<prompt> Most common artery responsible for hemorrhage in peptic ulcer is:Gastro epiploic arteryLeft gastric arteryGastro duodenal arterySuperior mesenteric artery  <response>: Ans: Gastro duodenal artery Ref: Sabiston Textbook of Singers, 19th Edition -1164Explanation:Peptic ulcer disease PUDMost common cause of upper GI hemorrhageApproximately 10 to 15 of patients with PUD develop bleedingBleeding is the most common indication for operation and the most common cause for death in PUD.Duodenal ulcers are common then gastric ulcersSource of bleeding from Duodenal ulcer - Gastroduodenal arterySource of bleeding from Gastric ulcer - Left Gastric arteryManagementResuscitationIntravenous Proton Pump Inhibitors are started in all patients.Upper Gastro Intestinal Endoscopy UGIE should be done within 24 hoursAnti H.Pylori treatment if the patient tests positive for H.PyloriFurther management is based on findings at UGIE using Forrest classificationEndoscopic TherapyFor cases of active bleeding as well as those with a visible vessel Forrest I to Ila.In case of an adherent clot Forrest lib, the clot is removed and the underlying lesion evaluated.Ulcers with a clean base or black spot dont require intervention.Endoscopic optionsEpinephrine injectionHeater probes,Monopolar oi bipolar electrocoagulation,Laser or argon plasma coagulation APCHemoclipsUsually a combination therapy involv ing injection and coagulation is employedIndications for SurgeryHemodynamic instability despite vigorous resuscitation 6u transfusionFailure of endoscopic techniques to arrest hemorrhageRecurrent hemorrhage after initial stabilization with up to two attempts at obtaining endoscopic hemostasisShock associated with recurrent hemorrhageContinued slow bleeding with a transfusion requirement 3udayRelative IndicationsRare blood type or difficult crossmatchRefusal of transfusionShock on presentationAdvanced ageSevere comorbid diseaseBleeding chronic gastric ulcer for which malignancy is suspectedForrest ClassificationGradeDescriptionRebleeding risklaActive, pulsatile bleedingHighlbActive, nonpulsatile bleedingHighIIaNonbleeding visible vesselHighIIbAdherent clotIntermediateIIcUlcer with black spotLowIIIiClean, nonbleeding ulcer bedLow 