A Case of Bleeding from a Postbulbar Duodenal Ulcer Successfully Treated by Surgery
Background: Postbulbar duodenal ulcers bleed more easily than duodenal bulbar ulcers. In cases of hemorrhagic shock that does not improve with rapid fluid infusion or blood transfusion, emergency surgery should be considered. However, emergency surgery in patients with hemorrhagic shock or coagulopathy usually has a remarkably poor outcome. We herein report a case of bleeding from a postbulbar duodenal ulcer with hemorrhagic shock that was successfully treated by surgery. Case presentation: A 60-year-old man was admitted to our hospital because of suspected septic shock associated with Rickettsia tsutsugamushi disease. His condition was stabilized after admission. However, on the fourth day after hospital admission, the patient suddenly developed melena and shock. His blood pressure was stabilized by massive fluid infusion. Close examination led to a diagnosis of bleeding from an ulcer in the horizontal part of duodenum. Hemostasis was achieved with cauterization and clips under endoscopy. However, rebleeding was observed on the same day. Because the patient was in shock, we performed emergency surgery. We decided not to perform ulcerectomy because of his poor general condition. We made a longitudinal incision in the duodenum and cauterized the bleeding ulcer. Next, we covered the ulcer with the surrounding duodenal mucosal–muscular layer to prevent rebleeding from the ulcer. The duodenal incision was longitudinally closed with a running suture. Furthermore, we added a gastrojejunostomy (Devine’s modified method) to prevent irritants such as food from passing through the ulcer. The patient’s general condition was stable postoperatively, and no rebleeding occurred. Conclusions: We experienced a case of bleeding from a postbulbar duodenal ulcer with hemorrhagic shock, which was rescued by surgery. Postoperative ulcer bleeding was prevented by surgical cautery followed by covering the ulcer with duodenal mucosa-muscular layer and gastrojejunal anastomosis.
