Despite the significant decrease in the surgical treatment of complicated peptic ulcer over the past two decades, duodenal ulcer remains one of the most common sources of upper gastrointestinal (UGI) bleeding. The incidence of bleeding from duodenal ulcers that is severe enough to necessitate emergency endoscopic or operative intervention also has not decreased over the past decade.

Patients may present with hematemesis or melena in varying degree of hypovolemic shock. If the patient is unstable, he or she should be taken to an intensive care unit and resuscitated immediately. Resuscitation of an unstable patient is begun by establishing a secure airway and ensuring adequate ventilation. Oxygen should be given, with a low threshold for endotracheal intubation. Isotonic crystalloid is infused after reliable intravenous (two large bore, short peripheral catheters) catheters are placed. For patients in class 3 or 4 shock or those with poor peripheral access, a single lumen 8 French central line should be considered. A urinary catheter should be inserted with close monitoring of urine output. A complete blood count, blood chemistries (including tests of liver function and renal function), and measurement of the prothrombin time and the partial thromboplastin time should be drawn, and a specimen should be sent to the blood bank for typing and crossmatching.

Attempts to establish the cause of bleeding should only be attempted after the initial measures to protect the airway and stabilize the patient have been completed. The next step is nasogastric (NG) aspiration. A bloody aspirate is an indication for esophagogastroduodenoscopy, as is a clear, nonbilious aspirate if a bleeding site distal to the pylorus has not been excluded. The source of the bleeding is unlikely to be the stomach or duodenum with a nonbloody, bile-stained aspirate. Nonetheless, if subsequent evaluation of the lower GI tract for the source of the bleeding is unrewarding, a duodenal ulcer that had stopped bleeding prior to NG tube passage should still be considered. Esophagogastroduodenoscopy should then be performed to confirm the presence of a duodenal ulcer. Most bleeding duodenal ulcers may be controlled endoscopically, although the degree of success to be expected in individual cases varies according to the expertise of the endoscopist.

In general, a 6-unit blood transfusion or bleeding that is not able to be controlled endoscopically mandates surgical intervention. Likewise, ongoing hemorrhage in a hemodynamically unstable patient (especially an elderly one) calls for immediate surgical therapy. The following endoscopic findings for patients whose bleeding is controlled endoscopically should also be strongly considered for surgical therapy: (1) a visible vessel, (2) active bleeding, (3) adherent clot, and (4) giant ulcers.

If the bleeding is controlled endoscopically, intravenous proton pump inhibitor therapy should be given either in a bolus twice daily or by continuous infusion. Antibiotics directed against Helicobacter pylori (e.g., a 14-day course of metronidazole, 500 mg p.o., t.i.d.; omeprazole, 20 mg p.o., b.i.d.; and clarithromycin, 500 mg p.o., b.i.d.) should be administered if the organism is present, as treatment has been shown to reduce rebleeding rates. If bleeding recurs, a second attempt at endoscopic control should be made. Repeat endoscopic treatment reduces the need for surgery without increasing the risk of death and is associated with fewer complications than surgery.

For patients who do require urgent operative intervention from a bleeding duodenal ulcer, duodenotomy, suture control of hemorrhage, and subsequent pyloroplasty and truncal vagotomy allows for best balance between expeditious and effective treatment. Some have advocated selective vagotomy or highly selective vagotomy to reduce postvagotomy syndromes; however, selective vagotomy affords little advantage over truncal vagotomy. Moreover, highly selective vagotomy is a procedure that most surgeons are unfamiliar with and requires significant expertise to effectively reduce the chance of rebleeding. The proximal (truncal) vagus nerve anatomy is more consistent resulting in the fact that truncal vagotomy is more easily reproduced and expeditious when performed by the majority of surgeons.