Omeprazol Drip for Gastrointestinal Bleeding
For patients with non-variceal upper gastrointestinal bleeding and high-risk endoscopic stigmata (active bleeding, visible vessel, or adherent clot) who undergo successful endoscopic hemostasis, administer omeprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for exactly 72 hours. 1
Dosing Protocol
Initial bolus: 80 mg omeprazole IV administered immediately after successful endoscopic hemostasis 2, 1
Continuous infusion: 8 mg/hour for exactly 72 hours following the bolus 2, 1
Transition to oral therapy: After completing the 72-hour infusion, switch to oral omeprazole 40 mg twice daily for days 4-14, then 40 mg once daily from day 15 onward 1, 3
Total duration: Continue oral PPI therapy for 6-8 weeks total to allow complete mucosal healing 2, 1
Evidence Supporting High-Dose Continuous Infusion
The high-dose continuous infusion regimen significantly reduces critical outcomes compared to placebo or H2-receptor antagonists:
- Mortality reduction: OR 0.56 (95% CI 0.34-0.94) 1, 3
- Rebleeding reduction: OR 0.43 (95% CI 0.29-0.63), with rates dropping from 10.3% to 5.9% 2, 1
- Decreased need for surgery and endoscopic retreatment 2
- Reduced transfusion requirements and shorter hospital stays 1, 3
The World Society of Emergency Surgery (2020) provides a moderate-quality evidence base (Grade 2B) for this recommendation, while the American College of Gastroenterology and American College of Physicians provide the strongest guideline support 2, 1
Physiologic Rationale
The continuous high-dose infusion is necessary because clot stability requires maintaining gastric pH >6 for platelet aggregation, while clot lysis occurs when pH drops below 6 1, 3. High-dose PPIs achieve this pH threshold more effectively than H2-receptor antagonists 2, 1. The 8 mg/hour continuous infusion maintains this critical pH level throughout the 72-hour high-risk period for rebleeding 4
Pre-Endoscopy Considerations
Start PPI therapy immediately upon presentation, even before endoscopy 2, 1. Pre-endoscopy PPI administration reduces the proportion of patients with stigmata of recent bleeding at index endoscopy and decreases the need for endoscopic therapy 2. However, this carries a weaker recommendation (Grade 2B) and does not impact mortality, rebleeding, or surgical need as significantly as post-hemostasis therapy 2
Critical Caveats and Common Pitfalls
Never delay urgent endoscopy while relying solely on PPI therapy 2, 1. PPIs are adjunctive therapy to endoscopic hemostasis, not a replacement for it 1. The mortality and rebleeding benefits are only seen when PPIs are combined with successful endoscopic treatment 2, 1
Do not discontinue therapy prematurely 1. Stopping PPI before completing the full 6-8 week course prevents adequate mucosal healing 2, 1
Do not use lower doses in high-risk patients 1. The mortality benefit is specifically demonstrated with the high-dose continuous infusion protocol (80 mg bolus + 8 mg/hour), not with standard once-daily dosing 2, 1
Benefits are most pronounced in high-risk patients 1. The evidence supporting this regimen applies specifically to patients with high-risk endoscopic stigmata (active bleeding, visible vessel, or adherent clot) who undergo successful endoscopic hemostasis 2, 1
Long-Term Management
Test all patients for H. pylori infection 2, 1. Provide eradication therapy if positive, as this reduces recurrent bleeding risk 2, 3. Eradication can be started immediately or during follow-up; there is no rationale for urgent IV eradication therapy 3
Long-term PPI therapy beyond 6-8 weeks is not recommended unless the patient has ongoing NSAID use 2, 1. Once mucosal healing is achieved, continuing PPIs indefinitely is unnecessary except in specific high-risk scenarios 2
Special Populations
Hepatic impairment: Reduce dosage to 10 mg once daily for patients with Child-Pugh Class A, B, or C 5
Asian patients: Consider dose reduction to 10 mg once daily 5
Pediatric patients (≥2 years): Adjust dosing based on body surface area, using 40 mg/1.73 m² bolus followed by infusion proportional to adult dose 6