What is the management of esophageal (oesophageal) ulceration bleeding?

From the Guidelines

Management of esophageal ulceration bleeding requires prompt intervention with a combination of medical therapy, endoscopic treatment, and supportive care, prioritizing intravenous high-dose proton-pump inhibitor (PPI) therapy after successful endoscopic hemostasis to decrease rebleeding and mortality in patients with high-risk stigmata, as recommended by the international consensus guidelines 1.

Initial Management

Initial management should focus on hemodynamic stabilization with intravenous fluid resuscitation and blood transfusion if hemoglobin is below 7-8 g/dL.

• Start a proton pump inhibitor (PPI) such as esomeprazole 80mg IV bolus followed by 8mg/hour continuous infusion for 72 hours to reduce gastric acid production and promote ulcer healing.
• Urgent endoscopy should be performed within 24 hours to identify the bleeding source and apply endoscopic therapy.

Endoscopic Therapy

Endoscopic options include:

• Thermal coagulation
• Injection therapy with epinephrine (1:10,000 dilution, 0.5-1mL aliquots around the ulcer)
• Mechanical therapy with hemoclips For patients with variceal bleeding, band ligation or sclerotherapy may be necessary.

Post-Endoscopy Care

Following endoscopy, continue oral PPI therapy (e.g., omeprazole 40mg twice daily) for 4-8 weeks.

• Sucralfate suspension 1g four times daily can provide additional mucosal protection.
• Avoid NSAIDs and other potential irritants.
• If Helicobacter pylori is detected, eradication therapy should be initiated with a 14-day regimen of amoxicillin 1g twice daily, clarithromycin 500mg twice daily, and a PPI twice daily.

Refractory Bleeding

For refractory bleeding, consider angiographic embolization or surgical intervention.

• The aggressive acid suppression promotes clot stability and ulcer healing, while endoscopic therapy directly addresses the bleeding vessel, significantly reducing rebleeding rates and mortality, as supported by the guidelines 1 and other studies 1.

From the Research

Management of Oesophageal Ulceration Bleeding

• The management of oesophageal ulceration bleeding can be achieved through the use of proton pump inhibitors (PPIs) such as omeprazole 2.
• Omeprazole has been shown to be effective in healing esophageal ulcers and preventing recurrent hemorrhage in patients with cirrhosis 2.
• The use of PPIs in the management of gastroesophageal varices has been reviewed, and the evidence suggests that they can reduce esophageal ulcer size post-elective esophageal ligation 3.
• However, the available evidence does not support a role of PPIs for long-term prophylaxis of portal hypertension-related bleeding and high-dose infusion for acute management of GEV hemorrhage 3.

Treatment Options

• Omeprazole has been compared to other PPIs such as pantoprazole in the treatment of Helicobacter pylori-positive duodenal ulcer, and has been shown to be effective in ulcer healing and H. pylori eradication 4.
• The use of omeprazole in combination with antibiotics has been shown to be effective in eradicating H. pylori and healing duodenal ulcers 5, 4.
• PPIs such as omeprazole and pantoprazole have also been shown to be effective in preventing NSAID-induced gastrointestinal damage and healing NSAID-induced peptic ulcers 5, 6.

Dosage and Administration

• The usual dosage of omeprazole is 10-40 mg daily for adults and 10-20 mg daily for children 5.
• The use of high-dose PPIs such as omeprazole 40 mg daily has been shown to be effective in healing esophageal ulcers and preventing recurrent hemorrhage 2.
• The duration of treatment with PPIs can vary depending on the indication, but short-course treatment (10 days) has been shown to be effective in reducing ulcer size post-endoscopic variceal ligation 3.