Bleeding peptic ulcer

Meta-analysis of proton pump inhibitors in treatment of bleeding peptic ulcers

OBJECTIVE

To evaluate the efficacy of proton pump inhibitors (PPIs) compared with placebo and histamine receptor antagonists (H2RAs) for reducing the incidence of rebleeding, surgery, and death in acute gastrointestinal bleeding (GIB) associated with peptic ulcer disease.

DATA SOURCES

A systematic search of the English-language literature was performed using MEDLINE, EMBASE, and Pre-MEDLINE (from 1966 to September 2000) and a manual search of references.

STUDY SELECTION

Randomized, controlled trials evaluating any PPI for acute GIB in adults with the end points of rebleeding, surgery of death.

DATA SYNTHESIS

Nine trials (1829 pts.) were included. The relative odds of rebleeding indicated a 50% reduction in the PPI-treated group (OR 0.50, 95% CI 0.33 to 0.77; p = 0.002, NNTB 9; 95% CI NNTB 6 to 13). The relative odds of surgery indicated a 53% reduction in the PPI-treated group (OR 0.47, 95% CI 0.29 to 0.77; p = 0.003; NNTB 17, 95% CI 12 to 35). The relative odds for mortality indicated a nonsignificant 8% decrease in the odds of death in the PPI-treated group (OR 0.92, 95% CI 0.46 to 1.83, p = 0.81; NNTB 323, 95% CI NNTB 47 to infinity to NNTH 33).

CONCLUSIONS

PPIs are superior to H2RAs and placebo in preventing rebleeding and the need for surgery in patients with GIB, although they do not appear to reduce mortality.

Interventional endoscopy

Interventional endoscopy is a general label given to endoscopic procedures used to deal with a variety of gastrointestinal disorders. The interventional endoscopic procedures of interest in this review are those used specifically with gastric disorders. They include hemostasis, endoscopic ultrasound, endoscopic mucosal resection, stenting, percutaneous endoscopic gastrostomy tube placement and photodynamic laser therapy. Here, we review the latest data related to (a) a number of general issues having an impact on this diverse group of procedures (eg, such as proper patient selection criteria, consent in the era of open access endoscopy, protocol for anticoagulation, and sedation); (b) the methodology and outcomes of each of these unique procedures as they apply to the stomach; and (c) some of the latest technologic advances and developments that will potentially have an impact the future use of these procedures.

Epidemiology of NSAID-related gastroduodenal mucosal injury

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the agents most frequently used against musculoskeletal and rheumatic disorders throughout the world. The gastroduodenal adverse effects include dyspepsia without endoscopically proven damage, asymptomatic endoscopic lesions of submucosal haemorrhage, erosions and ulcers, and-most important-ulcer complications. Established risk factors for NSAID-associated ulcer complications include patient-specific factors such as advanced age, female gender, a history of peptic ulcer, and drug-specific factors such as the use of non-selective NSAIDs (type, dose, duration, multiple use) and concomitant anticoagulant drugs or corticosteroids. Probable risk factors comprise Helicobacter pylori infection and heavy consumption of alcohol, whereas use of selective serotonin re-uptake inhibitors, smoking and a number of other factors have also been proposed to contribute. Knowledge of absolute risk estimates is important for clinical decision making. The aim of this chapter is to summarize the epidemiological data related to the broad spectrum of iatrogenic gastroduodenal mucosal injury.

Management principles of gastrointestinal bleeding

There is now a multitude of technologic and pharmacologic options available to clinicians caring for patients with gastrointestinal (GI) bleeding; however, drugs and technology are no substitute for understanding and properly executing the basic management principles of GI bleeding. This article focuses on the most common causes of GI bleeding and emphasizes the importance of the primary care provider's role in the management of these patients. Also, by answering questions we are commonly asked as gastroenterology consultants, we hope to provide insight into current diagnostic and therapeutic options and the most appropriate use of these options.

Proton pump inhibitors versus H2-antagonists: a meta-analysis of their efficacy in treating bleeding peptic ulcer

PURPOSE

To evaluate whether proton pump inhibitors are more effective than H2-antagonists (H2-A) for the treatment of bleeding peptic ulcer.

DATA SOURCES

PubMed database until January 2000.

STUDY SELECTION

Comparative randomized trials of proton pump inhibitors (omeprazole, lansoprazole, or pantoprazole) vs. H2-A (cimetidine, ranitidine or famotidine).

DATA EXTRACTION

Meta-analysis combining the odds ratios (OR) of the individual studies in a global OR (Peto method). OUTCOMES EVALUATED: Persistent or recurrent bleeding, need for surgery, or mortality.

DATA SYNTHESIS

Eleven studies fulfilled the inclusion criteria and contained data for at least one of the planned comparisons. Persistent or recurrent bleeding was reported in 6.7% (95% CI: 4.9-8.6%) of the patients treated with proton pump inhibitors, and in 13.4% (95% CI: 10.8-16%) of those treated with H2-A (OR 0.4; 95% CI: 0.27-0.59) (chi2-homogeneity test, 18; P=0.09). Surgery was needed in 5.2% (95% CI: 3.4-6.9%) of the patients treated with proton pump inhibitors, and in 6.9% (95% CI: 4.9-8.9%) of the patients treated with H2-A (OR 0.7; 95% CI: 0.43-1.13). Respective percentages for mortality were 1.6% (95% CI: 0.9-2.9%) and 2.2% (95% CI: 1.3-3.7%) (OR 0.69; 95% CI: 0.31-1.57). SUB-ANALYSIS: Five studies evaluated the effect of both therapies given in bolus injections on persistent or recurrent bleeding rate, which was 6% (95% CI: 3.6-8.3%) and 8.1% (95% CI: 5.3-10.9%), respectively (OR, 0.57; 95% CI: 0.31-1.05). Persistent or recurrent bleeding in high risk patients (Forrest Ia, Ib and IIa) occurred in 13.2% (95% CI: 7.9-8%) of the patients treated with proton pump inhibitors and in 34.5% (27-42%) of those treated with H2-A (OR 0.28; 95% CI: 0.16-0.48). In patients not having endoscopic therapy, persistent or recurrent bleeding was reported, respectively, in 4.3% (95% CI: 2.7-6.7%) and in 12% (95% CI: 8.7-15%) (OR 0.24; 95% CI: 0.13-0.43). Less marked differences were observed in patients having adjunct endoscopic therapy: 10.3% (95% CI: 6.7-13.8%) and 15.2% (11.1-19.3%) (OR 0.59; 95% CI: 0.36-0.97). Moreover, the significance disappeared in this group when a single outlier study was excluded.

