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Yen HH, Wu PY, Wu TL, Huang SP, Chen YY, Chen MF, Lin WC, Tsai CL, Lin KP. Forrest Classification for Bleeding Peptic Ulcer: A New Look at the Old Endoscopic Classification. Diagnostics (Basel) 2022; 12:diagnostics12051066. [PMID: 35626222 PMCID: PMC9139956 DOI: 10.3390/diagnostics12051066] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/20/2022] [Accepted: 04/20/2022] [Indexed: 12/10/2022] Open
Abstract
The management of peptic ulcer bleeding is clinically challenging. For decades, the Forrest classification has been used for risk stratification for nonvariceal ulcer bleeding. The perception and interpretation of the Forrest classification vary among different endoscopists. The relationship between the bleeder and ulcer images and the different stages of the Forrest classification has not been studied yet. Endoscopic still images of 276 patients with peptic ulcer bleeding for the past 3 years were retrieved and reviewed. The intra-rater agreement and inter-rater agreement were compared. The obtained endoscopic images were manually drawn to delineate the extent of the ulcer and bleeding area. The areas of the region of interest were compared between the different stages of the Forrest classification. A total of 276 images were first classified by two experienced tutor endoscopists. The images were reviewed by six other endoscopists. A good intra-rater correlation was observed (0.92–0.98). A good inter-rater correlation was observed among the different levels of experience (0.639–0.859). The correlation was higher among tutor and junior endoscopists than among experienced endoscopists. Low-risk Forrest IIC and III lesions show distinct patterns compared to high-risk Forrest I, IIA, or IIB lesions. We found good agreement of the Forrest classification among different endoscopists in a single institution. This is the first study to quantitively analyze the obtained and explain the distinct patterns of bleeding ulcers from endoscopy images.
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Affiliation(s)
- Hsu-Heng Yen
- Department of Internal Medicine, Division of Gastroenterology, Changhua Christian Hospital, Changhua 500209, Taiwan; (H.-H.Y.); (T.-L.W.); (S.-P.H.); (Y.-Y.C.)
- General Education Center, Chienkuo Technology University, Changhua 500020, Taiwan
- Department of Electrical Engineering, Chung Yuan Christian University, Taoyuan 320314, Taiwan; (P.-Y.W.); (M.-F.C.)
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 400, Taiwan
| | - Ping-Yu Wu
- Department of Electrical Engineering, Chung Yuan Christian University, Taoyuan 320314, Taiwan; (P.-Y.W.); (M.-F.C.)
| | - Tung-Lung Wu
- Department of Internal Medicine, Division of Gastroenterology, Changhua Christian Hospital, Changhua 500209, Taiwan; (H.-H.Y.); (T.-L.W.); (S.-P.H.); (Y.-Y.C.)
| | - Siou-Ping Huang
- Department of Internal Medicine, Division of Gastroenterology, Changhua Christian Hospital, Changhua 500209, Taiwan; (H.-H.Y.); (T.-L.W.); (S.-P.H.); (Y.-Y.C.)
| | - Yang-Yuan Chen
- Department of Internal Medicine, Division of Gastroenterology, Changhua Christian Hospital, Changhua 500209, Taiwan; (H.-H.Y.); (T.-L.W.); (S.-P.H.); (Y.-Y.C.)
| | - Mei-Fen Chen
- Department of Electrical Engineering, Chung Yuan Christian University, Taoyuan 320314, Taiwan; (P.-Y.W.); (M.-F.C.)
- Technology Translation Center for Medical Device, Chung Yuan Christian University, Taoyuan 320314, Taiwan; (W.-C.L.); (C.-L.T.)
| | - Wen-Chen Lin
- Technology Translation Center for Medical Device, Chung Yuan Christian University, Taoyuan 320314, Taiwan; (W.-C.L.); (C.-L.T.)
| | - Cheng-Lun Tsai
- Technology Translation Center for Medical Device, Chung Yuan Christian University, Taoyuan 320314, Taiwan; (W.-C.L.); (C.-L.T.)
- Department of Biomedical Engineering, Chung Yuan Christian University, Taoyuan 320314, Taiwan
| | - Kang-Ping Lin
- Department of Electrical Engineering, Chung Yuan Christian University, Taoyuan 320314, Taiwan; (P.-Y.W.); (M.-F.C.)
- Technology Translation Center for Medical Device, Chung Yuan Christian University, Taoyuan 320314, Taiwan; (W.-C.L.); (C.-L.T.)
- Correspondence:
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Clarke K, Adler N, Agrawal D, Bhakta D, Sata SS, Singh S, Gupta A, Pahwa A, Pherson E, Sun A, Volpicelli F, Cho HJ. Indications for the Use of Proton Pump Inhibitors for Stress Ulcer Prophylaxis and Peptic Ulcer Bleeding in Hospitalized Patients. Am J Med 2022; 135:313-317. [PMID: 34655535 DOI: 10.1016/j.amjmed.2021.09.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 12/11/2022]
Abstract
Proton pump inhibitors are widely used throughout the world for the treatment of gastrointestinal disorders that are related to acid secretion, such as peptic ulcer disease and dyspepsia. Another common indication for proton pump inhibitors is stress ulcer prophylaxis. Proton pump inhibitors have proven efficacy for the treatment of acid-related gastrointestinal disorders, but there is concern that their use may be associated with the development of significant complications, such as fractures, Clostridium difficile infection, acute kidney injury, chronic kidney disease, and hypomagnesemia. Proton pump inhibitors are overused in the hospital setting, both for stress ulcer prophylaxis and gastrointestinal bleeding, and then they are often inappropriately continued after discharge from the hospital. This narrative review article outlines the evidence surrounding appropriate proton pump inhibitor use for stress ulcer prophylaxis and peptic ulcer bleeding.
