15-24: Complications of Peptic Ulcer Disease

1. GI HEMORRHAGE

General Considerations

Approximately 50% of all episodes of upper GI bleeding are due to peptic ulcer. Clinically significant bleeding occurs in 10% of ulcer patients. About 80% of patients stop bleeding spontaneously and generally have an uneventful recovery; the remaining 20% have more severe bleeding. The overall mortality rate for ulcer bleeding is 7%, but it is higher in older patients, in patients with comorbid medical problems, and in patients with hospital-associated bleeding. Mortality is also higher in patients who present with persistent hypotension or shock, bright red blood in the vomitus or nasogastric lavage fluid, or severe coagulopathy.

Clinical Findings

A. Symptoms and Signs

Up to 20% of patients have no antecedent symptoms of pain; this is particularly true of patients receiving NSAIDs. Common presenting signs include melena and hematemesis. Massive upper GI bleeding or rapid GI transit may result in hematochezia rather than melena; this may be misinterpreted as signifying a lower tract bleeding source. Nasogastric lavage that demonstrates “coffee grounds” or bright red blood confirms an upper tract source. Recovered nasogastric lavage fluid that is negative for blood does not exclude active bleeding from a duodenal ulcer.

B. Laboratory Findings

The hematocrit may fall as a result of bleeding or expansion of the intravascular volume with intravenous fluids. The BUN may rise as a result of absorption of blood nitrogen from the small intestine and prerenal azotemia.

Treatment

The assessment and initial management of upper GI tract bleeding are discussed above. Specific issues pertaining to peptic ulcer bleeding are described below.

A. Medical Therapy

1. Antisecretory agents

Intravenous PPIs should be administered for 3 days in patients with ulcers whose endoscopic appearance suggests a high risk of rebleeding after endoscopic therapy. Intravenous PPIs have been associated with a reduction in rebleeding, transfusions, need for further endoscopic therapy, and surgery in the subset of patients with high-risk ulcers, ie, an ulcer with active bleeding, visible vessel, or adherent clot. After initial successful endoscopic treatment of ulcer hemorrhage, intravenous esomeprazole, pantoprazole, or omeprazole (80 mg bolus injection, followed by 8 mg/hour continuous infusion for 72 hours) reduces the rebleeding rate from approximately 20% to less than 10%; however, intravenous omeprazole is not available in the United States.