CONCLUSIONS

Proton pump inhibitors are more effective than H2-A in preventing persistent or recurrent bleeding from peptic ulcer, although this advantage seems to be more evident in patients not having adjunct sclerosis therapy. This beneficial effect seems to be similar or even more marked in patients with Forrest Ia, Ib or IIa ulcers. However, proton pump inhibitors are not more effective than H2-A for reducing surgery or mortality rates. Nevertheless, the data are too scarce and heterogeneous to draw definitive conclusions, and further comparative trials are clearly warranted.

Gastrointestinal bleeding in the elderly

Among patients with acute gastrointestinal bleeding, older age is associated with an increased rate of comorbidity, greater medication use, and atypical clinical presentations. The aging of the population makes the evaluation and management of gastrointestinal bleeding in the elderly a special and increasingly common clinical challenge. The unique features and common causes of upper and lower gastrointestinal bleeding in the elderly are reviewed. Important management issues considered include hemodynamic resuscitation; anticoagulation; and medical, surgical, and endoscopic therapy.

Occurrence and relapse of bleeding from duodenal ulcer: respective roles of acid secretion and Helicobacter pylori infection

BACKGROUND

Helicobacter pylori infection, gastric acid hypersecretion and NSAID consumption may cause peptic ulcer.

AIM

To investigate the respective roles of H. pylori and acid secretion in bleeding duodenal ulcer.

PATIENTS AND METHODS

A total of 99 duodenal ulcer patients were referred for evaluation of acid secretion: seven with Zollinger-Ellison Syndrome; 14 with hypersecretory duodenal ulcer, defined by the coexistence of elevated basal acid output and pentagastrin acid output; and 78 duodenal ulcer patients with normal acid output. All non-Zollinger-Ellison Syndrome patients were H. pylori-positive and cured of infection. All patients were followed-up for a 36-month period, to assess the occurrence of bleeding episodes.

RESULTS

Twenty-nine patients had at least one bleeding episode in the 4 years before the study. Bleeding was more frequent in males and in patients on NSAIDs. The mean basal acid output was not higher among bleeders. In the 21 patients (14 hypersecretory duodenal ulcer, seven Zollinger-Ellison Syndrome) with basal acid output > 10 meg/h and pentagastrin acid output > 44.5 meg/h, the risk of bleeding was higher (OR 6.5; 95% CI: 2-21). In the follow-up period, three out of 83 (3.3%) non-Zollinger-Ellison Syndrome patients had a H. pylori-negative duodenal ulcer with bleeding. The risk of bleeding after H. pylori cure was not higher in hypersecretory duodenal ulcer patients (P > 0.3), nor among patients with previous bleeding episodes (P > 0.2).

CONCLUSIONS

In H. pylori-positive duodenal ulcer patients, the coexistence of elevated basal acid output and pentagastrin acid output leads to a sixfold increase in the risk of bleeding. After H. pylori cure, gastric acid hypersecretion is not a risk factor for bleeding. However, duodenal ulcer recurrence with bleeding may occasionally occur in patients cured of H. pylori, even if acid output is normal.

The role of acid suppressants in upper gastrointestinal ulcer bleeding

Re-bleeding and mortality remain significant in peptic ulcer haemorrhage despite the widespread use of endoscopic therapy. The acidic gastric environment interferes with coagulation. In vitro studies show that an intragastric pH of above 6 results in normal blood coagulation and platelet function. Because of induced tachyphylaxis, H(2)-receptor antagonists are not able to maintain a high pH. In addition, in randomized trials using H(2)-receptor antagonists, there was no reduction in re-bleeding and mortality. High-dose intravenous proton pump inhibitors are capable of maintaining a pH above 6. Four randomized trials, using high-dose intravenous proton pump inhibitors, significantly improved the outcome (in terms of a reduction in re-bleeding and surgery) in patients with peptic ulcer haemorrhage. Mortality was, however, not reduced. The additional effect of acid-suppressant agents after successful endoscopic therapy is limited to the reduction of re-bleeding and need for surgery, with no effect on mortality.

Dyspepsia in pregnancy

Dyspepsia with or without nausea is common during pregnancy. Known ulcer disease, gastritis, and GERD may improve during pregnancy. Many women have a stoic and long-suffering posture during pregnancy owing to an unrealistic expectation concerning the teratogenicity of commonly used drugs. It is appropriate in medicine to alleviate pain and suffering when possible, and many drugs can be used safely and effectively to control upper gastrointestinal tract symptoms. When symptoms are persistent into the late second trimester, refractory to pharmacologic treatment, or severe, H. pylori infection, complications of ulcer disease, and underlying cancer should be suspected and sequentially ruled out. More timely treatment and work-up of nonobstetric disease during pregnancy is expected to lower perinatal complications.

Proton-pump inhibitors for acute peptic ulcer bleeding

OBJECTIVE

To review the use of proton-pump inhibitors for acute peptic ulcer bleeding.

DATA SOURCES

Articles were obtained through computerized searches of MEDLINE (1966-September 2000). Additionally, several textbooks containing information on the diagnosis and management of acute peptic ulcer bleeding were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references.

STUDY SELECTION

All randomized studies and pharmacoeconomic evaluations that used proton-pump inhibitor therapy for acute peptic ulcer bleeding were included. Randomized controlled trials and meta-analyses involving other therapies for treating peptic ulcer bleeding were also reviewed for possible inclusion.

DATA EXTRACTION

The primary outcomes extracted from the literature were persistent or recurrent bleeding, transfusion requirements, need for endoscopic intervention or surgery, length of stay, and mortality.

DATA SYNTHESIS

Data from double-blind, placebo-controlled trials involving more than 1000 patients demonstrate that short-term, high-dose omeprazole therapy is effective for reducing bleeding and transfusion requirements in patients with acute peptic ulcer bleeding. The patients most likely to benefit from this therapy are hospitalized patients at high risk for rebleeding and patients in whom endoscopic evaluation must be delayed or is unavailable.

CONCLUSIONS

Omeprazole (and likely other proton-pump inhibitors) is useful in reducing bleeding and transfusion requirements in patients with acute peptic ulcer bleeding, although better delineation of appropriate candidates is needed.

