What is the treatment for gastric ulcer bleeding?

Treatment for Gastric Ulcer Bleeding

Endoscopy is the first recommended diagnostic and therapeutic tool for gastric ulcer bleeding, followed by high-dose proton pump inhibitor therapy and addressing underlying causes. 1

Initial Assessment and Resuscitation

• Hemodynamic stabilization:

  • Maintain hemoglobin level >7 g/dL 1
  • Fluid resuscitation to achieve systolic blood pressure of 90-100 mmHg 1
  • Monitor vital signs, urine output, and lactate levels

• Pre-endoscopic management:

  • Start PPI therapy as soon as possible 1
  • Consider administering erythromycin before endoscopy to improve visualization 1

Endoscopic Management

Timing of Endoscopy

• Urgent endoscopy (≤12 hours) for high-risk patients with active bleeding or hemodynamic instability 1
• Early endoscopy (≤24 hours) for stable patients 1

Endoscopic Treatment Based on Forrest Classification

1. Active bleeding (Forrest Ia - spurting, Ib - oozing):

   • Dual modality endoscopic therapy recommended 1
   • Combination of injection therapy (adrenaline) plus thermal or mechanical method 1

2. Non-bleeding visible vessel (Forrest IIa):

   • Endoscopic therapy strongly recommended 1
   • Options include thermal methods (heater probe, BICAP), mechanical clips, or combination therapy 1

3. Adherent clot (Forrest IIb):

   • Consider endoscopic therapy after clot removal 1

4. Flat spots or clean base (Forrest IIc, III):

   • No endoscopic therapy required 1

Post-Endoscopic Management

Pharmacological Therapy

• High-dose PPI therapy:

  • 80 mg IV bolus followed by continuous infusion of 8 mg/hour for 72 hours after successful endoscopic hemostasis 1, 2
  • This regimen significantly reduces rebleeding rates, need for surgery, and mortality 1

• Maintenance therapy:

  • Continue PPI for 6-8 weeks to allow complete mucosal healing 1
  • Long-term PPI only indicated if ongoing NSAID use or H. pylori infection 1

Management of Recurrent Bleeding

1. Repeat endoscopy as first-line treatment 1
2. Angioembolization if endoscopic therapy fails and patient is stable 1
3. Surgical intervention if bleeding persists despite endoscopic and angiographic attempts 1

Addressing Underlying Causes

• H. pylori eradication if positive (test all patients with gastric ulcer bleeding) 1
• Discontinue NSAIDs if possible 1
• Biopsy the ulcer to exclude malignancy 1

Special Considerations

• Patients with comorbidities have higher risk of rebleeding and may benefit from extended PPI therapy 3
• Patients requiring antithrombotic agents should have these medications reintroduced early after bleeding is controlled (typically within 7 days for aspirin in patients with cardiovascular disease) 4, 5

Common Pitfalls to Avoid

1. Delaying endoscopy in unstable patients with ongoing bleeding 1
2. Inadequate PPI dosing - intermittent bolus or oral administration fails to maintain intragastric pH ≥6, which is necessary for clot stability 6
3. Missing underlying malignancy - always biopsy gastric ulcers 1
4. Neglecting H. pylori testing and eradication, which is essential for preventing recurrence 1
5. Premature discontinuation of PPI therapy before complete healing occurs 1

The combination of prompt endoscopic intervention and high-dose PPI therapy represents the cornerstone of management for gastric ulcer bleeding, with significant improvements in patient outcomes when properly implemented.