Description: A multidisciplinary group of 34 experts from 15 countries developed this update and expansion of the recommendations on the management of acute nonvariceal upper gastrointestinal bleeding (UGIB) from 2003. Methods: The Appraisal of Guidelines for Research and Evaluation (AGREE) process and independent ethics protocols were used. Sources of data included original and published systematic reviews; randomized, controlled trials; and abstracts up to October 2008. Quality of evidence and strength of recommendations have been rated by using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Recommendations: Recommendations emphasize early risk stratification, by using validated prognostic scales, and early endoscopy (within 24 hours). Endoscopic hemostasis remains indicated for high-risk lesions, whereas data support attempts to dislodge clots with hemostatic, pharmacologic, or combination treatment of the underlying stigmata. Clips or thermocoagulation, alone or with epinephrine injection, are effective methods; epinephrine injection alone is not recommended. Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended. Preendoscopy proton-pump inhibitor (PPI) therapy may downstage the lesion; intravenous high-dose PPI therapy after successful endoscopic hemostasis decreases both rebleeding and mortality in patients with high-risk stigmata. Although selected patients can be discharged promptly after endoscopy, high-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis. For patients with UGIB who require a nonsteroidal anti-inflammatory drug, a PPI with a cyclooxygenase-2 inhibitor is preferred to reduce rebleeding. Patients with UGIB who require secondary cardiovascular prophylaxis should start receiving acetylsalicylic acid (ASA) again as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days); ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding.

International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(02)07273-2.pdf

Role of Helicobacter pylori infection and non-steroidal anti-inflammatory drugs in peptic-ulcer disease: a meta-analysis.

Peptic ulcer is the most common cause of acute hemorrhage in the upper gastrointestinal tract, accounting for about 50 percent of cases1–14. There are approximately 150,000 hospitalizations per year in the United States for evaluation and treatment of bleeding ulcers (based on 1985 estimates and excluding federal hospitals)15. Although hospitalization and surgery for uncomplicated ulcers have decreased in the United States and Europe over the past 20 to 30 years, the number of hospital admissions for hemorrhage associated with ulcers has remained relatively unchanged15–17. It is noteworthy that the incidence of bleeding ulcers appears to . . .

Bleeding peptic ulcer.

Background After endoscopic treatment of bleeding peptic ulcers, bleeding recurs in 15 to 20 percent of patients. Methods We assessed whether the use of a high dose of a proton-pump inhibitor would reduce the frequency of recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. Patients with actively bleeding ulcers or ulcers with nonbleeding visible vessels were treated with an epinephrine injection followed by thermocoagulation. After hemostasis had been achieved, they were randomly assigned in a double-blind fashion to receive omeprazole (given as a bolus intravenous injection of 80 mg followed by an infusion of 8 mg per hour for 72 hours) or placebo. After the infusion, all patients were given 20 mg of omeprazole orally per day for eight weeks. The primary end point was recurrent bleeding within 30 days after endoscopy. Results We enrolled 240 patients, 120 in each group. Bleeding recurred within 30 days in 8 patients (6.7 percent) in the omeprazole group, as compared with 27 (22.5 per...

/pdf/effect-of-intravenous-omeprazole-on-recurrent-bleeding-after-2a0hyssb3l.pdf

Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.

Management of Patients With Ulcer Bleeding

Background A blood clot in a peptic ulcer is unstable in a low pH environment. The use of omeprazole may prevent rebleeding by elevating intragastric pH in patients with bleeding peptic ulcer after hemostasis has been achieved. Objectives To assess the influence of using omeprazole and cimetidine on 24-hour intragastric pH and to determine their ability to prevent rebleeding after having achieved initial hemostasis in patients with active bleeding or nonbleeding visible vessels. Methods One hundred patients with bleeding peptic ulcers who had obtained initial hemostasis were enrolled in this randomized comparative trial. In the cimetidine group (n=50), a 300-mg intravenous bolus of cimetidine was given, followed by a 1200-mg continuous infusion daily for 3 days. Thereafter, 400 mg of cimetidine was given orally twice daily for 2 months. In the omeprazole group (n=50), a 40-mg intravenous bolus of omeprazole was given, followed by 160 mg of continuous infusion daily for 3 days. Thereafter, 20 mg of omeprazole was given orally once daily for 2 months. A pH meter was inserted in each patient's fundus under fluoroscopic guidance after the intravenous bolus of cimetidine or omeprazole had been administered. Results The stigmata of recent hemorrhage before endoscopic therapy in the omeprazole and cimetidine groups were, respectively, spurting (9 vs 12), oozing (4 vs 9), and nonbleeding visible vessel (37 vs 29) ( P >.05). The duration of intragastric pH higher than 6.0 was longer in the omeprazole group (mean[±SD], 84.4±22.9%) than that of the cimetidine group (mean[±SD], 53.5±32.3%) ( P P =.004). There was a tendency for patients in the omeprazole group to require less blood transfusion (median, 0 mL; range, 0-2500 mL) than those in the cimetidine group (median, 0 mL; range, 0-5000 mL) ( P =.08). The hospital stay and number of operations and mortality rate were similar between both groups. Conclusions The use of omeprazole is more effective than cimetidine in increasing intragastric pH and reducing rebleeding episodes in patients with bleeding peptic ulcers after successful endoscopic therapy. This suggests that omeprazole should be used routinely after successful endoscopic therapy.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/190919/ioi70155.pdf

