No benefit found

Proton Pump Inhibitors (PPIs) Given for Acute Upper Gastrointestinal Bleeding Given Prior to Endoscopic Diagnosis

 

The numbers presented are from the best studies that are currently available. Some of these studies will NEVER be repeated and so this is all we'll ever have to go on. There will be continued study in some areas and we aim to incorporate this forward into our site. We're constantly monitoring the literature for updates (if you think there is something we've missed, email us!). The conclusions we draw are a best estimate, folks. We've presented what we think is the closest thing to the truth about this intervention, but our data is only as good as the studies that underlie it — and often, the studies aren't as complete or as good as we'd like. We present one number here for the NNT, but please realize this is an estimate and there is a range for what this intervention can offer a given person. That range will depend upon the person's spectrum of disease (mild/moderate/severe), their demographic, their subtype of disease, the setting of the intervention, their general health, and literally thousands of other variables. Using these numbers in practice means taking a number of large leaps about all of these variables, and also about the veracity of the underlying research. Therefore, as with any 'high quality' data, the application of data requires a doctor's expertise and deliberate consideration.

In Summary, for those who took the PPI:
  • 100% saw no benefit
  • 0% were helped by being saved from death, needing surgery, preventing repeat bleeding
  • 0.0% were harmed by death, serious side effects
In Other Words:
  • None were helped (life saved, preventing surgery, prevent repeat bleeding)
  • None were harmed (death, serious side effects)

Where We Get The Numbers:

Source: Sreedharan A, Martin J, Leontiadis GI, Dorward S, Howden CW, Forman D, Moayyedi P. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010 Jul 7;7:CD005415. Review. PubMed PMID: 20614440.

Efficacy Endpoints: Major Endpoints: Mortality, Re-bleeding, Need for surgical intervention.

Minor Endpoints: Need for endoscopic hemostasis, Blood transfusion, Decrease in Hospital Days.

Harm Endpoints: Delaying definitive diagnosis and treatment, direct cost to patient, indirect cost (change in level of care, nursing care, emergency department flow, etc.)

Narrative: Acute upper gastrointestinal bleeding is a potentially life threatening condition that can demand aggressive intervention from the emergency physicians. Although bleeding can originate in any area above the ligament of Treitz, the majority of bleeding is from a peptic ulcer1,2. Proton pump inhibitors (PPIs) work by reducing gastric acid secretion, neutralizing gastric pH, increasing clot formation3 and decreasing clot lysis4. Intravenous proton pump inhibitors have traditionally been used after endoscopic hemostasis and are believed to prevent re-bleeding and decrease the need for surgery5. Patients with undifferentiated upper GI bleed, however, are often also placed on continuous PPI therapy prior to endoscopy6. This practice can delay definitive diagnosis and endoscopic treatment. Since 37-45% of undifferentiated upper GI bleed is not from a peptic ulcer1,2 patients can be subject to unnecessary medications and cost.

Four randomized control trials comprising of almost 1500 patients were included in the analysis. In this systematic review, PPIs failed to reduce death, re-bleeding rates, or the need for surgery. They did reduce the incidence of high risk lesions found during endoscopic evaluation. There was not sufficient evidence to assess for amount of blood transfused or decrease in hospitalized days, though one trial in the review and one recent trial (citation) showed that there was no difference in either.

Caveats: There were a relatively small number of patients in the PPI group (about 760) and there is a male preponderance in most of the studies. Though studies were conducted in both Asia and Europe, the relatively low numbers might limit generalizability. Also, a decrease in high risk stigmata on endoscopic evaluation may represent a clinically useful outcome if it reduced the need for hemostatic intervention. A study by Lau1 showed that there was a 14% reduction in endoscopic hemostasis in the PPI group, with a number needed to treat to prevent one intervention of 7.

Author: Koustav Mukherjee, MD

Published/Updated: January 7, 2010

Lau, JY et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med. 2007. Apr 19;356(16):1631-40.
Barkun, A. et al. The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE): Endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting. Am J Gastroenterol. 2004. Jul;99(7):1238-46.
Chaimoff C et al. The effect of pH on platelet and coagulation factor activities. Am J Surg. 1978. Aug;136(2):257-9.
Green FW Jr et al. Effect of acid and pepsin on blood coagulation and platelet aggregation. A possible contributor prolonged gastroduodenal mucosal hemorrhage. Gastroenterology. 1978. Jan;74(1):38-43.
Gralnek IM et al. Management of acute bleeding from a peptic ulcer. N Engl J Med. 2008. Aug 28;359(9):928-37.
Enns R et al. Description of prescribing practices in patients with upper gastrointestinal bleeding receiving intravenous proton pump inhibitors: a multicentre evaluation. Can J Gastroenterol. 2004. Sep;18(9):567-71.
 
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