Critical review of acid suppression in nonvariceal, acute, uppergastrointestinal bleeding

Nonvariceal, upper gastrointestinal (GI) bleeding is a very common source of morbidity and mortality. The concept of ulcer clot dissolution being facilitated by a low gastric pH has allowed us to better understand the pathophysiology of nonvariceal upper GI bleeding. Placebo-controlled trials have shown the benefit of oral proton pump inhibitor administration in contrast to H(2) receptor antagonists. Furthermore, our recent experience with intravenous proton pump inhibitors has reinforced these observations.

Upper Gastrointestinal Bleeding of Nonvariceal Origin in the ICU Setting

Upper gastrointestinal bleeding (UGI) is a common medical emergency in the intensive care unit (ICU). Although it can be caused by a number of gastrointestinal disorders, its management usually follows a few simple management rules. Prior to endoscopy, the key to management is to resuscitate the patient, to determine the need for airway protection, and to assess the need for transfusions according to the American Society of Gastrointestinal Endoscopy guidelines. During endoscopy, the key to management is to recognize the cause of the bleeding and to achieve hemostasis. Following endoscopy, the key to management is to determine the need for medical therapy and to determine a proper disposition for the patient given his potential risk for rebleeding. Stress-related erosions syndrome (SRES) is a disease that usually develops in the ICU setting and is known to be associated with a high degree of morbidity and mortality. Although it is approached in the same fashion as other causes of UGI bleeding, patients tend to do better if they are recognized early and treated prophylactically. Criteria for proper patient selection and the recommended prophylactic therapy are reviewed.

Potential uses of intravenous proton pump inhibitors to control gastric acid secretion

Proton pump inhibitors are the most effective agents for suppressing gastric acidity and are the preferred therapy for many acid-related conditions. While proton pump inhibitors have been accessible in intravenous formulations in several European countries, they have been available only as oral drugs in the United States. In the near future, the proton pump inhibitor pantoprazole is likely to become available in an intravenous formulation for American patients. Potential uses for intravenous proton pump inhibitors include treatment of Zollinger-Ellison syndrome and peptic ulcers complicated by bleeding or gastric outlet obstruction, as well as prevention of stress ulcers and acid-induced lung injury. These intravenous proton pump inhibitors are also likely to be beneficial to patients undergoing long-term maintenance with oral proton pump inhibitors who cannot take oral therapy for a period of time. Intravenous pantoprazole is especially distinguished in its lack of clinically relevant drug interactions, and it requires no dosage adjustment for patients with renal insufficiency or with mild to moderate hepatic dysfunction. Both omeprazole and pantoprazole are well tolerated in both oral and intravenous forms. Although further studies are needed to define their roles clearly, the availability of intravenous formulations of proton pump inhibitors will certainly assist with the treatment of gastric acid-related disorders.

Non-variceal upper gastrointestinal bleeding

Severe upper gastrointestinal bleeding remains a common medical emergency. In the last two decades endoscopy has become the cornerstone of diagnosis, risk stratification and treatment of peptic ulcer bleeding. Clinical assessment and endoscopic recognition of the stigmata of recent haemorrhage can allow the identification of patients with a high risk of rebleeding. Patients with active bleeding at the time of endoscopy and with non-bleeding visible vessels should receive endoscopic treatment. Studies comparing different treatment modalities are mostly single centre studies with relatively small groups of patients and therefore lack statistical power. Furthermore most of those trials were heterogeneous because of differences in the end points, differences in the risk factors for rebleeding and differences in the levels of experience of the endoscopists in both recognition and treatment of bleeding ulcers. Recently different treatment modalities have been studied. The injection of clot-inducing factors, a combination of injection and thermal therapies, repeat endoscopies and the use of mechanical devices such as clips and ligatures are promising new techniques. However, there are, at present, no convincing data to suggest that any one of these treatment modalities is superior when looking at the overall group of patients with bleeding peptic ulcer. Larger randomized controlled trials must focus on tailoring therapies and using the optimal therapy for different subgroups of patients.

Endoclips versus heater probe in preventing early recurrent bleeding from peptic ulcer: a prospective and randomized trial

BACKGROUND

Endoscopic application of hemoclips (HC) was prospectively compared with heat probe (HP) treatment in patients with bleeding ulcers.

METHODS

One hundred thirteen patients with major stigmata of ulcer hemorrhage were randomly assigned to receive HP (n = 57) or HC (n = 56). Clinical and endoscopic features were comparable in both groups. Recurrent bleeding was retreated with the modality previously used. Patients in whom treatment or retreatment was unsuccessful underwent emergency surgery.

RESULTS

Hemostasis, adequate treatment of visible vessel, 30-day mortality, and emergency surgery rates were similar for both groups. Recurrent bleeding was 21% for HP and 1.8% for HC (p < 0.05). Length of hospital stay and transfusion requirements were significantly lower in the HC group. There was no evidence of clip-induced tissue injury or impaired ulcer healing. Clips dislodged spontaneously in most patients within 8 weeks of treatment. No further hemorrhage occurred on a median follow-up of 11 months (range 1-23).

CONCLUSIONS

The hemoclip is safe and effective in the treatment of severe ulcer bleeding and is superior to HP in preventing early recurrent bleeding.

Managing patients with acute, nonvariceal gastrointestinal hemorrhage: development and effectiveness of a clinical care pathway

OBJECTIVES

To develop a clinical care pathway for the management of patients with acute upper or lower nonvariceal GI hemorrhage (GIH) who do not require immediate surgical intervention. To test the effectiveness and safety of the pathway in improving the efficiency of care for patients with acute GIH.

METHODS

A multidisciplinary team developed the evidence-based GIH clinical care pathway by consensus techniques. In a quasiexperimental design, pathway outcomes were measured prospectively during the first 8 months of pathway implementation, and compared to similar time periods in the 2 prior yr. Effectiveness measures were the number of patients <65 yr of age admitted for GIH and the hospital length of stay for all patients. Thirty-day safety outcomes were the rates of recurrent GIH, mortality, and readmission to hospital for any reason.

