How to Administer IV Omeprazole for Ulcer Bleeding
For bleeding peptic ulcers after successful endoscopic hemostasis, administer omeprazole as an 80 mg IV bolus followed by 8 mg/hour continuous infusion for exactly 72 hours. 1
Initial Dosing Protocol
Start PPI therapy as soon as possible, even before endoscopy, to potentially reduce stigmata of recent bleeding and the need for endoscopic therapy. 2, 1 However, do not delay urgent endoscopic intervention—PPIs are adjunctive therapy, not a replacement for endoscopy in active bleeding. 2, 1
The High-Dose Regimen
- Loading dose: 80 mg IV bolus 1
- Maintenance infusion: 8 mg/hour continuous IV infusion 1
- Duration: Continue for exactly 72 hours after successful endoscopic hemostasis 2, 1
This high-dose regimen is superior to standard dosing. A randomized controlled trial demonstrated that high-dose omeprazole (80 mg bolus + 8 mg/hour) significantly reduced rebleeding compared to standard-dose omeprazole (40 mg daily), with rebleeding rates of 3% vs. 16% respectively. 3 The high-dose regimen also reduced mortality from hemorrhagic shock (0% vs. 11%) and need for surgery (1% vs. 9%). 4
Physiologic Rationale
Blood clot stability requires a gastric pH above 6 for platelet aggregation, while clot lysis occurs when pH drops below 6. 1 The 80 mg bolus followed by 8 mg/hour infusion maintains intragastric pH above 6 consistently for 72 hours, which is necessary for hemostasis and clot stability. 5, 6 Standard-dose regimens fail to maintain this pH threshold reliably. 6
Transition to Oral Therapy
After completing the 72-hour IV infusion:
- Transition to oral omeprazole 40 mg twice daily for days 4-14 1
- Then reduce to 40 mg once daily from day 15 onward 1
- Continue oral PPI therapy for 6-8 weeks total to allow complete mucosal healing 2, 1
Long-Term Management
Long-term PPI therapy beyond 6-8 weeks is NOT recommended unless the patient has ongoing NSAID use. 2, 1
Essential Additional Steps
- Test all patients for H. pylori infection and provide eradication therapy if positive 2, 1
- Discontinue NSAIDs when possible 7
- Failure to eradicate H. pylori leads to rebleeding rates of 40-50% over 10 years 7
Pre-Endoscopy Adjuncts
Consider administering erythromycin before endoscopy to enhance gastric visualization and reduce the need for repeat endoscopy. 2, 7 This improves viewing but does not impact mortality or surgical intervention rates. 2
Critical Pitfalls to Avoid
- Never discontinue PPI therapy before 6-8 weeks—this prevents adequate mucosal healing 1, 7
- Never rely solely on PPI therapy without endoscopic intervention in active bleeding 2, 1, 7
- Never use lower-dose regimens in high-risk patients (those with Forrest Ia, Ib, IIa, or IIb lesions)—the mortality benefit is seen only with high-dose continuous infusion 1
- Never reduce the infusion rate during the 72-hour period—dose reduction to 4 mg/hour or 2 mg/hour results in suboptimal pH control 5
Evidence Quality
The World Society of Emergency Surgery guidelines (2020) provide the framework for this approach, with a strong recommendation (1B) for 6-8 week PPI therapy and weak recommendation (2B) for the high-dose 72-hour infusion. 2 The American College of Gastroenterology and American College of Physicians support the 80 mg bolus + 8 mg/hour × 72 hours protocol. 1 This regimen reduces rebleeding (5.9% vs. 10.3%), need for surgery, and mortality compared to placebo or lower doses. 2