Treatment Of Bleeding Peptic Ulcers Research Articles

Efficacy of pantoprazole and omeprazole in treatment of peptic ulcer bleeding

Efficacy of pantoprazole and omeprazole in treatment of peptic ulcer bleeding

115 Hemospray Versus the Combined Conventional Technique for Endoscopic Treatment of Bleeding Peptic Ulcers: A Pilot Randomized Controlled Study

115 Hemospray Versus the Combined Conventional Technique for Endoscopic Treatment of Bleeding Peptic Ulcers: A Pilot Randomized Controlled Study

When Should Antiplatelet Agents Be Resumed After Successful Endoscopic Hemostasis in Patients with Peptic Ulcer Bleeding?

During treatment for peptic ulcer bleeding (PUB), it is imperative to determine the effect of antiplatelet agents on recurrent bleeding in order to balance risks and benefits. We compared the rate of recurrent bleeding in antiplatelet users and non-users. This retrospective study analyzed prospectively collected data from PUB patients treated by endoscopic modalities between August 2007 and December 2014. We evaluated and compared the rate of recurrent bleeding within 30days in antiplatelet users and non-users; we also categorized antiplatelet users into continuation (≤3days) and withdrawal (>3days) groups. A total of 490 patients were enrolled in the study, 302 (61.6%) and 188 (38.4%) in the non-user and antiplatelet user groups, respectively. The recurrent bleeding rate among antiplatelet users (10.1%) was significantly higher than that among non-users (5.0%; p=0.029). Among 188 antiplatelet users, 51 (27.1%) and 137 (72.9%) were assigned to the continuation and withdrawal groups, respectively. The rate of recurrent bleeding did not differ significantly between groups (11.7 vs. 5.9%, p=0.241). Multivariate analysis revealed chronic kidney disease as a risk factor [odds ratio (OR) 2.890, 95% confidence interval (CI) 1.079-7.742, p=0.035]. However, antiplatelet use (OR 1.691, 95% CI 0.813-3.517, p=0.160) was not. This study highlights the need for clinicians to consider underlying diseases in antiplatelet users under the appropriate antiplatelet therapy during the post-hemostasis period. Furthermore, the optimal time to resume antiplatelet agents may be 3days after successful endoscopic hemostasis in patients with PUB.

Topical tranexamic acid as a novel treatment for bleeding peptic ulcer: A randomised controlled trial

Background:Peptic ulcers are among the most common causes of upper gastrointestinal (GI) bleeding in children. The standard care for GI bleeding is endoscopy for diagnostic and therapeutic purposes. We aimed to assess the effect of topical tranexamic acid (TXA) via endoscopic procedures in children with GI bleeding caused by bleeding ulcers.Procedure:In this randomised controlled trial, 120 children were evaluated by diagnostic procedures for GI bleeding, of which 63 (30 girls, 33 boys) aged 1-month to 15 years were recruited. The patients were randomly divided into case and control groups. In the case group, TXA was administered directly under endoscopic therapy. In the control group, epinephrine (1/10,000) was submucosally injected to the four quadrants of ulcer margins as the routine endoscopic therapy. In both groups, the patients received supportive medical therapy with intravenous fluids and proton pump inhibitor drugs.Results:The mean ± standard deviation age of the children was 5 ± 2.03 years. Rebleeding occurred in 15 (11.4%) and 21 (9.8%) patients in the case and control groups, respectively (P = 0.50). The frequency of blood transfusion episodes (P = 0.06) and duration of hospital stay (P = 0.07) were not statistically different between the groups.Conclusion:Using topical TXA via endoscopic procedures may be effective in cases of GI bleedings caused by active bleeding ulcers. In order to establish this therapeutic effect, a large number of clinical studies are needed.

