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Clinical trials have shown that high-dose proton-pump inhibitors (PPIs), given after upper endoscopy in patients with bleeding peptic ulcers, reduce the incidence of rebleeding. But is there additional benefit from PPI therapy given before endoscopy?
To answer this question, researchers in Hong Kong randomized 638 patients admitted with upper gastrointestinal bleeding to receive IV omeprazole (80-mg bolus, followed by 8-mg/hr infusion) or placebo until endoscopy was performed the next morning. After endoscopy, all patients with peptic ulcers received PPI therapy. Hemodynamically unstable patients were excluded from the trial.
Peptic ulcer was the source of bleeding in 60% of patients. Among these patients, active bleeding was noted at endoscopy significantly less frequently among omeprazole recipients than among placebo recipients (6% vs. 15%), and endoscopic therapy (epinephrine and electrocoagulation) was required less often. The omeprazole group had a slightly shorter hospital stay than the placebo group (mean, 4.5 vs. 4.9 days), but there were no differences between groups in transfusion requirements, need for surgery, or incidence of recurrent bleeding.
Lau JY et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med 2007 Apr 19; 356:1631-40.
Comment
This trial corroborates the wisdom of what has already become the standard of care for patients with upper GI bleeding in the U.S. — initiation of a high-dose PPI while the patient awaits upper endoscopy. When endoscopy is performed within 24 hours, the main benefit of pre-endoscopy PPI therapy is a reduced need for endoscopic therapy.