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Affiliation(s)
- Karen Clarke
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta, Ga.
| | - Nicole Adler
- Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Deepak Agrawal
- Division of Gastroenterology and Hepatology, Dell Seton Medical Center, Austin, Tex
| | - Dimpal Bhakta
- Division of Gastroenterology, New York University School of Medicine, New York, NY
| | - Suchita Shah Sata
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Sarguni Singh
- Division of Hospital Medicine, University of Colorado, Aurora
| | - Arjun Gupta
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Amit Pahwa
- Division of General Internal Medicine, Division of General Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Emily Pherson
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Md
| | - Alexander Sun
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Frank Volpicelli
- Department of Medicine, New York University Grossman School of Medicine, New York, NY; Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hyung J Cho
- Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; New York City Health and Hospitals, New York, NY
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Kanno T, Yuan Y, Tse F, Howden CW, Moayyedi P, Leontiadis GI. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev 2022; 1:CD005415. [PMID: 34995368 PMCID: PMC8741303 DOI: 10.1002/14651858.cd005415.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Upper gastrointestinal (GI) bleeding is a common reason for emergency hospital admission. Proton pump inhibitors (PPIs) reduce gastric acid production and are used to manage upper GI bleeding. However, there is conflicting evidence regarding the clinical efficacy of proton pump inhibitors initiated before endoscopy in people with upper gastrointestinal bleeding. OBJECTIVES To assess the effects of PPI treatment initiated prior to endoscopy in people with acute upper GI bleeding. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase and CINAHL databases and major conference proceedings to October 2008, for the previous versions of this review, and in April 2018, October 2019, and 3 June 2021 for this update. We also contacted experts in the field and searched trial registries and references of trials for any additional trials. SELECTION CRITERIA We selected randomised controlled trials (RCTs) that compared treatment with a PPI (oral or intravenous) versus control treatment with either placebo, histamine-2 receptor antagonist (H2RA) or no treatment, prior to endoscopy in hospitalised people with uninvestigated upper GI bleeding. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed study eligibility, extracted study data and assessed risk of bias. Outcomes assessed at 30 days were: mortality (our primary outcome), rebleeding, surgery, high-risk stigmata of recent haemorrhage (active bleeding, non-bleeding visible vessel or adherent clot) at index endoscopy, endoscopic haemostatic treatment at index endoscopy, time to discharge, blood transfusion requirements and adverse effects. We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included six RCTs comprising 2223 participants. No new studies have been published after the literature search performed in 2008 for the previous version of this review. Of the included studies, we considered one to be at low risk of bias, two to be at unclear risk of bias, and three at high risk of bias. Our meta-analyses suggest that pre-endoscopic PPI use may not reduce mortality (OR 1.14, 95% CI 0.76 to 1.70; 5 studies; low-certainty evidence), and may reduce rebleeding (OR 0.81, 95% CI 0.62 to 1.06; 5 studies; low-certainty evidence). In addition, pre-endoscopic PPI use may not reduce the need for surgery (OR 0.91, 95% CI 0.65 to 1.26; 6 studies; low-certainty evidence), and may not reduce the proportion of participants with high-risk stigmata of recent haemorrhage at index endoscopy (OR 0.80, 95% CI 0.52 to 1.21; 4 studies; low-certainty evidence). Pre-endoscopic PPI use likely reduces the need for endoscopic haemostatic treatment at index endoscopy (OR 0.68, 95% CI 0.50 to 0.93; 3 studies; moderate-certainty evidence). There were insufficient data to determine the effect of pre-endoscopic PPI use on blood transfusions (2 studies; meta-analysis not possible; very low-certainty evidence) and time to discharge (1 study; very low-certainty evidence). There was no substantial heterogeneity amongst trials in any analysis. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that PPI treatment initiated before endoscopy for upper GI bleeding likely reduces the requirement for endoscopic haemostatic treatment at index endoscopy. However, there is insufficient evidence to conclude whether pre-endoscopic PPI treatment increases, reduces or has no effect on other clinical outcomes, including mortality, rebleeding and need for surgery. Further well-designed RCTs that conform to current standards for endoscopic haemostatic treatment and appropriate co-interventions, and that ensure high-dose PPIs are only given to people who received endoscopic haemostatic treatment, regardless of initial randomisation, are warranted. However, as it may be unrealistic to achieve the optimal information size, pragmatic multicentre trials may provide valuable evidence on this topic.
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Affiliation(s)
- Takeshi Kanno
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Division of Gastroenterology, Tohoku University Hospital, Sendai, Japan
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yuhong Yuan
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| | - Frances Tse
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| | - Colin W Howden
- Division of Gastroenterology, University of Tennessee, Memphis, TN, USA
| | - Paul Moayyedi
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| | - Grigorios I Leontiadis
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
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Current Status and Future Perspective of Artificial Intelligence in the Management of Peptic Ulcer Bleeding: A Review of Recent Literature. J Clin Med 2021; 10:jcm10163527. [PMID: 34441823 PMCID: PMC8397124 DOI: 10.3390/jcm10163527] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 02/07/2023] Open
Abstract
With the decreasing incidence of peptic ulcer bleeding (PUB) over the past two decades, the clinician experience of managing patients with PUB has also declined, especially for young endoscopists. A patient with PUB management requires collaborative care involving the emergency department, gastroenterologist, radiologist, and surgeon, from initial assessment to hospital discharge. The application of artificial intelligence (AI) methods has remarkably improved people's lives. In particular, AI systems have shown great potential in many areas of gastroenterology to increase human performance. Colonoscopy polyp detection or diagnosis by an AI system was recently introduced for commercial use to improve endoscopist performance. Although PUB is a longstanding health problem, these newly introduced AI technologies may soon impact endoscopists' clinical practice by improving the quality of care for these patients. To update the current status of AI application in PUB, we reviewed recent relevant literature and provided future perspectives that are required to integrate such AI tools into real-world practice.
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Yen HH, Wu PY, Su PY, Yang CW, Chen YY, Chen MF, Lin WC, Tsai CL, Lin KP. Performance Comparison of the Deep Learning and the Human Endoscopist for Bleeding Peptic Ulcer Disease. J Med Biol Eng 2021. [DOI: 10.1007/s40846-021-00608-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Abstract
Purpose
Management of peptic ulcer bleeding is clinically challenging. Accurate characterization of the bleeding during endoscopy is key for endoscopic therapy. This study aimed to assess whether a deep learning model can aid in the classification of bleeding peptic ulcer disease.
Methods
Endoscopic still images of patients (n = 1694) with peptic ulcer bleeding for the last 5 years were retrieved and reviewed. Overall, 2289 images were collected for deep learning model training, and 449 images were validated for the performance test. Two expert endoscopists classified the images into different classes based on their appearance. Four deep learning models, including Mobile Net V2, VGG16, Inception V4, and ResNet50, were proposed and pre-trained by ImageNet with the established convolutional neural network algorithm. A comparison of the endoscopists and trained deep learning model was performed to evaluate the model’s performance on a dataset of 449 testing images.
Results
The results first presented the performance comparisons of four deep learning models. The Mobile Net V2 presented the optimal performance of the proposal models. The Mobile Net V2 was chosen for further comparing the performance with the diagnostic results obtained by one senior and one novice endoscopists. The sensitivity and specificity were acceptable for the prediction of “normal” lesions in both 3-class and 4-class classifications. For the 3-class category, the sensitivity and specificity were 94.83% and 92.36%, respectively. For the 4-class category, the sensitivity and specificity were 95.40% and 92.70%, respectively. The interobserver agreement of the testing dataset of the model was moderate to substantial with the senior endoscopist. The accuracy of the determination of endoscopic therapy required and high-risk endoscopic therapy of the deep learning model was higher than that of the novice endoscopist.
