The Effect of Endoscopic Therapy in Patients Receiving Omeprazole for Bleeding Ulcers with Nonbleeding Visible Vessels or Adherent Clots

A Randomized Comparison

19 August 2003 | Volume 139 Issue 4 | Pages 237-243

Background: The optimal treatment of ulcers with nonbleeding visible vessels and adherent clots is unclear.

Objective: To compare intravenous omeprazole infusion plus endoscopic therapy with intravenous omeprazole infusion alone for prevention of recurrent bleeding from ulcers with nonbleeding visible vessels or adherent clots.

Design: Single-blind randomized study with blinded evaluation of study end points.

Setting: An endoscopy center in a university hospital in Hong Kong.

Patients: 156 persons with upper gastrointestinal bleeding and ulcers showing nonbleeding visible vessels or adherent clots.

Intervention: Combination of endoscopic therapy and omeprazole infusion versus sham endoscopic therapy and omeprazole infusion.

Measurements: Recurrent ulcer bleeding before discharge and within 30 days.

Results: 78 patients were recruited in each group. Ulcer bleeding recurred before discharge in seven patients who received intravenous omeprazole alone (9%) and no patients who received combined therapy (difference, 9 percentage points [95% CI, 1.7 to 17.6 percentage points]; P = 0.01). The probability of recurrent bleeding within 30 days was 11.6% (9 patients) in the omeprazole-alone group and 1.1% (1 patient) in the combined therapy group (difference, 10.5 percentage points [CI, 1.7 to 19.8 percentage points]; P = 0.009). Patients in the combined therapy group required less transfusion (difference in median units of blood transfused, 1 unit [CI, 0 to 2 units]; P = 0.02). One patient in the combined therapy group had surgery for ulcer perforation. Four patients receiving omeprazole alone (5.1%) and two patients receiving combined therapy (2.6%) died within 30 days.

Conclusion: The combination of endoscopic therapy and omeprazole infusion is superior to omeprazole infusion alone for preventing recurrent bleeding from ulcers with nonbleeding visible vessels and adherent clots.

Editors' Notes Context Endoscopic hemostasis plus omeprazole in patients with actively bleeding ulcers prevents recurrent bleeding. Are both needed if endoscopy shows a nonbleeding vessel or nonbleeding clot? Contribution This randomized trial included 156 patients admitted for bleeding whose endoscopies, performed within 24 hours of admission, showed ulcers with nonbleeding vessels or adherent clots. Approximately 12% of patients receiving omeprazole alone had recurrent bleeding within 30 days compared with approximately 1% who received endoscopic hemostasis (thermocoagulation and epinephrine injection) plus omeprazole. Implications Endoscopic hemostasis plus omeprazole better prevents recurrent bleeding than does omeprazole alone in patients who have recently bled from an ulcer but do not have actively bleeding vessels at endoscopy. –The Editors

 

Author and Article Information

From Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong.

Acknowledgments: The authors thank Ms. Jessica Ching and Mr. Albert Cheung for statistical advice and the nursing staff of the Endoscopy Center for their generous support.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Joseph J.Y. Sung, MD, Endoscopy Center, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, Hong Kong; e-mail, joesung{at}cuhk.edu.hk.

Current Author Addresses: Drs. Sung, Chan, Lau, Leung, Wu, Ng, and Chung and Ms. Yung: Endoscopy Center, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, Hong Kong.

Author Contributions: Conception and design: J.J.Y. Sung, F.K.L. Chan, J.Y.W. Lau, S.C.S. Chung.

Analysis and interpretation of the data: F.K.L. Chan, M.-Y. Yung.

Drafting of the article: J.J.Y. Sung.

Critical revision of the article for important intellectual content: F.K.L. Chan, J.Y.W. Lau.

Final approval of the article: J.J.Y. Sung, S.C.S. Chung.

Provision of study materials or patients: J.J.Y. Sung, W.-K. Leung, J.C.Y. Wu, E.K.W. Ng.

Administrative, technical, or logistic support: M.-Y. Yung.