Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers

Impact of intravenous omeprazole on Helicobacter pylori eradication by triple therapy in patients with peptic ulcer bleeding

AIM

To test the impact of intravenous omeprazole on Helicobacter pylori eradication for bleeding peptic ulcers.

METHODS

A total of 175 H. pylori-infected patients with bleeding peptic ulcers were randomized into either an omeprazole group or a ranitidine group, receiving intravenous omeprazole or ranitidine for 3 days after endoscopy. Afterwards, 1-week triple therapy was used to eradicate H. pylori for both groups. Six weeks later, either a 13C-urea breath test or follow-up endoscopy was performed to assess the success of H. pylori eradication.

RESULTS

The rebleeding rate was lower in the omeprazole group vs. the ranitidine group (6% vs. 17%, P < 0.05). The H. pylori eradication rate was higher in the omeprazole group (intention-to-treat analysis: 83% vs. 66%, P < 0.05; per protocol analysis: 93% vs. 80%, P < 0.05). For patients with duodenal ulcers, the per protocol H. pylori eradication rate of the omeprazole group was higher than that of the ranitidine group (93% vs. 73%, P < 0.05).

CONCLUSIONS

Intravenous omeprazole can decrease the risk of rebleeding of peptic ulcers. For duodenal ulcers, in particular, intravenous omeprazole may even improve the H. pylori eradication rate of the subsequent triple therapy.

Endoscopy in the elderly patient

In the elderly who require endoscopy for diagnosis and /or intervention, the endoscopist should be aware of the special risks related to the presence of concomitant systemic diseases. This is especially pertinent in the use of sedatives and analgesics due to the altered physiological functions related to ageing. This can be further complicated by the fact that elderly patients are often prescribed multiple drugs, which makes for the possibility of serious drug interactions. Endoscopy is a minimally invasive technique that is safer than conventional surgery in many conditions. The endoscopist must take into consideration the important factors related to quality of life, as well as the wishes of the patients and their families. The endoscopist must be sympathetic to their wishes and realize when investigation and treatment are not appropriate.

Physiology and organ-related pathology of the elderly: stomach ulcers

Peptic ulcer disease, particularly as a result of its complications, is a burden that is focused on the elderly through their higher Helicobacter pylori prevalence and use of non-steroidal anti-inflammatory drugs (NSAIDs). In these patients, senescence may further increase ulcer susceptibility, particularly in the stomach, by the loss of mucosal protection and repair mechanisms. Age is mainly a marker for the increased prevalence of other complicated ulcer risk factors such as previous ulcer history and use of anti-coagulants, steroids and aspirin. The development of selective cyclo-oxygenase inhibitors (coxibs) has reduced the specific risk of NSAID ulceration, but the residual incidence in high risk patients remains substantially higher than that in young patients without other risk factors. The argument for early surgery versus endoscopic therapy in high risk patients with bleeding ulcers has not been resolved, both having a high mortality. There is still potential for the development of new strategies to prevent primary and secondary ulcers, either by new drug development or by expanding existing co-prescription strategies.

Gastrointestinal bleeding in the elderly

Gastrointestinal bleeding in elderly individuals is a frequent cause of consultation with a physician and of hospital admissions. Co-morbidity and greater medication use in this steadily growing patient group influence the clinical course and adversely affect outcome. Clinical presentation is often predictable and guides subsequent patient management. Due to a surprising lack of prospective controlled data in the area of gastrointestinal bleeding, the selection of diagnostic and therapeutic manoeuvres often depends more on local expertise and availability than on an algorithmic approach. Advances in endoscopic, medical, radiological and surgical treatment modalities offer promising new diagnostic and therapeutic tools, particularly in concerted applications. Outcome studies on the appropriate sequence and linking of these modalities are urgently needed. This chapter will address clinical presentation, aetiology, diagnosis and treatment of both upper and lower gastrointestinal bleeding in the elderly.

