A 25-year-old man is involved in an automobile accident with resultant injuries including bilateral closed femur fractures, left pulmonary contusion, and closed head injury. On post-injury day 4, significant upper gastrointestinal hemorrhage begins. Endoscopic examination reveals an area of confluent ulceration with bleeding in the gastric fundus. Endoscopic hemostasis fails. Appropriate immediate management includes:

Initial effos to control gastric hemorrhage consist of gastric lavage using warmed saline. Lavage serves to fragment existing clots and to remove any pooled blood, reducing fibrinolysis at bleeding sites. Over 80% of patients who present with upper gastrointestinal hemorrhage stop bleeding using this approach. Definitive treatment of ongoing acute active stress bleeding by antacids is largely unsuccessful. Administration of H2-receptor blocking agents once active gastrointestinal bleeding has commenced is also usually ineffective as a definitive form of therapy. The endoscope has become the preferred therapeutic as well as diagnostic instrument with electrocautery and laser photocoagulation capabilities. If endoscopic therapy fails, angiography offers an additional means for the control of bleeding by selective infusion of vasopressin into the splanchnic circulation the left gastric aery. Vasopressin is administered by continuous infusion through the catheter at a rate of 0.2 to 0.4 IU/min for a maximum of 48 to 72 hours. About 10% to 20% of patients with acute stress ulcers continue to bleed or have recurrent bleeding despite these measures. In these patients, total gastrectomy has a moality ranging from 17% to 100%. In general, operative moality rates for acute stress-induced hemorrhage range from 30% to 60% regardless of the surgical procedure undeaken.