Management of acute bleeding upper gastrointestinal ulcers in the era of endoscopic and intravenous proton pump inhibitor therapy

Section of Gastroenterology, University of Manitoba, St Boniface General Hospital, Winnipeg, Manitoba Correspondence: Dr Alexandra Ilnyckyj, St Boniface General Hospital, 409 Tache Avenue, Winnipeg, Manitoba R2H 2A6. Telephone 204-237-2796, fax 204-233-7154, e-mail ailnycky@sbgh.mb.ca Received for publication August 23, 2004. Accepted January 3, 2005 A Ilnyckyj, G Mathew. Management of acute bleeding upper gastrointestinal ulcers in the era of endoscopic and intravenous proton pump inhibitor therapy. Can J Gastroenterol 2005;19(3):157-159.

G astrointestinal bleeding (GIB) is an important indication for hospitalization.Upper GIB (UGIB) is five times more common than lower GIB (1,2).Despite advances in knowledge and therapy, contemporary data demonstrate rebleeding, surgical and mortality rates for UGIB to be 14.1%, 6.5% and 5.4%, respectively (3).These sobering statistics mandate a review of GIB management to ensure clinical practice reflects the best treatments available (4).

REVIEW OF GIB MANAGEMENT
Local therapy Endoscopic treatment is not required in clean-based ulcers (5)(6)(7).Intervention on lesions with active bleeding, a visible vessel or adherent clot should be undertaken.Treatment of active bleeding has been shown to be well treated with combination therapy of adrenaline injection (diluted with saline 1:10000) and thermal coagulation (8,9).However, in the treatment of lesions with a visible vessel, combination treatment has not been shown to be more effective than using thermal coagulation alone (8,9).There is ongoing debate regarding the ideal management of lesions with an adherent clot (10)(11)(12)(13).

Helicobacter pylori
All patients presenting with an ulcerative lesion of the upper GI tract should be examined for the presence of Helicobacter pylori infection.The most sensitive and specific testing is accomplished through histological examination of a gastric biopsy taken at the time of endoscopy.The sample can be tested for urease production if H pylori is not identified by the pathologist.A less desirable approach consists of measuring antibody levels against H pylori.All patients who test positive for H pylori in the setting of an acute ulcer presentation should receive eradicative therapy at some point.

AIM
The aim of the present study was to determine whether treatment of UGIB attributable to acute ulcers was consistent with contemporary management practices (4).

METHODS
There are two tertiary teaching hospitals in Winnipeg, Manitoba (population 750,000).Both centres have a dedicated GI bleed service which provides 24 h consultation and endoscopic intervention for patients presenting with acute GIB.The service is staffed by gastroenterologists and general surgeons.Patients presenting with GIB requiring hospitalization are admitted under the care of a clinical teaching unit, either medical or surgical.The GI bleed service functions in the capacity of a consultative team.
A retrospective chart review for a six-month period dated January to June 2002 was undertaken.International Classification of Diseases, Ninth Revision (ICD-9) (20) codes on patient discharge summaries were used by the medical records department to extract charts.The ICD-9 codes extracted included GI bleed (578), peptic ulcer disease (536), gastric ulcer (531) and duodenal ulcer (532).
Charts were reviewed by a senior GI Fellow and data were collected using a standardized method.The Fellow reviewed the entire hospital chart with specific attention to the GI bleed team consultation, the endoscopy report, emergency room record if present, doctors orders, chart notes made by the GI bleed team, medication records, discharge summary, discharge recommendations and pathology and microbiology reports.
To meet entry criteria, the endoscopy report had to document an acute gastric or duodenal ulcer as the source of the bleeding.Patients whose source of bleeding were diagnosed as a nonulcer source, multiple sources or unknown source were excluded.
The present review aimed to determine how the ulcer was treated with regard to the three issues relevant to the management of UGIB; specifically: • local treatment (source document: endoscopy report); • acid suppressive therapy (source documents: physician order sheets and drug administration sheets); and • H pylori testing and eradication (source documents: GI consultation record, pathology report, microbiology report, drug administration sheets, chart progress notes, discharge summary and discharge recommendations to primary care physician).
High-risk lesions were defined as lesions with adherent clot, visible vessel or actively bleeding ulcer.Low-risk lesions included clean-based ulcers or ulcers with heme stains.

