Proton Pump Inhibitor Treatment Initiated Prior to Endoscopic Diagnosis in Acute Upper Gastrointestinal Bleeding

Summary

A Cochrane review [Abstract] 1 included 6 RCTs with a total of 2223 patients to assess the clinical effectiveness of proton pump inhibitor (PPI) treatment compared to placebo or histamin-2-receptor antagonist (H2RA), initiated prior to endoscopy in acute upper gastrointestinal bleeding.

Primary outcome was all-cause mortality (within 30 days), secondary outcomes included re-bleeding rate, requirement for surgery within 30 days, length of hospital stay and need for blood transfusion.

Four trials used intravenous omeprazole as active treatment, compared to placebo in 3, and to i.v. ranitidine in one study. One study compared oral lansoprazole to placebo and one study intravenous pantoprazole to placebo. There was no statistically significant effect of PPI treatment on mortality (OR 1.12; 95% CI 0.75 to 1.68, 6 trials, n=2223), on re-bleeding (OR 0.81; 95% CI 0.62 to 1.06, 5 trials, n=2121), on need for surgery (OR 0.90, 95% CI 0.65 to 1.25; 5 trials, n=2165) or on need for blood transfusion (OR 0.95, 95% CI 0.78 to 1.16; 4 trials, n=1512). Analysis of the effect on length of hospital stay was inconclusive.

Clinical comments

Only a small proportion of patients received endoscopic haemostatic treatment (EHT); it remains uncertain if the combination of high dose PPI in conjunction with a more aggressive endoscopic therapy would influence the outcome positively.