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      A Real World Report on Intravenous High-Dose and Non-High-Dose Proton-Pump Inhibitors Therapy in Patients with Endoscopically Treated High-Risk Peptic Ulcer Bleeding

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          Abstract

          Background and Study Aims. The optimal dose of intravenous proton-pump inhibitor (PPI) therapy for the prevention of peptic ulcer (PU) rebleeding remains controversial. This study aimed to understand the real world experiences in prescribing high-dose PPI and non-high-dose PPI for preventing rebleeding after endoscopic treatment of high-risk PU. Patients and Methods. A total of 220 subjects who received high-dose and non-high-dose pantoprazole for confirmed acute PU bleeding that were successfully treated endoscopically were enrolled. They were divided into rebleeding ( n = 177) and non-rebleeding groups ( n = 43). Randomized matching of the treatment-control group was performed. Patients were randomly selected for non-high-dose and high-dose PPI groups ( n = 44 in each group). Results. Univariate analysis showed, significant variables related to rebleeding were female, higher creatinine levels, and higher Rockall scores (≧6). Before case-control matching, the high-dose PPI group had higher creatinine level, higher percentage of shock at presentation, and higher Rockall scores. After randomized treatment-control matching, no statistical differences were observed for rebleeding rates between the high-dose and non-high-dose groups after case-control matching. Conclusion. This study suggests that intravenous high-dose pantoprazole may not be superior to non-high-dose regimen in reducing rebleeding in high-risk peptic ulcer bleeding after successful endoscopic therapy.

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          Risk assessment after acute upper gastrointestinal haemorrhage.

          T A Rockall, R. F. Logan, H Devlin … (1996)
          The aim of this study was to establish the relative importance of risk factors for mortality after acute upper gastrointestinal haemorrhage, and to formulate a simple numerical scoring system that categorizes patients by risk. A prospective, unselected, multicentre, population based study was undertaken using standardised questionnaires in two phases one year apart. A total of 4185 cases of acute upper gastrointestinal haemorrhage over the age of 16 identified over a four month period in 1993 and 1625 cases identified subsequently over a three month period in 1994 were included in the study. It was found that age, shock, comorbidity, diagnosis, major stigmata of recent haemorrhage, and rebleeding are all independent predictors of mortality when assessed using multiple logistic regression. A numerical score using these parameters has been developed that closely follows the predictions generated by logistical regression equations. Haemoglobin, sex, presentation (other than shock), and drug therapy (non-steroidal anti-inflammatory drugs and anticoagulants) are not represented in the final model. When tested for general applicability in a second population, the scoring system was found to reproducibly predict mortality in each risk category. In conclusion, a simple numerical score can be used to categorize patients presenting with acute upper gastrointestinal haemorrhage by risk of death. This score can be used to determine case mix when comparing outcomes in audit and research and to calculate risk standardised mortality. In addition, this risk score can identify 15% of all cases with acute upper gastrointestinal haemorrhage at the time of presentation and 26% of cases after endoscopy who are at low risk of rebleeding and negligible risk of death and who might therefore be considered for early discharge or outpatient treatment with consequent resource savings.
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            International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding.

            Alan N Barkun, Marc Bardou, Ernst J. Kuipers … (2010)
            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. 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 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.
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              Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000.

              Dania van der Meer, E. A. Rauws, G Tytgat … (2003)
              The aim of this study was to examine recent time trends in incidence and outcome of upper GI bleeding. Prospective data collection on all patients presenting with acute upper GI bleeding from a defined geographical area in the period 1993/1994 and 2000. Incidence decreased from 61.7/100,000 in 1993/94 to 47.7/100,000 persons annually in 2000, corresponding to a 23% decrease in incidence after age adjustment (95% CI = 15-30%). The incidence was higher among patients of more advanced age. Rebleeding (16% vs 15%) and mortality (14% vs 13%) did not differ between the two time periods. Ulcer bleeding was the most frequent cause of bleeding, at 40% (1993/94) and 46% (2000). Incidence remained stable for both duodenal and gastric ulcer bleeding. Almost one half of all patients with peptic ulcer bleeding were using nonsteroidal anti-inflammatory drugs or aspirin. Also, among patients with ulcer bleeding, rebleeding (22% vs 20%) and mortality (15% vs 14%) did not differ between the two time periods. Increasing age, presence of severe and life-threatening comorbidity, and rebleeding were associated with higher mortality. Between 1993/1994 and 2000, among patients with acute upper GI bleeding, the incidence rate of upper GI bleeding significantly decreased, but no improvement was seen in the risk of rebleeding or mortality in these patients. The incidence rate of ulcer bleeding remained stable. Prevention of ulcer bleeding is important.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Gastroenterol Res Pract
                Journal ID (iso-abbrev): Gastroenterol Res Pract
                Journal ID (publisher-id): GRP
                Title: Gastroenterology Research and Practice
                Publisher: Hindawi Publishing Corporation
                ISSN (Print): 1687-6121
                ISSN (Electronic): 1687-630X
                Publication date (Print): 2012
                Publication date (Electronic): 11 July 2012
                Volume: 2012
                Electronic Location Identifier: 858612
                Affiliations
                Division of Hepato-Gastroenterology, Department of Internal Medicine and Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 123 Ta-Pei Road, Niaosung Hsiang, Kaohsiung City 833, Taiwan
                Author notes

                Academic Editor: Ping-I Hsu

                Article
                DOI: 10.1155/2012/858612
                PMC ID: 3403596
                PubMed ID: 22844276
                SO-VID: e20294c4-e559-47c6-92fe-52bc72ef3aa0
                Copyright © Copyright © 2012 Lung-Sheng Lu et al.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 13 April 2012
                Date revision received : 13 May 2012
                Date accepted : 21 May 2012
                Categories
                Subject: Research Article

                ScienceOpen disciplines: Gastroenterology & Hepatology
                Data availability:
                ScienceOpen disciplines: Gastroenterology & Hepatology

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