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Managing acute upper GI bleeding, preventing recurrences

Cleveland Clinic Journal of Medicine. 2010 February;77(2):131-142 | 10.3949/ccjm.77a.09035
February 1, 2010|Cleveland Clinic Journal of Medicine
Mazen Albeldawi, MD;Mohammed A. Qadeer, MD, MPH;John J. Vargo, MD, MPH
Author and Disclosure Information

Mazen Albeldawi, MD
Department of Internal Medicine, Cleveland Clinic

Mohammed A. Qadeer, MD, MPH
Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic

John J. Vargo, MD, MPH
Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic

Address: John J. Vargo, MD, MPH, Department of Gastroenterology and Hepatology, A30, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail: vargoj@ccf.org

Dr. Vargo has disclosed that he has received consulting fees from Ethicon EndoSurgery and honoraria for teaching and speaking from Olympus America, Inc.

ABSTRACTAcute upper gastrointestinal (GI) bleeding is common and potentially life-threatening and needs a prompt assessment and aggressive medical management. All patients need to undergo endoscopy to diagnose, assess, and possibly treat any underlying lesion. In addition, patients found to have bleeding ulcers should receive a proton pump inhibitor, the dosage and duration of treatment depending on the endoscopic findings and clinical factors.

KEY POINTS

  • The first priority is to ensure that the patient is hemodynamically stable, which often requires admission to the intensive care unit for monitoring and fluid resuscitation.
  • Peptic ulcers account for most cases of upper GI bleeding, but bleeding from varices has a much higher case-fatality rate and always demands aggressive treatment.
  • Patients with ulcer disease should be tested and treated for Helicobacter pylori infection.
  • Patients with a history of bleeding ulcers who need long-term treatment with aspirin or a nonsteroidal anti-inflammatory drug should also be prescribed a proton pump inhibitor.

TREATMENT AND PREVENTION OF NSAID-RELATED GI INJURY

About 1 in 20 users of NSAIDs develop GI complications and ulcers of varying degrees of severity, as do one in seven NSAID users over the age of 65. In fact, NSAID use accounts for 30% of hospitalizations for upper GI bleeding and deaths from this cause.82–85 In addition, approximately 15% to 30% of NSAID users have clinically silent but endoscopically evident peptic ulcers.86

NSAIDs contribute to ulcer development by depleting prostaglandins. Thus, misoprostol (Cytotec), a synthetic prostaglandin, has been used to reduce this side effect.

In a clinical trial, misoprostol reduced the incidence of NSAID-associated GI complications by 40%.87 Furthermore, it has been shown to be better than placebo in preventing recurrent gastric ulcers in patients with a history of gastric ulcer who were receiving low-dose aspirin.88

However, misoprostol is rarely used because it can cause diarrhea and abdominal cramping. Rather, the preferred drugs for preventing and treating NSAID- and aspirin-related GI lesions are proton pump inhibitors.

Numerous clinical trials using endoscopic end points showed that proton pump inhibitors in standard doses significantly reduce the incidence of ulcers associated with the use of NSAIDs.89 Proton pump inhibitor therapy has achieved a significant reduction in relative risk of upper GI bleeding in patients who received low-dose aspirin therapy, as confirmed by epidemiologic studies.90,91 The number of NSAID-related ulcers found on endoscopy could be reduced by an estimated 90% simply by using proton pump inhibitors.92

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