From the Guidelines
Proton pump inhibitors (PPIs) are indicated in suspected upper gastrointestinal bleeding, particularly for patients who are bleeding uncontrollably while awaiting endoscopy or for those with nonvariceal bleeding who are awaiting surgery or for whom surgery is contraindicated. For patients with suspected upper GI bleeding, immediate PPI therapy should be initiated with high-dose intravenous options such as pantoprazole, esomeprazole, or omeprazole at 80mg IV bolus followed by 8mg/hour continuous infusion for 72 hours, or alternatively, 40mg IV twice daily, as supported by the consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding 1. This therapy should be started alongside arrangements for urgent endoscopy, ideally within 24 hours. PPIs work by reducing gastric acid production, which helps stabilize blood clots and reduces rebleeding risk. They create a less acidic environment that promotes platelet aggregation and clot formation at bleeding sites. While PPIs don't stop active bleeding, they improve outcomes by reducing rebleeding rates, decreasing the need for surgical intervention, and potentially lowering mortality, especially in high-risk patients with active bleeding or visible vessels, as demonstrated by four randomized trials and two recent meta-analyses 1.
Key points to consider in the management of suspected upper GI bleeding with PPIs include:
- Initiating high-dose intravenous PPI therapy as soon as possible
- Arranging for urgent endoscopy within 24 hours
- Transitioning to oral PPI therapy after initial management, typically 40mg daily for 4-8 weeks
- The duration of PPI therapy depending on the underlying cause of bleeding and findings during endoscopy
- The favorable safety profile of PPIs in the acute setting, making them a useful therapy for patients who are bleeding uncontrollably or awaiting surgery 1.
In terms of specific patient populations, PPI therapy is particularly beneficial for patients with high-risk stigmata following endoscopic therapy, as it has been shown to decrease rebleeding and reduce the need for surgery compared with H2-receptor antagonists or placebo 1. Additionally, PPIs may also reduce mortality rates in these high-risk patients, as demonstrated by the McGill University meta-analyses 1. Overall, the use of PPIs in suspected upper GI bleeding is supported by strong evidence and should be considered a key component of management, particularly in high-risk patients.
From the Research
Indications for PPI in Suspected Upper Gastrointestinal Bleed
- PPIs are often used before endoscopy in suspected upper gastrointestinal bleed and maintained, regardless of endoscopic findings, after the endoscopy in many centers 2.
- The use of PPIs prior to endoscopy in upper GI bleeding may reduce the need for endoscopic haemostatic treatment at index endoscopy, but there is insufficient evidence to conclude whether pre-endoscopic PPI treatment increases, reduces or has no effect on other clinical outcomes, including mortality, rebleeding and need for surgery 3.
- PPIs as medical therapy are an attractive adjuvant to endoscopic treatment in UGIB, but the method and dose of PPI therapy remains controversial 4.
Management of Acute Upper Gastrointestinal Bleed
- Patients with suspected upper GI bleeding should receive intravenous fluids as needed for resuscitation and red cell transfusion at a hemoglobin threshold of 70-80 g/L, and PPIs may be administered after resuscitation is initiated 5.
- Endoscopy should be undertaken within 24 hours, with earlier endoscopy considered after resuscitation in patients at high risk, and patients who require endoscopic therapy for ulcer bleeding should receive high dose PPIs after endoscopy 5.
- Current evidence-based updates concerning UGIB for emergency clinicians include the use of PPIs, prokinetic agents, and vasoactive medications, and endoscopy is the diagnostic and therapeutic modality of choice 6.