Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding

Dr. Waleed Kh. S. MahrousGastroenterology and Hepatology Consultant

Should we give a PPI IV before endoscopy in patients with

upper GI bleeding?

Yes

No

Probably Yes

Probably No

Should we give a PPI IV before endoscopy in patients with

upper GI bleeding?

Yes

No (SIGN, BSG , NICE)Probably Yes (ACG , ASGE,

AGA)

Probably No

Interdiction

Experimental data suggest that acid suppression and increased pH are important in clot stabilisation and hence potentially in reducing rebleeding .

Major Endpoints:

Mortality

Re-bleeding

Need for surgical intervention.

Minor Endpoints:

- Need for endoscopic

hemostasis,

- Blood transfusion,

- Decrease in Hospital

Days.

Efficacy Endpoints

Also, a decrease in high risk stigmata on endoscopic evaluation may represent a clinically useful outcome if it reduced the need for hemostatic intervention.

A study showed that there was a 14% reduction in endoscopic hemostasis in the PPI group, with a number needed to treat to prevent one intervention of 7.

Efficacy Endpoints

Delaying definitive diagnosis and treatment,

Direct cost to patient,

Indirect cost (change in level of care, nursing care, emergency department flow, etc.)

Since 37-45% of undifferentiated upper GI bleed is not from a peptic ulcer1,2 patients can be subject to unnecessary medications and cost.

Harm Endpoints:

Proton pump inhibitors

Do not offer acid-suppression drugs (proton pump inhibitors or H2-receptor antagonists) before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding.

Pre-endoscopic therapy with high-dose PPI may reduce the numbers of patients who require endoscopic therapy, but there is no evidence that it alters important clinical outcomes and there is insufficient evidence to support this practice.

A proton pump inhibitors should not be used prior to diagnosis by endoscopy in patients presenting with acute upper gastrointestinal bleeding.

PRE-ENDOSCOPIC MEDICAL THERAPY

Proton pump inhibitor therapy

Recommendations.6. Pre-endoscopic intravenous proton pump inhibitor (PPI) (e.g., 80 mg bolus followed by 8

mg/h infusion) may be considered to decrease the proportion of patients who have higher risk stigmata of hemorrhage at endoscopy and who receive endoscopic therapy.

However, PPIs do not improve clinical outcomes such as further bleeding, surgery, or death (Conditional recommendation, high-quality evidence).

If endoscopy will be delayed or cannot be performed, intravenous PPI is recommended to reduce further bleeding (Conditional recommendation, moderate-quality evidence).

Before-procedure proton pump inhibitor therapy

The role of proton pump inhibitor (PPI) therapy in patients with suspected acute UGIB was systematically reviewed in a Cochrane meta-analysis that included 6 randomized controlled trials (RCT) published between 1992 and 2007.22

The analysis found that patients with nonvariceal UGIB administered intravenous PPI therapy prior to endoscopy did not experience any statistically significant differences in the outcomes of mortality, rebleeding, or progression to surgery compared with patients in the control group.

However, the analysis did show that before-procedure PPI therapy resulted in significantly reduced rates of high-risk stigmata identified on endoscopy (odds ratio [OR] 0.67; 95% confidence interval [CI], 0.54-0.84) and need for endoscopic therapy (OR 0.68; 95% CI, 0.50-0.93).

Therefore, intravenous PPI therapy is recommended for patients who are suspected of having acute UGIB.

Implications for Practice

PPI therapy is already widely initiated before endoscopy in patients with upper gastrointestinal bleeding.

The present analysis did not find significant improvement with PPI treatment for clinically important outcomes including rebleeding, surgery or mortality.

The reduced rate of serious endoscopic stigmata of bleeding found at endoscopy among patients given PPI therapy before endoscopy and the reduced requirement for endoscopic haemostatic treatment are of uncertain clinical significance.

However, PPI therapy may have a role if prompt endoscopy is not readily available.

Implications for Practice

Implications for Practice

Among such patients in whom PPI therapy is initiated before endoscopy, therapy can obviously be discontinued if endoscopy finds no evidence of bleeding or evidence of bleeding from an alternate source (for example, oesophageal or gastric varices).