RESULTS
Two hundred eighty charts were identified by medical records which fulfilled the previously stated ICD-9 codes during the study interval.A review of these charts identified 55 patients that met entry criteria; specifically, an acute GI bleed referred to the GI bleeding service which was attributable to a gastric or duodenal ulcer.Of the 55 patients, 42 were treated by a gastroenterologist and 13 by a surgeon.
Twenty-four of the 26 patients diagnosed with clean-based (low-risk) ulcers received no endoscopic intervention; two received endoscopic therapy (injection) (Table 1).Twentyfour of the 29 patients diagnosed with high-risk lesions were treated with injection therapy, which consisted of a variable dose of adrenaline diluted with saline 1:10000.Sixteen of 29 high-risk lesions were treated with electrical or thermal energy.Another two high-risk lesions were treated with a hemoclip.Two of the 29 patients diagnosed with high-risk lesions did not receive any endoscopic therapy (Table 1).
Eighteen of 55 patients (33%) had H pylori biopsies taken at the time of their endoscopy.An additional seven of 55 patients had H pylori addressed in some manner; either serological testing was obtained or recommended, or empirical antibiotic therapy was given or recommended in the future.Thirty of 55 patients (55%) presenting with an UGIB attributable to an upper GI ulcer did not have an H pylori biopsy obtained, serology requested or empirical therapy recommended.
Twenty-five of 29 patients with high-risk ulcers and five of 26 patients with low-risk ulcers received proton pump   inhibitor therapy intravenously (Table 2).The intravenous dosage was a bolus of 80 mg of pantoprazole followed by an intravenous infusion of 8 mg/h.The duration of the infusion was not reviewed.The all-cause mortality in the present study was 11% (six of 55 patients).All deaths occurred in patients who suffered with multiple medical comorbidities.The mean age of these six patients was 78 years.The mean time to death was 42 days after admission (range two to 115 days).

DISCUSSION
The present review overwhelmingly demonstrates that physicians are treating UGIB attributable to an acute ulcer appropriately with respect to local therapy and acid suppression.
Unfortunately, H pylori testing and treatment is not maximized.Failure to undertake biopsy acquisition for H pylori has been described by other workers (21).In this national database of 8000 patients with acute upper gastrointestinal ulcers, 33% did not have biopsies taken for H pylori.Of note, the database included only patients with nonbleeding acute ulcers, whereas all of our patients were presenting with bleeding ulcers.This may explain the higher rate of nonacquisition in our study.
The omission of H pylori biopsy acquisition is especially disappointing because eradication of H pylori is the greatest advancement in peptic ulcer disease management to date.We speculate that this may be attributable to compartmentalized care.During presentation, UGIB management is focused on volume repletion and stabilization of the patient.During endoscopy, local therapy is foremost; acquisition of the biopsy for H pylori may be undermined.The disparity between the national database review and our own data support this speculation.Thereafter, hospitalization may not afford opportunities to review the issues pertinent to UGIB.Either short or prolonged hospital stay may detract from the importance of H pylori testing and treatment if H pylori biopsy was not obtained during the gastroscopy.As well, fragmentation of care among the endoscopist, the admitting physician and the family physician may further contribute to omission of H pylori testing and treatment.

CONCLUSIONS
Despite the management of acute GIB by a dedicated bleed service, our review revealed significant weaknesses in the management of this common and costly disease.High-risk lesions are not uniformly treated with endoscopic interventions.Of greater magnitude is the failure in acquiring an H pylori biopsy, or undertaking serological testing or advising empirical therapy in those in whom biopsy was not obtained.Compartmentalization and fragmentation of care may contribute to oversight.Regardless, the GI bleed consultant must be vigilant to ensure H pylori status and treatment is addressed because the organism is integral to the pathogenesis of peptic ulcer disease.