The Treatment and Risk Factors of Peptic Ulcer Bleeding

The incidence of acute upper gastrointestinal bleeding has been 100/100000 inhabitants in Western countries. Peptic ulcer bleeding (PUB) was the source of bleeding in 50% of these cases. The incidence of non-complicated peptic ulcer has decreased while that of PUB has increased. The mortality of bleeding patients has not significantly decreased despite new therapeutic options. Controversial results in few studies concerning the medical treatment of PUB after endoscopic treatment complicates sound clinical decision making in patient care. Furthermore, the risk profile of these patients and the impact of treatment on H.pylori have been studied seldom, especially in Finnish patients. The significance of gastric acid inhibition following successful endoscopic therapy in preventing rebleeding and reducing mortality in PUB was studied by testing the equivalence of a regular dose (20 mg once a day for 72 hours, n = 73) and a high dose of omeprazole (80 mg bolus + 8 mg/h for 72 hours, n = 69) in a prospective randomised double blind trial. Both doses were equally effective based on rebleeding rates, need of emergency surgery and mortality. The factors associated with rebleeding were shock on admission and duodenal ulcer (DU). In PUB an intragastric pH-level > 4 is considered necessary to prevent dissolving of the formed fibrin clot. Therefore, intragastric pH monitoring for 72 hours was performed in 7 of patients of the regular and 6 of the high dose group. The regular dose of omeprazole raised both mean and median 24-hour intragastric pH > 4 in patients with PUB. This reduction in the acidity together with endoscopic therapy is probably sufficient to maintain haemostasis. The high dose kept the pH almost constantly > 6. A case-control study of PUB patients (n = 94) and controls (n = 94) of age ( 5 years) and sex matched non-ulcer patients attending elective endoscopy was undertaken to analyse risk factors for PUB. A questionnaire concerning possible risk factors was completed. H.pylori was determined positive if histology and/or urease test were positive. CagA antibodies of IgG class of H.pylori were determined by an immunoblot method. H.pylori infection, the use of ASA, other NSAIDs with 1 defined daily doses, smoking 20 cigarettes daily and previous DU were independent risk factors for PUB. Two of them were present simultaneously in 2/3 of the patients. However, the combination of risk factors did not increase the risk. Of H.pylori positive subjects, 97% of the cases and 96% of the controls had CagA strains. ASA, ibuprofen, ketoprofen and smoking had a dose-dependent association with PUB. The effect of a 3-day treatment of omeprazole on the colonisation of H.pylori in the stomach was studied in patients with PUB. H.pylori status was assessed by histology and urease test of gastric biopsies at pre-entry and after 3 days of therapy in 51 patients receiving the regular dose and in 50 patients receiving the high dose of omeprazole. A marked disappearance of H.pylori was found with both regimens, but with the high dose, tests for the diagnosis of H.pylori became negative significantly more often than with the regular dose, 60% vs. 27.5%, p = 0.001 (any test), 67.6% vs. 31.7%, p = 0.003 (histology) and 82.2% vs. 43.6%, p = 0.001 (urease test). Samples to find H.pylori should be taken before any omeprazole treatment, or the presence of the bacteria may be overlooked. National Library of Medicine Classification: QV 69, QV 95, QW 154, WI 141, WI 350, WI 360, WI 370 Medical subject headings: Anti-Inflammatory Agents, Non-Steroidal; Anti-Ulcer Agents; Aspirin; Double-Blind Method; Duodenal Ulcer; Endoscopy, Digestive System; Helicobacter pylori; Mortality; Omeprazole; Peptic Ulcer Hemorrhage/drug therapy; Peptic Ulcer Hemorrhage/prevention and control; Prospective Studies; Randomized Controlled Trials; Risk factors; Smoking; Stomach Ulcer/complications; Warfarin To Jouko, Maria, Annmari and Max