Meta-analysis of proton pump inhibitors in treatment of bleeding peptic ulcers

OBJECTIVE

To evaluate the efficacy of proton pump inhibitors (PPIs) compared with placebo and histamine receptor antagonists (H2RAs) for reducing the incidence of rebleeding, surgery, and death in acute gastrointestinal bleeding (GIB) associated with peptic ulcer disease.

DATA SOURCES

A systematic search of the English-language literature was performed using MEDLINE, EMBASE, and Pre-MEDLINE (from 1966 to September 2000) and a manual search of references.

STUDY SELECTION

Randomized, controlled trials evaluating any PPI for acute GIB in adults with the end points of rebleeding, surgery of death.

DATA SYNTHESIS

Nine trials (1829 pts.) were included. The relative odds of rebleeding indicated a 50% reduction in the PPI-treated group (OR 0.50, 95% CI 0.33 to 0.77; p = 0.002, NNTB 9; 95% CI NNTB 6 to 13). The relative odds of surgery indicated a 53% reduction in the PPI-treated group (OR 0.47, 95% CI 0.29 to 0.77; p = 0.003; NNTB 17, 95% CI 12 to 35). The relative odds for mortality indicated a nonsignificant 8% decrease in the odds of death in the PPI-treated group (OR 0.92, 95% CI 0.46 to 1.83, p = 0.81; NNTB 323, 95% CI NNTB 47 to infinity to NNTH 33).

CONCLUSIONS

PPIs are superior to H2RAs and placebo in preventing rebleeding and the need for surgery in patients with GIB, although they do not appear to reduce mortality.

Replacement of oral proton pump inhibitors with intravenous pantoprazole to effectively control gastric acid hypersecretion in patients with Zollinger-Ellison syndrome

OBJECTIVES

In patients with Zollinger-Ellison syndrome (ZES) or other conditions requiring oral doses of proton pump inhibitors, it frequently becomes necessary to use parenterally administered gastric acid inhibitors. However, i.v. histamine-2 receptor antagonists are not effective at usual doses and lose their effectiveness because of tachyphlaxis. With the approval in the United States of i.v. pantoprazole, a substituted benzimidazole available in i.v. formulation, it will become possible to acutely manage gastric acid secretion in the acute care setting of a hospital. This study was developed to monitor the safety and establish the efficacy of i.v. pantoprazole as an alternative to oral proton pump inhibitors for the control of gastric acid hypersecretion in patients with ZES.

METHODS

The efficacy of replacing oral PPI therapy with i.v. pantoprazole was evaluated in 14 ZES patients. After study enrollment, patients taking their current doses of oral PPI (omeprazole or lansoprazole) were switched to pantoprazole i.v. for 6 days during an 8-day inpatient period in the clinical research center. Effective control was defined as an acid output (AO) of < 10 mEq/h (< 5 mEq/h in patients with prior gastric acid-reducing surgery).

RESULTS

The mean age of the 14 patients enrolled in the study was 52.4 yr (range = 38-67). Mean basal AO was 0.55 +/- 0.32 mEq/h and mean fasting gastrin was 1089 pg/ml (range = 36-3720). Four patients were also diagnosed with the multiple endocrine neoplasia type I syndrome, nine were male, and two had previously undergone acid-reducing surgery. Before study enrollment, gastric acid hypersecretion was controlled in nine of 14 patients with omeprazole (20-200 mg daily) and five of 14 with lansoprazole (30-210 mg daily). In the oral phase of the study all patients had adequate control of gastric acid secretion, with a mean AO of 0.55 +/- 0.32 mEq/h (mean +/- SEM). Thereafter, 80 mg of i.v. pantoprazole was administered b.i.d. for 7 days by a brief (15 min) infusion and the dose was titrated upward to a predetermined maximum of 240 mg/24 h to control AO. A dose of 80 mg b.i.d. of i.v. pantoprazole controlled AO in 13 of 14 of the patients (93%) for the duration of the study (p > 0.05 compared to baseline values for all timepoints). One sporadic ZES patient (oral control value = 0.65 mEq/h on 100 mg of omeprazole b.i.d. p.o.) was not controlled with 80 mg of i.v. pantoprazole b.i.d. and dosage was titrated upward to 120 mg b.i.d. after day 2.