Endoscopic hemostasis for peptic ulcer bleeding: systematic review and meta-analyses of randomized controlled trials

Peptic ulcer represents the most common cause of upper gastrointestinal bleeding. Endoscopic therapy can reduce the risks of rebleeding, continued bleeding, need for surgery, and mortality. The objective of this review is to compare the different modalities of endoscopic therapy. Studies were identified by searching electronic databases MEDLINE, Embase, Cochrane, LILACS, DARE, and CINAHL. We selected randomized clinical trials that assessed contemporary endoscopic hemostatic techniques. The outcomes evaluated were: initial hemostasis, rebleeding rate, need for surgery, and mortality. The possibility of publication bias was evaluated by funnel plots. An additional analysis was made, including only the higher-quality trials. Twenty-eight trials involving 2988 patients were evaluated. Injection therapy alone was inferior to injection therapy with hemoclip and with thermal coagulation when evaluating rebleeding and the need for emergency surgery. Hemoclip was superior to injection therapy in terms of rebleeding; there were no statistically significant differences between hemoclip alone and hemoclip with injection therapy. There was considerable heterogeneity in the comparisons between hemoclip and thermal coagulation. There were no statistically significant differences between thermal coagulation and injection therapy, though their combination was superior, in terms of rebleeding, to thermal coagulation alone. Injection therapy should not be used alone. Hemoclip is superior to injection therapy, and combining hemoclip with an injectate does not improve hemostatic efficacy above hemoclip alone. Thermal coagulation has similar efficacy as injection therapy; combining these appears to be superior to thermal coagulation alone. Therefore, we recommend the application of hemoclips or the combined use of injection therapy with thermal coagulation for the treatment of peptic ulcer bleeding.

Endoscopic Suturing for Ulcer Exclusion in Patients With Massively Bleeding Large Gastric Ulcer

Bleeding peptic ulcer is one of the most important causes for hospitalization worldwide. Though endoscopic hemostasis is the current standard of treatment for bleeding peptic ulcers, ulcer rebleeding remained a chief cause of mortality.1Chiu P.W. et al.Clin Gastroenterol Hepatol. 2009; 3: 311-316Abstract Full Text Full Text PDF Scopus (88) Google Scholar One of the important strategies to improve outcomes for bleeding peptic ulcers is to prevent rebleeding. Indeed, endoscopic features for ulcers with high risk of rebleeding include ulcers larger than 2 cm, actively bleeding and those located at posterior duodenal bulb or high lesser curvature.2Johnston J.H. et al.Gastroenterology. 1987; 92: 1101-1108Abstract Full Text PDF PubMed Scopus (111) Google Scholar With the use of high-dose intravenous proton pump inhibitors (PPI), those who developed rebleeding after PPI infusion were patients with significant perioperative risks, high proportion of comorbidities, as well as older age which rendered them high-risk surgical candidates.3Elmunzer B.J. et al.Am J Gastroenterol. 2008; 103: 2625-2632Crossref PubMed Scopus (119) Google Scholar A prototype endoscopic suturing device had been investigated for the safety and efficacy in achieving hemostasis among massively bleeding gastric ulcers.4Chiu P.W. et al.Dig Surg. 2009; 26: 243-248Crossref PubMed Scopus (16) Google Scholar This is an initial report on the clinical application of surgical ulcer exclusion using endoscopic suturing for large bleeding gastric ulcer. The Apollo Overstitch is an endoscopic suturing system which consists of a cap-based suturing system with a curved suture arm extending from one of the dual channels and the anchor exchange system extending from the same channel. The handle to control the suture plication system was mounted onto the shaft of a double-channel endoscope (Olympus 2T100 scope, Olympus Co Ltd, Hong Kong). The Overstitch system attached to the double-channel endoscope was introduced into the stomach through an overtube. The bleeding ulcer was first located with an ordinary single-channel endoscope. Endoscopic suturing begins with the needle first driving through the distal edge of the bleeding ulcer. After closing the curved needle driver, the detachable needle should be grasped by the anchor exchange and detached from the needle driver. After opening the needle driver, the endoscope with Overstitch should be moved away from the distal ulcer edge. The needle should be placed back in the needle driver by the anchor exchange. The needle should then be driven over the proximal edge of the ulcer and the procedure repeated until the 2 edges of the ulcer can be pulled together. The needle anchor should be dropped, while the anchor exchange is replaced by the cinching device which passes along the 2 ‘O’ polypropylene suture. After passage of the cinch to ulcer edge, the polypropylene suture should be tightened against the end of the cinch. The cinch is then closed to cut the stitch and release the plug to tighten the suture, and the ulcer should be excluded from an intragastric high acidity environment to stop current bleeding and prevent rebleeding. Three patients received endoscopic ulcer exclusion for a massively bleeding gastric ulcer. This video shows endoscopic suturing for ulcer exclusion in an actively bleeding gastric ulcer. The patient was a 78-year-old man who presented with passage of tarry stool for 3 days; upper endoscopy showing a 2 cm large gastric ulcer at angular incisura with visible vessel. There was active bleeding from visible vessel (Figure 1). The Overstitch device was introduced through an overtube. The first suture plication was performed over the superior edge of the ulcer. After exchange of the anchor, the second suture plication was performed over the inferior ulcer edge. This process was continued until a figure of eight suture was formed over the ulcer. The anchor was then dropped and the suture was tightened with the cinching device. The ulcer was excluded with adequate hemostasis (Figure 2). The patient had no clinical evidence of rebleeding, and a repeated endoscopy in 72 hours confirmed secure closure of the ulcer.Figure 2Ulcer exclusion achieved after tightening of overstitch.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Surgical exclusion of bleeding ulcer is a conventional treatment for prevention of further bleeding through suture closure of the ulcer and excluding it from intragastric acidity. This is the first technological report on clinical application of endoscopic surgical suturing for ulcer exclusion. The success of endoscopic ulcer exclusion will lead to improvement in primary endoscopic hemostasis, and theoretically excluding the ulcer from acid to prevent further bleeding. The ulcer exclusion shall be a better method to prevent rebleeding compared with adjunctive high-dose proton pump inhibitor infusion or prophylactic angiographic embolization. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI0NDRlMDkxM2NmMGRhNGUwNGJiZDFkODUyMjRjMjQxYyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjgxMzYwNDY3fQ.XXJzrp-6yqa5X_Fxu-t93ZJmJ4gGt5KEIICkg-xZWs2P9QUVTwPcWU5BIAoyY161WQqS9Xoq2xlMpMeFIa03TVHD9haMAQ-SBed6va3cMQtozXytNgaNMojGDSQwMA4hN2-dG7kGlLfGkDlU3dV9Oi0epZaZBfhQIxkNVWPYU76Fm68LSNLJ7_1G29qT5DlWZrSOHsW10o5dkts0yBD9W0Bc9PUUOiJX1P41J4-g2lAv77tNCIPyZNrVzhbQnAt1xIYBD1YAb1HHnXEHF1q2P_ISMMsqrfBJmW0OLGH8PblHrNNDwqnDn3pnyRIekdVxovny7vwoogxhrPzxLQT2mw Download .mp4 (43.03 MB) Help with .mp4 files Video 1

