Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding

Angelo Andriulli; Vito Annese; Gioacchino Leandro

doi:10.7326/0003-4819-141-1-200407060-00027

Letters |6 July 2004

Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding

Angelo Andriulli, MD; Vito Annese, MD; Gioacchino Leandro, MD

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TO THE EDITOR:

We congratulate the members of the Nonvariceal Upper GI Bleeding Consensus Conference Group for their guidelines on managing patients with nonvariceal bleeding (1). We disagree, however, with recommendation 17, which stresses the value of an intravenous bolus followed by continuous infusion of proton-pump inhibitors for decreasing rebleeding in patients who have undergone successful endoscopic therapy. The statement is ambiguous and only partially true.

In the 4 trials cited by the authors as confirmatory evidence (2-5), high-dose continuous infusions of proton-pump inhibitors administered in combination with endoscopic therapy were compared with endoscopic therapy and placebo (2), cimetidine (3, 4), and ranitidine plus somatostatin (5) and were shown to have better efficacy. However, when the comparison group was endoscopic therapy and bolus proton-pump inhibitors at standard doses, the high-dose regimen did not result in a better outcome (6). The members of the Consensus Conference Group disregarded the latter study because 25% of patients had low-risk endoscopic lesions. However, they did not consider a further study by Schonekas and colleagues (7), which unfortunately has been published only in abstract form, in which bolus pantoprazole at standard doses proved as effective as intravenous continuous infusion. In a meta-analysis of the value of proton-pump inhibitors in patients bleeding from peptic ulcers, we found that the additive benefit in patients who have had successful endoscopic therapy is independent of both route of administration and dose (8).

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2004 American College of Physicians

Letters |6 July 2004

Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding

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Letters |6 July 2004

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