Management of Acute Bleeding Upper GI Ulcers in the Era of Endoscopic and IV PPI Therapy

Abstract

Despite advances in therapy, the morbidity and mortality of gastrointestinal bleeding remains high. A review of current practice patterns was undertaken in St Boniface General Hospital, Winnipeg, Manitoba to assess the standard of care provided. To determine whether upper gastrointestinal bleeding (UGIB) attributable to a single acute ulcer is treated appropriately with respect to local therapy, acid suppression and Helicobacter pylori status. A retrospective chart review identified patients with consecutive acute UGIB attributable to a single gastric or duodenal ulcer presenting to a tertiary care centre over a six-month period. The lesions were classified as high- or low-risk based on endoscopic appearance. Local care of the ulcer, acid suppressive therapy and management of H. pylori were determined by reviewing pertinent chart materials. Appropriate care was defined for all three end points a priori using literature-supported standards of care. Fifty-five patients who met study criteria were identified. Twenty-six of 55 (47%) and 29 of 55 (52%) lesions were considered to be low- and high-risk respectively. Of the high-risk lesions, two of 29 received no local therapy, 24 of 29 received adrenaline injection and two had an endoclip placed. Of the 27 patients whose lesions were treated, 16 received thermal coagulation. Twenty-five of 29 (88%) received intravenous proton pump inhibitors. Thirty-three of 55 (55%) patients did not have H. pylori status considered in their management. Weaknesses in the management of UGIB were identified, particularly with respect to addressing the role of H. pylori. Fragmentation and compartmentalization of patient care may be important contributing factors.