Conclusions
In this study, the deep learning model performed better than inexperienced endoscopists. Further improvement of the model may aid in clinical decision-making during clinical practice, especially for trainee endoscopist.
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Csiki E, Szabó H, Hanák L, Szakács Z, Kiss S, Vörhendi N, Pécsi D, Hegyi E, Hegyi P, Erőss B. Oral Proton Pump Inhibitors May Be as Effective as Intravenous in Peptic Ulcer Bleeding: A Systematic Review and Meta-analysis. Clin Transl Gastroenterol 2021; 12:e00341. [PMID: 33988530 PMCID: PMC8049165 DOI: 10.14309/ctg.0000000000000341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 03/05/2021] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Current guidelines recommend intravenous (IV) proton pump inhibitor (PPI) therapy in peptic ulcer bleeding (PUB). We aimed to compare the efficacy of oral and IV administration of PPIs in PUB. METHODS We performed a systematic search in 4 databases for randomized controlled trials, which compared the outcomes of oral PPI therapy with IV PPI therapy for PUB. The primary outcomes were 30-day recurrent bleeding and 30-day mortality. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for dichotomous outcomes, while weighted mean differences (WMDs) with CI were calculated for continuous outcomes in meta-analysis. The protocol was registered a priori onto PROSPERO (CRD42020155852). RESULTS A total of 14 randomized controlled trials reported 1,951 peptic ulcer patients, 977 and 974 of which were in the control and intervention groups, respectively. There were no statistically significant differences between oral and IV administration regarding 30-day rebleeding rate (OR = 0.96, CI: 0.65-1.44); 30-day mortality (OR = 0.70, CI: 0.35-1.40); length of hospital stay (WMD = -0.25, CI: -0.93 to -0.42); transfusion requirements (WMD = -0.09, CI: -0.07 to 0.24); need for surgery (OR = 0.91, CI: 0.40-2.07); further endoscopic therapy (OR = 1.04, CI: 0.56-1.93); and need for re-endoscopy (OR = 0.81, CI: 0.52-1.28). Heterogeneity was negligible in all analysis, except for the analysis on the length of hospitalization (I2 = 82.3%, P = 0.001). DISCUSSION Recent evidence suggests that the oral administration of PPI is not inferior to the IV PPI treatment in PUB after endoscopic management, but further studies are warranted.
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Affiliation(s)
- Endre Csiki
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Department of Gastroenterology, Mureş County Clinical Hospital, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu-Mureş, Faculty of Medicine, Târgu-Mureş, Romania
| | - Hanna Szabó
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
- George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Faculty of Medicine, Târgu-Mureş, Romania
| | - Lilla Hanák
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Szabolcs Kiss
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Nóra Vörhendi
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Dániel Pécsi
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Eszter Hegyi
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
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Karim R, Hameed R, Ali K, Tahir A. Comparison of Oral versus Intravenous Proton Pump Inhibitors in Preventing Re-bleeding from Peptic Ulcer after Successful Endoscopic Therapy. Cureus 2020; 12:e6741. [PMID: 32133263 PMCID: PMC7034768 DOI: 10.7759/cureus.6741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Perforation, obstruction, and bleeding remain the most frequently encountered complications of peptic ulcer disease (PUD). Bleeding may be in the form of hematemesis or melena. The treatment of choice in patients with a bleeding peptic ulcer is endoscopic ligation to maintain the hemostatic balance followed by the administration of proton pump inhibitors (PPIs). This study focuses on the evaluation and comparison of intravenous (IV) and oral PPIs in terms of prevention of re-bleeding after successful endoscopy for peptic ulcers. Methods A prospective, comparative study was conducted in a tertiary care hospital in Pakistan from January 1, 2018 to June 30, 2019. The trial included known cases of PUD admitted with active upper gastrointestinal bleeding (UGIB). They were randomly divided into two groups: one received oral pantoprazole and the other was administered IV pantoprazole. The outcomes for both groups were compared. Data was entered and analyzed using Statistical Package for the Social Sciences (SPSS) software version 23.0 (IBM, Armonk, NY) Results There were 96 (48%) patients in the IV pantoprazole group and 104 (52%) in the oral group. From 24 hours after the medication onwards, the IV pantoprazole group showed a significant improvement in hemoglobin (Hb) levels (p: 0.01); the group also showed improvement in supine systolic BP at 48 hours (p: 0.04) and in diastolic BP at both 12 and 48 hours as compared to the oral pantoprazole group (p: 0.05). The mean duration of hospital stay, need for blood transfusion and repeat endoscopy, re-bleeding, and mortality rates were similar for both groups (p: >0.05). Conclusion We could not find any statistically significant difference between oral and IV routes of pantoprazole administration in the prevention of rebleeding when used after successful therapeutic endoscopy in patients with bleeding PUDs.
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Affiliation(s)
- Rashid Karim
- Gastroenterology, Dera Ghazi Khan Medical College and Hospital, Dera Ghazi Khan, PAK
| | - Rizwan Hameed
- Gastroenterology, Dera Ghazi Khan Medical College and Hospital, Dera Ghazi Khan, PAK
| | - Kashif Ali
- Internal Medicine, Dera Ghazi Khan Medical College and Hospital, Dera Ghazi Khan, PAK
| | - Amber Tahir
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
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Sung JJY, Chiu PCY, Chan FKL, Lau JYW, Goh KL, Ho LHY, Jung HY, Sollano JD, Gotoda T, Reddy N, Singh R, Sugano K, Wu KC, Wu CY, Bjorkman DJ, Jensen DM, Kuipers EJ, Lanas A. Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018. Gut 2018; 67:1757-1768. [PMID: 29691276 PMCID: PMC6145289 DOI: 10.1136/gutjnl-2018-316276] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 12/14/2022]
Abstract
Non-variceal upper gastrointestinal bleeding remains an important emergency condition, leading to significant morbidity and mortality. As endoscopic therapy is the 'gold standard' of management, treatment of these patients can be considered in three stages: pre-endoscopic treatment, endoscopic haemostasis and post-endoscopic management. Since publication of the Asia-Pacific consensus on non-variceal upper gastrointestinal bleeding (NVUGIB) 7 years ago, there have been significant advancements in the clinical management of patients in all three stages. These include pre-endoscopy risk stratification scores, blood and platelet transfusion, use of proton pump inhibitors; during endoscopy new haemostasis techniques (haemostatic powder spray and over-the-scope clips); and post-endoscopy management by second-look endoscopy and medication strategies. Emerging techniques, including capsule endoscopy and Doppler endoscopic probe in assessing adequacy of endoscopic therapy, and the pre-emptive use of angiographic embolisation, are attracting new attention. An emerging problem is the increasing use of dual antiplatelet agents and direct oral anticoagulants in patients with cardiac and cerebrovascular diseases. Guidelines on the discontinuation and then resumption of these agents in patients presenting with NVUGIB are very much needed. The Asia-Pacific Working Group examined recent evidence and recommends practical management guidelines in this updated consensus statement.
