What are the treatment goals for upper gastrointestinal bleeding due to a peptic ulcer?

Treatment Goals for Upper Gastrointestinal Bleeding Due to Peptic Ulcer

The primary treatment goals are to achieve hemostasis, prevent rebleeding, reduce mortality, and ensure complete ulcer healing through a combination of early resuscitation, endoscopic therapy, high-dose proton pump inhibitor therapy, and H. pylori eradication when present. 1

Immediate Resuscitation Goals

Target hemoglobin ≥7 g/dL during the resuscitation phase using a restrictive transfusion strategy, which has been shown to significantly improve outcomes compared to liberal transfusion (targeting Hb >9 g/dL). 1

Additional resuscitation targets mirror those used in bleeding trauma patients: 1

• Systolic blood pressure 90-100 mmHg until major bleeding is controlled
• Normalization of lactate and base deficit
• Correction and prevention of coagulopathy (INR >1.5 is associated with increased mortality risk) 1

Risk Stratification and Timing of Endoscopy

Use the Glasgow-Blatchford score to identify patients requiring intervention (blood transfusion or endoscopy) and the Rockall score to assess risk of adverse outcomes. 1

Perform endoscopy within 24 hours for all patients with suspected peptic ulcer bleeding, with timing adjusted based on risk: 1

• Very low-risk patients: Outpatient endoscopy acceptable
• Low-risk patients: Early inpatient endoscopy (≤24 hours)
• High-risk patients: Urgent inpatient endoscopy (≤12 hours)

Critical caveat: In hemodynamically unstable patients, very early endoscopy (≤6 hours) may paradoxically increase mortality risk; stabilize first, then perform endoscopy between 6-24 hours. 1

Endoscopic Hemostasis Goals

Achieve definitive hemostasis in all high-risk stigmata lesions (Forrest 1a spurting, 1b oozing, 2a visible vessel) using endoscopic therapy. 1

Apply dual modality endoscopic therapy combining epinephrine injection with either thermocoagulation (heater probe, bipolar electrocoagulation) or mechanical clips, as this approach reduces rebleeding compared to epinephrine alone in actively bleeding ulcers. 1

Endoscopic therapy has been proven to: 1

• Reduce rebleeding rates
• Decrease need for surgery
• Lower mortality

Pharmacologic Goals

Administer high-dose intravenous PPI therapy immediately after successful endoscopic hemostasis: 80 mg omeprazole bolus followed by 8 mg/hour continuous infusion for 72 hours in patients with high-risk stigmata. 1, 2

Transition to oral PPI 40 mg twice daily for 11 days (completing 14 days total of high-dose therapy), then reduce to 40 mg once daily and continue for a total of 6-8 weeks to ensure complete mucosal healing. 2

Important pitfall: Pre-endoscopic PPI administration may reduce need for endoscopic therapy but does not improve mortality, rebleeding, or surgical outcomes, and should never delay urgent endoscopy. 2

H. pylori Eradication Goals

Test all patients for H. pylori infection and provide eradication therapy if positive, as successful eradication reduces rebleeding rates from 26-62% down to 0-2%. 2, 3

Start eradication treatment as soon as oral feeding is reintroduced rather than waiting for discharge, using standard triple therapy (PPI + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily) for 14 days. 3, 4

Critical pitfall: Diagnostic tests for H. pylori show 25-55% false-negative rates during acute upper GI bleeding; repeat testing outside the acute bleeding context if initially negative. 3

Confirm eradication at least 4 weeks after completing therapy using urea breath test (88-95% sensitivity) or stool antigen test (94% sensitivity), performed off PPI therapy for at least 2 weeks to maximize accuracy. 3, 4

NSAID and Aspirin Management Goals

Immediately discontinue all NSAIDs and aspirin during the acute bleeding episode. 2, 3

For patients requiring cardiovascular prophylaxis: 2

• Restart aspirin within 1-7 days (ideally 1-3 days) once hemostasis is achieved, along with PPI therapy
• Continue indefinite PPI therapy for all aspirin users with cardiovascular disease

If NSAIDs must be resumed for valid medical reasons: 2

• Use the least harmful agent (ibuprofen)
• Combine with PPI therapy indefinitely
• Consider COX-2 selective inhibitors as an alternative, though these still require PPI co-therapy

Follow-Up and Healing Confirmation Goals

Perform repeat endoscopy at 6 weeks post-discharge for all gastric ulcers to confirm healing and exclude malignancy. 2, 4

Duodenal ulcers do not require routine endoscopic confirmation of healing after H. pylori eradication, unless the patient must continue NSAID therapy. 4

Discontinue PPI after documented H. pylori eradication in uncomplicated cases, as rebleeding becomes extremely rare once the infection is cleared. 2

Surgical Intervention Goals

Reserve surgery for patients with bleeding refractory to endoscopic treatment, perforation, or gastric outlet obstruction. 1, 4

Involve consultant surgeon and anesthesiologist early in high-risk cases, as mortality after urgent surgery correlates directly with preoperative physiologic status assessed by APACHE II score. 3

For selected high-risk patients (ulcers ≥2 cm, lesser curve or posterior bulbar location, shock on presentation, elderly with comorbidities), consider angiographic embolization as an alternative to surgery, particularly in those unfit for operation. 5