Digestive Tract Anatomy, Human Anatomy, USMLE Step 1 - Full Vignette with Extended Explanations

Описание: A 38-year-old man presents with multiple episodes of hematemesis, melena, and presyncope, alongside a history of peptic ulcer disease and recent blood product resuscitation. After two failed endoscopic attempts to control active duodenal bleeding, imaging localizes brisk hemorrhage to the gastroduodenal and pancreaticoduodenal arteries. What clinical considerations and anatomical features must be evaluated to determine the most effective next step for definitive hemorrhage control after unsuccessful endoscopic therapy?

VIDEO INFO
Category: Digestive Tract Anatomy, Human Anatomy, USMLE Step 1
Difficulty: Expert - Expert level - For those seeking deep understanding
Question Type: Treatment Failure
Case Type: ED Case

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QUESTION
A 38-year-old man presents to the emergency department with three episodes of hematemesis and black stools since this morning accompanied by presyncope and epigastric discomfort. He reports remote peptic ulcer disease as a teenager and a hospitalization two years ago for a bleeding duodenal ulcer treated with endoscopic clipping; Helicobacter pylori status is unknown. He denies NSAID use because of an allergy. Alcohol use is occasional; he quit injection drug use at age 22....

OPTIONS
A. Immediate selective transcatheter arterial embolization of the gastroduodenal artery using a sandwich technique that occludes the GDA both proximal and distal to the ulcer-related branch and includes coil or glue occlusion of the posterior superior pancreaticoduodenal branch seen on CTA, performe...
B. Selective microcatheter embolization limited to the distal gastroduodenal artery distal to the bleeding point using coils only, leaving proximal inflow from the right gastric and pancreaticoduodenal arcades intact to preserve hepatic flow, with transfer to a step-down unit after the procedure and...
C. Primary n-butyl cyanoacrylate embolization of the anterior superior pancreaticoduodenal branch alone based on ulcer location, while deferring gastroduodenal artery occlusion to reduce theoretical hepatic ischemia risk, followed by intermittent IV PPI dosing only and subsequent ward-level observat...
D. Empiric prophylactic embolization of the left gastric and right gastroepiploic arteries without targeting the gastroduodenal artery, scheduled after several hours of further stabilization because angiography may be initially negative, with routine post-procedure care on a monitored floor and oral...

CORRECT ANSWER
A. Immediate selective transcatheter arterial embolization of the gastroduodenal artery using a sandwich technique that occludes the GDA both proximal and distal to the ulcer-related branch and includes coil or glue occlusion of the posterior superior pancreaticoduodenal branch seen on CTA, performed in the angiography suite without delay, with continued high-dose IV PPI infusion and ICU monitoring.

EXPLANATION
After two expert endoscopic attempts fail for a spurting posterior duodenal bulb ulcer, the next definitive step is targeted transcatheter arterial embolization of the gastroduodenal artery using a sandwich technique, with proximal and distal protection and treatment of the posterior superior pancreaticoduodenal branch localized on CT angiography. This approach addresses the dominant inflow and the robust retrograde arcade that otherwise causes persistent or recurrent hemorrhage via collateral backfilling....


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