About peptic ulcer bleeding

A peptic ulcer is a deep and sharply demarcated break in the lining of the stomach or duodenum – when in the stomach it is described as a gastric ulcer and when in the duodenum a duodenal ulcer.[1] A peptic ulcer forms when the mucus membrane of the esophagus, stomach or duodenum is damaged by the action of gastric acid.[2]

Peptic ulcer bleeding is a potentially life-threatening event that occurs as a complication of peptic ulcer disease. It occurs when the ulcer erodes into an underlying blood vessel. The resulting blood loss can be significant as clotting and platelet function is impaired in the acidic environment. If, after gastric ulcer treatment such as endoscopic intervention or pharmacological therapy, peptic ulcer rebleeding occurs, there is an increased risk of morbidity and mortality.[3],[4] Approximately 20% of patients with this condition will experience severe bleeding that requires hospitalization and up to 14% of these patients will die within 30 days.[4],[5],[6],[7],[8]

Causes of peptic ulcer bleeding

The two major causes of peptic ulcers are infection with Helicobacter pylori (H. pylori) or the long-term use of medicines such as non-steroidal anti-inflammatory drugs (NSAIDs) or low-dose acetylsalicylic acid (ASA or aspirin).[9],[10] Maintenance treatment to optimally manage these risks can support long-term healing of the ulcer.[9],[10]

Management and Treatment of Peptic Ulcer Bleeding

The goals of gastric ulcer treatment for peptic ulcer bleeding include the cessation of bleeding, prevention of ulcer rebleeding, and long-term healing of ulcers. [3],[11] Treatment is focused on initial resuscitation, endoscopic treatment for rebleeding and surgery if bleeding remains uncontrolled. [3]

Despite improvements in endoscopic therapy, the occurrence of ulcer rebleeding and the need for re-treatment remain high; 11 the 30 day mortality rate has not significantly decreased over the last 30 years. [4],[12] Consequently, attention has fallen on the key role gastric acid secretion plays in the mucosal damage associated with ulcer development8. Data suggest that patients with peptic ulcer bleeding need a near maximum level of acid suppression, the target level being pH>6. [9],[13],[14].

A number of proton pump inhibitors (PPIs), including Nexium, are indicated for long-term use in gastroesophageal reflux disease and prevention of NSAID induced ulcers. Nexium i.v. is the first proton pump inhibitor (PPI) to be indicated in Europe for prevention of re-bleeding following therapeutic endoscopy for acute bleeding gastric or duodenal ulcers.  Nexium has been shown to significantly reduce the use of hospital resources in patients by reducing endoscopic retreatment, blood transfusions, and length of hospital stay due to re-bleeding, compared to placebo.[15]

Following cessation of bleeding and prevention of rebleeding in the secondary-care setting, the long-term healing of peptic ulcers can be effectively achieved in a primary care environment.

Health economics considerations of Peptic Ulcer Bleeding

The health economic impact of peptic ulcer bleeding is significant, especially in the case of rebleeds which may require surgery, repeat endoscopy and blood transfusions, with the cost of ulcer rebleeding alone approximately $10,000 per patient for thirty days.[16]

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References

1. www.Nexium.net. Retrieved March 2008
2. Dorland’s Illustrated Medical Dictionary. Ed: Taylor EJ. WB Saunders Company Philadelphia, 1985
3. Holtman G, Howden W. Review article: management of peptic ulcer bleeding – the roles of proton pump inhibitors and H.pylori eradication. Ailmentary Pharmacology & Therapeutics 2004; 19 (Suppl 1): 66-70
4. Van Leerdam M, Vreeburg E, Rauws E at al. Acute upper GI bleeding: Did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/4 and 2000. American Journal of Gastroenterology, 2003; 98(7):1494-9
5. Lassen A. Complicated and uncomplicated peptic ulcers in a Danish county 1993-2002: a population-based cohort study. Am J Gastroenterol 2006;101(5):945-53
6. Soplepmann J, Peetsalu A, Peetsalu M et al. Peptic ulcer haemorrhage in Tartu County, Estonia: epidemiology and mortality risk factors. Scand J Gastroenterol 1997;32(12):1195-200
7. Thompsen R., Riis A., Christensen S., Nogaard M., Sorensen H. Diabetes and 30-day mortality from peptic ulcer bleeding and perforation: a Danish population-based cohot study, Diabetes Care,  vol:29 pp805-10, 2006
8. Mose et al. Thirty-day mortality after peptic ulcer bleeding in hospitalized patients receiving low-dose aspirin at time of admission. Am J Geriatr Pharmacother 2006;4(3):244-50
9. Lanas A, Scheiman J. Low-dose aspirin and upper gastrointestinal damage: epidemiology, prevention and treatment. Current Medical Research and Opinion 2007;23(1):163-73
10. Scheiman J, Yeomans N, Talley N et al. Summing the risk of NSAID therapy. The Lancet 2007; 369:1580-1581
11. Sung J, Mössner J, Barkun et al. on behalf of the PUB Study Group. Intravenous esomeprazole for prevention of peptic ulcer rebleeding: rationale / design of the Peptic Ulcer Bleed Study, Alimentary Pharmacology & Therapeutics, 2008; 27, 666-667
12. Rockall T, Logan R., Devlin H, Northfield T. Incidence and mortality from acute upper gastrointestinal haemorrhage in the Unites Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage, BMJ vol: 311 pp 222-6, 1995
13. Green F, Kaplan M, Curtis L et al. Effect of acid and pepsin on blood coagulation and platlet aggregation, Gastoenterology, 1978; 74:38-43
14. Patchett SE, Enright H, Afdhal N. Clot lysis by gastric juice: an in vitro study. Gut 1989;30:1704-1707
15. Sung J, Barkun A, Kuipers E et al., Intravenous esomeprazole for prevention of recurrent peptic ulcer bleeding: a randomized trial. Annals of Internal Medicine 2009:150:7
16. Barkun A, Herba K, Adam V et al. The cost-effectiveness of high-dose oral proton pump inhibition after endoscopy in the acute treatment of peptic ulcer bleeding.  Aliment Pharmacol Ther 2004; 20: 195–202