Bleeding peptic ulcers

Patients who present acutely with upper gastrointestinal bleeding should have prompt endoscopy. This often identifies the cause and determines the risk of ongoing or recurrent bleeding and appropriate management.

Management may involve endoscopic therapy, proton pump inhibitor (PPI) therapy and blood transfusion.

Endoscopic therapy is required if an ulcer is identified and there are endoscopic stigmata of recent or active haemorrhage that predict a higher risk of ongoing or recurrent bleeding (ie visible vessel, clot on an ulcer base, or active bleeding); this is usually effective to control bleeding. Haemostatic techniques include electrocautery, heater probes, application of clips or injection with adrenaline (epinephrine). Endoscopic haemostatic sprays, radiological embolisation or surgery are sometimes required to manage uncontrolled bleeding.

PPI therapy reduces the risk of ulcer rebleeding. Intravenous PPI therapy should be started before endoscopy if there is evidence of significant upper gastrointestinal bleeding and there may be delay in endoscopy; however, this is not required in stable patients and where endoscopy is done promptly.

Initial studies of PPIs for bleeding peptic ulcers used an intravenous injection followed by a continuous infusion; but administration via intermittent intravenous injection has similar efficacy. Suitable regimens administered by intravenous infusion includeLaine, 2021:

1esomeprazole 80 mg intravenously over 15 to 30 minutes, then 8 mg/hour by intravenous infusion for up to 3 days (see below for duration) esomeprazole esomeprazole esomeprazole

1omeprazole 80 mg intravenously over 15 to 30 minutes, then 8 mg/hour by intravenous infusion for up to 3 days (see below for duration) omeprazole omeprazole omeprazole

1pantoprazole 80 mg intravenously over 15 to 30 minutes, then 8 mg/hour by intravenous infusion for up to 3 days (see below for duration). pantoprazole pantoprazole pantoprazole

Suitable regimens administered by intermittent intravenous dosing include:

1esomeprazole 40 mg intravenously, 12-hourly for up to 3 days esomeprazole esomeprazole esomeprazole

1omeprazole 40 mg intravenously, 12-hourly for up to 3 days omeprazole omeprazole omeprazole

1pantoprazole 40 mg intravenously, 12-hourly for up to 3 days. pantoprazole pantoprazole pantoprazole

The duration of intravenous therapy depends on results of the endoscopy. If endoscopy shows high-risk features (ie active bleeding, a nonbleeding visible vessel or adherent clot), intravenous PPI therapy should be continued for 3 days before switching to oral therapy. If endoscopy shows low-risk features (ie a flat, pigmented spot or a clean-based ulcer), the patient does not need intravenous PPI therapy and should be switched to oral therapyGralnek, 2008. For all bleeding peptic ulcers, oral high-dose PPI therapy should be continued for about 8 weeks (for dosage regimens, see Distal oesophageal spasm).

Blood transfusion may be required for resuscitation of patients with a bleeding ulcer. Recent data suggests that a restrictive transfusion strategy, aiming for a haemoglobin concentration of 70 to 80 g/L, results in improved survival, fewer adverse events and lower rebleeding rates. However, a target of 90 to 100 g/L should be used in patients with massive exsanguinating haemorrhage, coronary artery disease, or peripheral or cerebral vascular diseaseLanas, 2017 Villanueva, 2013.