Recent advances in the management of peptic ulcer bleeding

Abstract

Acute upper gastrointestinal haemorrhage due to peptic ulcer bleeding remains an important cause of emergency presentation and hospital admission. Despite advances in many aspects of management, peptic ulcer bleeding is still associated with significant morbidity, mortality, and healthcare costs. Comprehensive international guidelines have been published, but advances as well as controversies continue to evolve. Important recent advances include the evidence supporting a more restrictive transfusion strategy aiming for a target haemoglobin of 70–90 g/l. Comparative studies have confirmed that the Glasgow–Blatchford score remains the most useful score for predicting the need for intervention as well as for identifying the lowest-risk patients suitable for outpatient management. New scores, including the AIMS65 and Progetto Nazionale Emorragia Digestiva score, may be more accurate in predicting mortality. Pre-endoscopy erythromycin appears to improve outcomes and is probably underused. High-dose oral proton pump inhibition (PPI) for 11 days after PPI infusion is advantageous in those with a Rockall score of 6 or more. Oral is as effective as parenteral iron at restoring haemoglobin levels after a peptic ulcer bleed and both are superior to placebo in this respect. Within endoscopic techniques, haemostatic powders and over-the-scope clips can be used when other methods have failed. A disposable Doppler probe appears to provide more accurate determination of both rebleeding risk and the success of endoscopic therapy than purely visual guidance. Non- Helicobacter pylori, non-aspirin/non-steroidal anti-inflammatory drug ulcers contribute an increasing percentage of bleeding peptic ulcers and are associated with a poor prognosis and high rebleeding rate. The optimal management of these ulcers remains to be determined.

First-line endoscopic treatment with over-the-scope clips in patients with either upper or lower gastrointestinal bleeding: a multicenter study

“…An effective endoscopic procedure at the first attempt is clinically relevant not only for achieving stable primary hemostasis, but also for preventing rebleeding 5 . Endoscopic hemostasis is currently performed with different approaches, by using diverse devices 8 . Unfortunately, endoscopic thermocoagulation is able to consistently seal only small bleeding arteries (< 2 mm).…”

Selective COX-2 inhibitors are safe and effective

“…I am disappointed that The BMJ published a poorly referenced letter on the dangers of selective non-steroidal anti-inflammatory drug (NSAID) prescribing in the Quality and Outcomes Framework 1. The guidance advocating prescription of selective COX-2 inhibitors for patients at high risk of gastrointestinal complications is correct and evidence based 234. To follow another path and use a non-selective NSAID in this situation is putting patients unnecessarily at risk and cannot be supported.…”

Endoscopic closure devices: A review of technique and application for hemostasis

“…Despite ongoing improvements to traditional methods, rates of successful hemostasis are variable and reduction of re-bleeding rates, emergency surgery and overall mortality from GI hemorrhage have yet to significantly improve. 51,54,55 Thus, the application of newer technology to achieve hemostasis, such as OTSC, EDSL, and endoscopic suturing devices could be the long-awaited resolution to this common medical emergency. A summary of the advantages, disadvantages and cost of each endoscopic closure device is shown in Table 1.…”