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Affiliation(s)
- Joseph JY Sung
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Philip CY Chiu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Francis K L Chan
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - James YW Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Khean-lee Goh
- Department of Gastroenterology and Hepatology, University of Malaya, Kuala Lumpur, Malaysia
| | - Lawrence HY Ho
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Jose D Sollano
- UST Hospital, University of Santo Tomas, Manila, Philippines
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Nihon University School of Medicine, Tokyo, Japan
| | - Nageshwar Reddy
- Asian Institute of Gastroenterology, Asian Healthcare Foundation, Hyderabad, India
| | - Rajvinder Singh
- Department of Medicine, Lyell McEwin Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Kentaro Sugano
- Department of Medicine, Jichi Medical School, Shimotsuke, Japan
| | - Kai-chun Wu
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, Xi’an, China
| | | | | | | | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Angel Lanas
- Department of Gastroenterology, University Hospital, Zaragoza, Spain
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Valizadeh Toosi SM, Elahi Vahed AR, Maleki I, Bari Z. Comparison of Oral versus Intravenous Proton Pump Inhibitors in Preventing Re-bleeding from Peptic Ulcer after Successful Endoscopic Therapy. Middle East J Dig Dis 2018; 10:236-241. [PMID: 31049171 PMCID: PMC6488504 DOI: 10.15171/mejdd.2018.116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 07/18/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND
Proton pump inhibitors (PPIs) are now widely prescribed for the management of patients with acute
upper gastrointestinal bleeding; although its optimal dose and route of administration has remained a
controversial issue. The aim of this study was to assess the clinical effectiveness of high dose oral versus
intravenous (IV) PPI after successful endoscopic therapy in patients with bleeding peptic ulcer disease.
METHODS
178 patients with active upper gastrointestinal bleeding due to a peptic ulcer with stigmata
of high risk for re-bleeding entered the study. After successful endoscopic hemostasis, they were
randomized to receive either high dose oral pantoprazole (80 mg stat and 80 mg twice daily for 3
days) or high dose intravenous pantoprazole (80 mg IV infusion within 30 minutes and 8 mg per
hour for 3 days). After the 3rd day, the patients in both groups received oral pantoprazole 40 mg
twice daily for one month. The end points were comparing the rate of re-bleeding or mortality, and
the need for blood transfusion or surgery during the first month between the two groups.
RESULTS
There were not significant statistical differences between the two groups in the volume of
blood transfusion, mean duration of hospital stay, need to surgery, or mortality rates. However, the
rates of re-bleeding were 2.3% (2:88) in the IV group and 3.3% (3:90) in the oral group (p = 0.6).
CONCLUSION
According to our findings, it seems that high dose oral PPI can be a good alternative to high
dose IV PPI in patients with bleeding peptic ulcer who are at high risk of re-bleeding. Due to the
lower cost and the availability of oral PPIs, their use can be economically much more affordable.
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Affiliation(s)
- Seyed Mohammad Valizadeh Toosi
- Assistant Professor of Gastroenterology, Gut and Liver Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Iradj Maleki
- Associate Professor of Gastroenterology, Gut and Liver Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Zohreh Bari
- Assistant Professor of Gastroenterology, Gut and Liver Research Center, Mazandaran University of Medical Sciences, Sari, Iran
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Uchiyama T, Higurashi T, Kuriyama H, Kondo Y, Hata Y, Nakajima A. Oral esomeprazole vs injectable omeprazole for the prevention of hemorrhage after endoscopic submucosal dissection. World J Gastrointest Endosc 2017; 9:514-520. [PMID: 29085562 PMCID: PMC5648994 DOI: 10.4253/wjge.v9.i10.514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/19/2017] [Accepted: 07/17/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the effectiveness of oral esomeprazole (EPZ) vs injectable omeprazole (OPZ) therapy to prevent hemorrhage after endoscopic submucosal dissection (ESD).
METHODS A case-control study was conducted using a quasi-randomized analysis with propensity score matching. A total of 258 patients were enrolled in this study. Patients were treated with either oral EPZ or injectable OPZ. The endpoint was the incidence of hemorrhage after ESD.
RESULTS Data of 71 subjects treated with oral EPZ and 172 subjects treated with injectable OPZ were analyzed. Analysis of 65 matched samples revealed no difference in the incidence of hemorrhage after ESD between the oral EPZ and injectable OPZ groups (OR = 0.89, 95%CI: 0.35-2.27, P ≥ 0.99).
CONCLUSION We conclude that oral EPZ therapy is a useful alternative to injectable PPI therapy for the prevention of hemorrhage after ESD.
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Affiliation(s)
- Takashi Uchiyama
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama city, Kanagawa Prefecture 236-0042, Japan
- Department of Gastroenterology, Chigasaki Municipal Hospital, Chigasaki city, Kanagawa Prefecture 235-0042, Japan
| | - Takuma Higurashi
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama city, Kanagawa Prefecture 236-0042, Japan
| | - Hitoshi Kuriyama
- Department of Gastroenterology, Chigasaki Municipal Hospital, Chigasaki city, Kanagawa Prefecture 235-0042, Japan
| | - Yoshinobu Kondo
- Department of Endocrinology and Metabolism, Chigasaki Municipal Hospital, Chigasaki city, Kanagawa Prefecture 235-0042, Japan
| | - Yasuo Hata
- Department of Gastroenterology, Chigasaki Municipal Hospital, Chigasaki city, Kanagawa Prefecture 235-0042, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama city, Kanagawa Prefecture 236-0042, Japan
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Value of Oral Proton Pump Inhibitors in Acute, Nonvariceal Upper Gastrointestinal Bleeding: A Network Meta-Analysis. J Clin Gastroenterol 2017; 51:707-719. [PMID: 27505402 DOI: 10.1097/mcg.0000000000000625] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Intravenous (IV) proton pump inhibitors (PPI) are the standard medical treatment in acute nonvariceal upper gastrointestinal bleeding (ANVGIB). Optimal route of PPI delivery has been questioned. AIM The aim was to perform a systematic review and network meta-analysis for the endpoints of risk of rebleeding, length of stay (LOS), surgery (ROS), mortality, and total units of blood transfused (UBT) among trials evaluating acid suppressive medications in ANVGIB. METHODS A total of 39 studies using IV PPI drip, IV scheduled PPI, oral PPI, H2-receptor antagonists, and placebo were identified. Network meta-analysis was used for indirect comparisons and Bayesian Markov Chain Monte Carlo methods for calculation of probability superiority. RESULTS No difference was observed between IV PPI drip and scheduled IV PPI for mortality (relative risk=1.11; 95% credibility interval, 0.56-2.21), LOS (0.04, -0.49 to 0.44), ROS (1.27, 0.64-2.35) and risk of rebleeding within 72 hours, 1 week, and 1 month [(0.98, 0.48-1.95), (0.59, 0.13-2.03), (0.82, 0.28-2.16)]. Oral PPIs were as effective as IV scheduled PPIs and IV PPI drip for LOS (0.22, -0.61 to 0.79 and 0.16, -0.56 to 0.80) and UBT (-0.25, -1.23 to 0.65 and -0.06, -0.71 to 0.65) and superior to IV PPI drip for ROS (0.30, 0.10 to 0.78). CONCLUSION Scheduled IV PPIs were as effective as IV PPI drip for most outcomes. Oral PPIs were comparable to scheduled IV for LOS and UBT and superior to IV PPI drip for ROS. Conclusions should be tempered by low frequency endpoints such as ROS, but question the need for IV PPI drip in ANVGIB.
