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Conservative management of bleeding duodenal ulcer without a visible vessel: prospective randomized trial
E Saperas1, J M Piqué, R Pérez Ayuso
1Gastroenterology Service, Hospital Clínic i Provincial, University of Barcelona, Spain.
Insights
For bleeding duodenal ulcers without active arterial bleeding, expectant management is safer than early surgery. This approach significantly reduces mortality risk in elderly patients, improving outcomes for gastrointestinal hemorrhage.
Area of Science:
- Gastroenterology
- Surgical Oncology
- Internal Medicine
Background:
- Bleeding duodenal ulcers are a common cause of gastrointestinal hemorrhage.
- Management strategies for bleeding duodenal ulcers, particularly in elderly patients, require careful consideration.
- Endoscopic findings are crucial for determining appropriate treatment pathways.
Purpose of the Study:
- To compare the efficacy and safety of early surgery versus expectant management for bleeding duodenal ulcers in patients aged 50 and above.
- To evaluate the impact of different management strategies on overall mortality rates.
- To identify optimal treatment protocols for non-massive bleeding duodenal ulcers.
Main Methods:
- A prospective randomized therapeutic trial involving 69 patients aged 50+ with bleeding duodenal ulcers.
- Patients were assigned to either immediate (early surgery) or delayed (expectant management) surgical intervention.
- Endoscopic evaluation was used to categorize bleeding severity and visible vessel presence.
Main Results:
- Overall mortality in the study cohort was 8.6%.
- Early surgery resulted in a mortality rate of 14.7%, significantly higher than the 2.9% observed with expectant management (Risk Ratio 5.07).
- The two treatment groups were comparable in terms of baseline characteristics and bleeding presentation.
Conclusions:
- Expectant management is a safer and more advisable approach for bleeding duodenal ulcers when massive bleeding or visible arterial vessels are absent on endoscopy.
- This strategy is particularly beneficial for elderly patients (50 and above), leading to a substantial reduction in mortality.
- Clinical decision-making for bleeding duodenal ulcers should prioritize endoscopic findings and patient age to guide treatment choices.
Abstract:
Between January 1983 and December 1985, 305 patients were admitted to our hospital because of bleeding duodenal ulcer. A subgroup of 69 patients aged 50 or above in whom emergency endoscopy showed non-arterial bleeding or signs of recent haemorrhage without a visible vessel entered a prospective therapeutic trial. The patients were randomized to receive either (1) early surgery, implying immediate operation, or (2) expectant management, with surgery reserved only for patients with further haemorrhage. The two groups were homogeneous with respect to age, sex, prior ingestion of ulcerogenic drugs, mode of bleeding, admission haematocrit, number with hypovolaemic shock and number with active bleeding on initial endoscopy. Overall mortality was 8.6 per cent. Mortality in patients submitted to early surgery was five times higher than that in those allocated to expectant therapy (14.7 per cent versus 2.9 per cent; risk ratio 5.07). The results suggest that expectant management is advisable in patients with bleeding duodenal ulcer not bleeding massively and in whom endoscopy does not disclose spurting arterial bleeding or a visible vessel.