RESULTS

Of 368 patients studied after pathway implementation, 81 (22%) were managed as outpatients. The number of admissions for pathway patients <65 yr of age was significantly lower compared to 691 prepathway patients (p < 0.002). Mean length of stay (+/- 95% CI) for pathway inpatients was 3.5 (3.1, 3.9) days, compared to 5.3 (4.9, 5.7) and 4.6 (4.2, 5) days in the 2 prepathway yr, respectively (p < 0.001). Multivariable regression controlling for admission vital signs, comorbid conditions, age, and the etiology of GIH confirmed that admission after pathway implementation was an independent predictor of a reduced length of hospital stay. There were no significant between-year differences in the 30-day rates of recurrent GIH, mortality, or hospital readmission.

CONCLUSION

A multidisciplinary clinical care pathway may improve the efficiency of caring for patients with acute upper or lower nonvariceal GIH. Decreasing the number of admissions for GIH and reducing the hospital length of stay can be achieved without increasing the number of adverse outcomes.

Pantoprazole: a new proton pump inhibitor

OBJECTIVE

This paper reviews the pharmacology, clinical efficacy, and tolerability of pantoprazole in comparison with those of other available proton pump inhibitors (PPIs).

METHODS

Relevant English-language research and review articles were identified by database searches of MEDLINE, International Pharmaceutical Abstracts, and UnCover, and by examining the reference lists of the articles so identified. In selecting data for inclusion, the author gave preference to full-length articles published in peer-reviewed journals.

RESULTS

Like other PPIs, pantoprazole exerts its pharmacodynamic actions by binding to the proton pump (H+,K+ -adenosine triphosphatase) in the parietal cells, but, compared with other PPIs, its binding may be more specific for the proton pump. Pantoprazole is well absorbed when administered as an enteric-coated, delayed-release tablet, with an oral bioavailability of approximately 77%. It is hepatically metabolized via cytochrome P2C19 to hydroxypantoprazole, an inactive metabolite that subsequently undergoes sulfate conjugation. The elimination half-life ranges from 0.9 to 1.9 hours and is independent of dose. Pantoprazole has similar efficacy to other PPIs in the healing of gastric and duodenal ulcers, as well as erosive esophagitis, and as part of triple-drug regimens for the eradication of Helicobacter pylori from the gastric mucosa. It is well tolerated, with the most common adverse effects being headache, diarrhea, flatulence, and abdominal pain. In clinical studies, it has been shown to have no interactions with various other agents, including carbamazepine, cisapride, cyclosporine, digoxin, phenytoin, theophylline, and warfarin.

CONCLUSIONS

Pantoprazole appears to be as effective as other PPIs. Its low potential for drug interactions may give it an advantage in patients taking other drugs.

Interventional procedures

During the past year, numerous articles were published on interventional procedures of the stomach, focusing on upper gastrointestinal tract bleeding, gastric cancer, gastric outlet obstruction, and benign disease. In the area of upper gastrointestinal tract bleeding, early endoscopy is warranted for early therapeutic intervention and for triage. In patients with bleeding related to peptic ulcer disease, combination therapy (epinephrine injection in conjunction with electrocoagulation therapy) remains the standard of care. Hemoclipping is a new technique that may be helpful in cases in which conventional therapy fails. Repeat endoscopy should always be considered in patients in whom the first attempt at endoscopic therapy fails. In patients with bleeding related to portal hypertension, prophylactic antibiotics may decrease the risk of infections. Banding remains the therapy of choice for this group of patients. There is no documented benefit for combination therapy (banding and sclerotherapy). Transjugular intrahepatic portosystemic shunts may be helpful in the treatment of hypertensive portal gastropathy but not gastric vascular ectasias. In the area of gastric cancer, management revolves around staging. This can be accomplished best through the use of CT scan and endoscopic ultrasound. In patients with early limited disease, attempt at endoscopic mucosal resection should be considered. This technique can be performed in a variety of ways: the most common method seems to be through the use of a saline injection, to separate the mucosa-submucosal layer, followed by a cap-assisted snare resection with suction. The safety, efficacy, and outcome of this technique are reviewed. Gastric outlet obstruction remains a difficult problem to treat endoscopically. However, there is some evidence that endoscopic therapy may be successful in benign disease and should be considered prior to surgical intervention.

Hospitalization for peptic ulcer bleeding: evaluation of a risk scoring system in clinical practice

BACKGROUND

Upper gastrointestinal tract haemorrhage is a common cause of hospitalization: resource utilization in management of peptic ulcer bleeding varies considerably with no apparent effect on patient outcome. Several risk score systems based on endoscopic and clinical data have been proposed and validated in order to aid patient management.

AIM

To assess clinical reliability of a scoring system and to define guidelines to improve efficiency of patient management without reducing efficacy

METHODS

We considered all patients admitted to our unit for bleeding peptic ulcer over a one-year period. Every patient had an early endoscopy (within 12 hours) and therapy according to the appearance of the ulcer defined by Forrest classification. All subjects were classified into low-, intermediate- and high-risk patients on basis of clinical and endoscopic features according to "Cedar Sinai Medical Center predictive index" which was applied retrospectively in first six months then perspectively for the last period using the results obtained from first semester. For each risk group, we compared Length of Hospital Stay number of blood units used in transfusion, rebleeding rate, need for surgery as well as mortality in the two periods, using Student t test. We correlated Length of Hospital Stay and every score parameter by applying analysis of variance to results over the one-year period.

RESULTS

Study population consists of 91 patients. Recurrent bleeding was observed in only three entering the high-risk group, only one of whom needed surgery Overall mortality was 9.8% (9 patients, only one for rebleeding). Variance analysis showed that the only parameter of the "Cedar Sinai Medical Center predictive index" which correlated with Length of Hospital Stay was comorbidity (p < or =0.05). Comparing the two periods, a close application of the score in the last six months allowed Length of Hospital Stay to be reduced in low-risk patients (t test with p=0.004) resulting in early discharge of 33% of cases without affecting patient outcome.

CONCLUSIONS

This study confirms the reliability of the "Cedar Sinai Medical Center predictive index" in clinical practice improving the strategy of applying economic resources. Longer Length of Hospital Stay of intermediate- and high-risk groups is influenced more by comorbidities than by endoscopic findings. Early discharge was possible in one third of low risk patients. An accurate evaluation clinical para meters on admission together with early endoscopy may achieve the goal of reducing costs with a correct patient management.