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Tringali A, Manta R, Sica M, Bassotti G, Marmo R, Mutignani M. Comparing intravenous and oral proton pump inhibitor therapy for bleeding peptic ulcers following endoscopic management: a systematic review and meta-analysis. Br J Clin Pharmacol 2017; 83:1619-1635. [PMID: 28181291 DOI: 10.1111/bcp.13258] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 12/28/2016] [Accepted: 01/31/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND AIMS The efficacy of proton pump inhibitors (PPIs) has been demonstrated for bleeding peptic ulcers but the route of administration remains controversial. Several studies have demonstrated that high-dose oral PPIs are as effective as intravenous PPIs in reducing recurrent bleeding. However, current guidelines recommend intravenous PPIs after endoscopic treatment. Previous data based on numbers that were too small to enable a firm conclusion to be reached suggested that oral and intravenous PPIs had equivalent efficacy. We undertook a meta-analysis to compare oral and intravenous PPIs in patients with bleeding peptic ulcers after endoscopic management. METHODS A literature search was undertaken using MEDLINE, EMBASE and the Cochrane Library, between 1990 and February 2016, to identify all randomized controlled trials (RCTs) that assessed the efficacy of PPIs administered by different routes. Nine RCTs, involving 1036 patients, were analysed. Outcomes were: recurrent bleeding, blood transfusion requirement, duration of hospital stay, a need for repeat endoscopy, surgery and 30-day mortality. RESULTS There were no differences in the rebleeding rates [odds ratio (OR) 0.93, 95% confidence interval (CI) 0.60, 1.46; P = 0.77], need for surgery (OR 0.77, 95% CI 0.25, 2.40; P = 0.65), need for repeat endoscopy (OR 0.69, 95% CI 0.39, 1.21; P = 0.19), need for blood transfusion [(MD) -0.03, 95% CI -0.26, 0.19; P = 0.76], duration of hospital stay (MD -0.61, 95% CI -1.45, 0.23; P = 0.16) or 30-day mortality (OR 0.89, 95% CI 0.27, 2.43; P = 0.84) according to the route of administration. CONCLUSIONS Oral PPIs represent better value for money, with clinical efficacy equivalent to intravenous PPIs.
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Affiliation(s)
- Alberto Tringali
- Endoscopy Unit, Niguarda Hospital, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Raffaele Manta
- Endoscopy Unit, Niguarda Hospital, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Mariano Sica
- Endoscopy Unit, Niguarda Hospital, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Gabrio Bassotti
- Gastroenterology & Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia, Italy
| | - Riccardo Marmo
- Gastroenterologia ed Endoscopia Digestiva del PO di Polla, Salerno, Italy
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de la Coba Ortiz C, Argüelles Arias F, Martín de Argila de Prados C, Júdez Gutiérrez J, Linares Rodríguez A, Ortega Alonso A, Rodríguez de Santiago E, Rodríguez-Téllez M, Vera Mendoza MI, Aguilera Castro L, Álvarez Sánchez Á, Andrade Bellido RJ, Bao Pérez F, Castro Fernández M, Giganto Tomé F. Proton-pump inhibitors adverse effects: a review of the evidence and position statement by the Sociedad Española de Patología Digestiva. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:207-24. [PMID: 27034082 DOI: 10.17235/reed.2016.4232/2016] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION In the last few years a significant number of papers have related the use of proton-pump inhibitors (PPIs) to potential serious adverse effects that have resulted in social unrest. OBJECTIVE The goal of this paper was to provide a literature review for the development of an institutional position statement by Sociedad Española de Patología Digestiva (SEPD) regarding the safety of long-term PPI use. MATERIAL AND METHODS A comprehensive review of the literature was performed to draw conclusions based on a critical assessment of the following: a) current PPI indications; b) vitamin B12 deficiency and neurological disorders; c) magnesium deficiency; d) bone fractures; e) enteric infection and pneumonia; f) interactions with thienopyridine derivatives; e) complications in cirrhotic patients. RESULTS Current PPI indications have remained unchanged for years now, and are well established. A general screening of vitamin B12 levels is not recommended for all patients on a PPI; however, it does seem necessary that magnesium levels be measured at therapy onset, and then monitored in subjects on other drugs that may induce hypomagnesemia. A higher risk for bone fractures is present, even though causality cannot be concluded for this association. The association between PPIs and infection with Clostridium difficile is mild to moderate, and the risk for pneumonia is low. In patients with cardiovascular risk receiving thienopyridines derivatives it is prudent to adequately consider gastrointestinal and cardiovascular risks, given the absence of definitive evidence regardin potential drug-drug interactions; if gastrointestinal risk is found to be moderate or high, effective prevention should be in place with a PPI. PPIs should be cautiously indicated in patients with decompensated cirrhosis. CONCLUSIONS PPIs are safe drugs whose benefits outweigh their potential side effects both short-term and long-term, provided their indication, dosage, and duration are appropriate.