High Dose Proton Pump Inhibitor Infusion Versus Bolus Injection for the Prevention of Bleeding After Endoscopic Submucosal Dissection: Prospective Randomized Controlled Study.

A high dose of continuous intravenous infusion of proton pump inhibitor (PPI) is the standard treatment for peptic ulcer bleeding. The optimal dose for the prevention of bleeding after endoscopic submucosal dissection (ESD) is unclear. The purpose of this study was to determine whether stronger acid suppression more effectively prevents bleeding and high risk ulcer stigma (HRS) after gastric ESD. A total of 273 patients who underwent ESD were randomly assigned to one of two treatment groups: the continuous infusion group and the bolus injection group. Second-look endoscopy was performed on the following day after ESD. The incidences and risk factors of HRS identified by second-look endoscopy and delayed bleeding were analyzed. There were no differences in the incidences of HRS and delayed bleeding between two treatment groups. The incidence of HRS was 15.8 % (43/273) and the gross morphology (flat or depressed) was identified as a significant factor associated with HRS. The incidence of delayed bleeding was 8.4 % (23/273) and the gross morphology (flat) and the presence of submucosal invasive cancer were identified as the associated risk factors for delayed bleeding. The incidences of delayed bleeding and HRS identified by second-look endoscopy were not affected by PPI infusion methods. Flat or depressed morphologic lesions and submucosal invasive cancer should be closely monitored.

