A 68-year-old man on aspirin and omeprazole presents with haematemesis. Endoscopy reveals a 12 mm duodenal ulcer with an actively bleeding vessel (Forrest classification Ia). Which is the most critical next step after achieving endoscopic haemostasis?
- A Oral PPI twice daily and discharge after endoscopic haemostasis
- B IV high-dose PPI infusion (80 mg bolus then 8 mg/hour for 72 hours) ✓
- C Emergency surgical oversewing without PPI
- D Repeat endoscopy at 24 hours regardless of clinical stability
Explanation
Following successful endoscopic haemostasis of a Forrest Ia (active spurting) or Ib (oozing) peptic ulcer, international guidelines (ACG, ESGE) mandate high-dose IV PPI — omeprazole or pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours. This significantly reduces re-bleeding risk by maintaining intragastric pH > 6, which stabilises platelet aggregation and clot formation at the ulcer base. Oral PPI alone is insufficient for active bleeding lesions. Routine second-look endoscopy is not recommended unless there is clinical evidence of re-bleeding.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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