CONCLUSIONS

There were no serious adverse events observed. Intravenous pantoprazole provides gastric acid secretory control that is equivalent to the acid suppression observed with oral proton pump inhibitors. Most ZES patients (93%) maintained effective control of AO previously established with oral PPIs when switched to 80 mg of i.v. pantoprazole b.i.d.; however, for difficult-to-control patients, doses > 80 mg b.i.d. may be required.

Interventional endoscopy

Interventional endoscopy is a general label given to endoscopic procedures used to deal with a variety of gastrointestinal disorders. The interventional endoscopic procedures of interest in this review are those used specifically with gastric disorders. They include hemostasis, endoscopic ultrasound, endoscopic mucosal resection, stenting, percutaneous endoscopic gastrostomy tube placement and photodynamic laser therapy. Here, we review the latest data related to (a) a number of general issues having an impact on this diverse group of procedures (eg, such as proper patient selection criteria, consent in the era of open access endoscopy, protocol for anticoagulation, and sedation); (b) the methodology and outcomes of each of these unique procedures as they apply to the stomach; and (c) some of the latest technologic advances and developments that will potentially have an impact the future use of these procedures.

Omeprazole as adjuvant therapy to endoscopic combination injection sclerotherapy for treating bleeding peptic ulcer

BACKGROUND

Therapeutic endoscopy has provided a new means of treating bleeding peptic ulcers. Additional medical therapy may enhance the therapeutic benefit. Hemostasis is highly pH dependent and is severely impaired at low pH. Proton pump inhibitors, by achieving a significantly higher inhibition of gastric acidity, may improve the therapeutic outcomes after endoscopic treatment of ulcers.

PATIENT AND METHODS

We enrolled 166 patients with hemorrhage from duodenal, gastric, or stomal ulcers and signs of recent hemorrhage, as confirmed by endoscopy. Twenty-six patients had ulcers with an arterial spurt, 41 patients had active ooze, 37 had a visible vessel, and 62 patients had an adherent clot. All patients received endoscopic injection sclerotherapy using 1:10,000 adrenaline and 1% polidocanol and were randomly assigned to receive omeprazole (40 mg orally) every 12 hours for 5 days or an identical-looking placebo. The outcome measures used were recurrent bleeding, surgery, blood transfusion, and hospital stay.

RESULTS

Six (7%) of 82 patients in the omeprazole group had recurrent bleeding, as compared with 18 (21%) in the placebo group (P = 0.02). Two patients in the omeprazole group and 7 patients in the placebo group needed surgery to control their bleeding (P = 0.17). One patient in the omeprazole group and 2 patients in the placebo group died (P = 0.98). Twenty-nine patients (35%) in the omeprazole group and 61 patients (73%) in the placebo group received blood transfusions (P <0.001). The average hospital stay was 4.6 +/- 1.1 days in the omeprazole group and 6.0 +/- 0.7 days in the placebo group (P <0.001).

CONCLUSION

The addition of oral omeprazole to combination injection sclerotherapy decreases the rate of recurrent bleeding, reduces the need for surgery and transfusion, and shortens the hospital stay for patients with stigmata of recent hemorrhage.

The role of acid suppressants in upper gastrointestinal ulcer bleeding

Re-bleeding and mortality remain significant in peptic ulcer haemorrhage despite the widespread use of endoscopic therapy. The acidic gastric environment interferes with coagulation. In vitro studies show that an intragastric pH of above 6 results in normal blood coagulation and platelet function. Because of induced tachyphylaxis, H(2)-receptor antagonists are not able to maintain a high pH. In addition, in randomized trials using H(2)-receptor antagonists, there was no reduction in re-bleeding and mortality. High-dose intravenous proton pump inhibitors are capable of maintaining a pH above 6. Four randomized trials, using high-dose intravenous proton pump inhibitors, significantly improved the outcome (in terms of a reduction in re-bleeding and surgery) in patients with peptic ulcer haemorrhage. Mortality was, however, not reduced. The additional effect of acid-suppressant agents after successful endoscopic therapy is limited to the reduction of re-bleeding and need for surgery, with no effect on mortality.

