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Answer 4
  1. Endoscopic therapy. The patient has a high-risk lesion—an ulcer with a visible vessel—and the risk of rebleeding over the next 24 hours is very high. Endoscopic therapy in the form of mechanical therapy (eg, clips), thermal therapy (eg, electrocautery), or injection (eg, epinephrine) is successful for treating ulcers in the majority of cases. Surgical consultation would be warranted if endoscopic therapy failed or if the ulcer had perforated the stomach. A nasogastric tube would add little benefit at this point in the patient’s course given that there is no active bleeding and the tube could traumatize the ulcer and produce further bleeding. IV octreotide, which reduces splanchnic blood flow, is routinely used in patients with variceal bleeding, but its use in patients with peptic ulcer bleeding is controversial. Given the high-risk nature of the lesion, observation combined with nothing by mouth status and IV PPI therapy would be inadequate.

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