EFFICACY OF ENDOSCOPIC INJECTION THERAPY WITH HSE 3% COMBINED WITH HIGH-DOSE PROTON PUMP INHIBITOR IN PEPTIC ULCER BLEEDING

Background: Peptic ulcer bleeding is one of the common medical emergencies with a high rate of mortality. Endoscopic hemostasis with HSE 3% injection is an effective treatment for patients with peptic ulcer bleeding, helps to save cost and avoid an unnecessary emergency surgery. Objective: To determine the success rate of endoscopic hemostatic with HSE 3% injection in patients with peptic ulcer bleeding. Patients and methods: A prospective, cross sectional study on 41 patients with peptic ulcer bleeding admitted in Can Tho Central General Hospital, from August 2012 to April 2013. All the patients underwent emergency endoscopy for hemostasis by injecting HSE 3% solution, and high- dose PPI use. Results: The rate of Forrest class IA, IB, IIA, IIB was 12.2%, 56.1%, 19.5% and 12.2%, respectively. The rate active bleeding group (Forrest class IA/IB) was 668.3%, while hemostatic group with high risk of rebleeding was 31.7%. The success rate was 92.7%, and the rebleeding rate was 7.3%. Conclusion: Endoscopic HSE 3% injection combined with high- dose PPI is an effective, relatively safe treatment for peptic ulcer bleeding. Key words: peptic ulcer bleeding, HSE, endoscopic hemostasis therapy.

Clinical effects of esomeprazole, amoxicillin and clarithromycin combined with traditional Chinese medicine decoction in treatment of peptic ulcer bleeding

目的：探讨埃索美拉唑镁肠溶片＋阿莫西林胶囊＋克拉霉素胶囊联合中药汤剂治疗消化性溃疡出血（peptic ulcer bleeding,PUB）的临床效果.方法：按照实际用药情况将山东省安丘市人民医院收治的96例PUB患者分为中西医组61例和西医组35例,西医组患者给予埃索美拉唑镁肠溶片＋阿莫西林胶囊＋克拉霉素胶囊治疗,中西医组在此基础上加用中药汤剂辨证治疗,比较两组患者止血时间、治疗前后症状总积分变化情况以及疗程结束时幽门螺旋杆菌（Helicobacter pylori,H.pylori）根除情况以及临床疗效.结果：两组患者治疗后症状总积分均显著下降,与治疗前比较（10.62分±2.53分vs 33.50分±2.91分,17.30分1.98分vs 32.25分±2.48分）,差异具有统计学意义（P〈0.05）;中西医组患者平均止血时间和治疗后症状总积分均显著低于西医组（3.02 d±1.48 d vs 4.48 d±1.72 d,10.62分±2.53分vs 17.30分±1.98分）,差异具有统计学意义（P〈0.05）;中西医组患者疗程结束时H.pylori根除率显著高于西医组（93.44%vs 80.00%）,差异具有统计学意义（P〈0.05）;中西医组患者治愈率和总有效率显著高于西医组（59.02%vs 34.29%,93.44%v s 82.86%）,差异具有统计学意义（P〈0.05）.结论：中西医结合治疗PUB止血快,能够显著改善患者中医证候、提高H.pylori根除率和临床疗效,可作为治疗PUB的优选方案.

Improving Treatment of Peptic Ulcer Bleeding

Peptic ulcer bleeding (PUB) remains a major cause of hospitalizations. Consensus, evidence-based guidelines have outlined recommended care processes to improve the outcomes of patients with PUB (Ann Intern Med 2010; 152:101). Researchers in Denmark recently assessed trends in care processes and clinical outcomes in 13,498 patients hospitalized for PUB between 2004 and 2011 as part of an ongoing …

Improving Quality of Care in Peptic Ulcer Bleeding: Nationwide Cohort Study of 13,498 Consecutive Patients in the Danish Clinical Register of Emergency Surgery