Proton-pump inhibitors for acute peptic ulcer bleeding

OBJECTIVE

To review the use of proton-pump inhibitors for acute peptic ulcer bleeding.

DATA SOURCES

Articles were obtained through computerized searches of MEDLINE (1966-September 2000). Additionally, several textbooks containing information on the diagnosis and management of acute peptic ulcer bleeding were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references.

STUDY SELECTION

All randomized studies and pharmacoeconomic evaluations that used proton-pump inhibitor therapy for acute peptic ulcer bleeding were included. Randomized controlled trials and meta-analyses involving other therapies for treating peptic ulcer bleeding were also reviewed for possible inclusion.

DATA EXTRACTION

The primary outcomes extracted from the literature were persistent or recurrent bleeding, transfusion requirements, need for endoscopic intervention or surgery, length of stay, and mortality.

DATA SYNTHESIS

Data from double-blind, placebo-controlled trials involving more than 1000 patients demonstrate that short-term, high-dose omeprazole therapy is effective for reducing bleeding and transfusion requirements in patients with acute peptic ulcer bleeding. The patients most likely to benefit from this therapy are hospitalized patients at high risk for rebleeding and patients in whom endoscopic evaluation must be delayed or is unavailable.

CONCLUSIONS

Omeprazole (and likely other proton-pump inhibitors) is useful in reducing bleeding and transfusion requirements in patients with acute peptic ulcer bleeding, although better delineation of appropriate candidates is needed.

Role of acid suppressants in prophylaxis of NSAID damage

Gastric acid contributes to the pathogenesis of non-steroidal anti-inflammatory drug (NSAID)-induced ulceration via several mechanisms, including conversion of superficial to deeper injury, impairment of haemostasis, and interference with ulcer healing. The suppression of acid secretion has been shown to reduce the severity of NSAID-induced mucosal damage in experimental models and clinical studies. Current evidence indicates that proton pump inhibitors (PPIs) are the preferred treatment for the healing of gastric ulcers when NSAIDs cannot be discontinued. PPIs are superior to standard-dose H(2)-receptor antagonists and equivalent to low-dose misoprostol in preventing NSAID-induced gastric ulcers. Whether there is any significant advantage of PPIs over higher doses of H(2)-receptor antagonists or misoprostol is unknown. The efficacy of PPIs is enhanced in the presence of H. Pylori infection. Omeprazole has been shown to be effective for the secondary prevention of ulcer bleeding in H. pylori -infected NSAID users. The efficacy of PPIs for the prevention of ulcer complications in H. pylori-negative NSAID users remains uncertain.

Enhanced mucosal fibrinolytic activity in gastroduodenal ulcer haemorrhage and the beneficial effect of acid suppression

BACKGROUND

The high mortality rate in patients with upper gastrointestinal bleeding appears to be particularly related to re-bleeding. The haemostatic mechanisms that may influence the re-bleeding of ulcers are largely unknown.

AIM

We studied and analysed fibrinolytic activity in bleeding ulcer patients and the effect of acid suppression on this activity.

METHODS

Fibrinolytic activity was analysed in mucosal biopsies from 29 bleeding gastroduodenal ulcer patients and six controls. We analysed levels of D-Dimer, fibrin plate lysis area, plasminogen activator activity, plasminogen activator inhibitor activity, and plasmin antiplasmin complexes.

RESULTS

Significantly more fibrinolytic activity was detected in biopsies from patients with bleeding ulcers compared to controls. Moreover, in patients with endoscopic stigmata of recent haemorrhage, mucosal fibrinolytic activity was higher compared to patients without stigmata of recent haemorrhage. In mucosal biopsies of patients that had used acid suppression before admission, a decreased fibrinolytic activity was found compared to patients without such therapy. This effect of acid suppression on fibrinolytic activity was confirmed in nine patients before and after a 24-h ranitidine infusion.