Advances in diagnostic and therapeutic endoscopy

Endoscopy is extremely valuable in the evaluation of disorders of the luminal gastrointestinal tract, pancreas, and biliary system. Endoscopy as a medical discipline continues to evolve and is becoming increasingly therapeutic in nature. Minimally invasive endoscopic intervention now is effective in a wide variety of disorders, including gastrointestinal hemorrhage, obstructive diseases of the intestinal or biliary tree, and early detection or prevention of neoplastic disease of the colon and esophagus. The development of EUS technology has expanded greatly the potential utility of endoscopy as a diagnostic and a therapeutic modality, and further technologic advances are anticipated.

Role of Doppler US in acute peptic ulcer hemorrhage: can it predict failure of endoscopic therapy?

BACKGROUND

Recurrent bleeding after successful primary endoscopic hemostasis of acutely bleeding ulcers is a significant problem. This study evaluates endoscopic Doppler ultrasound (US) in assessing risk of recurrent bleeding in patients presenting with acute peptic ulcer hemorrhage.

METHODS

In this prospective, double-blind, nonrandomized trial, patients were enrolled from a single academic institution. Only patients with endoscopically confirmed gastric, duodenal, pyloric, or anastomotic ulcers were enrolled. The therapeutic endoscopist was blinded to the Doppler US signal from the ulcer and based treatment decisions on standard guidelines. A 16 MHz pulsed-wave, linear scanning, US probe was used through the accessory channel of an endoscope to assess for the presence of a Doppler signal.

RESULTS

Fifty-two of 139 screened patients entered the trial (55 Doppler sessions). Endoscopic therapy was performed in 42% (30-day recurrent bleeding rate of 17%). Ulcers that remained persistently Doppler positive immediately after endoscopic therapy had a significantly higher rate of recurrent bleeding than ulcers where the Doppler signal was abolished: 100% versus 11% (p = 0.003). There were no bleeding-related deaths.

CONCLUSIONS

A persistently positive Doppler US signal appears to be a marker of inadequate endoscopic therapy in patients with acutely bleeding peptic ulcers.

Treatment of Helicobacter pylori in patients with duodenal ulcer hemorrhage--a long-term randomized, controlled study

OBJECTIVE

Eradication of Helicobacter pylori (H. pylori) in patients with uncomplicated duodenal ulcers prevents long-term recurrence of ulcers. We aimed to study whether treatment of H. pylori prevents the long-term recurrence of duodenal ulcer hemorrhage.

METHODS

Patients with duodenal ulcer bleeding and confirmed H. pylori infection were recruited. A total of 120 patients were randomly assigned to triple therapy (DeNoltab 120 mg, amoxycillin 500 mg, and metronidazole 300 mg four times daily) or DeNoltab 120 mg four times daily alone. No maintenance therapy was given during the follow-up period. The endpoints were the cumulative rates of symptomatic and bleeding duodenal ulcer recurrences.

RESULTS

Of the patients receiving the triple regimen, 85.1% had H. pylori eradicated as compared to 2.0% of patients receiving DeNoltab (p < 0.05). More patients in the DeNoltab group than those in the Triple group had recurrence of ulcer bleeding, but this did not reach statistical significance (12/60 vs 6/60, p = 0.20). Logistic regression analysis on clinical, personal, and endoscopic characteristics identified persistent H. pylori infection as the only independent predictor of recurrence of duodenal ulcer bleeding.

CONCLUSIONS

Treatment of H. pylori alone with the present bismuth-based triple therapy in patients with duodenal ulcer hemorrhage did not result in significant reduction in further bleeding episodes, although a trend was seen for the group that was given triple therapy. On the other hand, posttreatment H. pylori status was found to be an independent predictor of bleeding recurrence.

Nonvariceal upper gastrointestinal bleeding: differences in outcome for patients admitted to internal medicine and gastroenterological services

OBJECTIVE

It has been suggested that admission to a gastroenterology service (GAS) is associated with a better prognosis and lower cost for treatment of gastrointestinal (GI) diseases, such as upper GI bleeding (UGB). However, a large potential bias by higher comorbidity on internal medicine services (MED) could not be excluded from these studies. We therefore compared patients with upper GI bleeding admitted to a gastroenterology or internal medicine department, with special emphasis on prognostic factors, such as comorbidity, and outcome.

METHODS

Between 1991 and 1995, 322 patients were admitted to our hospital for UGB. Forty-five patients had variceal and 277 patients had nonvariceal upper GI bleeding (NUGB). Of 232 patients with primary NUGB, 125 were admitted to GAS and 93 to MED. The charts of these patients were revised, comorbidity was carefully recorded, and the Rockall risk score was calculated. All deaths were individually classified as unavoidable, mostly due to severe underlying illness, or potentially avoidable.

RESULTS

No differences in delay for endoscopy or treatment were observed between GAS and MED. The rebleeding, surgery, and mortality rates in GAS and MED patients were 11.6% versus 11.5% (NS), 7.8% versus 7.3% (NS), and 2.4% versus 10.8% (p = 0.02), respectively. Rockall scores differed between GAS and MED patients (3.1 +/- 1.8 vs 3.7 +/- 1.7, p = 0.02). The mortality rate stratified by Rockall score was lower for the GAS patients. However, individual analysis revealed that only three of 13 deaths were potentially avoidable: two of 10 at the MED and one of three at the GAS.

CONCLUSION

The lower mortality among nonvariceal upper GI bleeding patients admitted to a gastroenterological service compared to an internal medicine service was mainly due to lesser comorbidity. This effect was not detected by stratification according to Rockall, but shown with analysis of individual patient charts only. The latter underscores the potential pitfalls when comparing outcome or cost of treatment between different medical services.

Acute gastrointestinal bleeding

Acute gastrointestinal bleeding is a significant worldwide medical problem. Despite modern measures for diagnosis and treatment, morbidity and mortality rates associated with gastrointestinal bleeding remain largely unchanged. Aggressive medical resuscitation while initiating an evaluation to localize the site of blood loss remains the key to successful management of acute gastrointestinal bleeding. A multidisciplinary approach with early involvement of a gastroenterologist, surgeon, and radiologist can be extremely helpful in the management of these patients. With the logical and direct approach to the evaluation of patients with gastrointestinal bleeding described in this article, most episodes can be managed successfully.

