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Treatment for High-Risk Nonbleeding Ulcers

Combination endoscopic and proton-pump-inhibitor therapy was more effective than pharmacologic therapy alone.

Both endoscopic therapy and high-dose proton-pump inhibition (PPI) can prevent recurrent bleeding in patients with high-risk nonbleeding ulcers (i.e., ulcers with visible vessels or adherent clots). Results from a previous study showed that endoscopic therapy plus PPI was superior to endoscopic therapy alone (Journal Watch Aug 18 2000), but large definitive trials in which combination therapy is compared with PPI alone are lacking.

Researchers in Hong Kong compared sham endoscopic therapy (gentle irrigation) with endoscopic epinephrine injection, thermocoagulation, and clot removal (if indicated) in 156 patients with upper gastrointestinal bleeding and inactive bleeding ulcers with visible vessels or clots. All participants received intravenous omeprazole (80-mg bolus, then 8 mg/hour for 72 hours), followed by daily oral omeprazole (20 mg).

Physicians who were blinded to treatment used prespecified criteria to determine recurrent bleeding. Recurrent bleeding within 30 days was significantly less common in the endoscopic-treatment group -- 1% versus 12%. The median number of units of blood transfused within 30 days of treatment was lower in the endoscopic-treatment group, and fewer endoscopically treated patients than medically treated patients were hospitalized for longer than 5 days.

Comment: These results are impressive, but the dose and duration of omeprazole treatment and the benefits of endoscopic therapy must be confirmed in a larger trial. Nonetheless, an editorialist recommends that, while we await such a study, high-risk nonbleeding ulcers be treated with endoscopic thermocoagulation and high-dose proton-pump-inhibitor infusion.

— Richard Saitz, MD, MPH, FACP, FASAM

Published in Journal Watch General Medicine September 16, 2003

Citation(s):

Sung JJY et al. The effect of endoscopic therapy in patients receiving omeprazole for bleeding ulcers with nonbleeding visible vessels or adherent clots: A randomized comparison. Ann Intern Med 2003 Aug 19; 139:237-43.

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• Medline abstract (Free)

Jensen DM. Treatment of patients at high risk for recurrent bleeding from a peptic ulcer. Ann Intern Med 2003 Aug 19; 139:294-5.

• Original article (Subscription may be required)
• Medline abstract (Free)