CONCLUSIONS

Fibrinolytic activity is enhanced in patients with bleeding gastroduodenal ulcers. Acid suppressive therapy decreases this increased activity, which may be one of the mechanisms explaining the potential beneficial effect of this therapy.

Upper Gastrointestinal Bleeding of Nonvariceal Origin in the ICU Setting

Upper gastrointestinal bleeding (UGI) is a common medical emergency in the intensive care unit (ICU). Although it can be caused by a number of gastrointestinal disorders, its management usually follows a few simple management rules. Prior to endoscopy, the key to management is to resuscitate the patient, to determine the need for airway protection, and to assess the need for transfusions according to the American Society of Gastrointestinal Endoscopy guidelines. During endoscopy, the key to management is to recognize the cause of the bleeding and to achieve hemostasis. Following endoscopy, the key to management is to determine the need for medical therapy and to determine a proper disposition for the patient given his potential risk for rebleeding. Stress-related erosions syndrome (SRES) is a disease that usually develops in the ICU setting and is known to be associated with a high degree of morbidity and mortality. Although it is approached in the same fashion as other causes of UGI bleeding, patients tend to do better if they are recognized early and treated prophylactically. Criteria for proper patient selection and the recommended prophylactic therapy are reviewed.

[Bleeding gastroduodenal ulcer: results of surgical management]

AIM OF THE STUDY

The aim of this retrospective study was to report the mortality and morbidity after surgery for bleeding peptic ulcer while the population is aging and while the medical treatment and endoscopic procedures are improving.

PATIENTS AND METHODS

This retrospective study between 1994 and 1999 included 49 patients, 15 women, 34 men, aged 72 +/- 14 years. Patients were separated into three groups: ten with uncontrollable haemorrhages, 28 with recurrent haemorrhages and 11 with persistent haemorrhages. These patients were classified ASA II (n = 6), ASA III (n = 20), ASA IV (n = 21) and ASA V (n = 2). The surgical procedures for gastric ulcers (n = 5) were resection-oversewing (n = 2) or partial gastric resection (n = 3). The surgical procedures for duodenal ulcers (n = 44) were oversewing (n = 30), partial gastric resection (n = 10) or exploratory duodenotomy (n = 4).

RESULTS

The overall postoperative mortality rate was 20.4% (10/49). The mortality rate was 40% (4/10) in patients with massive haemorrhage, 7% (2/28) in patients with recurrent haemorrhage, and 36% (4/11) in patients with persistent haemorrhage. There was no significant difference in the mortality rate in relation to the surgical procedures. The morbidity rate was 45%, including three bleeding recurrences after suture and three duodenal leakages after partial gastric resection.

CONCLUSION

The morbidity and mortality rate after surgery for bleeding peptic ulcer is still high. Recurrent haemorrhages don't worsen the prognosis. Delayed surgery for persistent haemorrhage is associated with a severe prognosis.

Switching between intravenous and oral pantoprazole

Proton pump inhibitors (PPIs) are the most effective antisecretory drugs available for controlling gastric acid acidity and volume. They are the drugs of choice in the treatment of moderate-to-severe gastroesophageal reflux disease, hypersecretory disorders, and peptic ulcers. Currently in the United States, they are only available in an oral formulation. However, pantoprazole will soon be available in an intravenous formulation and will extend the power of PPIs to inpatient hospital settings. Intravenous pantoprazole has been shown to be effective and safe in clinical trials. Intravenous pantoprazole is indicated for the treatment of patients who require PPI therapy but who are unable to take oral medication. Intravenous pantoprazole has been shown to maintain acid suppression in patients switched from oral PPIs, so no change in dosage is required when switching from one formulation to the other. Potential hospital-based uses for intravenous PPI therapy include perioperative use as prophylaxis for acid aspiration syndrome during induction of anesthesia, prophylaxis for stress-related mucosal disease, and management of gastrointestinal bleeding from stress or acid peptic disease.