Efficacy Comparison of Divided and Infusion Intravenous Pantoprazole Methods after Endoscopic Therapy in Patients with Acute Gastrointestinal Bleeding

Background:

Intravenous pantoprazole administration in patients with severe bleeding under urgent endoscopic therapy is effective. Furthermore, its infusion dose is useful to control bleeding; however, it is not economical. In this study, clinical outcomes and intravenous infusion of pantoprazole after endoscopic therapy plus efficacy of infusion dosage and divided doses are compared.

Materials and Methods:

This prospective, comparative study conducted on 18 adult (>18 years) patients referred to Al Zahra Hospital for hematemesis and melena bleeding who underwent endoscopic treatment with pantoprazole which divided into two groups of forty patients. First group received intravenous infusion for 80 mg and 8 mg/h. The second group received intravenous infusion with divided doses as 40 mg twice daily for 3 days. Clinical outcomes such as rebleeding, duration of hospitalization, amount of blood transfused, and mortality within 3 days after endoscopic treatment were collected and analyzed by SPSS software (version 20) using independent t-test, Chi-square test, and Fisher's exact test.

Results:

Duration of hospitalization in the pantoprazole infusion group was 5.42 ± 4.62 days, with three patients (7.5%) having rebleeding, and in the divided pantoprazole group was 5.90 ± 3.08 days, with four patients (10%) having rebleeding, and overall, only one person died in the divided pantoprazole group (2.5%) out of eighty patients. No significant difference was observed between two groups in terms of clinical outcomes (P > 0.05).

Conclusion:

Regarding to results, it can be stated that both methods with specified dosage had significant impact on improvement of hematemesis and melena. Furthermore, due to lower costs, low dose of pantoprazole in divided approach as 40 mg/12 h is proposed.

Upper gastrointestinal bleeding caused by severe esophagitis: a unique clinical syndrome

BACKGROUND

We have recognized a unique clinical syndrome in patients with upper gastrointestinal bleeding who are found to have severe esophagitis.

AIM

We aimed to more clearly describe the clinical entity of upper gastrointestinal bleeding in patients with severe esophagitis.

METHODS

We conducted a retrospective matched case-control study designed to investigate clinical features in patients with carefully defined upper gastrointestinal bleeding and severe esophagitis. Patient data were captured prospectively via a Gastrointestinal Bleeding Healthcare Registry, which collects data on all patients admitted with gastrointestinal bleeding. Patients with endoscopically documented esophagitis (cases) were matched with randomly selected controls that had upper gastrointestinal bleeding caused by other lesions.

RESULTS

Epidemiologic features in patients with esophagitis were similar to those with other causes of upper gastrointestinal bleeding. However, hematemesis was more common in patients with esophagitis 86% (102/119) than in controls 55% (196/357) (p < 0.0001), while melena was less common in patients with esophagitis 38% (45/119) than in controls 68% (244/357) (p < 0.0001). Additionally, the more severe the esophagitis, the more frequent was melena. Patients with esophagitis had less abnormal vital signs, lesser decreases in hematocrit, and lesser increases in BUN. Both pre- and postRockall scores were lower in patients with esophagitis compared with controls (p = 0.01, and p < 0.0001, respectively). Length of hospital stay (p = 0.002), rebleeding rate at 42 days (p = 0.0007), and mortality were less in patients with esophagitis than controls. Finally, analysis of patients with esophagitis and cirrhosis suggested that this group of patients had more severe bleeding than those without cirrhosis.

CONCLUSIONS

We have described a unique clinical syndrome in patients with upper gastrointestinal bleeding who have erosive esophagitis. This syndrome is manifest by typical clinical features and is associated with favorable outcomes.

Outcomes of peptic ulcer bleeding following treatment with proton pump inhibitors in routine clinical practice: 935 patients with high- or low-risk stigmata

OBJECTIVE

To assess rates of further bleeding, surgery and mortality in patients hospitalized owing to peptic ulcer bleeding.

MATERIALS AND METHODS

Consecutive patients hospitalized for peptic ulcer bleeding and treated with a proton pump inhibitor (PPI) (esomeprazole or pantoprazole) were identified retrospectively in 12 centers in Spain. Patients were included if they had high-risk stigmata (Forrest class Ia-IIb, underwent therapeutic endoscopy and received intravenous PPI ≥120 mg/day for ≥24 h) or low-risk stigmata (Forrest class IIc-III, underwent no therapeutic endoscopy and received intravenous or oral PPI [any dose]).

RESULTS

Of 935 identified patients, 58.3% had high-risk stigmata and 41.7% had low-risk stigmata. After endoscopy, 88.3% of high-risk patients and 22.1% of low-risk patients received intravenous PPI therapy at doses of at least 160 mg/day. Further bleeding within 72 h occurred in 9.4% and 2.1% of high- and low-risk patients, respectively (p < 0.001). Surgery to stop bleeding was required within 30 days in 3.5% and 0.8% of high- and low-risk patients, respectively (p = 0.007). Mortality at 30 days was similar in both groups (3.3% in high-risk and 2.3% in low-risk patients).

CONCLUSION

Among patients hospitalized owing to peptic ulcer bleeding and treated with PPIs, patients with high-risk stigmata have a higher risk of further bleeding and surgery, but not of death, than those with low-risk stigmata.

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.

Esomeprazole for the treatment of peptic ulcer bleeding

Peptic ulcer bleeding is the most common cause of acute bleeding in the upper GI tract. The incidence of peptic ulcer bleeding has slowly decreased and endoscopic treatment options have improved; nevertheless, it remains a very common condition with a 7-15% mortality. Acidic environments have a negative effect on hemostasis. Therefore, acid inhibitors have been applied in the adjuvant treatment of peptic ulcer bleeding, both in preventing rebleeding and in treating the underlying cause. This requires profound acid suppressive therapy aiming for a rapid onset of effect and a persistent intragastric pH above 6. This can only be achieved by proton pump inhibitors (PPIs). Esomeprazole is the S-isomer of omeprazole, and the first PPI to consist of only the active isomer. A number of studies have compared esomeprazole with other PPIs, demonstrating a faster and more persistent increase in intragastric pH with the use of esomeprazole than with other agents. Continuous high-dose intravenous treatment with esomeprazole decreases rebleeding, surgery, transfusion rates and hospital days in peptic ulcer bleeding.