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Affiliation(s)
| | | | | | - Javier Júdez Gutiérrez
- Departamento de Gestión del Conocimiento, Sociedad Española de Patología Digestiva SEPD, España
| | | | - Aida Ortega Alonso
- UGC Enfermedades Digestivas, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria, España
| | | | - Manuel Rodríguez-Téllez
- UGC Intercentros de Aparato Digestivo , Hospital Universitario Virgen de la Macarena (HUVM), España
| | | | | | - Ángel Álvarez Sánchez
- Servicio de Aparato Digestivo, Hospital Clínico San Carlos. Universidad Complutense de Madrid., España
| | - Raúl Jesús Andrade Bellido
- Unidad de Gestión Clinica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria, España
| | | | | | - Froilán Giganto Tomé
- Servicio de Aparato Digestivo, Hospital Universitario Central de Asturias, España
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Aguilera-Castro L, Martín-de-Argila-dePrados C, Albillos-Martínez A. Practical considerations in the management of proton-pump inhibitors. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:145-53. [PMID: 26666270 DOI: 10.17235/reed.2015.3812/2015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Proton-pump inhibitors (PPIs) are one of the most active ingredients prescribed in Spain. In recent decades there has been an overuse of these drugs in both outpatient clinics and hospitals that has lead to a significant increase in healthcare spending and to an increase in the risk of possible side effects. It is important for health professionals to know the accepted indications and the correct doses for the use of these drugs. On the market there are different types of PPI: omeprazole, pantoprazole, lansoprazole, rabeprazole and esomeprazole. Omeprazole is the oldest and most used PPI, being also the cheapest. Although there are no important differences between PPIs in curing diseases, esomeprazole, a new-generation PPI, has proved to be more effective in eradicating H. pylori and in healing severe esophagitis compared to other PPIs. In recent years the use of generic drugs has spread; these drugs have the same bioavailability than the original drugs. In the case of PPIs, the few comparative studies available in the literature between original and generic drugs have shown no significant differences in clinical efficacy.
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Wang H, Lang L, Ou N, Shi R, Hu H, Hu P, Jiang J. Pharmacokinetics, Pharmacodynamics and Safety of Multiple-Infusion Ilaprazole in Healthy Chinese Subjects. Clin Drug Investig 2016; 36:463-70. [PMID: 27067231 DOI: 10.1007/s40261-016-0390-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Ilaprazole is a novel proton pump inhibitor that provides effective and long lasting inhibition of intragastric acid secretion. The objectives of this study were to investigate the pharmacokinetics, pharmacodynamics, and safety of intravenous ilaprazole after multiple administrations in healthy Chinese subjects. METHODS This was an open-label and multiple-dose clinical study. Ten healthy Chinese subjects received 10 mg ilaprazole infusion once daily for 5 days. Helicobacter pylori status was examined. Blood samples were collected and intragastric pH was recorded for 24 h. Safety was assessed throughout the study. RESULTS There was no accumulation after multiple administrations. The mean steady-state half-life and clearance were comparable to those following single administration. Ilaprazole provided sustainable and significant intragastric pH control in terms of percentage time at pH >4, pH >6 within 24 h and mean 24-h pH values. The pH value within 24 h was affected by Helicobacter pylori infection in subjects with continuous infusion. Intravenous ilaprazole was safe and there were no serious adverse events. CONCLUSION Intravenous ilaprazole provided stable pharmacokinetics and pharmacodynamics at a dose of 10 mg once daily for 5 days, and was well tolerated in healthy subjects.
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Affiliation(s)
- Hongyun Wang
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Liwei Lang
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Ning Ou
- Jiangsu Province Hospital, Nanjing, Jiangsu, 210029, China
| | - Ruihua Shi
- Jiangsu Province Hospital, Nanjing, Jiangsu, 210029, China
| | - Haitang Hu
- Livzon Pharmaceutical Co., Ltd., Zhuhai, Guangdong, 519020, China
| | - Pei Hu
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Ji Jiang
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
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Chwiesko A, Charkiewicz R, Niklinski J, Luczaj W, Skrzydlewska E, Milewski R, Baniukiewicz A, Wroblewski E, Rosolowski M, Dabrowski A. Effects of different omeprazole dosing on gastric pH in non-variceal upper gastrointestinal bleeding: A randomized prospective study. J Dig Dis 2016; 17:588-599. [PMID: 27518195 DOI: 10.1111/1751-2980.12393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/15/2016] [Accepted: 08/08/2016] [Indexed: 01/10/2023]
Abstract
OBJECTIVE We aimed to identify the best method of omeprazole (OME) application with respect to intragastric pH, cytochrome P450 2C19 (CYP2C19) genotype and phenotype. METHODS The patients with non-variceal upper gastrointestinal bleeding (NVUGIB) were prospectively enrolled. After the achievement of endoscopic hemostasis, the patients were randomized to 40-mg intravenous (i.v.) OME bolus injection every 12 h or 8-mg/h continuous i.v. infusion for 72 h after an 80-mg i.v. OME bolus administration. The intragastric pH was recorded for 72 h. The CYP2C19 variant alleles (*2, *3, *17) were analyzed and the serum concentrations of OME and 5-hydroxyomeprazole (5-OH OME) were determined. RESULTS Altogether 41 Caucasians (18 in the OME infusion [OI] group and 23 in the OME bolus [OB] group) were analyzed. The median percentage of time with an intragastric pH > 4.0 was higher in the infusion group than in the OB group over 48 h (100% vs 96.6%, P = 0.009) and 72 h (100% vs 87.6%, P = 0.006), and that at an intragastric pH >6.0 was higher in the OI group than the OB group over 72 h (97.9% vs 63.5%, P = 0.04). Helicobacter pylori infection was correlated with the fastest increase in intragastric pH, especially in the OI group. In both groups, CYP2C19 genotypes (*1/*1, *1/*17, *17/*17) had no essential effect on intragastric pH. CONCLUSIONS In patients with NVUGIB, OME i.v. bolus followed by continuous infusion is more effective than OME i.v. bolus every 12 h in maintaining higher intragastric pH, regardless of CYP2C19 genetic polymorphisms. H. pylori infection accelerates the initial elevation of intragastric pH.
