So a patient comes in with hypotension, tachycardia. His family found him down on the bathroom floor laying in a pool of dark maroon stool. In the ER he is immediately intubated and we resuscitate him with saline and PRBC's. An orogastric tube is placed and massive amounts of blood is evacuated from the stomach. The stomach is then copiously lavaged with saline until clear. An upper endoscopy is subsequently performed that morning which shows 4-5 large duodenal ulcers. But none of them are actively bleeding. No visible vessels are present.
He goes to the ICU on a protonix drip and stabilizes his hemoglobin for 48 hours. Then one Sunday he drops his pressure and starts passing large amounts of blackish-red stool. The GI doc and I are there simultaneously. His blood pressure is tenuous, despite aggressive resuscitation. It seems like he has re-bled from his duodenal ulcers and may need emergency surgery.
But the orogastric tube is putting out bilious contents. The GI guy quickly slips an endoscope into his stomach. And then there's no blood. The ulcers appear stable. Bile washes back from the duodenum.
What is the next step? What operation do you think the dude will need?