Peptic ulcer bleeding

WITHDRAWN: Proton pump inhibitor treatment for acute peptic ulcer bleeding

BACKGROUND

Randomised controlled trials (RCTs) evaluating the clinical effect of proton pump inhibitors (PPIs) in peptic ulcer (PU) bleeding yield conflicting results.

OBJECTIVES

To evaluate the efficacy of PPIs in acute bleeding from PU using evidence from RCTs.

SEARCH STRATEGY

We searched CENTRAL, The Cochrane Library (Issue 4, 2004), MEDLINE (1966 to November 2004), EMBASE (1980 to November 2004), proceedings of major meetings to November 2004, and reference lists of articles. We contacted pharmaceutical companies and experts in the field.

SELECTION CRITERIA

RCTs of PPI treatment (oral or intravenous) compared with placebo or H(2)-receptor antagonist (H(2)RA) in acute bleeding from PU.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data independently, assessed study validity, summarised studies and undertook meta-analysis. The influence of study characteristics on the outcomes was examined by subgroup analyses and meta-regression.

MAIN RESULTS

Twenty-four RCTs comprising 4373 participants in total were included. Statistical heterogeneity was found among trials for rebleeding (P = 0.04), but not for all-cause mortality (P = 0.24) or surgery (P = 0.45). There was no significant difference in all-cause mortality rates between PPI and control treatment; pooled rates were 3.9% on PPI versus 3.8% on control (odds ratio (OR) 1.01; 95% CI 0.74 to 1.40). PPIs significantly reduced rebleeding compared to control; pooled rates were 10.6% with PPI versus 17.3% with control treatment (OR 0.49; 95% CI 0.37 to 0.65). PPI treatment significantly reduced surgery compared with control; pooled rates were 6.1% on PPI versus 9.3% on control (OR 0.61; 95% CI 0.48 to 0.78). There was no evidence to suggest that results on mortality and rebleeding were dependent on study quality, route of PPI administration, type of control treatment or application of initial endoscopic haemostatic treatment. PPIs significantly reduced surgery compared with placebo but not when compared with H(2)RA. There was no evidence to suggest that study quality, route of PPI administration or application of initial endoscopic haemostatic treatment influenced results on surgery. PPI treatment appeared more efficacious in studies conducted in Asia compared to studies conducted elsewhere. All-cause mortality was reduced only in Asian studies; reductions in rebleeding and surgery were quantitatively greater in Asian studies. Among patients with active bleeding or non-bleeding visible vessel, PPI treatment reduced mortality (OR 0.53; 95% CI 0.31 to 0.91), rebleeding and surgery.

AUTHORS' CONCLUSIONS

PPI treatment in PU bleeding reduces rebleeding and surgery compared with placebo or H(2)RA, but there is no evidence of an overall effect on all-cause mortality.

Comparison of the Effectiveness of Interventional Endoscopy in Bleeding Peptic Ulcer Disease according to the Timing of Endoscopy

BACKGROUND/AIMS

The optimal timing for interventional endoscopy in bleeding peptic ulcer disease is controversial. This study compared the outcomes between early endoscopy and delayed endoscopy in patients with bleeding peptic ulcer disease.

METHODS

We conducted a prospective analysis of data from 90 patients with bleeding peptic ulcer disease who visited the emergency room between May 2006 and September 2007. Patients were categorized into two groups: the early-endoscopy group (admitted during the daytime or at night with prompt endoscopic management) and the delayed-endoscopy group (admitted at night or during weekends, with endoscopic management delayed until the next day). We compared the clinical outcomes of endoscopy between the two groups.

RESULTS

There were 49 patients in the early-endoscopy group and 41 patients in the delayed-endoscopy group. Patient demographics, clinical characteristics, bleeding control modality, and Rockall score did not differ between the two groups. There were also no significant differences between the early- and delayed-endoscopy groups in the re-bleeding rate (3/49 vs 5/41, p=0.313), the duration of hospital stay (10.7 vs 9.3 days, p=0.437), and the total amount of blood transfused (3.4 vs 2.7 units, p=0.240).

CONCLUSIONS

The effectiveness of interventional endoscopy for patients with bleeding peptic ulcer disease is not significantly affected by the timing of endoscopy.

Proton pump inhibitor treatment for acute peptic ulcer bleeding

BACKGROUND

Randomised controlled trials (RCTs) evaluating the clinical effect of proton pump inhibitors (PPIs) in peptic ulcer (PU) bleeding yield conflicting results.

OBJECTIVES

To evaluate the efficacy of PPIs in acute bleeding from PU using evidence from RCTs.