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Affiliation(s)
- Adam Chwiesko
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Radoslaw Charkiewicz
- Department of Clinical Molecular Biology, Medical University of Bialystok, Bialystok, Poland
| | - Jacek Niklinski
- Department of Clinical Molecular Biology, Medical University of Bialystok, Bialystok, Poland
| | - Wojciech Luczaj
- Department of Inorganic and Analytical Chemistry, Medical University of Bialystok, Bialystok, Poland
| | - Elzbieta Skrzydlewska
- Department of Inorganic and Analytical Chemistry, Medical University of Bialystok, Bialystok, Poland
| | - Robert Milewski
- Department of Statistics and Medical Informatics, Medical University of Bialystok, Bialystok, Poland
| | - Andrzej Baniukiewicz
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Eugeniusz Wroblewski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Mariusz Rosolowski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Andrzej Dabrowski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
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Jian Z, Li H, Race NS, Ma T, Jin H, Yin Z. Is the era of intravenous proton pump inhibitors coming to an end in patients with bleeding peptic ulcers? Meta-analysis of the published literature. Br J Clin Pharmacol 2016; 82:880-9. [PMID: 26679691 DOI: 10.1111/bcp.12866] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 11/27/2015] [Accepted: 12/15/2015] [Indexed: 11/29/2022] Open
Abstract
AIMS Oral and intravenous proton pump inhibitors (PPIs) are equipotent in raising gastric pH. However, it is not known whether oral PPIs can replace intravenous PPIs in patients with bleeding peptic ulcers. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials to compare oral and intravenous PPIs among patients with peptic ulcer bleeding. A search of all major databases and relevant journals from inception to April 2015, without a restriction on languages, was performed. RESULTS A total of 859 patients from seven randomized controlled trials were included in the meta-analysis. Similar pooled outcome measures were demonstrated between the two groups in terms of oral PPIs vs. intravenous PPIs in the rate of recurrent bleeding within the 30-day follow-up period [risk ratio = 0.90; 95% confidence interval (CI): 0.58, 1.39; P = 0.62; I(2) = 0%). In terms of the rate of mortality, both oral and intravenous PPIs showed similar outcomes, and the pooled risk ratio was 0.88 (95% CI: 0.29, 2.71; P = 0.82; I(2) = 0%). Likewise, no significant difference was detected in the need for blood transfusion and length of hospital stay; the pooled mean differences were -0.14 (95% CI: -0.39, 0.12; P = 0.29; I(2) = 32%) and -0.60 (95% CI: -1.42, 0.23; P = 0.16; I(2) = 79%), respectively. CONCLUSIONS Our results suggest that oral PPIs are a feasible, safe alternative to intravenous PPIs in patients with bleeding peptic ulcers, and may be able to replace intravenous PPIs as the treatment of choice in these patients.
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Affiliation(s)
- Zhixiang Jian
- General Surgery Department of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hui Li
- Neurological Department of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Nicholas S Race
- Purdue University Weldon School of Biomedical Engineering, Indiana University School of Medicine, B.S. Biomedical Engineering, Rose-Hulman Institute of Technology, Terre Haute, IN, USA
| | - Tingting Ma
- Gynaecology and Obstetrics Department, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Haosheng Jin
- General Surgery Department of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zi Yin
- General Surgery Department of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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Gjeorgjievski M, Cappell MS. Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy. World J Hepatol 2016; 8:231-62. [PMID: 26855694 PMCID: PMC4733466 DOI: 10.4254/wjh.v8.i4.231] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 11/30/2015] [Accepted: 01/16/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To describe the pathophysiology, clinical presentation, natural history, and therapy of portal hypertensive gastropathy (PHG) based on a systematic literature review. METHODS Computerized search of the literature was performed via PubMed using the following medical subject headings or keywords: "portal" and "gastropathy"; or "portal" and "hypertensive"; or "congestive" and "gastropathy"; or "congestive" and "gastroenteropathy". The following criteria were applied for study inclusion: Publication in peer-reviewed journals, and publication since 1980. Articles were independently evaluated by each author and selected for inclusion by consensus after discussion based on the following criteria: Well-designed, prospective trials; recent studies; large study populations; and study emphasis on PHG. RESULTS PHG is diagnosed by characteristic endoscopic findings of small polygonal areas of variable erythema surrounded by a pale, reticular border in a mosaic pattern in the gastric fundus/body in a patient with cirrhotic or non-cirrhotic portal hypertension. Histologic findings include capillary and venule dilatation, congestion, and tortuosity, without vascular fibrin thrombi or inflammatory cells in gastric submucosa. PHG is differentiated from gastric antral vascular ectasia by a different endoscopic appearance. The etiology of PHG is inadequately understood. Portal hypertension is necessary but insufficient to develop PHG because many patients have portal hypertension without PHG. PHG increases in frequency with more severe portal hypertension, advanced liver disease, longer liver disease duration, presence of esophageal varices, and endoscopic variceal obliteration. PHG pathogenesis is related to a hyperdynamic circulation, induced by portal hypertension, characterized by increased intrahepatic resistance to flow, increased splanchnic flow, increased total gastric flow, and most likely decreased gastric mucosal flow. Gastric mucosa in PHG shows increased susceptibility to gastrotoxic chemicals and poor wound healing. Nitrous oxide, free radicals, tumor necrosis factor-alpha, and glucagon may contribute to PHG development. Acute and chronic gastrointestinal bleeding are the only clinical complications. Bleeding is typically mild-to-moderate. Endoscopic therapy is rarely useful because the bleeding is typically diffuse. Acute bleeding is primarily treated with octreotide, often with concomitant proton pump inhibitor therapy, or secondarily treated with vasopressin or terlipressin. Nonselective β-adrenergic receptor antagonists, particularly propranolol, are used to prevent bleeding after an acute episode or for chronic bleeding. Iron deficiency anemia from chronic bleeding may require iron replacement therapy. Transjugular-intrahepatic-portosystemic-shunt and liver transplantation are highly successful ultimate therapies because they reduce the underlying portal hypertension. CONCLUSION PHG is important to recognize in patients with cirrhotic or non-cirrhotic portal hypertension because it can cause acute or chronic GI bleeding that often requires pharmacologic therapy.
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Affiliation(s)
- Mihajlo Gjeorgjievski
- Mihajlo Gjeorgjievski, Mitchell S Cappell, Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
| | - Mitchell S Cappell
- Mihajlo Gjeorgjievski, Mitchell S Cappell, Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
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Zhang YS, Li Q, He BS, Liu R, Li ZJ. Proton pump inhibitors therapy vs H 2 receptor antagonists therapy for upper gastrointestinal bleeding after endoscopy: A meta-analysis. World J Gastroenterol 2015; 21:6341-6351. [PMID: 26034370 PMCID: PMC4445112 DOI: 10.3748/wjg.v21.i20.6341] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 09/23/2014] [Accepted: 11/11/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the therapeutic effects of proton pump inhibitors vs H2 receptor antagonists for upper gastrointestinal bleeding in patients after successful endoscopy.
METHODS: We searched the Cochrane library, MEDLINE, EMBASE and PubMed for randomized controlled trials until July 2014 for this study. The risk of bias was evaluated by the Cochrane Collaboration’s tool and all of the studies had acceptable quality. The main outcomes included mortality, re-bleeding, received surgery rate, blood transfusion units and hospital stay time. These outcomes were estimated using odds ratios (OR) and mean difference with 95% confidence interval (CI). RevMan 5.3.3 software and Stata 12.0 software were used for data analyses.
