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Clinical Question:
Do certain subgroups of patients with bleeding peptic ulcer benefit more
from proton pump inhibitors than others?
Bottom Line:
Combination of endotherapy with either PPIs or H2RAs is indicated for
nonbleeding ulcers at endoscopy with the intent to reduce rebleeding and
surgery. Its value may extend to bleeding lesions, but current data are
scanty. The benefit appears to be independent from route and doses of PPIs,
as oral, bolus, or infusional methods are all effective.
Reference:
Andriulli A, Annese V, Caruso N, et al. Proton-pump inhibitors and outcome
of endoscopic hemostasis in bleeding peptic ulcers: a series of
meta-analyses. Am J Gastroenterol 2005; 100:207-19.
Study Design:
Meta-analysis (randomized controlled trials)
Setting:
Inpatient
Synopsis:
The author perform meta-analyses of studies on outcome of bleeding ulcers of
different proton-pump inhibitors (PPIs) regimens, after stratification of
patients by endoscopic stigmata, and analysis of studies with and without
endotherapy. A total of 35 randomized trials comparing PPIs to placebo
and/or H2-receptor antagonists (H2RAs) in 4,843 patients with high-risk
endoscopic stigmata were retrieved. Outcomes were rebleeding, surgery, and
mortality. Monotherapy with oral or bolus PPIs was superior to placebo and
H2RAs in reducing rebleeding in both bleeders and nonbleeders at index
endoscopy; the need for surgery was reduced only when compared to H2RAs. In
nonbleeders, PPI monotherapy was as effective as a combination of
endotherapy with H2RAs. A combination of endotherapy with PPIs was superior
to monotherapy in reducing bleeding and surgery, and superior to endotherapy
alone in minimizing rebleeding, but not surgery; the benefit was lost when
confronted to endotherapy plus H2RAs, whether PPIs were given as infusion or
bolus. By pooling data from studies comparing high doses of PPIs as
continuous infusion versus regular doses as intermittent bolus, rebleeding,
surgery, and mortality were not significantly different. |