What is the treatment approach for a patient with gastritis and bleeding, potentially caused by Helicobacter pylori infection or NSAID (Non-Steroidal Anti-Inflammatory Drug) use?

Treatment of Gastritis with Bleeding

For patients with gastritis and bleeding, immediately initiate high-dose intravenous PPI therapy (80mg bolus followed by 8mg/hour continuous infusion for 72 hours after endoscopic hemostasis), test for H. pylori with eradication therapy if positive, and discontinue all NSAIDs immediately. 1

Immediate Pharmacologic Management

Proton pump inhibitor therapy is the cornerstone of treatment:

• Administer an IV loading dose of 80mg omeprazole (or equivalent PPI) followed by continuous infusion at 8mg/hour for 72 hours after successful endoscopic therapy in patients with high-risk stigmata 1, 2
• This represents a strong recommendation with moderate-quality evidence (100% consensus) from the International Consensus Group 1
• Do not use H2-receptor antagonists as they are ineffective for acute ulcer bleeding 1, 3
• Somatostatin and octreotide are not routinely recommended for acute ulcer bleeding 1

After the initial 72-hour infusion:

• Transition to oral PPI 40mg twice daily for 11 days (completing 14 days total of high-dose therapy) 1, 2
• Then reduce to 40mg once daily and continue for a total duration of 6-8 weeks to allow complete mucosal healing 2, 3

Endoscopic Evaluation and Therapy

Timing and approach:

• Perform upper endoscopy within 24 hours of presentation following hemodynamic resuscitation 3
• Endoscopic hemostasis should be performed for high-risk stigmata (active bleeding, visible vessel, or adherent clot) 1
• If rebleeding occurs, a second attempt at endoscopic therapy is generally recommended 1
• Routine second-look endoscopy is not recommended 1

If endoscopic therapy fails:

• Seek surgical consultation for patients in whom endoscopic therapy has failed 1
• Where available, percutaneous embolization can be considered as an alternative to surgery 1

Helicobacter pylori Management

Testing is mandatory:

• All patients with bleeding peptic ulcers must be tested for H. pylori and receive eradication therapy if present, with confirmation of eradication 1, 2
• Negative H. pylori tests obtained during acute bleeding should be repeated outside the acute setting due to high false-negative rates 1, 2
• Tests for H. pylori exhibit increased false-negative rates in the context of acute bleeding and high-dose PPI therapy 1, 2

Eradication therapy:

• Initiate 14-day triple therapy: PPI twice daily, clarithromycin 500mg twice daily, and amoxicillin 1000mg twice daily if local clarithromycin resistance is low (<15%) 3, 4
• H. pylori eradication reduces ulcer recurrence from >60% per year to 2.6% and essentially abolishes recurrent bleeding 4, 5
• Post-treatment H. pylori infection status is an independent predictor of rebleeding 1

NSAID Management

Immediate discontinuation is critical:

• Discontinue all NSAIDs immediately as this alone heals 95% of ulcers and reduces recurrence from 40% to 9% 3, 4
• All NSAIDs and aspirin should be immediately suspended during active bleeding 2

For patients requiring continued NSAID therapy:

• In patients with previous ulcer bleeding who require an NSAID, the combination of a PPI and a COX-2 inhibitor is recommended to reduce the risk for recurrent bleeding 1
• Recognize that treatment with a traditional NSAID plus a PPI or COX-2 inhibitor alone is still associated with a clinically important risk for recurrent ulcer bleeding 1
• If NSAIDs cannot be discontinued, switch to a selective COX-2 inhibitor (celecoxib) with lower gastric toxicity and maintain long-term PPI therapy 4

Antiplatelet and Anticoagulation Management

For patients on aspirin:

• In patients who receive low-dose aspirin and develop acute ulcer bleeding, aspirin therapy should be restarted as soon as the risk for cardiovascular complication is thought to outweigh the risk for bleeding 1
• Typically restart aspirin within 1-7 days (ideally 1-3 days) once hemostasis is achieved, along with PPI therapy 2

For patients on antiplatelet or anticoagulant therapy:

• In patients with previous ulcer bleeding receiving single- or dual-antiplatelet therapy, use PPI therapy (conditional recommendation, low-quality evidence) 1
• In patients requiring continued anticoagulant therapy (vitamin K antagonists, DOACs), use PPI therapy (conditional recommendation, very low-quality evidence) 1, 3

Hospitalization and Feeding

Post-endoscopy management:

• Most patients who have undergone endoscopic hemostasis for high-risk stigmata should be hospitalized for at least 72 hours thereafter 1
• Patients at low risk after endoscopy can be fed within 24 hours 1, 3
• Low-risk patients (Mallory-Weiss tear or ulcer with clean base/flat spot) may be discharged immediately after stabilization 1, 3

Follow-Up Strategy

For gastric ulcers specifically:

• A follow-up endoscopy should be performed approximately 6 weeks after discharge to confirm ulcer healing and exclude malignancy 2
• This follow-up endoscopy is mandatory in gastric ulcers (unlike duodenal ulcers) due to the risk of underlying malignancy 2

Long-term PPI therapy:

• Discontinue PPI after documented H. pylori eradication as rebleeding becomes extremely rare 2, 4
• Maintain indefinite PPI therapy for patients requiring continued NSAIDs or aspirin with cardiovascular disease 2

Common Pitfalls to Avoid

• Do not delay endoscopy for nasogastric tube placement or lavage 3
• Do not rely on a single negative H. pylori test during acute bleeding—always confirm with repeat testing 1, 2
• Do not use empirical PPI therapy alone without H. pylori testing, as this results in inadequate treatment and high recurrence rates 4
• Do not assume H. pylori and NSAIDs are mutually exclusive—H. pylori infection increases the risk of ulcer bleeding in patients taking NSAIDs 6, 7, 5