Clinical and endoscopic aspects in the evolution of patients with bleeding peptic ulcer--a cohort study

BACKGROUND

Bleeding ulcers are a major problem in public health and represent approximately half of all the cases of upper gastrointestinal hemorrhage in the United States. This study aims to determine the prognostic value of factors such as clinical history, laboratory and endoscopic findings in the occurrence of new episodes of bleeding in patients who have upper gastrointestinal hemorrhage caused by gastric or duodenal peptic ulcer.

METHODS

A cohort study with 94 patients was designed to investigate prognostic factors to the occurrence of new episodes of bleeding.

RESULTS

From the 94 patients studied, 88 did not present a new bleeding episode in the 7 days following hospital admission. The incidence of rebleeding was significantly higher in those patients with hemoglobin < 6 g/dL at the admission (P = 0.03, RR = 6.2). The localization of the ulcers in bulb was positively associated to rebleeding (P = 0.003). The rebleeding group needed a greater number of units transfunded (P = 0.03) and the time of hospitalization was longer than the time of the hemostasia group (P = 0.0349).

CONCLUSIONS

The identification of patients with risk of death by bleeding peptic ulcer remains as a challenge, once few factors are capable of predicting the severity of the evolution. The identification of such factors will allow the choice of the better therapeutic conduct improving the diagnosis and decreasing the rate of rebleeding and the mortality.

Current status of endoscopic therapy for ulcer bleeding

This article provides an overview of the therapeutic endoscopic modalities available for the treatment of peptic ulcer bleeding. The benefits of endoscopic haemostasis have been fully demonstrated by three meta-analyses, which included most of the controlled trials published until 1992. In this review, an emphasis is placed on randomized, prospective comparative trials published during the past 20 years. Using an evidence-based medicine approach, the results of meta-analyses are translated into efficacy measures known as relative and absolute risk reductions, and number needed to treat. Single-modality treatments with injection agents such as epinephrine, sclerosants and thrombogenic substances, or with thermal therapies, are efficacious and comparable. Combination therapy involving injection and thermal techniques may offer an advantage over single-method therapy. The differences in the results between clinical trials and routine clinical practice, and among the various randomized studies, are probably related to operators' experience and variations in technique rather than to inconsistency of endoscopic haemostasis.

Therapeutic endoscopy for nonvariceal gastrointestinal bleeding

This article reviews the role of therapeutic endoscopy in the diagnosis and treatment of nonvariceal upper and lower gastrointestinal (GI) hemorrhage. The initial approach to patients with GI bleeding is reviewed. Endoscopic treatment of various stigmata of recent peptic ulcer hemorrhage is discussed in detail. Management of less common causes of nonvariceal bleeding, such as Dieulafoy's lesions, Mallory-Weiss tears, angiomas, and bleeding colonic diverticula is described. Recommendations for endoscopic techniques are based on the results of UCLA-CURE hemostasis studies.

Value of stigmata in decision-making in gastrointestinal haemorrhage

The stigmata of recent haemorrhage are endoscopically identified features that have a predictive value for the risk of further bleeding and thus help to determine which patients should receive endoscopic therapy. In conjunction with endoscopic features, clinical features related to the magnitude of bleeding and to patient co-morbidity have important independent effects on the risk of further haemorrhage. Stigmata have been best studied in the context of bleeding ulcers, the most common cause of upper gastrointestinal bleeding. Stigmata in ulcers are usually classified as active bleeding (spurting or oozing), a non-bleeding visible vessel, an adherent clot, a flat pigmented spot, or a clean base, in order of decreasing risk of further haemorrhage. Ulcer size and location may also affect the re-bleeding potential. Recent data suggest that both non-pigmented visible vessels and adherent clots have a higher risk of re-bleeding than was previously thought. The wide variation in prevalence and re-bleeding rates reported for various stigmata in the literature probably reflects variations in the definitions of stigmata and of re-bleeding, the vigour with which the ulcer bases are washed, the co-morbidity and ages of the patients, and the severity of bleeding encountered. Inter-observer agreement in the classification of stigmata is relatively poor and limits the utility of endoscopic features alone in making decisions regarding the management of patients with bleeding peptic ulcers. Imaging devices such as Doppler probes are being evaluated to refine the identification of underlying vessels and their re-bleeding potential, but the utility of these is currently uncertain. The findings of low-risk endoscopic stigmata in a haemodynamically and otherwise stable patient can in many cases allow out-patient management.

Gastrointestinal bleeding in older people

Aging is associated with an increased rate of comorbidity, greater medication use, and atypical clinical presentations. The aging of the population makes the evaluation and management of gastrointestinal bleeding in older people a special and increasingly common clinical challenge. The unique features and common causes of upper and lower gastrointestinal bleeding in older people are reviewed. Important management issues considered include hemodynamic resuscitation, anticoagulation, and endoscopic and surgical therapy.

Characterization of gastrointestinal bleeding in severely ill hospitalized patients

OBJECTIVE

To characterize the source of bleeding and the prognosis in critically ill patients with upper gastrointestinal hemorrhage that developed while in the hospital.

SETTING

Intensive care units of a large academic tertiary-care center.

DESIGN

Retrospective cohort study.

SUBJECTS

Patients undergoing endoscopy in intensive care units for gastrointestinal bleeding that developed while in the hospital.

MEASUREMENTS AND MAIN RESULTS

Medical records were available for 142 patients. Of these, 66 met the criteria for in-hospital bleeding. Peptic ulcer disease, present in 56% of patients, was the most common bleeding source identified. Of patients with peptic ulcer disease, nine of 37 (24%) had stigmata of recent hemorrhage. Ten patients (15%) received endoscopic hemostasis interventions (eight receiving therapy for bleeding ulcers, two receiving therapy for esophageal varices). The in-hospital mortality rate was 42%. The cause of death was sepsis and/or multiple system organ failure in 21 patients (75%); the gastrointestinal bleeding may have contributed to the onset of sepsis in one of these patients. No patients died directly of gastrointestinal bleeding.

CONCLUSIONS

Critically ill patients who bleed while in the hospital have similar sources of bleeding and rates of endoscopically directed therapy as patients admitted to hospital with bleeding. The mortality rate is very high in patients with bleeding that develops in the hospital, and this is usually a result of systemic disease. These data may help clinicians and patients to estimate the potential benefit of urgent endoscopy in critically ill patients.