SEARCH STRATEGY

We searched CENTRAL, The Cochrane Library (Issue 4, 2004), MEDLINE (1966 to November 2004), EMBASE (1980 to November 2004), proceedings of major meetings to November 2004, and reference lists of articles. We contacted pharmaceutical companies and experts in the field.

SELECTION CRITERIA

RCTs of PPI treatment (oral or intravenous) compared with placebo or H(2)-receptor antagonist (H(2)RA) in acute bleeding from PU.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data independently, assessed study validity, summarised studies and undertook meta-analysis. The influence of study characteristics on the outcomes was examined by subgroup analyses and meta-regression.

MAIN RESULTS

Twenty-four RCTs comprising 4373 participants in total were included. Statistical heterogeneity was found among trials for rebleeding (P = 0.04), but not for all-cause mortality (P = 0.24) or surgery (P = 0.45). There was no significant difference in all-cause mortality rates between PPI and control treatment; pooled rates were 3.9% on PPI versus 3.8% on control (odds ratio (OR) 1.01; 95% CI 0.74 to 1.40). PPIs significantly reduced rebleeding compared to control; pooled rates were 10.6% with PPI versus 17.3% with control treatment (OR 0.49; 95% CI 0.37 to 0.65). PPI treatment significantly reduced surgery compared with control; pooled rates were 6.1% on PPI versus 9.3% on control (OR 0.61; 95% CI 0.48 to 0.78). There was no evidence to suggest that results on mortality and rebleeding were dependent on study quality, route of PPI administration, type of control treatment or application of initial endoscopic haemostatic treatment. PPIs significantly reduced surgery compared with placebo but not when compared with H(2)RA. There was no evidence to suggest that study quality, route of PPI administration or application of initial endoscopic haemostatic treatment influenced results on surgery. PPI treatment appeared more efficacious in studies conducted in Asia compared to studies conducted elsewhere. All-cause mortality was reduced only in Asian studies; reductions in rebleeding and surgery were quantitatively greater in Asian studies. Among patients with active bleeding or non-bleeding visible vessel, PPI treatment reduced mortality (OR 0.53; 95% CI 0.31 to 0.91), rebleeding and surgery.

AUTHORS' CONCLUSIONS

PPI treatment in PU bleeding reduces rebleeding and surgery compared with placebo or H(2)RA, but there is no evidence of an overall effect on all-cause mortality.

Effectiveness of an upper-gastrointestinal haemorrhage unit: a prospective analysis of 900 consecutive cases using the Rockall score as a method of risk standardisation

OBJECTIVES

To assess the effectiveness of a centralised upper-gastrointestinal haemorrhage (UGIH) unit.

METHODS

The UK Audit of acute UGIH resulted in the formulation of a simple numerical scoring system. The Rockall score categorises patients by risk factors for death and allows case-mix comparisons. A total of 900 consecutive patients admitted to a UGIH unit between October 1995 and July 1998 were analysed prospectively. Patients were given an initial Rockall score and, if endoscopy was performed, a complete score. This method of risk stratification allowed the proportion of deaths (in our study) to be compared with the National Audit using risk standardised mortality ratios.

RESULTS

The distribution of both initial and final Rockall scores was significantly higher in our study than in the National Audit. A total of 73 (8.1%) patients died, compared with the National Audit mortality of 14%. Risk-standardised mortality ratios using both initial and complete Rockall scores were significantly lower in our study when compared with those in the National Audit.

CONCLUSION

A specialised UGIH unit is associated with a lower proportion of deaths from UGIH, despite comprising a greater number of high-risk patients than the National Audit. This lower mortality therefore cannot be attributed to a more favourable case mix and demonstrates that further improvements in mortality for UGIH can be made.

Proton pump inhibitor treatment for acute peptic ulcer bleeding

BACKGROUND

Peptic ulcer (PU) bleeding is associated with substantial morbidity, mortality and healthcare cost. Randomised controlled trials (RCTs) evaluating the clinical effect of proton pump inhibitors (PPIs) in peptic ulcer bleeding have yielded conflicting results.

OBJECTIVES

To evaluate the efficacy of PPIs in the management of acute bleeding from PU using evidence from RCTs.

SEARCH STRATEGY

We performed a search of CENTRAL, The Cochrane Library (Issue 3, 2003), MEDLINE (1966 to February 2003) and EMBASE (1980 to February 2003) and proceedings of recent major meetings through to February 2003. We searched the reference lists of articles and contacted pharmaceutical companies and experts in the field for additional published or unpublished data.

