S4727 Emergent Management of a Bleeding Posterior Duodenal Ulcer: A Case for Early Surgical Involvement

Introduction: Upper gastrointestinal bleeding (UGIB) is a common and life-threatening emergency, with an incidence of 100–180 per 100,000 annually. Peptic ulcer disease remains the most common cause. Endoscopic therapy is first-line, but surgical intervention may be necessary in refractory bleeding or hemodynamic instability. Case Description/Methods: A previously healthy 25-year-old man presented with 3 days of worsening epigastric pain, followed by hematemesis, melena, and dark-colored diarrhea. He was tachycardic and orthostatic on arrival. Laboratory studies revealed a hemoglobin of 12.8 g/dL, which dropped to 7.2 g/dL within 24 hours. He was resuscitated with intravenous fluids and admitted to the medical intensive care unit. High-dose intravenous proton pump inhibitors and sucralfate were initiated. Urgent esophagogastroduodenoscopy revealed an actively bleeding posterior duodenal ulcer, but the procedure was aborted due to hypotension and clinical deterioration. Emergent exploratory laparotomy identified a large, actively bleeding posterior duodenal ulcer. Hemostasis was achieved by ulcer ligation. Intraoperative findings of pyloric narrowing prompted a Heineke-Mikulicz pyloroplasty to address suspected gastric outlet obstruction and ensure long-term drainage. Estimated intraoperative blood loss was 1,200 mL. Postoperative recovery was uneventful. The patient advanced to a regular diet and was discharged in stable condition. At 1-month follow-up, he remained asymptomatic with no recurrence of bleeding. Discussion: Endoscopy is central in UGIB management, but hemodynamic instability can limit its success, especially in posterior duodenal ulcers involving major vessels. When endoscopic control fails, timely surgical intervention becomes critical. Per American College of Gastroenterology/American Society for Gastrointestinal Endoscopy guidelines, early surgical consultation is indicated when visualization is poor, bleeding persists, or instability occurs. In this case, surgery achieved definitive hemostasis and prevented further deterioration. Heineke-Mikulicz pyloroplasty was selected for its simplicity and effectiveness in relieving pyloric narrowing while preserving anatomy, ideal for young patients without prior surgery. Though angiographic embolization is an emerging option, it may be limited by patient instability or resource availability. Here, surgery was both appropriate and life-saving. This case supports a collaborative strategy: begin with endoscopy, but escalate early to surgery when clinically indicated to ensure the best outcomes.