Endoscopic hemostasis attempt during intra-aortic balloon occlusion for massively bleeding duodenal ulcer. A case report

A 71-year-old man was admitted in an unconscious state with bloody stools. By endoscopy we detected a large amount of blood in the duodenal bulb and a portion of an ulcer lesion on the posterior wall. We were unable to locate the bleeding vessel because of duodenal deformity and massive hemorrhage. Despite blood transfusion, the patient's state continued to deteriorate. His blood pressure was below 80 mm Hg. To treat the shock, we inserted the intra-aortic balloon occlusion (IABO) catheter, which maintained the blood pressure of the upper half of the body and lessened gastrointestinal bleeding. We then attempted endoscopic hemostasis without success. We were able to transfer the patient to the operation room with while maintaining the blood pressure. The operative findings indicated penetration of the duodenal ulcer into the pancreas and stiff adhesion with the peritoneum. Oozing was observed at several locations of the ulcer floor (pancreas itself) and the gastro-duodenal artery had ruptured at 2 sites. The JSGE guideline for the management of peptic ulcer recommends interventional radiology and surgery in cases where endoscopic hemostasis is difficult. However, in patients exhibiting hemodynamic instability with critically uncontrollable hemorrhagic shock, IABO can be effective in maintaining blood pressure and transferring patients safely.