The use of intravenous H2-receptor antagonists in a tertiary care hospital

OBJECTIVE

The rationale for the widespread use of intravenous H2 receptor antagonists(IVH2 RA) in hospitalized patients is not clear. We therefore examined prescribing patterns and, using strict criteria, determined whether use was appropriate. Cost of administration and potential savings were also determined.

METHODS

Data were obtained prospectively on 100 consecutive patients prescribed intravenous ranitidine and retrospectively on patients admitted with gastrointestinal (GI) bleeding.

RESULTS

For the prospective study, various indications for prescribing intravenous ranitidine were given, including postoperative patients and patients treated with steroids. Using criteria from published literature 80% of the use was considered inappropriate. Nearly 40% of the doses were given while the patient was tolerating oral intake. Creatinine clearance was impaired in 26% of patients, though only one had dosage reduction. Estimated annual cost of intravenous ranitidine was $317,000. The retrospective study of 86 consecutive patients admitted with GI bleeding revealed that all patients received intravenous ranitidine on admission, none of which was considered appropriate. The final diagnoses were peptic ulcer (49), colonic process (11), esophagitis (seven), gastric erosions (five), esophageal varices (five), Mallory-Weiss tears (four), duodenitis (two), no diagnosis (three), and jejunal ulcer (one).

CONCLUSIONS

Inappropriate use of intravenous ranitidine is common. This includes inappropriate indication, dosage, and duration of use. Large financial benefits could have been obtained if close attention was given to prescribing patterns.

Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial

BACKGROUND

Many patients with upper gastrointestinal (GI) bleeding have a benign outcome and could receive less intensive and costly care if accurately identified. We sought to determine whether early endoscopy performed shortly after admission in the emergency department could significantly reduce the health care use and costs of caring for patients with nonvariceal upper GI bleeding without adversely affecting the clinical outcome.

METHODS

All eligible patients with upper GI bleeding and stable vital signs were randomized after admission to undergo endoscopy in 1 to 2 days (control) or early endoscopy in the emergency department. Patients with low-risk findings on early endoscopy were discharged directly from the emergency department. Clinical outcomes and costs were prospectively assessed for 30 days.

RESULTS

We randomized 110 consecutive stable patients with nonvariceal upper GI bleeding during the 12-month study period. The baseline demographic features, endoscopic findings, and the clinical outcomes were no different between the two groups. However the findings of the early endoscopy allowed us to immediately discharge 26 of 56 (46%) patients randomized to that group. No patient discharged from the emergency department suffered an adverse outcome. The hospital stay (median of 1 day [interquartile range of 0 to 3 days] vs. 2 days [interquartile range of 2 to 3 days], p = 0.0001) and the cost of care ($2068 [interquartile range of $928 to $3960] versus $3662 [interquartile range of $2473 to $7280], p = 0.00006) were significantly less for the early endoscopy group.

CONCLUSIONS

Early endoscopy performed shortly after admission in the emergency department safely triaged 46% of patients with nonvariceal upper GI bleeding to outpatient care, which significantly reduced hospital stay and costs.

Review article: acid suppression in non-variceal acute upper gastrointestinal bleeding

Despite a decreased incidence of ulcer disease and improvements in the management of acute upper gastrointestinal (GI) bleeding, mortality remains at about 6-7%. Although endoscopic haemostatic therapy has been demonstrated to be the mainstay of management, the search continues for less invasive medical modalities that might also improve patient outcome. In vitro data have indicated the important role of acid in impairing haemostasis and causing clot digestion. Therefore, theoretically, maintenance of a high intragastric pH (above 6.0) during management of upper GI bleeding is warranted. Until recently, available agents did not permit such a sustained elevation in gastric pH. Early studies with H2-receptor antagonists have not demonstrated significant improvements in important patient outcomes, such as rebleeding, surgery or mortality. With the availability of intravenous formulations of proton pump inhibitors, it is now possible to aim at maintaining gastric pH above 6.0 for 24 h per day. Recent clinical trial data would appear to support the use of proton pump inhibitors to decrease the rate of rebleeding and the need for surgery. This paper provides a review of non-variceal acute GI bleeding, with special reference to the role of proton pump inhibitors in this clinical setting.

Drug therapy for non-variceal upper gastrointestinal bleeding. Assessment of options

The efficacy of somatostatin and octreotide have been widely studied in the control of bleeding from oesophageal varices. It has also been suggested that these drugs may be useful for the control of non-variceal upper gastrointestinal (UGI) bleeding, including that from peptic ulcers. In approximately 80% of patients presenting with non-variceal UGI bleeding, haemorrhage ceases spontaneously and does not recur. However, the remaining 20% of patients require active treatment. Results from recent studies have indicated that somatostatin is an effective treatment for the control of non-variceal UGI bleeding in high-risk patients, i.e. those in whom haemorrhage does not cease spontaneously or is likely to recur. In contrast there is no good evidence available at present to support a role for octreotide, histamine (H(2) antagonists) or proton pump inhibitors in this indication. The efficacy of somatostatin in controlling bleeding in patients with non-variceal UGI bleeding at high risk of mortality upon admission, or rebleeding following endoscopy, coupled with an excellent safety and tolerability profile, suggests it may be a valuable therapeutic option in the management of non-variceal bleeding.

Will Helicobacter pylori affect short-term rebleeding rate in peptic ulcer bleeding patients after successful endoscopic therapy?

OBJECTIVE

Helicobacter pylori (H. pylori) can augment the pH-increasing effect of omeprazole in patients with peptic ulcer. A high intragastric pH may be helpful in preventing recurrent hemorrhage by stabilizing the blood clot at the ulcer base of bleeding peptic ulcer patients. Therefore, we hypothesized that omeprazole may reduce short-term rebleeding rate in these patients with H. pylori infection after initial hemostasis had been obtained.

METHODS

Between July 1996 and December 1998, 65 bleeding peptic ulcer patients (24 gastric ulcer, 41 duodenal ulcer) who had obtained initial hemostasis with endoscopic therapy were enrolled in this trial. Thirty (46.2%) of them were found to have H. pylori infection by a rapid urease test and pathological examination. For all studied patients, omeprazole was given 40 mg intravenously every 6 h for 3 days. Thereafter, omeprazole was given 20 mg per os (p.o.) once daily for 2 months. A pH meter was inserted in the fundus of each patient under fluoroscopic guidance after intravenous omeprazole had been administered. The occurrence of rebleeding episode was observed for 14 days.