SELECTION CRITERIA

RCTs of PPI treatment (oral or intravenous) compared with either placebo or H(2)-receptor antagonist (H(2)RA) in patients with acute bleeding from PU were included if they met pre-defined criteria.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data independently on a purpose-designed data extraction form. Validity of included studies was assessed by adequacy of randomisation method and other pre-defined criteria. Studies were summarised and meta-analysis was undertaken. The influence of factors on the outcomes was assessed.

MAIN RESULTS

Twenty-one RCTs with a total of 2915 participants were included. Statistical heterogeneity was found among trials for rebleeding (P = 0.05), but not for mortality (P = 0.26) or surgery (P = 0.42). There was no significant difference in mortality rates between PPI and control treatment; pooled rates were 5.2% on PPI versus 4.6% on control (odds ratio (OR) 1.11; 95% CI 0.79 to 1.57). PPI treatment significantly reduced rates of surgical intervention compared with control; pooled rates were 8.4% on PPI versus 13.0% on control (OR 0.59; 95% CI 0.46 to 0.76). PPIs significantly reduced rebleeding compared to control; pooled rates were 10.6% with PPI (range: 0% to 24.4%) versus 18.7% with control treatment (range: 2.3% to 39.1%), the OR was 0.46 (95% CI 0.33 to 0.64). Results on mortality and rebleeding rates were independent of route of PPI administration, type of control treatment or application of initial endoscopic haemostatic treatment. Surgical intervention rates varied with type of control (PPI significantly reduced surgical intervention rates compared with placebo and not when compared with H(2)RA) but not with route of PPI administration or application of initial endoscopic haemostatic treatment.

REVIEWERS' CONCLUSIONS

PPI treatment in PU bleeding reduces rebleeding and surgical intervention rates in studies comparing treatment with placebo or H(2)RA, but there is no evidence of an effect on mortality.

Simplified acute physiology score II: a valid role in the assessment of patients with medically refractory upper gastrointestinal bleeding?

BACKGROUND AND AIM

Medically refractory upper gastrointestinal hemorrhage (UGIH) is a complex clinical problem. Selection of patients suitable for surgery is difficult and often involves subjective clinical judgment. The simplified acute physiology score (SAPS) II is a validated predictor of mortality in the intensive care setting. Our aim was to assess the SAPS II score in patients with medically refractory UGIH who were referred for a surgical opinion. Patients were subsequently classed as 'accepted' or 'declined' for surgery and SAPS II scores were compared between these two groups.

METHODS

From July 1996 to July 1999, patients referred for surgical intervention with UGIH were included (varices excluded). The SAPS II was calculated at the time of surgical referral. This was converted into a mortality probability using multiple regression analysis. Clinical outcome was defined as either survival to discharge or death while an inpatient.

RESULTS

Ninety-nine patients were referred for surgical review. Sixty-five patients were accepted for surgery and 34 were declined. The mean SAPS II score for those who were accepted was 31.7 (mortality probability 0.16, actual mortality 15.4%, 10/65) and 30.2 (mortality probability 0.15, actual mortality 29.4%, 10/34) for those who were declined.

CONCLUSION

The SAPS II scores were no different between the two groups. Observed mortality was consistent with mortality predicted in the operated group but twice that predicted in those where surgical intervention was declined. This suggests that clinical selection criteria for patients undergoing surgery for UGIH are inconsistent.

Impact of intravenous omeprazole on Helicobacter pylori eradication by triple therapy in patients with peptic ulcer bleeding

AIM

To test the impact of intravenous omeprazole on Helicobacter pylori eradication for bleeding peptic ulcers.

METHODS

A total of 175 H. pylori-infected patients with bleeding peptic ulcers were randomized into either an omeprazole group or a ranitidine group, receiving intravenous omeprazole or ranitidine for 3 days after endoscopy. Afterwards, 1-week triple therapy was used to eradicate H. pylori for both groups. Six weeks later, either a 13C-urea breath test or follow-up endoscopy was performed to assess the success of H. pylori eradication.

RESULTS

The rebleeding rate was lower in the omeprazole group vs. the ranitidine group (6% vs. 17%, P < 0.05). The H. pylori eradication rate was higher in the omeprazole group (intention-to-treat analysis: 83% vs. 66%, P < 0.05; per protocol analysis: 93% vs. 80%, P < 0.05). For patients with duodenal ulcers, the per protocol H. pylori eradication rate of the omeprazole group was higher than that of the ranitidine group (93% vs. 73%, P < 0.05).

CONCLUSIONS

Intravenous omeprazole can decrease the risk of rebleeding of peptic ulcers. For duodenal ulcers, in particular, intravenous omeprazole may even improve the H. pylori eradication rate of the subsequent triple therapy.