Abstract
This case is unique because it demonstrates the simultaneous presence of multiple major predictors of endoscopic hemostasis failure in a single patient with ulcerative bleeding, clearly illustrating their cumulative and clinically decisive impact. A 75-year-old patient was admitted with massive duodenal bleeding complicated by hemorrhagic shock, severe anemia, renal dysfunction, and coagulopathy associated with warfarin therapy. Endoscopy revealed a large posterior duodenal ulcer with active spurting arterial bleeding corresponding to Forrest Ia classification. Combined endoscopic hemostasis was initially achieved; however, early recurrent bleeding developed within six hours. Repeat endoscopic intervention was technically unsuccessful due to deep crater morphology and anatomical location adjacent to a major arterial branch. Definitive hemostasis was obtained through selective angiography and endovascular embolization of a branch of the gastroduodenal artery. This case highlights the critical importance of cumulative risk assessment and supports early multidisciplinary decision-making with timely transition to endovascular management in patients presenting with multiple high-risk features.