What is the best management for a patient with a bleeding peptic ulcer, particularly one with a history of nonsteroidal anti-inflammatory drug (NSAID) use, such as aspirin?

Management of Bleeding Peptic Ulcer in Aspirin-Related Disease

For a middle-aged man with aspirin-induced peptic ulcer bleeding that has stopped, the best management is high-dose intravenous PPI therapy: 80 mg bolus pre-endoscopy followed by continuous infusion of 8 mg/hour for 72 hours, then transition to high-dose oral PPI (Option D). This approach significantly reduces rebleeding, need for surgery, and mortality compared to other regimens.

Immediate Pharmacologic Management

Start intravenous PPI therapy immediately upon presentation, before endoscopy. 1, 2

• Pre-endoscopic PPI therapy downstages the lesion and reduces the proportion of patients requiring endoscopic intervention at index endoscopy 1
• However, PPI administration should not delay urgent endoscopy in actively bleeding patients 1

Endoscopic Evaluation and Treatment

Perform endoscopy within 24 hours of presentation to assess bleeding stigmata and provide therapeutic intervention if needed. 1, 2

• Endoscopic hemostasis is indicated for high-risk stigmata including active bleeding (Forrest 1a, 1b) or visible vessel (Forrest 2a) 1
• Use combination therapy with thermocoagulation or clips plus epinephrine injection rather than epinephrine alone 1, 2

Post-Endoscopic PPI Regimen

After successful endoscopic hemostasis for high-risk lesions, administer the following PPI protocol: 1, 3

1. 80 mg intravenous bolus (if not already given pre-endoscopy)
2. 8 mg/hour continuous infusion for 72 hours
3. Transition to high-dose oral PPI (typically 40 mg twice daily) for 6-8 weeks

This high-dose regimen (80 mg bolus + 8 mg/h infusion) significantly reduces rebleeding rates (5.9% vs 10.3%, p=0.03) and need for surgical intervention compared to placebo. 1, 3 The continuous infusion maintains gastric pH ≥6, which is critical for clot stabilization and prevention of pepsin-mediated clot lysis. 3

Why This Regimen Over Others:

• Option A (High-dose oral PPI BID): While oral PPIs are effective for ulcer healing, they do not achieve the rapid and sustained acid suppression needed in the acute bleeding phase 4
• Option B (IV PPI 24 hours then oral): Insufficient duration; rebleeding risk remains elevated beyond 24 hours 1
• Option C (IV PPI 48 hours then oral): Better than 24 hours but still suboptimal; the 72-hour window is evidence-based for high-risk lesions 1

Hospitalization Duration

High-risk patients should remain hospitalized for at least 72 hours after endoscopic hemostasis to monitor for rebleeding, which typically occurs within this timeframe. 1, 2

Critical Follow-Up Management

Aspirin Management

For this patient requiring aspirin for cardiovascular protection, restart aspirin within 5-7 days after the bleeding episode once hemostasis is confirmed. 1, 5

• Early aspirin reintroduction (within 5 days) is associated with lower 30-day cardiovascular and overall mortality despite a small increase in rebleeding risk 5
• Continue aspirin with long-term PPI co-therapy to prevent recurrent bleeding 1

Helicobacter pylori Testing

Test all patients for H. pylori and provide eradication therapy if positive, with confirmation of eradication. 1, 2

• H. pylori eradication dramatically reduces rebleeding rates in peptic ulcer disease 1
• Even in NSAID/aspirin-related ulcers, many centers advocate H. pylori eradication 1

Long-Term PPI Therapy

Continue PPI therapy long-term (beyond the initial 6-8 weeks) given ongoing aspirin use. 1

• Patients with history of upper GI bleeding who require ongoing aspirin therapy should receive indefinite PPI gastroprotection 1
• The combination of aspirin plus PPI is superior to clopidogrel alone for preventing recurrent bleeding 1

Common Pitfalls to Avoid

• Do not use H2-receptor antagonists instead of PPIs in this high-risk scenario; PPIs provide superior acid suppression and better outcomes 1
• Do not use epinephrine injection monotherapy for endoscopic hemostasis; always combine with thermal coagulation or clips 1
• Do not discontinue aspirin indefinitely in patients requiring secondary cardiovascular prevention; the cardiovascular risks outweigh GI risks after initial stabilization 1, 5
• Do not use standard-dose or intermittent PPI dosing in the acute phase; continuous high-dose infusion is required for optimal outcomes 1, 3