Abstract & Commentary
Synopsis: There are arguments about the optimal treatment for ulcers with nonbleeding visible vessels and adherent clots. This study showed that the combination of endoscopic hemostasis with IV proton pump inhibitor therapy is superior to PPI alone in management of such patients.
Source: Sung JJ, et al. Ann Intern Med. 2003;139:237-243.
GI hemorrhage is a dreaded complication of ulcer disease, whether idiopathic, Helicobacter pylori related, or due to NSAIDs. Most physicians medically treat GI bleeding with acid suppression. Proton pump inhibitors (PPI) are used in this setting with increasing frequency. In the United States, IV pantoprazole (Protonixä) is the PPI available for this purpose. Elsewhere in the world, IV omeprazole is often used. Gastroenterologists often perform urgent endoscopy in patients presenting with GI hemorrhage, and they commonly treat bleeding vessels with local injection or thermal therapy. Use of endoscopic hemostasis in nonbleeding vessels or for ulcers with adherent clots has not been widely accepted. Several articles suggest that PPI therapy can decrease ulcer rebleeding in this setting. This study of 156 patients with bleeding ulcers with adherent clots or visible vessels compared IV omeprazole alone to IV omeprazole plus endoscopic hemostasis using a heater probe and injection of diluted epinephrine. Sham endoscopy involved only gentle irrigation of the ulcersite without other manipulation. Nine of 54 patients receiving omeprazole alone had recurrent bleeding compared to none of 63 treated with PPI plus endoscopic hemostasis. Adherent clots without visible vessels were less likely to bleed than all ulcers with visible vessels.
Comment by Malcolm Robinson, MD, FACP, FACG
Data continue to accumulate that support aggressive acid suppression in the setting of gastrointestinal hemorrhage due to ulcer disease. It now seems clear that more ulcer patients than previously thought could benefit from aggressive endoscopic therapeutic intervention. The dose of IV omeprazole used in this study was 80 mg by bolus, followed by the constant infusion of 8 mg/hour. Similar dose requirements exist for pantoprazole, the only PPI that is currently available in an intravenous form in the United States. Prompt gastroenterology consultation appears to be highly appropriate in patients presenting with upper GI hemorrhage.
Dr. Robinson, Medical Director, Oklahoma Foundation for Digestive Research; Clinical Professor of Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK, is Associate Editor of Internal Medicine Alert.