Article

Current concepts: Management of acute bleeding from a peptic ulcer

Department of Gastroenterology and Gastrointestinal Outcomes Unit, Rambam Health Care Campus and Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel.
New England Journal of Medicine (Impact Factor: 54.42). 09/2008; 359(9):928-37. DOI: 10.1056/NEJMra0706113
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    • "Discussion UGIB is a common cause of hospital visits and admissions, at a cost estimated as US$2.5 billion annually [Albeldawi et al. 2010]. It carries a mortality of up to 10% [Gralnek et al. 2008]. "
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    ABSTRACT: Upper gastrointestinal bleeding (UGIB) accounts for 400,000 hospital admissions in the US each year. Despite advances, mortality rates remain high and are estimated to be 5-10%. Early therapeutic endoscopy is widely recommended as a means of reducing morbidity and mortality. The Rockall and Blatchford scores are clinical scoring systems devised to assist in risk stratifying patients with UGIB. In a prior study we found that rapid live bedside video capsule endoscopy (VCE) utilizing Pillcam ESO(®) correctly identified patients with high-risk stigmata of bleeding seen on upper endoscopy. In this study, we compare the accuracy of the Rockall and Blatchford scores with Pillcam ESO(®) in predicting high-risk endoscopic stigmata. Pre-endoscopy Blatchford and Rockall scores were calculated for 25 patients (14 males, 11 females) presenting to the emergency room with acute UGIB. The average patient was 66 years of age. A total of 24 out of 25 patients underwent upper endoscopy within 24 hours. One patient did not undergo endoscopy due to clinical instability. The timing of endoscopy was based on clinical parameters in 12 patients, and on live view VCE with Pillcam ESO(®) in the other 13 patients. Positive VCE was defined as red blood, clot or coffee grounds. Mean Rockall and Blatchford scores for all 24 patients were compared to determine potential differences between high- and low-risk patients. Rockall and Blatchford scores were also compared with VCE findings. Of 24 patients, 13 had high-risk stigmata on upper endoscopy. The mean Rockall and Blatchford scores were 3 and 13, respectively. In the 11 patients without stigmata, the mean Rockall and Blatchford scores were 2 and 11, respectively. There was no statistically significant difference between the Blatchford scores of the two groups (95% confidence interval [CI] -5.1 to 1.3; p = 0.22). There was no statistically significant difference between the Rockall scores of the two groups (95% CI -2.3 to 0.3; p = 0.11). In the subgroup of 12 patients who underwent VCE prior to endoscopy, 8/12 had positive findings, which were all confirmed at endoscopy. All 4 patients with negative VCE had no high-risk stigmata at endoscopy. In emergency room patients with acute UGIB, neither the Rockall nor the Blatchford scores were able to differentiate high- and low-risk patients identified at endoscopy. Live view VCE, however, was accurate in predicting high-risk endoscopic stigmata, and may be better suited as a risk stratification tool. Additional studies with a larger cohort will be required to validate these findings.
    Therapeutic Advances in Gastroenterology 05/2013; 6(3):193-8. DOI:10.1177/1756283X13481020
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    • "Renal function was evaluated by estimated glomerular filtration rate calculated using the 4-variable Modification of Diet in Renal Disease Study equations and classified according to the K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease [15]. High-risk ulcers were defined as Forrest grade higher or equal to 2b [3]. Rebleeding was defined as new onset of hematemesis, coffee-ground vomitus, or hematochezia, with an increasing pulse rate >110 beats/min and decreasing blood pressure below 90 mmHg after a 24-hour period of stable vital signs and hematocrit following endoscopic treatment [11, 16–18]. "
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    ABSTRACT: Background and Study Aims. The optimal dose of intravenous proton-pump inhibitor (PPI) therapy for the prevention of peptic ulcer (PU) rebleeding remains controversial. This study aimed to understand the real world experiences in prescribing high-dose PPI and non-high-dose PPI for preventing rebleeding after endoscopic treatment of high-risk PU. Patients and Methods. A total of 220 subjects who received high-dose and non-high-dose pantoprazole for confirmed acute PU bleeding that were successfully treated endoscopically were enrolled. They were divided into rebleeding (n = 177) and non-rebleeding groups (n = 43). Randomized matching of the treatment-control group was performed. Patients were randomly selected for non-high-dose and high-dose PPI groups (n = 44 in each group). Results. Univariate analysis showed, significant variables related to rebleeding were female, higher creatinine levels, and higher Rockall scores (≧6). Before case-control matching, the high-dose PPI group had higher creatinine level, higher percentage of shock at presentation, and higher Rockall scores. After randomized treatment-control matching, no statistical differences were observed for rebleeding rates between the high-dose and non-high-dose groups after case-control matching. Conclusion. This study suggests that intravenous high-dose pantoprazole may not be superior to non-high-dose regimen in reducing rebleeding in high-risk peptic ulcer bleeding after successful endoscopic therapy.
    Gastroenterology Research and Practice 07/2012; 2012:858612. DOI:10.1155/2012/858612 · 1.75 Impact Factor
  • Acta Endoscopica 01/2014; DOI:10.1007/s10190-013-0331-3 · 0.16 Impact Factor
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