Even without PPI, oozing peptic ulcers rarely rebleed after endoscopic hemostasis

Last Updated: 2017-02-15

By Lorraine L. Janeczko

NEW YORK (Reuters Health) – The rebleeding rate of oozing peptic ulcer bleeds (PUB) after successful endoscopic therapy is low, and 72 hours of IV proton pump inhibitor (PPI) does not lower the rate further, according to results of a large multinational randomized trial.

"After successful endoscopic hemostasis, patients with Forrest classification IB (FIB) - oozing - ulcers had very low PUB rebleeding rates, whether they were treated with PPI or placebo. This suggests that the prognostic classification of FIB ulcers as high-risk stigmata of recent hemorrhage (SRH) and the recommendation to treat them with high doses of intravenous PPIs after successful endoscopic hemostasis should be re-evaluated," lead author Dr. Dennis M. Jensen of the David Geffen School of Medicine at UCLA in Los Angeles, California told Reuters Health.

"Based upon the very low rebleeding rates after successful endoscopic therapy and the lack of additional benefits for PPIs, patients with Forrest IB PUBs may not need high-dose IV PPI therapy for 72 hours and prolonged hospital stays," he said in an email.

Using a dataset from a previously reported study (http://bit.ly/2liCbq2), Dr. Jensen and his colleagues evaluated the risk factors for early rebleeding after successful endoscopic hemostasis for FIB PUBs compared with other SRH.

As reported in American Journal of Gastroenterology, online January 17, they conducted post hoc multivariable analyses of 760 patients treated with either high-dose IV esomeprazole or placebo for 72 hours.

Among the 388 patients treated with placebo after successful endoscopic hemostasis, rebleeding rates by SRH were 22.5% with spurting arterial bleeding (FIA), 17.6% with adherent clot (FIIB), 11.3% with non-bleeding visible vessel (FIIA), and 4.9% with oozing bleeding (FIB).

Compared to patients with FIB, those with FIA, FIIB, and FIIA were at higher risk of rebleeding, with odds ratios ranging from 2.61 with FIIA to 6.66 with FIA. After hemostasis, at 72 hours, PUB rebleeding rates for FIB patients were 5.4% with esomeprazole and 4.9% with placebo. But rebleeding rates for FIA, FIIA and FIIB were lower for PPI than for placebo. The result of the treatment by SRH interaction test was not significant.

Dr. Irving Waxman of the University of Chicago Medicine Center for Care and Discovery, said in an email, "For daily clinical practice, these findings are important given that they provide information as to how to triage and manage patients who are identified with SRH FIB during endoscopy."

"For example," said Dr. Waxman, who was not involved in the study, "we could extrapolate that the very low rebleeding rate after endoscopic therapy could reduce the need for ICU observation or shorten hospitalization and save costs by avoiding IV PPIs, which are currently being used routinely for this group of patients."

"The only caveat here is that the study comes from expert centers in the endoscopic evaluation and treatment of PUB," Dr. Waxman noted. "It remains to be seen if general gastroenterologists will adopt this new change in their management algorithm and how confident the endoscopists will be in their endoscopic evaluation and classification of the SRH as well as the endoscopic hemostasis they perform."

Dr. Deborah A. Fisher of Duke University in Durham, North Carolina, said in an email that the study has significant implications for clinical care and research.

"In general, use of PPI has been questioned because of increasing reports of associations with side effects after chronic use. While this study looked at short-term acute use, avoiding a medication that has no benefit is critical for optimal patient care as it decreases the risk and cost of care," she noted.

"For research, the study clearly shows that for study design and analysis, combining spurting PUB (i.e., Forrest 1A) and oozing PUB (i.e., Forrest 1B) is inappropriate because the rebleeding rates and response to IV PPI are significantly different," added Dr. Fisher, who also was not involved in the study.

Astra-Zeneca and grants from the Veterans Administration and National Institutes of Health funded the study.

SOURCE: http://bit.ly/2kr80x2

Am J Gastroenterol 2017.