A 55-year-old man admitted with melena is resuscitated and given intravenous pantoprazole. Endoscopy shows a 1 cm duodenal bulb ulcer with a clean-based non-bleeding visible vessel (Forrest IIa) and no active spurting. Which endoscopic strategy gives the lowest rate of rebleeding?
- A Epinephrine injection combined with a second definitive modality such as thermal coagulation or endoclips ✓
- B Observation with repeat endoscopy after 48 hours
- C Epinephrine injection alone followed by high-dose proton pump inhibitor infusion
- D Immediate angiographic embolisation without endoscopic therapy
Correct answer: A. Epinephrine injection combined with a second definitive modality such as thermal coagulation or endoclips
Explanation
Forrest IIa ulcers carry a rebleeding risk around 50 percent without therapy. Epinephrine injection achieves temporary haemostasis but does not seal the vessel, so guidelines require combination with a mechanical or thermal method, which roughly halves rebleeding compared with injection alone. Angiography is reserved for endoscopic failure, and scheduled repeat endoscopy without treatment leaves the vessel untreated.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.