Oral Proton Pump Inhibitors Are as Effective as Endoscopic Treatment for Bleeding Peptic Ulcer: A Prospective, Randomized, Controlled Trial

Abstract

In managing patients with bleeding peptic ulcers, it has been reported that pharmacologic treatment can be an alternative to endoscopic treatment. We compared the hemostasis rates of the endoscopic treatment, hemoclipping, and the pharmacologic treatment, oral proton pump inhibitors (PPIs), in bleeding peptic ulcer. A randomized prospective study was performed on 129 bleeding peptic ulcer patients with hematemesis or melena. Sixty-two patients were treated by endoscopic hemoclipping and subsequently H(2) receptor antagonists were injected intravenously (hemoclipping group), and 67 patients were treated with an oral PPI without endoscopic treatment (PPI group). The 24-hr gastric pH test was performed sequentially following the treatment. The initial hemostasis rate of the hemoclipping group was 93.5% (58/62) and the rebleeding rate was 6.9% (4/58), and the hemostasis rate of the PPI group was 92.5% (62/67) and the rebleeding rate was 7.5% (5/67), which were not different. The 24-hr gastric pH was 4.54+/-2.56 in the hemoclipping group and 5.97+/-1.30 in the PPI group (P<0.037). In the bleeding peptic ulcer patients, the hemostasis rate with the oral administration of PPIs was not different from that with the endoscopic hemoclipping treatment.

Effects of high-dose versus low-dose proton pump inhibitors for treatment of gastrointestinal ulcer bleeding: a meta-analysis of randomized controlled trials

“… 22 Numerous studies have shown that decreasing the acidity and increasing the pH of gastric acid after surgery can significantly reduce the incidence of re-bleeding after endoscopic hemostasis. 15 , 16 , 23 Gastric acid excretion in the stomach is proportional to the number of parietal cells, which also determines the number of active proton pumps. 24 Recent studies have shown that intravenous PPIs can significantly reduce the incidence of adverse events after surgery, but the optimal dosage and route of administration are still controversial.…”

Proton Pump Inhibitors – Their Pharmacological Impact on the Clinical Management of Acid-Related Disorders

“…Meta-analysesindicatethatendoscopichemostasis hasr educed rebleeding and surgicali nterventionsby over6 0%and mortality by45 % [93].Profound PPI-induced acid suppression (intragastricpHabove6.0)optimizess tability of blood clots overlaying the ulcerand reducest he risko frebleeding afterendoscopichemostases [4,58].According toseveralrecentr eviews and meta-analyses [1,6,20,64,[80][81][82][83][84]high dosed PPIs(given byiv-bolus +infusion) will significantlyr educe( in comparison top lacebo) the risko frebleeding (mean oddsr atios(OR):0.46-0.81) and need fors urgery (OR: 0.32 -0.96). However,mortality,the most important clinicalo utcome wasonlyr educed significantly(OR: 0.35) in 7Asiantrials [80][81][82][83][84].Becausem ost PPIsare primarilymetabolized byt he polymorphicC YP2C19 and PMsarem uchm oref requentin Asians(about 20 %) thani nCaucasians(about 3%),one could speculatethatdruge xposurewill bem orep ronounced and thus moree ffectivei nAsianp opulations.Recentlyit wass hownthatoraltreatmentw ithPPIsisapparently aseffectiveast heirintravenous application [65,101] and the highercosts involved withiv-administration will notjustifythispreference [138].…”

Management of upper gastrointestinal bleeding

“…In another Asian population, a high dose of oral omeprazole (40 mg twice daily) reduced rebleeding signifi cantly more than placebo in ulcer patients with NBVV or adherent clots who did not receive endoscopic therapy [29]. More recent trials have suggested that 1) high-dose oral PPI (pantoprazole 40 mg twice daily [30] or omeprazole 40 mg/d [31]) is just as effective as an intravenous infusion after endoscopy therapy; 2) oral PPI (omeprazole 40 mg twice daily) was similar to intravenous omeprazole in effectiveness in ulcer patients with low-risk stigmata of hemorrhage [32]; and 3) oral PPI (rabeprazole 20 mg twice daily) was as effective as endoscopic treatment with hemoclips [33].…”