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
Source: PubMed
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    ABSTRACT: Gastric bleeding is one of the irritant problems in ulcer patients. In this study, we evaluated hemostatic action of ulcer-coating powder (EGF-endospray) on gastric ulcer animal models. EGF-endospray, containing epidermal growth factor, is designed to be applied through an endoscope. Hemostatic action of the EGF-endospray was evaluated on gastric hemorrhage models of rabbits and micro-pigs. The EGF-endospray was directly applied onto a mucosal resection (MR)-induced gastric bleeding focus in a rabbit model. In a porcine model, the EGF-endospray was applied once via an endoscopy to a bleeding lesion created by endoscopic submucosal dissection. The bleeding focus was then observed via an endoscope. In the rabbit model, EGF-endospray treatment significantly shortened mean bleeding time in comparison with other treatments (104.3 vs 548.0 vs 393.2 s for the EGF-endospray, the non-treated control and the epinephrine injection, respectively). In the micro-pig model, EGF-endospray showed immediate hemostatic action and prolonged covering of the bleeding focus for over 72 h. Histology proved mucosal thickness was more efficiently recovered in all EGF-endospray treated animals. The results of the present study suggest that the EGF-endospray is a promising hemostatic agent for GI bleeding.
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    ABSTRACT: Introduction: Histamine-2 receptor antagonists (H2RA) and proton pump inhibitors (PPI) are frequently used to prevent stress-related mucosal bleeding (SRMB). A paucity of data implicates these agents with pneumonia and Clostridium difficile infection (CDI). Areas covered: This review comparatively evaluates the effectiveness of H2RAs and PPIs and delineates their associations with these infectious complications. A literature review through 30 September 2014 was performed. Expert opinion: The rate of SRMB is declining, likely due better resuscitation strategies and the early provision of enteral nutrition. Therefore, gastric acid-suppressing therapies arguably reduce SRMB. However, they may contribute to pneumonia and CDI. The risks of these infectious complications depend on the extent of acid suppression and may vary by patient population. PPIs are associated with the greatest hazard for these infections, likely because they provide stronger acid suppression. Intermittent administration of H2RAs has theoretical advantages over continuous H2RA or PPI therapies as this dosing strategy does not fully suppress gastric acid and may limit infection risk. Placebo-controlled studies are warranted because clinical equipoise exists as the detrimental outcomes of these infections may outweigh the benefit of preventing SRMB given the infrequent occurrence of SRMB.
    Expert Opinion on Drug Safety 11/2014; 14(2):1-12. DOI:10.1517/14740338.2015.986456 · 2.74 Impact Factor
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    ABSTRACT: A close association has been established between climate and peptic ulcer bleeding (PUB). The incidence of PUB in cold climates is significantly higher than that in hot climates. In this study, gastric mucosal damage and its barrier function (through associated barrier factors) in extreme climate conditions were examined to investigate the pathogenesis of PUB in extreme cold climates. Gastric juice and biopsy specimens were collected from 176 patients with peptic ulcer. Conventional hematoxylin and eosin staining was used to exclude malignant ulcers. Helicobacter pylori infections were detected by modified Giemsa staining. pH values of the gastric juice samples were obtained on-site by precise pH dipstick readings. The protein expression levels of heat shock protein (HSP) 70, occludin, nitric oxide synthase (NOS), epidermal growth factor (EGF) and EGF receptor (EGFR) in the gastric mucosa were detected by immunohistochemistry. No significant differences were identified between the high and low bleeding risk groups in the rates of H. pylori infection and the pH values of the gastric juices in the extreme hot or cold climates. Furthermore, no statistically significant differences were identified in the protein expression levels of occludin, NOS, EGF and EGFR between the high and low bleeding risk groups. In the extreme cold climate, the expression of HSP70 and the mucus thickness of the gastric antrum in the high bleeding risk group were significantly lower than those in the low bleeding risk group. The protein expression levels of occludin, HSP70, NOS and EGFR in the extreme cold climate were significantly lower than those in the extreme hot climate, whereas the gastric acid secretion was significantly higher in the extreme cold climate than that in the extreme hot climate. In conclusion, low expression of HSP70 in the gastric mucosa and reduced gastric mucus thickness may play key roles in the mechanism of PUB in extreme cold climates. The significant decrease in barrier factors and increase in damage in extreme cold climates may be associated with the seasonal pattern of peptic ulcers.
    Experimental and therapeutic medicine 01/2015; 9(1):125-130. DOI:10.3892/etm.2014.2080 · 0.94 Impact Factor

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