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Management of upper gastrointestinal bleeding

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Abstract

Upper gastrointestinal bleeding secondary to ulcer disease is common and results in substantial patient morbidity and medical expense. After initial resuscitation to stabilize the patient, carefully performed endoscopy provides an accurate diagnosis and identifies high-risk ulcer patients who are likely to rebleed with medical therapy alone and will benefit most from endoscopic hemostasis. For patients with major stigmata of ulcer hemorrhage—active arterial bleeding, nonbleeding visible vessel, and adherent clot—combination therapy with epinephrine injection and either thermal coagulation (multipolar or heater probe) or endoclips is recommended. High-dose intravenous proton pump inhibitors are recommended as concomitant therapy after successful endoscopic hemostasis. Patients with minor stigmata or clean-based ulcers will not benefit from endoscopic treatment and should receive high-dose oral proton pump inhibitor therapy. Effective medical and endoscopic management of ulcer hemorrhage can significantly improve outcomes and decrease the cost of medical care by reducing rebleeding, transfusion requirements, and the need for surgery.

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References and Recommended Reading

  1. Kovacs TOG, Jensen DM: Recent advances in the endoscopic diagnosis and therapy of upper gastrointestinal, small intestinal, and colonic bleeding. Med Clin N Am 2002, 86:1319–1356.

    Article  PubMed  Google Scholar 

  2. Kovacs TOG: Mallory-Weiss tears, angiodysplasia, watermelon stomach and Dieulafoy’s: a potpourri. Tech Gastrointest Endosc 2005, 7:139–147.

    Article  Google Scholar 

  3. Winstead NS, Wilcox CM: Erythromycin prior to endoscopy for acute upper gastrointestinal hemorrhage: a cost-effectiveness analysis. Aliment Pharmacol Ther 2007, 26:1371–1377.

    Article  PubMed  CAS  Google Scholar 

  4. Kovacs TOG, Jensen DM: Endoscopic treatment of peptic ulcer bleeding. Curr Treat Opt Gastroenterol 2007, 10:143–148.

    Article  Google Scholar 

  5. Wong RCK: Endoscopic Doppler US probe for acute peptic ulcer hemorrhage. Gastrointest Endosc 2004, 60:804–812.

    Article  PubMed  Google Scholar 

  6. Chen V, Wong RCK: Endoscopic Doppler ultrasound versus endoscopic stigmata—directed management of acute peptic ulcer hemorrhage: a multimodel cost analysis. Dig Dis Sciences 2007, 52:149–160.

    Article  Google Scholar 

  7. Green FW Jr, Kaplan MM, Curtis LE, et al.: Effects of acid and pepsin on blood coagulation and platelet aggregation: a possible contributor to prolonged gastroduodenal mucosal hemorrhage. Gastroenterology 1978, 74:38–43.

    PubMed  CAS  Google Scholar 

  8. Labenz J, Peitz U, Leusing C, et al.: Efficacy of primed infusions with high dose ranitidine and omeprazole to maintain high intragastric pH in patients with peptic ulcer bleeding: a prospective, randomized, controlled study. Gut 1997, 40:36–41.

    PubMed  CAS  Google Scholar 

  9. Merki HS, Wilder-Smith CH: Do continuous infusions of omeprazole and ranitidine retain their effect after prolonged dosing? Gastroenterology 1994, 106:60–64.

    PubMed  CAS  Google Scholar 

  10. Netzer P, Gaia C, Sandoz M, et al.: Effect of repeated injection and continuous infusion of omeprazole and ranitidine on intragastric pH over 72 hours. Am J Gastroenterol 1999, 94:351–357.

    PubMed  CAS  Google Scholar 

  11. Lin HJ, Lo WC, Cheng YC, et al.: Role of intravenous omeprazole in patients with high-risk peptic ulcer bleeding after successful endoscopic epinephrine injection: a prospective, randomized, comparative trial. Am J Gastroenterol 2006, 101:500–505.

    Article  PubMed  CAS  Google Scholar 

  12. Lau JY, Sung JJ, Lee KK, et al.: Effects of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Engl J Med 2000, 343:310–316.

    Article  PubMed  CAS  Google Scholar 

  13. Sung JJY, Chan FKL, Lau JYW: The effect of endoscopic therapy in patients receiving omeprazole for bleeding ulcers with non-bleeding visible vessels or adherent clots. Ann Intern Med 2003, 139:237–243.

    PubMed  CAS  Google Scholar 

  14. Andriulli A, Annese V, Caruso N, et al.: Proton-pump inhibitors and outcome of endoscopic hemostasis in bleeding peptic ulcers: a series of meta-analyses. Am J Gastroenterol 2005, 100:207–219.

    Article  PubMed  CAS  Google Scholar 

  15. Bardou M, Toubouti Y, Benhaberou-Brun D, et al.: Metaanalysis: proton-pump inhibition in high-risk patients with peptic ulcer bleeding. Aliment Pharmacol Ther 2005, 21:677–686.

