Surgical management of actively bleeding duodenal ulcer.

SUMMARY

Background: The secondary prevention of bleeding from ulcers may be improved if antisecretory drugs are able to maintain a 24-h gastric pH close to neutral.



Aim: To evaluate the effect of intravenous famotidine at a conventional dose of 40 mg/day on 24-h intragastric pH in patients with a bleeding duodenal ulcer, and to determine the dose required to maintain gastric pH > 6 by use of a Gastrojet (MIC, Switzerland) device (a pH meter-controlled programmable pump).



Methods: Twelve patients (nine men, three women), aged 24–78 years, admitted for a bleeding duodenal ulcer, were studied after active bleeding had stopped for at least 6 h. Gastric pH was recorded for two consecutive 24-h periods, each starting at 16.00 hours. The patients were fasted during these periods and received an infusion of 2.5 L of isotonic glucose. They were given famotidine, as a continuous i.v. infusion of 40 mg during one period, and at a rate determined by the Gastrojet during the other period (in a random sequence), with the aim of maintaining the gastric pH above 6.



Results: The 24-h median (interquartile range) pH and the mean (± S.E.M.) percentage of the 24-h period with a gastric pH > 6 were both significantly higher during the Gastrojet period than during the continuous infusion: 6.4 (6.3–6.5) vs. 5.7 (2.7–6.4) (P 6 (mean ± S.E.M.) was significantly higher at night (22.00 to 07.00 hours) than during the rest of the day (88 ± 2 vs. 70 ± 6%; P < 0.005) and the mean quantity of famotidine delivered per hour was significantly lower during the night (6.3 ± 0.8 mg/h vs. 8.4 ± 0.5 mg/h; P < 0.02).



Conclusion: We conclude that 40 mg of famotidine delivered as a continuous i.v. infusion is not sufficient to maintain gastric pH > 6 for 24 h in duodenal ulcer patients. Our study with the Gastrojet device shows that it may be possible to achieve this goal by using a much larger dose, preferably delivered during the day.

Maintenance of gastric pH above 6 with intravenous famotidine in patients with a bleeding duodenal ulcer.

Department of General Surgery Despite recent diagnostic and therapeutic advances, the mortality rate for upper gastrointestinal bleeding has remained at 10% for the past three decades.1 T w o factors are probably responsible for this persistently high mortality rate. First, this population is composed of a larger than average proportion of elderly patients who have marked associated medical diseases. Second, advanced techniques in intensive care allow patients who are critically ill or have had multiple traumas to be supported for long periods of time; many of these patients subsequently develop upper gastrointestinal bleeding that may be fatal. Recent developments in the management of the patient with gastrointestinal bleeding include fiberoptic endoscopy, cimetidine therapy, gastric pH monitoring, and radiographic arterial embolization. Their clinical application is being investigated. Although bleeding episodes are controlled in most cases with medical management, approximately 15% to 20% of patients require surgery.1

https://www.ccjm.org/content/ccjom/49/2/97.full.pdf

Wilkholm L

Papers

The bleeding duodenal ulcer.