Bleeding peptic ulcer: surgical therapy.

The management of bleeding peptic ulcer disease varies with multiple clinical and endoscopic variables. For the patient with rapid hemorrhage and hemodynamic instability refractory to endoscopic control, operation clearly is indicated. For patients with a low probability of recurrent ulcer hemorrhage because of the absence of endoscopic stigmata or clinical predictors of further ulcer bleeding, nonoperative management with selective use of endoscopic hemostasis is appropriate. For the remaining patients with a moderate risk of recurrent ulcer hemorrhage, the clinician must use what is known of the clinical and endoscopic predictors of recurrent hemorrhage and arrive at a judgment regarding the selective use of endoscopic hemostasis and subsequent early operation. For elderly patients with a large duodenal or gastric ulcer who have experienced significant blood loss precipitating an episode of hypovolemic shock and who have endoscopic stigmata of ulcer hemorrhage, early elective operation after endoscopic hemostasis is the most judicious course. Surgery also is the wise choice for those patients in whom an initially successful attempt at endoscopic hemostasis fails and who rebleed while hospitalized. Recommendations for the surgical management of bleeding peptic ulcer disease include Immediate operation for (1) patients with rapidly exsanguinating ulcer hemorrhage and (2) patients with active bleeding and failure of endoscopic hemostasis to control the bleeding. Early elective operation after initial endoscopic hemostasis for (1) elderly patients with comorbid disease and/or hemodynamic instability who have active arterial ulcer hemorrhage (Forrest Ia) controlled with endoscopic hemostasis; (2) elderly patients with comorbid disease and/or hemodynamic instability who have a visible vessel in an ulcer crater (Forrest IIa) treated with endoscopic hemostasis: surgery is particularly advised in this circumstance for those with a positive arterial Doppler signal in the ulcer crater or a large posterior duodenal ulcer or a large lesser-curvature gastric ulcer; and (3) elderly patients with comorbid disease and/or hemodynamic instability who develop recurrent ulcer bleeding while hospitalized or with a total blood transfusion requirement exceeding 5 U.