RISK OF REBLEEDING IN PATIENTS WITH PEPTIC ULCER DISEASE RECEIVING ANTICOAGULATION

Abstract

Purpose: The risk of re-bleeding in patients with upper gastrointestinal hemorrhage (GIH) due to peptic ulcer disease is, in large part, dependent on the presence or absence of stigmata of ulcer hemorrhage during endoscopic evaluation. Ulcers with active bleeding, visible vessel, or adherent clot are stratified in a higher risk group compared to ulcers that are clean-based or possess a pigment spot. Endoscopic treatment of the former lesions leads to a significant decrease in the re-bleeding risk, although that risk can still be as high as 20–30%. Patients suffering from acute myocardial infarction (AMI) often undergo cardiac catheterization, which requires a heparin bolus. The risk of re-bleeding is unknown for patients with ulcer disease and AMI requiring catheterization and anticoagulation. The purpose of this study was to evaluate the re-bleeding risk in this patient population. Methods: A retrospective, single center, study from January 1, 1996-December 31, 2002, was performed identifying patients using ICD-9-CM codes for AMI, GIH, and esophagogastroduodenoscopy (EGD). Charts and electronic records were reviewed for demographics, clinical data, endoscopic findings, therapy, complications, and performance of cardiac catheterization. Results: A total of 183 patients underwent EGD within seven days of suffering an AMI and GIH. Twelve patients diagnosed with peptic ulcer disease subsequently required cardiac catheterization with heparin bolus. Endoscopic diagnoses were erosive gastritis (5), clean-based ulcer (5), ulcer with visible vessel (1), ulcer with adherent clot (1). The patient with an ulcer and visible vessel was treated with epinephrine and cautery. The patient with an ulcer with adherent clot was treated with cautery. All patients received therapy with a proton pump inhibitor. Cardiac catheterization was performed from 1 to 6 days after GIH diagnosis. All patients were given 1000U to 3000U boluses of heparin during cardiac catheterization. Five of the 15 patients (33%) also received ticlopidine or clopidogril. None of the patients rebled during the hospitalization. Conclusions: In this study of patients with acute GIH from peptic ulcer disease and AMI necessitating cardiac catherization with heparin bolus prior to ulcer healing, no patients rebled during the hospitalization. Peptic ulcer disease does not appear to be an absolute contraindication to short-term anticoagulation.