Review article: the role of pharmaco-therapy for acute variceal haemorrhage in the era of endoscopic haemostasis

Cost implications of administering intravenous proton pump inhibitors to all patients presenting to the emergency department with peptic ulcer bleeding

OBJECTIVES

Administering proton pump inhibitors (PPI) intravenously (iv) after endoscopic treatment of bleeding peptic ulcers reduces the incidence of rebleeding, the need for operative procedures, and hospitalizations. We assessed the cost implications of iv PPI initiated in all patients presenting to the emergency department (ED) with signs of upper gastrointestinal (UGI) bleeding.

METHODS

From a third-party payer perspective with a time horizon of 60 days, we built a decision analytic model comparing standard endoscopic therapy to a strategy in which all patients presenting to the ED with UGI bleeding would start iv PPI before endoscopy. After endoscopy, only those with peptic ulcers would be kept on iv PPI added to standard therapy. Probabilities of health events were extracted from published literature. Resource utilization profiles and costs (iv PPI, hospital stay for medical and operative procedures, and professional fees) were based on Medicare reimbursement data from a large hospital in Alabama. All costs were expressed in 2000 US dollars. Uncertainty was investigated through one-way sensitivity analyses and probabilistic analyses using Monte Carlo simulations.

RESULTS

In a hypothetical group of 1000 individuals, routine use of iv PPI prevented 40 rebleeds, 9 surgical procedures, and 223 hospital days, and led to incremental savings of dollars 920 per subject. Probabilistic sensitivity analyses indicated that the strategy of using iv PPI was likely to be dominant even when accounting for uncertainty.

CONCLUSIONS

Based on available evidence, routine administration of iv PPI to all persons presenting with UGI bleeding represents good value for money and merits consideration as standard hospital policy.

Recent advances in the endoscopic diagnosis and therapy of upper gastrointestinal, small intestinal, and colonic bleeding

Endoscopy has become the first and primary diagnostic and therapeutic modality in the management of patients with severe gastrointestinal bleeding. Panendoscopy, push enteroscopy, and colonoscopy provide the diagnostic, prognostic, and therapeutic elements to improve patient outcomes and to reduce morbidity and mortality from severe GI hemorrhage. Recent improvements in endoscopic hemostatic techniques and in imaging modalities using wireless capsule endoscopy suggest that diagnostic and therapeutic endoscopy will be even more important in determining patient outcomes in the future.

Octreotide for acute esophageal variceal bleeding: a meta-analysis

BACKGROUND & AIMS

Studies of octreotide have not demonstrated a consistent benefit in efficacy or safety compared with conventional therapies. This study statistically pooled existing trials to evaluate the safety and efficacy of octreotide for esophageal variceal hemorrhage.

METHODS

We identified randomized trials of octreotide for variceal hemorrhage from computerized databases, scientific meeting abstracts, and the manufacturer of octreotide. Blinded reviewers abstracted the data, and a meta-analysis was performed.

RESULTS

Octreotide improved control of esophageal variceal hemorrhage compared with all alternative therapies combined (relative risk [RR], 0.63; 95% confidence interval [CI], 0.51-0.77); vasopressin/terlipressin (RR, 0.58; 95% CI, 0.42-0.81); or no additional intervention/placebo (among patients that received initial sclerotherapy/banding before randomization) (RR, 0.46; 95% CI, 0.32-0.67). Octreotide had comparable efficacy to immediate sclerotherapy for control of bleeding (RR, 0.94; 95% CI, 0.55-1.62), fewer major complications than vasopressin/terlipessin (RR, 0.31; 95% CI, 0.11-0.87), and a complication profile comparable to no intervention/placebo (RR, 1.06; 95% CI, 0.72-1.55). No specific alternative therapy demonstrated a mortality benefit.

CONCLUSIONS

These results favor octreotide over vasopressin/terlipressin in the control of esophageal variceal bleeding and suggest it is a safe and effective adjunctive therapy after variceal obliteration techniques. Trials are needed to determine the optimal dose, route, and duration of octreotide treatment.

Comparison of endoscopic variceal sclerotherapy alone and in combination with octreotide in controlling acute variceal hemorrhage and early rebleeding in patients with low-risk cirrhosis

OBJECTIVE

Efficacy of endoscopic variceal sclerotherapy (EVS) alone and in combination with octreotide in controlling acute variceal bleeding and preventing early rebleeding was compared in a double-blind study.

METHODS

Consecutive patients presenting with variceal bleeding with low-risk liver cirrhosis were randomized into two groups. Group A received EVS with 3-5 ml of ethanolamine oleate per varix and placebo injection at 50 microg/h; group B received the combined therapy of EVS and octreotide 50 microg/h continuously for 5 days. A total of 70 patients (mean age, 38.4 +/- 8.6 yr) were selected for the study, which included 56 men (mean age, 37.9 +/- 8.5 yr) and 14 women (mean age, 40.6 +/- 9.0 yr). Thirty-five patients were allocated in each group.

RESULTS

In group A bleeding was controlled in 30 patients (85.7%) and in group B in 33 (94.3%) (p = 0.24). The number of patients who rebled during the first 5 days after sclerotherapy was eight (22.9%) and two (5.7%) in groups A and B, respectively (p = 0.04). The mean packs of blood transfused to the patients of groups A and B were 2.1 +/- 1.2 packs and 1.5 +/- 0.7 packs, respectively (p = 0.03). The mean hospital stay of group A was 6.6 +/- 1.3 days, whereas that in group B was 5.9 +/- 1.2 days (p = 0.04). One patient from each group died during the course of the study.

CONCLUSIONS

No significant difference was observed in arrest of bleeding in the two groups, but episodes of early rebleeding, blood transfusions, and hospital stay was significantly less in group B.