Observation
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World J Gastrointest Surg. Jan 27, 2010; 2(1): 9-13
Published online Jan 27, 2010. doi: 10.4240/wjgs.v2.i1.9
How evidence-based are current guidelines for managing patients with peptic ulcer bleeding?
Angelo Andriulli, Antonio Merla, Fabrizio Bossa, Marco Gentile, Giuseppe Biscaglia, Nazario Caruso
Angelo Andriulli, Antonio Merla, Fabrizio Bossa, Marco Gentile, Giuseppe Biscaglia, Nazario Caruso, Division of Gastroenterology, “Casa Sollievo Sofferenza” Hospital, IRCCS, viale Cappuccini 1, 71013 San Giovanni Rotondo, Italy
Author contributions: Andriulli A, Merla A and Caruso N were responsible for the literature review and the initial draft; Andriulli A, Bossa F, Gentile M and Biscaglia G prepared the final version of the manuscript.
Correspondence to: Angelo Andriulli, MD, Division of Gastroenterology, “Casa Sollievo Sofferenza” Hospital, IRCCS, viale Cappuccini 1, 71013 San Giovanni Rotondo, Italy. a.andriulli@operapadrepio.it
Telephone: +39-882-410263 Fax: +39-882-411879
Received: November 3, 2009
Revised: December 17, 2009
Accepted: December 24, 2009
Published online: January 27, 2010
Abstract

Current guidelines for managing ulcer bleeding state that patients with major stigmata should be managed by dual endoscopic therapy (injection with epinephrine plus a thermal or mechanical modality) followed by a high dose intravenous infusion of proton pump inhibitors (PPIs). This paper aims to review and critically evaluate evidence supporting the purported superiority of a continuous infusion over less intensive regimens of PPIs administration and the need for adding a second hemostatic endoscopic procedure to epinephrine injection. Systematic searches of PubMed, EMBASE and the Cochrane library were performed. There is strong evidence for an incremental benefit of PPIs over H2-receptor antagonists or placebo for the outcome of patients with peptic ulcer bleeding following endoscopic hemostasis. However, the benefit of PPIs is unrelated to either the dosage (intensive vs standard regimen) or the route of administration (intravenous vs oral). There is significant heterogeneity among the 15 studies that compared epinephrine with epinephrine plus a second modality, which might preclude the validity of reported summary estimates. Studies without second look endoscopy plus re-treatment of re-bleeding lesions showed a significant benefit of adding a second endoscopic modality for hemostasis, while studies with second-look and re-treatment showed equal efficacy between endoscopic mono and dual therapy. Inconclusive experimental evidence supports the current recommendation of the use of dual endoscopic hemostatic means and infusion of high-dose PPIs as standard therapy for patients with bleeding peptic ulcers. Presently, the combination of epinephrine monotherapy with standard doses of PPIs constitutes an appropriate treatment for the majority of patients.

Keywords: Guidelines; Ulcer bleeding; Peptic ulcer; Endoscopic therapy; Pharmacotherapy; Proton pump inhibitors