    Article  PubMed  CAS  Google Scholar 

  16. Leontiadis GI, Sharma VK, Howden CW: Systematic review and meta-analysis: enhanced efficacy of proton pump inhibitor therapy for peptic ulcer bleeding in Asia—a post hoc analysis from the Cochrane Collaboration. Aliment Pharmacol Ther 2005, 21:1055–1061.

    Article  PubMed  CAS  Google Scholar 

  17. Leontiadis GI, Sharma VK, Howden CW: Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev 2006, 1:CD002094.

    PubMed  Google Scholar 

  18. van Herwaarden MA, Samson M, van Nispen CHM, et al.: The effect of Helicobacter pylori eradication on intragastric pH during dosing with lansoprazole or ranitidine. Aliment Pharmacol Ther 1999, 13:731–740.

    Article  PubMed  Google Scholar 

  19. Barkun A, Racz I, van Rensburg C, et al.: Prevention of peptic ulcer rebleeding using continuous infusion of pantoprazole vs ranitidine: a multicenter, multinational, randomized, double blind, parallel-group comparison [abstract]. Gastroenterology 2004, 126:A–78.

    Google Scholar 

  20. Jensen DM, Pace SC, Soffer E, et al.: Continuous infusion of pantoprazole versus ranitidine for prevention of ulcer rebleeding: A US multicenter, randomized, double-blind study. Am J Gastroenterol 2006, 101:1991–1999.

    Article  PubMed  CAS  Google Scholar 

  21. Hsu PI, Lo GH, Lo CC, et al.: Intravenous pantoprazole versus ranitidine for prevention of rebleeding after endoscopic hemostasis of bleeding peptic ulcers. World J Gastroenterol 2004, 10:3666–3669.

    PubMed  CAS  Google Scholar 

  22. Howden CW, Metz DC, Hunt B, et al.: Dose-response evaluation of the antisecretory effect of continuous infusion intravenous lansoprazole regimen over 48 h. Aliment Pharmacol Ther 2006, 23:975–984.

    Article  PubMed  CAS  Google Scholar 

  23. Metz DC, Amer F, Hunt B, et al.: Lansoprazole regimens that sustain intragastric pH > 6.0: an evaluation of intermittent oral and continuous intravenous infusion dosages. Aliment Pharmacol Ther 2006, 23:985–995.

    Article  PubMed  CAS  Google Scholar 

  24. Keyvani L, Murthy S, Leeson S, Targownik LE: Pre-endoscopic proton pump inhibitor therapy reduces recurrent adverse gastrointestinal outcomes in patients with acute non-variceal upper gastrointestinal bleeding. Aliment Pharmacol Ther 2006, 24:1247–1255.

    Article  PubMed  CAS  Google Scholar 

  25. Lau JY, Leung WK, Wu JCY, et al.: Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med 2007, 356:1631–1640.

    Article  PubMed  CAS  Google Scholar 

  26. Dorward S, Sreedharan A, Leontiadis GI, et al.: Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev 2006, CD005415.

  27. Tsoi KK, Sung JJ: Cost-effectiveness analysis of high-dose omeprazole infusion before endoscopy for patients with upper GI bleeding. Gastrointest Endosc 2008, 67:1056–1063.

    Article  PubMed  Google Scholar 

  28. Al-Sobah S, Burkun AN, Herba K, et al.: Cost-effectiveness of proton-pump inhibition before endoscopy in upper gastrointestinal bleeding. Clin Gastroenterol Hepatol 2008, 6:418–425.

    Article  Google Scholar 

  29. Khuroo MS, Yattoo GN, Javid G, et al.: A comparison of omeprazole and placebo for bleeding peptic ulcer. N Engl J Med 1997, 336:1054–1058.

    Article  PubMed  CAS  Google Scholar 

  30. Bajaj JS, Dua KS, Hanson K, et al.: Prospective, randomized trial comparing effect of oral versus intravenous pantoprazole on rebleeding after nonvariceal upper gastrointestinal bleeding: a pilot study. Dig Dis Sci 2007, 52:2190–2194.

    Article  PubMed  CAS  Google Scholar 

  31. Murthy S, Keyvani L, Leeson S, Targownik LE: Intravenous versus high-dose oral proton pump inhibitor therapy after endoscopic hemostasis of high-risk lesions in patients with acute non-variceal upper gastrointestinal bleeding. Dig Dis Sci 2007, 52:1685–1690.

    Article  PubMed  Google Scholar 

  32. Yilmaz S, Bayan K, Juzunm Y, et al.: A head to head comparison of oral vs. intravenous omeprazole for patients with bleeding peptic ulcers with a clean base, flat spots, and adherent clots. World J Gastroenterol 2006, 12:7837–7843.

    PubMed  CAS  Google Scholar 

  33. Kim JI, Cheung DY, Cho SH, et al.: Oral proton pump inhibitors are as effective as endoscopic treatment for bleeding peptic ulcer: a prospective, randomized, controlled trial. Dig Dis Sci 2007, 52:3371–3376.

