4-10 THERAPY FOR BLEEDING PEPTIC ULCERS
(This editorial comments and expands on the preceding article)
The widespread use of aspirin and NSAIDs, even at low doses taken to prevent cardiovascular disease, has increased the risk of gastrointestinal bleeding.
In 70%-80% of patients with upper gastrointestinal bleeding, the bleeding stops spontaneously. The care of these patients includes administration of blood and fluids, establishment of a definite diagnosis, and medical therapy. Patients with continued or recurrent bleeding pose the greatest challenge. Prompt endoscopy is now routinely used.
Therapeutic endoscopy has about an 80% efficacy in stopping bleeding. In general, the various techniques have similar efficacies. Surgery is reserved for patients who have torrential bleeding or whose bleeding cannot be controlled by endoscopy.
The role of medical therapy remains uncertain. Although histamine H2-receptor antagonists are still routinely used in the initial care of patients with acute upper gastrointestinal bleeding, they provide little immediate benefit, if any. Proton pump inhibitors, which dramatically suppress gastric acid production have the potential to be effective treatment. Studies of omeprazole have been conflicting.
Some patients may benefit from initial treatment with proton-pump inhibitors—when therapeutic endoscopy is not available or impractical, when endoscopy is too risky, or the patient cannot co-operate.
"Although the findings reported in the preceding study are promising it is premature to recommend the routine use of proton-pump inhibitors for patients with bleeding peptic ulcers."
NEJM April 10, 1997; 336: 1091-93 Editorial from Univ. Of Massachusetts Medical Center, Worcester

Comment:
Is optimal treatment: 1) endoscopic evaluation and treatment (if indicated) alone, or 2) endoscopic evaluation and treatment (if indicated) plus a proton-pump inhibitor? I would vote for 2).
This illustrates an interesting point. We can learn much from our colleagues in different countries. A study comparing omeprazole with placebo without endoscopic treatment could not be done in the US. It would be unethical because it is not the best treatment available. In India, where endoscopy is not generally available, the study would be ethical. RTJ

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