The treatment of peptic ulcer bleeding (PUB) is complex, and mortality remains high. We present results from a nationwide initiative to monitor and improve the quality of care (QOC) in PUB. All Danish hospitals treating PUB patients between 2004 and 2011 prospectively registered demographic, clinical, and prognostic data. QOC was evaluated using eight process and outcome indicators, including time to initial endoscopy, hemostasis obtainment, proportion undergoing surgery, rebleeding risks, and 30-day mortality. A total of 13,498 PUB patients (median age 74 years) were included, of which one-quarter were in-hospital bleeders. Preadmission use of anticoagulants, multiple coexisting diseases, and the American Society of Anesthesiologists scores increased between 2004 and 2011. Considerable improvements were observed for most QOC indicators over time. Endoscopic treatment was successful with primary hemostasis achieved in more patients (94% in 2010-2011 vs. 89% in 2004-2006, relative risk (RR) 1.06 (95% confidence intervals 1.04-1.08)), endoscopy delay for hemodynamically unstable patients decreased during this period (43% vs. 34% had endoscopy within 6 h, RR 1.33 (1.10-1.61)), and fewer patients underwent open surgery (4% vs. 6%, RR 0.72 (0.59-0.87)). After controlling for time changes in prognostic factors, rebleeding rates improved (13% vs. 18%, adjusted RR 0.77 (0.66-0.91)). Crude 30-day mortality was unchanged (11% vs. 11%), whereas adjusted mortality decreased nonsignificantly over time (adjusted RR 0.89 (0.78-1.00)). QOC in PUB has improved substantially in Denmark, but the 30-day mortality remains high. Future initiatives to improve outcomes may include earlier endoscopy, having fully trained endoscopists on call, and increased focus on managing coexisting disease.

Endoscopic Management of Nonvariceal Upper Gastrointestinal Bleeding

This article describes the practical approach to endoscopic treatment of peptic ulcer bleeding and Dieulafoy's lesions including theoretical considerations of importance for the outcome. Endoscopic therapy is indicated in ulcers with active bleeding, a nonbleeding visible vessel, or an adherent clot. For high-risk ulcers (Forrest I–IIa), the authors of this article recommend initial treatment with injection of diluted adrenaline followed by a second hemostatic therapy (heater probe or clips). This article is part of an expert video encyclopedia.

Effect of proton pump inhibitors on the outcomes of peptic ulcer bleeding: comparison of event rates in routine clinical practice and a clinical trial

Objective. To assess clinical outcomes in patients treated with proton pump inhibitors (PPIs) after endoscopic hemostasis in routine clinical care, and to compare these outcomes to those seen in a randomized controlled trial (RCT) of i.v. esomeprazole. Materials and methods. Patients with peptic ulcer bleeding and endoscopic stigmata of recent hemorrhage, who were treated with i.v. esomeprazole or pantoprazole ≥120 mg/day following therapeutic endoscopy, were identified from 12 hospitals in Spain (n = 539). Outcomes assessed included further bleeding, all-cause mortality and surgery. The results were compared to those of the RCT. Results. Overall, 9.1% (95% confidence interval [CI]: 6.7–11.5) of patients experienced further bleeding within 72 h following initial endoscopy, 14.3% (95% CI: 11.3–17.2) of patients had further bleeding within 30 days and 3.3% (95% CI: 1.8–4.9) of patients died within 30 days. In the RCT, the rate of rebleeding within 72 h was significantly lower in the esomeprazole arm (5.9%) than in the placebo arm (10.3%; p = 0.026). The further bleeding rate in patients treated with esomeprazole in routine clinical practice (7.8%; 95% CI: 4.6–11.1) was between these two values. Similar results were seen with the other outcomes studied. Conclusions. The proportion of patients treated with i.v. esomeprazole in routine clinical practice who experienced further bleeding following endoscopic treatment for peptic ulcer bleeding was between the rates observed in the esomeprazole group and the placebo group in the RCT.

Could application of epinephrine improve hemostatic efficacy of hemoclips for bleeding peptic ulcers? A prospective randomized study

Bleeding from peptic ulcers can be effectively and safely treated with endoscopic hemoclips therapy. However, due to certain limiting factors of hemoclips, application of combination with another endoscopic method may give better results. The aim of this study was to examine the efficacy and safety of endoscopic hemoclips therapy and to evaluate potential benefits of this therapy combined with epinephrine in the treatment of bleeding peptic ulcers. This prospective randomized study included 70 patients with bleeding gastric or duodenal ulcer. In 34 of the patients endoscopic hemoclips therapy was applied (group I), and in 36 of them a combined therapy of hemoclips and epinephrine (group II). Initial hemostasis was achieved in most patients treated with endoscopic hemoclips therapy (94.1%) as well as in the patients treated with combination therapy (97.2%). After initial hemostasis achieved rebleeding occurred in 3 (9.3%) patients treated with hemoclips and in 2 (5.7%) patients treated with combination therapy, but this difference was not statistically significant (p > 0.05). The difference in the achieved final hemostasis between the group I (91.1%) and the group II (94.4%) was not statistically significant. Also, the differences between the two groups of patients in the need for blood transfusions, length of hospital stay, need for surgery and mortality were not statistically significant (p > 0.05). Endoscopic hemoclips therapy is effective and safe in treatment of bleeding peptic ulcers. Combination therapy of hemoclips and epinephrine has no advantage over hemoclips monotherapy.