RESULTS

In patients with H. pylori infection, intragastric pH (median, 95% confidence interval [CI]: 6.54, 5.90-6.68) was higher than in those without H. pylori infection (6.05, 5.59-6.50, p < 0.001). However, the patients with rebleeding (2 vs 3), volume of blood transfusion (median, range: 1000 ml, 0-2250 vs 750, 0-2000), number of operations (0 vs 1), mortality caused by bleeding (0 vs 0), and hospital stay (median, range: 6 days, 3-14 vs 7, 5-16) were not statistically different from those without H. pylori infection.

CONCLUSIONS

Omeprazole does increase intragastric pH in bleeding peptic ulcer patients with H. pylori infection. However, the presence of H. pylori infection does not affect the short-term rebleeding rate in these patients.

Risk factors for recurrent bleeding and mortality in human immunodeficiency virus infected patients with acute lower GI hemorrhage

BACKGROUND

Little is known about lower gastrointestinal (GI) hemorrhage in the human immunodeficiency virus (HIV) infected population. Our aim was to determine the underlying causes, the clinical outcome, and the risk factors for recurrent bleeding and mortality in HIV-infected patients with acute LGIH.

METHODS

We reviewed the medical records of consecutive HIV-infected patients with acute lower GI hemorrhage who were evaluated with endoscopy from January 1992 through January 1997 at Bellevue Hospital Center.

RESULTS

During the 5-year study period, 312 patients with acute lower GI hemorrhage underwent colonoscopy (n = 233) or flexible sigmoidoscopy (n = 79). Cytomegalovirus colitis (25.3%), lymphoma (12.2%), and idiopathic colitis (12.2%) were the most common causes identified. Within 30 days of presentation, recurrent bleeding occurred in 17.6% of patients. Independent predictors of recurrent bleeding included the presence of at least one comorbid illness, a hemoglobin level of less than 8 gm/dL, a platelet count of less than 100,000/mm3, and major stigmata of hemorrhage. The 30-day mortality from lower GI hemorrhage was 14.4%, and the presence of comorbid disease, recurrence of bleeding, and surgical intervention were found to be the only independent predictors of mortality in this patient population.

CONCLUSIONS

Acute lower GI hemorrhage in HIV-infected patients is most commonly caused by cytomegalovirus colitis and is associated with a high short-term morbidity and mortality.

Selective outpatient management of upper gastrointestinal bleeding in the elderly

OBJECTIVE

We sought to determine whether elderly patients with upper gastrointestinal bleeding can be safely managed as outpatients. We were also interested in determining the etiology of bleeding peptic ulcer disease in this population.

METHODS

Eighty-four patients (65 yr of age and older) were studied during a 23-month period. Urgent outpatient endoscopy was performed and clinical as well as endoscopic criteria were applied to determine the need for hospital admission. Patients with endoscopic findings that indicated a low risk for rebleeding were not admitted if they lacked one major or three minor predefined clinical criteria. All enrollees were followed after discharge from the clinic or hospital for 4 wk with hematocrit determination and clinical assessments. The main outcome measures were the number of patients who met our predefined clinical and endoscopic criteria for outpatient versus inpatient care and the differences in the rebleeding rates in these two groups.

RESULTS

Twenty-four (29%) patients were treated as outpatients; none rebled. In contrast, seven (12%) of the 60 inpatients had one or more rebleeding episodes (p = 0.002). Bleeding from peptic ulcer disease was associated with use of nonsteroidal antiinflammatory medications in 81% of patients.

CONCLUSIONS

Selective outpatient management of elderly patients with upper gastrointestinal bleeding can be done safely and has the potential to lead to reduced health care expenditures. Over-the-counter nonsteroidal antiinflammatory drugs are the most frequent cause of bleeding peptic ulcer disease in this population.

The effect of antibiotic therapy on bleeding from duodenal ulcer

OBJECTIVE

We conducted this study to test whether eradication of Helicobacter pylori (H. pylori) infection prevents hemorrhage related to duodenal ulcer.

METHODS

Patients with H. pylori infection and endoscopically proven duodenal ulcers without ulcer-related hemorrhage were enrolled into four randomized, double-blind, multicenter studies using the same study protocol. They were treated with clarithromycin plus omeprazole (441 patients), omeprazole alone (447 patients), or ranitidine alone (263 patients). Success of H. pylori eradication was evaluated by the 13C-urea breath test 4-6 wk after the last dose of study drug. Follow-up continued at monthly intervals up to 1 yr after the last dose of study drug.

RESULTS

Bleeding due to duodenal ulcer was not observed in any patients who received clarithromycin plus omeprazole, whereas five patients in the omeprazole treatment group and six patients in the ranitidine treatment group experienced an episode of ulcer-related hemorrhage during follow-up. All patients who experienced ulcer-related bleeding were male. When compared by bleeding, there were no significant differences with respect to ethnicity, alcohol consumption, or tobacco use. H. pylori infection was no longer detectable in 68% of patients after treatment with clarithromycin plus omeprazole, compared with 5% after treatment with omeprazole alone or 4% after treatment with ranitidine alone.

CONCLUSION

In a population of duodenal ulcer patients without predisposing risk factors for ulcer bleeding, antibiotic eradication or suppression of H. pylori infection prevented the occurrence of ulcer-related hemorrhage for up to 1 yr after therapy.

Clinical usefulness of 3% hydrogen peroxide in acute upper GI bleeding: a pilot study

BACKGROUND

A major problem in the endoscopic management of acute upper gastrointestinal (GI) bleeding is the presence of blood and clots overlying the bleeding source, preventing visualization of the lesion. A simple alternative is to alter the characteristics of blood such that it not only becomes easier to remove but also becomes translucent. We report the results of a pilot study on the use of hydrogen peroxide in patients with acute upper GI bleeding.

METHODS

Patients with acute upper GI bleeding were studied if the presence of blood or clots obscured the site of bleeding. The potential site of bleeding was initially sprayed with 200 mL water and then with 200 mL 3% hydrogen peroxide mixed with simethicone.

RESULTS

In 6 patients with acute upper GI bleeding, hydrogen peroxide spray resulted in good to excellent visualization of the bleeding source. Hemostasis occurred in 2 patients who were actively bleeding. There were no adverse effects or complications.

CONCLUSIONS

Hydrogen peroxide significantly enhanced clot dissolution and endoscopic visualization in patients with acute upper GI bleeding.