RESULTS: Ten randomized controlled trials involving 1283 patients were included in this review; 678 subjects were in the proton pump inhibitors (PPI) group and the remaining 605 subjects were in the H2 receptor antagonists (H2RA) group. The meta-analysis results revealed that after successful endoscopic therapy, compared with H2RA, PPI therapy had statistically significantly decreased the recurrent bleeding rate (OR = 0.36; 95%CI: 0.25-0.51) and receiving surgery rate (OR = 0.29; 95%CI: 0.09-0.96). There were no statistically significant differences in mortality (OR = 0.46; 95%CI: 0.17-1.23). However, significant heterogeneity was present in both the numbers of patients requiring blood transfusion after treatment [weighted mean difference (WMD), -0.70 unit; 95%CI: -1.64 - 0.25] and the time that patients remained hospitalized [WMD, -0.77 d; 95%CI: -1.87 - 0.34]. The Begg’s test (P = 0.283) and Egger’s test (P = 0.339) demonstrated that there was no publication bias in our meta-analysis.
CONCLUSION: In patients with upper gastrointestinal bleeding after successful endoscopic therapy, compared with H2RA, PPI may be a more effective therapy.
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Comparison of Intravenous plus Oral Pantoprazole Therapy and Oral Pantoprazole Alone for Preventing Gastrointestinal Bleeding in Acute Coronary Syndrome Patients with High Bleeding Risk. Heart Lung Circ 2015; 24:885-90. [PMID: 25837016 DOI: 10.1016/j.hlc.2015.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 02/17/2015] [Accepted: 02/20/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND It is unclear whether intravenous proton pump inhibition is more effective than oral administration in preventing gastrointestinal (GI) bleeding in high bleeding risk patients with acute coronary syndromes (ACS). METHODS AND RESULTS A total of 504 patients with ACS and high bleeding risk were randomly assigned into two groups. Study group (n=252) received intravenous pantoprazole for five days and subsequent oral pantoprazole for 12 months. Control group (n=252) received oral pantoprazole for 12 months. Major adverse cardiac events (death, re-infarction, re-revascularisation and stroke) and GI bleeding were registered after a follow-up of 12 months. No statistically significant differences were found in the major adverse cardiac events between the two groups after the follow-up (p >0.05). The incidence of major GI bleeding in the study group was lower than in the control group (1.2% vs. 3.9%, p=0.049). The bleeding rates in the first 30 days in the study group were also lower than in the control group (0.3% vs. 2.7%, p=0.032). CONCLUSIONS The main outcome of cardiac events did not differ between the treatment groups. Intravenous plus oral pantoprazole therapy seemed more effective than oral therapy alone in the prevention of GI bleeding in high bleeding risk patients with ACS.
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Sheu BS, Wu CY, Wu MS, Chiu CT, Lin CC, Hsu PI, Cheng HC, Lee TY, Wang HP, Lin JT. Consensus on control of risky nonvariceal upper gastrointestinal bleeding in Taiwan with National Health Insurance. BIOMED RESEARCH INTERNATIONAL 2014; 2014:563707. [PMID: 25197649 PMCID: PMC4147192 DOI: 10.1155/2014/563707] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 08/01/2014] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIMS To compose upper gastrointestinal bleeding (UGIB) consensus from a nationwide scale to improve the control of UGIB, especially for the high-risk comorbidity group. METHODS The steering committee defined the consensus scope to cover preendoscopy, endoscopy, postendoscopy, and overview from Taiwan National Health Insurance Research Database (NHIRD) assessments for UGIB. The expert group comprised thirty-two Taiwan experts of UGIB to conduct the consensus conference by a modified Delphi process through two separate iterations to modify the draft statements and to vote anonymously to reach consensus with an agreement ≥80% for each statement and to set the recommendation grade. RESULTS The consensus included 17 statements to highlight that patients with comorbidities, including liver cirrhosis, end-stage renal disease, probable chronic obstructive pulmonary disease, and diabetes, are at high risk of peptic ulcer bleeding and rebleeding. Special considerations are recommended for such risky patients, including raising hematocrit to 30% in uremia or acute myocardial infarction, aggressive acid secretory control in high Rockall scores, monitoring delayed rebleeding in uremia or cirrhosis, considering cycloxygenase-2 inhibitors plus PPI for pain control, and early resumption of antiplatelets plus PPI in coronary artery disease or stroke. CONCLUSIONS The consensus comprises recommendations to improve care of UGIB, especially for high-risk comorbidities.
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Affiliation(s)
- Bor-Shyang Sheu
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Ying Wu
- Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Cheng-Tang Chiu
- Gastroenterology Endoscopy Center, Chang Gung Memorial Hospital, Linko, Taiwan
| | - Chun-Che Lin
- Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ping-I Hsu
- Department of Internal Medicine, Tainan Hospital, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Hsiu-Chi Cheng
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Teng-Yu Lee
- Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jaw-Town Lin
- School of Medicine, Fu Jen Catholic University, No. 510 Zhongzheng Road, Xinzhuang District, New Taipei City 24205, Taiwan
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Tsoi KKF, Hirai HW, Sung JJY. Meta-analysis: comparison of oral vs. intravenous proton pump inhibitors in patients with peptic ulcer bleeding. Aliment Pharmacol Ther 2013; 38:721-8. [PMID: 23915096 DOI: 10.1111/apt.12441] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 06/12/2013] [Accepted: 07/14/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND The efficacy of adjuvant use of intravenous proton pump inhibitors (PPIs) after endoscopic therapy has been proved in peptic ulcer bleeding patients, but the efficacy of oral PPIs is uncertain. AIM To compare the clinical outcomes of oral PPIs vs. intravenous PPIs in patients with peptic ulcer bleeding. METHODS Prospective randomised controlled trials were systematically searched from OVID databases until June 2012. Trials comparing oral and intravenous PPIs among patients with peptic ulcer bleeding were included. Recurrent bleeding, length of hospitalisation, blood transfusion, requirement of surgery and mortality were measured. The risk of bias, study quality and heterogeneity were also evaluated. RESULTS Six randomised trials from 2006 to 2011 were included. A total of 615 patients were randomly assigned to receive oral PPIs (n = 302) or intravenous PPIs (n = 313). The mean age was 60 years and 71.1% was male. No significant difference between oral and intravenous PPIs was observed regarding recurrent bleeding (RR: 0.92, 95% CI: 0.56-1.50), mean volume of blood transfused (-0.02 unit, 95% CI: -0.29-0.24 unit), requirement of surgery (RR: 0.82, 95% CI: 0.19-3.61) and all-cause mortality (RR: 0.88, 95% CI: 0.29-2.71). The duration of hospital stay in days was significantly shortened in those using oral PPIs (-0.74 day, 95% CI: -1.10 day to -0.39 day). CONCLUSION Oral PPIs demonstrate a similar effectiveness to intravenous PPIs among patients with peptic ulcer bleeding, but the results were combined from open-labelled trials with limited sample size. A large double-blind non-inferiority trial is required to better assess the role of oral PPIs.
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Affiliation(s)
- K K F Tsoi
- The Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong
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