A prospective randomized comparative trial showing that omeprazole prevents rebleeding in patients with bleeding peptic ulcer after successful endoscopic therapy

The benefit of early endoscopy in the management of peptic ulcer bleeding remains controversial. In this study we looked at the role of early endoscopy in bleeding peptic ulcer patients with clear, "coffee grounds," or bloody nasogastric aspirate. A consecutive series of 325 patients with peptic ulcer bleeding were included (218 patients with clear aspirate, 77 patients with coffee-grounds aspirate, and 30 patients with bloody aspirate). They were randomized to receive early endoscopy (within 12 h of arrival at the emergency room) or delayed endoscopy (12 h after arrival at the emergency room). Early endoscopy did not benefit patients with clear or coffee-grounds aspirate. However, combined with endoscopic therapy, it did significantly benefit patients with bloody aspirate in reducing the need for blood transfusion (mean, 450 ml vs. 666 ml; p < 0.001) and hospital stay (mean, 4 vs. 14.5 days, p < 0.001). Early endoscopy and endoscopic therapy are not needed in bleeding peptic ulcer patients with clear or coffee-grounds nasogastric aspirate. However, early endoscopy and endoscopic therapy benefit patients with bloody nasogastric aspirate.

Early or delayed endoscopy for patients with peptic ulcer bleeding. A prospective randomized study.

http://dlweb01.tzuchi.com.tw/DL/AcdActive/content/research/document/gi/shiau/A%20prospective,%20radomized%20trial%20of%20large-versus%20small-volume%20endoscopic%20injection%20of%20epinephrine%20for%20peptic%20ulcer%20bleeding%20(91).pdf

A prospective, randomized trial of large- versus small-volume endoscopic injection of epinephrine for peptic ulcer bleeding.

A prospective, randomized trial of endoscopic hemoclip versus heater probe thermocoagulation for peptic ulcer bleeding

We conducted a prospective randomised controlled trial of 137 patients with massive peptic ulcer haemorrhage over a period of 12 months to compare the haemostatic effects of endoscopic heat probe thermocoagulation and pure alcohol injection. Seventy eight patients (56.9%) were in shock at the time of randomisation to the trial. The age, sex, number of patients in shock, haemoglobin value at the time of entry to the trial, number of patients with severe medical illness, location of bleeders, and stigmata of recent haemorrhage were comparable among the heat probe, pure alcohol, and control groups. The initial haemostatic effect of the heat probe was better than that of the pure alcohol injection (44 of 45 v 31 of 46, p = 0.0004). The ultimate haemostasis achieved by the heat probe group (41 of 45) was better than that of the pure alcohol group (31 of 46, p = 0.012) and of controls (24 of 46, p = 0.0001). The duration of hospital stay was shorter for patients in the heat probe group than for the control group (6.2 days v 13.8 days, p less than 0.05). The incidence of emergency surgery was less for the heat probe than the control group (three of 45 v 12 of 46, p = 0.027). The mortality rate was less in the heat probe than in the control group (one of 45 v seven of 46, p = 0.031). We suggest that heat probe thermocoagulation should be the first treatment of choice for arrest of massive peptic ulcer haemorrhage.

https://gut.bmj.com/content/gutjnl/31/7/753.full.pdf

Hwai Jeng Lin

Papers

A prospective randomized comparative trial showing that omeprazole prevents rebleeding in patients with bleeding peptic ulcer after successful endoscopic therapy

Early or delayed endoscopy for patients with peptic ulcer bleeding. A prospective randomized study.

A prospective, randomized trial of large- versus small-volume endoscopic injection of epinephrine for peptic ulcer bleeding.

A prospective, randomized trial of endoscopic hemoclip versus heater probe thermocoagulation for peptic ulcer bleeding

Heat probe thermocoagulation and pure alcohol injection in massive peptic ulcer haemorrhage: a prospective, randomised controlled trial.