High-dose versus low-dose intravenous proton pump inhibitor treatment for bleeding peptic ulcers

Evaluation of: Liu N, Liu L, Zhang H et al. Effect of intravenous proton pump inhibitor regimens and timing of endoscopy on clinical outcomes of peptic ulcer bleeding. J. Gastroenterol. Hepatol. 27(9), 1473–1479 (2012).Peptic ulcer bleeding is a common medical emergency associated with significant mortality and healthcare costs. All recent guidelines agree on the beneficial role of proton pump inhibitor treatment, but there is still controversy regarding the optimal dose and route of administration of proton pump inhibitors. The evaluated article reports on a large, single-center randomized controlled trial that compared the clinical efficacy of a low-dose twice-daily intravenous bolus regimen with a high-dose continuous intravenous infusion regimen in 875 patients with acute bleeding from peptic ulcers. The high-dose regimen was associated with significant reductions in rebleeding, blood transfusion requirements and length of hospital stay. There was no demonstrable difference in mortality or the need for endoscopic hemostatic treatment or surgery. We discuss the strengths and limitations of the evaluated article, as well as the implications for clinical practice.

Major complication after Histoacryl injection for endoscopic treatment of bleeding peptic ulcer

A 49-year-old man in hemorrhagic shock because of melena and hematemesis was referred from another hospital. On admission he was still normotensive (red cell count 2.08×106/μL, hemoglobin 61g/L). He had no prior known medical condition and did not take anymedication regularly. Emergency endoscopy revealed a large amount of fresh coagulated blood and bleeding from the arterial vessels in the stomach cardia. Endoscopic sclerotherapy was carried out with Sclerovein (Chemische Fabrik Kreussler & Co. GmbH, Wiesbaden, Germany) and N-butyl-2-cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany). After injection of 1.5mL Histoacryl, the bleeding stopped. On day 2, the patient had fever and complained of unbearable pain in the upper abdomen. A plain abdominal radiograph showed multiple linear radiopaque densities in all branches of celiac trunk (● Fig.1). Abdominal computed tomography (CT) revealed a perforated gallbladder with development of gangrene, as well as multiple infarctions in spleen, left liver lobe, and the hypoperfused distal part of pancreas (● Fig.2). On day 7, laparotomy was carried out, and the gallbladder and spleen were removed and abdominal drains were placed. The patient stayed in the intensive care unit for several days, with total parenteral nutrition and intravenous antibiotic therapy. He then developed acute pancreatitis with an external pancreatic fistula, which was treated conservatively. He was discharged on day 36 after the surgery. Serious complications of endoscopic injection therapy may be avoided by using of adhesive agents to treat bleeding gastric ulcers [1]. However, as the present case and a few similar cases show [1–3], inadvertent injection of any sclerosant can result in thrombosis of the splenic artery. Endoscopists should be aware of the close anatomic relationship between the stomach wall and the splenic artery. Inadvertent injection of Histoacryl into the splenic artery, in comparison with other agents, tends to obliterate several vessels of the celiac axis [3]. As suggested previously, Histoacryl injection should be considered as a last resort in the endoFig.2 Abdominal computed tomography (CT) scan showing a gallbladder necrosis with perforation and bmultifocal splenic infarctions and hypodense area in the left liver lobe. Fig.1 Plain abdominal radiogram after Histoacryl injection in a 49-year-old man in hemorrhagic shock because of melena and hematemesis. Radiopaque densities in the branches of the celiac trunk can be seen. UCTN – Unusual cases and technical notes E204

Comparison of haemostatic efficacy for endoscopic injection therapy of epinephrine and combination therapy of epinephrine and hemoclips for bleeding peptic ulcers

