Update
4/24/2007: Hot Topic: Management of Upper Gastrointestinal Bleeding: The Use of Omeprazole Before Endoscopy
Kurt J. Isselbacher
Distinguished Mallinckrodt Professor of Medicine, Harvard Medical School; Physician and Director, Massachusetts General Hospital Cancer Center, Boston
Related To: Chapter 272. Gastrointestinal Endoscopy; Chapter 274. Peptic Ulcer Disease and Related Disorders; Chapter 55. Disorders of Granulocytes and Monocytes
View in chapter
In patients with bleeding peptic ulcers, it has been shown that infusion of a high-dose proton pump inhibitor after hemostasis has been achieved during endoscopy reduces recurrent bleeding and improves clinical outcome. Since clot formation over arteries is dependent on pH, it is believed that a gastric pH > 6 may be critical to facilitate platelet aggregation. When given intravenously and at a high dose, proton pump inhibitors can be used to maintain a neutral gastric pH.
Treatment with proton pump inhibitors has often been initiated before endoscopy in patients presenting with upper GI bleeding. However, to date there has been lack of evidence to support this approach. Therefore, Lau and his colleagues in Hong Kong (2007) instituted a study to evaluate the preemptive infusion of omeprazole before endoscopy on the need for subsequent endoscopic therapy. Over 600 patients were enrolled and randomly assigned to omeprazole or placebo. They found the need for endoscopic treatment was lower in the omeprazole group (19.1% vs. 28.4%); but there were no differences between the two groups in the amount of blood transfused, in the number of patients who had recurrent bleeding or who underwent emergency surgery or who died within 30 days. The hospital stay was less than 3 days in 60% of patients in the omeprazole group compared with 49% in the placebo group. Also, fewer patients in the omeprazole group had actively bleeding ulcers and more of them had ulcers with clean bases.
There were some limitations to this study. There was no exclusion of long-term aspirin users who had coexisting cardiovascular problems. Furthermore, these observations may not be applicable to areas in the world with a higher prevalence of variceal bleeding than seen in Hong Kong where the incidence is approximately 60%.
In summary, these findings do not suggest that high-dose proton pump inhibitor infusions should replace early endoscopy in patients with upper GI bleeding. However, in patients awaiting endoscopy, the preemptive use of high-dose intravenous omeprazole should be considered.
Reference
Lau JY et al: Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med 356:1631, 2007 [PMID: 17442905]
4/24/2007: Hot Topic: Management of Upper Gastrointestinal Bleeding: The Use of Omeprazole Before Endoscopy
Kurt J. Isselbacher
Distinguished Mallinckrodt Professor of Medicine, Harvard Medical School; Physician and Director, Massachusetts General Hospital Cancer Center, Boston
Related To: Chapter 272. Gastrointestinal Endoscopy; Chapter 274. Peptic Ulcer Disease and Related Disorders; Chapter 55. Disorders of Granulocytes and Monocytes
View in chapter
In patients with bleeding peptic ulcers, it has been shown that infusion of a high-dose proton pump inhibitor after hemostasis has been achieved during endoscopy reduces recurrent bleeding and improves clinical outcome. Since clot formation over arteries is dependent on pH, it is believed that a gastric pH > 6 may be critical to facilitate platelet aggregation. When given intravenously and at a high dose, proton pump inhibitors can be used to maintain a neutral gastric pH.
Treatment with proton pump inhibitors has often been initiated before endoscopy in patients presenting with upper GI bleeding. However, to date there has been lack of evidence to support this approach. Therefore, Lau and his colleagues in Hong Kong (2007) instituted a study to evaluate the preemptive infusion of omeprazole before endoscopy on the need for subsequent endoscopic therapy. Over 600 patients were enrolled and randomly assigned to omeprazole or placebo. They found the need for endoscopic treatment was lower in the omeprazole group (19.1% vs. 28.4%); but there were no differences between the two groups in the amount of blood transfused, in the number of patients who had recurrent bleeding or who underwent emergency surgery or who died within 30 days. The hospital stay was less than 3 days in 60% of patients in the omeprazole group compared with 49% in the placebo group. Also, fewer patients in the omeprazole group had actively bleeding ulcers and more of them had ulcers with clean bases.
There were some limitations to this study. There was no exclusion of long-term aspirin users who had coexisting cardiovascular problems. Furthermore, these observations may not be applicable to areas in the world with a higher prevalence of variceal bleeding than seen in Hong Kong where the incidence is approximately 60%.
In summary, these findings do not suggest that high-dose proton pump inhibitor infusions should replace early endoscopy in patients with upper GI bleeding. However, in patients awaiting endoscopy, the preemptive use of high-dose intravenous omeprazole should be considered.
Reference
Lau JY et al: Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med 356:1631, 2007 [PMID: 17442905]
全站熱搜
留言列表
網誌文章精美卻不完整的白爛目錄 (10)