    Article  PubMed  CAS  Google Scholar 

  34. Laine L, Shah A, Bemanian S: Intragastric pH with oral vs intravenous bolus plus infusion proton pump inhibitor therapy in patients with bleeding ulcers. Gastroenterology 2008, 134:1836–1841.

    Article  PubMed  Google Scholar 

  35. Spiegel BMR, Dulai GS, Lim BS, et al.: The cost-effectiveness and budget impact of intravenous versus oral proton pump inhibitors in peptic ulcer hemorrhage. Clin Gastroenterol Hepatol 2006, 4:988–997.

    Article  PubMed  CAS  Google Scholar 

  36. Barkun AN, Herba K, Adam U, et al.: The cost-effectiveness of high-dose oral proton pump inhibition after endoscopy in the acute treatment of peptic ulcer bleeding. Aliment Pharmacol Ther 2004, 20:195–202.

    Article  PubMed  CAS  Google Scholar 

  37. Calvet X, Vergara M, Brullet E, et al.: Addition of a second endoscopic treatment following epinephrine injection improves outcome in high-risk bleeding ulcers. Gastroenterology 2004, 126:441–450.

    Article  PubMed  Google Scholar 

  38. Vergara M, Calvet X, Gisbert JP: Epinephrine injection versus epinephrine injection and a second endoscopic method in high risk bleeding ulcers. Cochrane Database Syst Rev 2007, CD005584.

  39. Jensen DM, Machicado GA: Endoscopic hemostasis of ulcer hemorrhage with injection, thermal, and combination methods. Tech Gastrointest Endosc 2005, 7:124–131.

    Article  Google Scholar 

  40. Technology Assessment Committee, Chuttani R, Barkun A, et al.: Endoscopic clip application devices. Gastrointest Endosc 2006, 63:746–750.

    Article  PubMed  Google Scholar 

  41. Saltzman JR, Strata LL, Di Sena V, et al.: Prospective trial of endoscopic clips versus combination therapy in upper GI bleeding. Am J Gastroenterol 2005, 97:1503–1508.

    Article  Google Scholar 

  42. Sung JJ, Tsai KK, Lai LH, et al.: Endoscopic clipping versus injection and thermo-coagulation in the treatment of non-variceal upper gastrointestinal bleeding: a meta-analysis. Gut 2007, 56:1364–1373.

    Article  PubMed  Google Scholar 

  43. Jensen DM, Machicado GA, Hirabayashi K: Randomized controlled study of 3 different types of hemoclips for hemostasis of bleeding canine acute gastric ulcers. Gastrointest Endosc 2006, 64:768–773.

    Article  PubMed  Google Scholar 

  44. Lin HJ, Lo WC, Cheng YC, Peing CL: Endoscopic hemoclip versus TriClip placement in patients with high-risk peptic ulcer bleeding. Am J Gastroenterol 2007, 102:539–543.

    Article  PubMed  Google Scholar 

  45. Chan CY, Yan KK, Siu WT, et al.: Endoscopic hemostasis by using the TriClip for peptic ulcer hemorrhage: a pilot study. Gastrointest Endosc 2008, 67:35–39.

    Article  PubMed  Google Scholar 

  46. Marmo R, Rotondano G, Piscopo R, et al.: Dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers: a meta-analysis of controlled trials. Am J Gastroenterol 2007, 102:279–289.

    Article  PubMed  Google Scholar 

  47. Park CH, Joo YE, Kim HS, et al.: A prospective, randomized trial comparing mechanical methods of hemostasis plus epinephrine injection to epinephrine injection alone for bleeding peptic ulcer. Gastrointest Endosc 2004, 60:173–179.

    Article  PubMed  Google Scholar 

  48. Lo CC, Hsu PI, Lo GH, et al.: Comparison of hemostatic efficacy for epinephrine injection alone and injection combined with hemoclip therapy in treating high-risk bleeding ulcers. Gastrointest Endosc 2006, 63:767–773.

    Article  PubMed  Google Scholar 

  49. Jensen DM, Kovacs TOG, Jutabha R, et al.: Randomized trial of medical or endoscopic therapy to prevent recurrent ulcer hemorrhage in patients with adherent clots. Gastroenterology 2002, 123:407–413.

    Article  PubMed  Google Scholar 

  50. Kahi CJ, Jensen DM, Sung JJY, et al.: Endoscopic therapy versus medical therapy for bleeding peptic ulcer with adherent clot: a meta-analysis. Gastroenterology 2005, 129:855–862.

    Article  PubMed  Google Scholar 

  51. Lau JJ, Sung JJY, Lam Y, et al.: Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med 1999, 340:751–756.

    Article  PubMed  CAS  Google Scholar 

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  1. CURE/Digestive Disease Research Center, VA Greater Los Angeles Healthcare System, Building 115, Room 212, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA

    Thomas O. G. Kovacs

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Correspondence to Thomas O. G. Kovacs.

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Kovacs, T.O.G. Management of upper gastrointestinal bleeding. Curr Gastroenterol Rep 10, 535–542 (2008). https://doi.org/10.1007/s11894-008-0099-3

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