Endoscopic injection therapy of epinephrine is safe and effective in the treatment of bleeding peptic ulcer, but with high risk of rebleeding. The combination therapy of epinephrine and hemoclips could lead to a reduction of rebleeding and a potential reduction in mortality. To investigate the efficacy and safety of epinephrine injection therapy and combination therapy with epinephrine and hemoclips in treating bleeding peptic ulcers. A prospective randomized study included 58 patients with bleeding gastric or duodenal ulcer. In 30 patients endoscopic injection therapy with diluted epinephrine was applied (group I), while in 28 patients combination therapy of epinephrine and hemoclips was applied (group II). RESULTS; Initial haemostasis was achieved in most patients treated with epinephrine injection therapy (93.3%) and patients treated with combination therapy of epinephrine and hemoclips (96.4%). After initial haemostasis was achieved rebleeding was significantly more frequent in the patients treated with epinephrine (28.5%) than in the patients treated with combination therapy (3.7%, p < 0.05). Two patients treated with epinephrine injection therapy were subjected to surgical intervention, whereas no patient treated with combination therapy needed surgery. Lethal ending occurred in one patient treated with epinephrine and in one patient treated with combination therapy. The difference between the two groups of patients in need for surgical intervention and mortality was not statistically significant. Combination therapy with epinephrine and hemoclips is more efficient than epinephrine alone in the treatment of bleeding peptic ulcers.

Effect of High-Dose Oral Rabeprazole on Recurrent Bleeding after Endoscopic Treatment of Bleeding Peptic Ulcers

Background. The aim of this study was to compare the effect of high-dose oral rabeprazole versus high-dose IV PPI on rebleeding after endoscopic treatment of bleeding peptic ulcers. Methods. This was a two-center, prospective, randomized, controlled trial. Patients with a high-risk bleeding peptic ulcer had endoscopic hemostasis and were randomly assigned to the high-dose oral rabeprazole group (20 mg twice daily for 72 hours) or the high-dose IV omeprazole group (80 mg as a bolus injection followed by continuous infusion at 8 mg/h for 72 hours). Results. The study was stopped because of slow enrollment (total n = 106). The rebleeding rates within 3 days were 3.7% (2 of 54 patients) given oral rabeprazole and 1.9% (1 of 52 patients) given IV omeprazole (P = 1.000). The rebleeding rates after 3 days were 1.9% and 0% (P = 1.000), respectively. The surgical intervention rates were 3.7% and 0% (P = 0.495), and the mortality rates were 1.9% and 0% (P = 1.000), respectively. Conclusions. The effect of high-dose oral rabeprazole did not differ significantly from that of high-dose IV omeprazole on rebleeding, surgical intervention, or mortality after endoscopic treatment of bleeding peptic ulcers, but this requires further evaluation.

Pantoprazole for the Treatment of Peptic Ulcer Bleeding and Prevention of Rebleeding

Adding proton pump inhibitors (PPIs) to endoscopic therapy has become the mainstay of treatment for peptic ulcer bleeding, with current consensus guidelines recommending high-dose intravenous (IV) PPI therapy (IV bolus followed by continuous therapy). However, whether or not high-dose PPI therapy is more effective than low-dose PPI therapy is still debated. Furthermore, maintaining pH ≥ 4 appears to prevent mucosal bleeding in patients with acute stress ulcers; thus, stress ulcer prophylaxis with acid-suppressing therapy has been increasingly recommended in intensive care units (ICUs). This review evaluates the evidence for the efficacy of IV pantoprazole, a PPI, in preventing ulcer rebleeding after endoscopic hemostasis, and in controlling gastric pH and protecting against upper gastrointestinal (GI) bleeding in high-risk ICU patients. The review concludes that IV pantoprazole provides an effective option in the treatment of upper GI bleeding, the prevention of rebleeding, and for the prophylaxis of acute bleeding stress ulcers.

Intramural hematoma of duodenum: An unusual complication after endoscopic therapy for a bleeding peptic ulcer

Intramural hematoma of duodenum (IDH) is a relatively unusual complication associated with endoscopic treatment of bleeding peptic ulcer. This unusual condition is usually seen in children following blunt trauma to the abdomen. We describe here a case of IDH occurring following endoscopic therapy for bleeding duodenal ulcer in an adult patient with end-stage renal disease. The hematomas appeared on the second day of endoscopic intervention, caused transient duodenal obstruction and resolved spontaneously with conservative treatment in a week.