UGIB) is defined as bleeding derived from a source proximal to the ligament of Treitz.

NSAIDs cause gastric and duodenal ulcers by inhibiting cyclooxygenase, which causes decreased mucosal prostaglandin synthesis and results in impaired mucosal defenses. Daily NSAID use causes an estimated 40-fold increase in gastric ulcer creation and an 8-fold increase in duodenal ulcer creation.

 

Sangrado por úlcera duodenal.

Video Endoscopic Sequence 4 of 11.

We started therapy with injections of absolute alcohol around the ulcer.

Duodenal ulcers are more common than gastric ulcers, but the incidence of bleeding is identical for both. In most cases, the bleeding is caused by the erosion of an artery in the base of the ulcer. In approximately 80% of patients, bleeding from a peptic ulcer stops spontaneously.

Long-term NSAID use is associated with a 20% incidence in the development of mucosal ulceration. Medical therapy includes avoiding the ulcerogenic drug and beginning a histamine-2 (H2)–receptor antagonist or a proton pump inhibitor that provides mucosal protection.

Gastrointestinal bleeding duodenal ulcer

Video Endoscopic Sequence 5 of 11.

Peptic ulcer with a protruding vessel

The development of endoscopy has provided clinicians with the ability for diagnostic and therapeutic approaches to bleeding from the gastrointestinal (GI) tract. Endoscopic examination of the upper GI tract provides useful information regarding the source and site of bleeding.

 

bleeding from duodenal ulcer

Video Endoscopic Sequence 6 of 11.

Endoscopy is helpful in defining the bleeding point

There was no recurrence of bleeding, recommending using pump inhibitors permanently due to liver cirrhosis. This recommendation had been indicated previously.

Since the late 1980s, endoscopic techniques to achieve hemostasis for bleeding ulcers and varices have continued to evolve. Endoscopy is now the method of choice for controlling active ulcer hemorrhage

In 1989, a National Institutes of Health (NIH) consensus conference on UGIB concluded that effective therapy was needed in the presence of active bleeding or a visible vessel. The conference affirmed that the treatment, when performed by an experienced endoscopist using 1 of 4 techniques (ie, injection of epinephrine or sclerosants, heater-probe coagulation, bipolar electrode coagulation, laser coagulation), was proven effective by the published evidence.

bleeding from duodenal ulcer

Video Endoscopic Sequence 7 of 11.

Endoscopic hemostasis has been a major therapeutic advancement in the management of peptic ulcer hemorrhage and has influenced surgical management. Injection sclerotherapy is a low cost, effective and safe procedure which is easy to implement in a variety of clinical settings. Early elective operation after initial endoscopic hemostasis is the wisest choice for elderly patients with co-existing disease and selected patients at high risk for recurrent bleeding.

Three other techniques have since been developed: endoscopic application of clips, use of banding devices, and argon plasma coagulation. Aside from ulcer hemorrhaging, other causes of gastrointestinal bleeding, including mucosal tears in the esophagus or upper stomach due to vomiting (Mallory-Weiss tears), venous blebs, and vascular ectasias, can also be treated with endoscopic coagulation.

 

bleeding from duodenal ulcer

Video Endoscopic Sequence 8 of 11.

Endoscopic injection therapy to prevent rebleeding from peptic ulcer with a protruding vessel, Attempting to control active bleeding using the recommended techniques with the appropriate equipment or instituting appropriate therapy for a high-risk lesion is important.

Endoscopists should use the technique with which they have the most familiarity. The endoscopy should not be started unless the endoscopist is equipped for any potential lesions (eg, ulcer, varix, angioectasia, tear, tumor). The patient should be monitored for recurrent bleeding and treated a second time if appropriate. A surgical consultation should be considered for all patients with gastrointestinal hemorrhage.

 

bleeding from duodenal ulcer

Video Endoscopic Sequence 9 of 11.

 

bleeding from duodenal ulcer

Video Endoscopic Sequence 10 of 11.

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bleeding from duodenal ulcer

Video Endoscopic Sequence 11 of 11.

Final status of the therapy, There was no re bleeding

Although most of the time colleagues use adrenaline, we use infiltrations of absolute alcohol with quite successful in stopping bleeding ulcers in the duodenum.

 

Sangrado del Tubo digestivo por Ulcera Gigante del Duodeno

Video Endoscopic Sequence 1 of 3.

Duodenal Giant Ulcer

A 85-year-old male, presented with bleeding from the upper digestive tract manifested with melena, endoscopy is performed finding this giant ulcer. Patient has medical History of having a duodenal ulcer 13 years previous.

Giant duodenal ulcers (GDUs) are a subset of duodenal ulcers that have historically resulted in greater morbidity than usual duodenal ulcers.

GDUs are still associated with high rates of morbidity, mortality and complications. Thus, surgical evaluation of a patient with a GDU should remain an integral part of patient care. These giant variants, while usually benign, can frequently harbor malignancy.

 

 

 

Ulcera Gigante del Duodeno

Video Endoscopic Sequence 2 of 3.

Due to a the scarce bleeding is managed conservatively with medication.

Benign giant duodenal ulcer appears to be a unique type of generalized peptic ulcer disease. Massive hemorrhage, perforation, and obstruction are frequent complications. The disorder is best diagnosed endoscopically and treated with one of the standard acid-reducing procedures.

Giant duodenal ulcer is a variant of peptic ulcer that is 2 cm in diameter or greater and essentially replaces the duodenal bulb.


 

 

Ulcera Duodenal Gigante

Video Endoscopic Sequence 3 of 3.

Another image and video clip of the ulcer

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