Older Man With Epigastric Pain and Melena

A 64-year-old man has experienced melena 4 or 5 times in the previous24 hours. He has had no emesis but complains of moderate epigastric pain.He has had similar-although milder-pain in recent weeks.HISTORY
A similar episode occurred 4 years earlier; however, there was lessmelena. He underwent endoscopy and was told he had ulcers but no tumor.Since then, he has taken H₂-blockers intermittently, particularly when heexperiences epigastric discomfort. He takes an angiotensin-converting enzymeinhibitor and a diuretic daily for essential hypertension. He smokes cigarsoccasionally and does not drink alcohol.PHYSICAL EXAMINATION
The patient appears pale; he is afebrile. Supine heart rate is 104 beatsper minute (bpm); upright, 120 bpm. Supine blood pressure is 110/75 mm Hg;upright, 90/60 mm Hg. There is no scleral icterus; mucosae are pale. Chest isclear. Tachycardia and a summation gallop are noted. Bowel sounds are audible.Deep palpation reveals moderate epigastric tenderness but no rebound; thereis no hepatosplenomegaly. Rectal examination results are normal; however,grossly melanotic stool is present, which is strongly positive for occult blood.LABORATORY AND IMAGING RESULTS
White blood cell count is 14,300/µL; platelet count is normal. Hemoglobinis 9.2 g/dL with normal mean corpuscular volume. Liver function tests and prothrombintime are normal. ECG reveals sinus tachycardia and left ventricularhypertrophy by voltage criteria, with nonspecific ST-T changes in leads I, aVL,and V₄ through V₆.You suspect that the patient has a bleeding peptic ulcer.Which of the following is not true in this setting?A. The most important prognostic indicator for death and complicationsis the patient's age.B. Aggressive, early, high-dose H₂-receptor antagonist therapy effectivelyprevents rebleeding in the first 72 hours.C. Endoscopy to assess the appearance of the ulcer can reveal prognosticfeatures that aid in acute management.D. Gastric lavage neither stops active bleeding nor prevents recurrentbleeding.E. Endoscopy should include testing for Helicobacter pylori; if H pyloriinfection is detected and eradicated, peptic ulcer rarely recurs.CORRECT ANSWER: BBleeding peptic ulcer accounts for about half of episodesof upper GI tract hemorrhage. The prognosis for mostpatients with peptic ulcer disease (PUD) is good. Yet despiteadvances in the knowledge of pathophysiology (ie,the discovery of H pylori as a causative agent) and theuse of endoscopy for diagnosis, prognosis, and therapy,mortality from the disease remains little changed at6% to 7%.¹This man's GI hemorrhage manifested as melena,which occurs in about 20% of patients with bleeding pepticulcers. Another 30% have hematemesis, while the remaining50% present with both conditions.¹ This patient's historyof recurrence is typical and was common before effectivetherapy to eradicate H pylori was introduced.Clinical features remain the most important indicatorsof poor outcomes (eg, the need for urgent surgery,death) in patients with PUD. This patient has several ofthese indicators: severe bleeding that requires urgent endoscopy,hemodynamic instability, and low hemoglobinlevel. Even so, the most important prognostic indicatorhere is the patient's age-64 years (choice A). Patientsolder than 60 years are significantly more likely to have apoor outcome. In a large study of more than 700 patientswith bleeding ulcers, mortality in patients under and over60 years was 0.5% and 10%, respectively-a 20-fold difference.² A more recent study showed similar results.³Endoscopy can reveal classic features such as ulcersize greater than 1 to 2 cm, stigmata of recent hemorrhage(eg, an adherent clot or pigment spots), and visiblevessels that are associated with an increased risk ofrebleeding and death. These findings can thus guidedecisions regarding use of endoscopic epinephrine andcoagulation, intensive care placement, and discharge(choice C).The time-honored maneuver of gastric lavage helpsdetermine whether hemorrhage is proximal to the ligamentof Treitz and can confirm severe bleeding and ahigh risk of rebleeding-which are indicated by failure toclear. However, gastric lavage does not stop bleeding orprevent recurrences (choice D).Treatment of risk factors diminishes the recurrenceof PUD and, by inference, reduces bleeding complicationsas well. The most prevalent and reversible risk factors forPUD are NSAID use and H pylori infection. NSAIDsshould be discontinued; if H pylori infection is detected byendoscopic testing, it should be eradicated (choice E).⁴Surprisingly, H₂-receptor antagonists are not effectivein preventing rebleeding in patients with acute bleedingPUD. The reduction in gastric acidity that these agentspromote was thought to constitute significant local therapyin such patients because a pH of more than 6 appearsto be necessary for platelet aggregation and fibrin clot formation.Yet many studies have failed to show that H₂-receptorantagonists significantly decrease rebleeding in thetraditional 72-hour window.⁵ Thus, H₂-receptor antagonisttherapy is not indicated for prevention of rebleeding (and,by inference, death) in this setting, although its use forlong-term healing is appropriate.Recent studies have shown that parenteral protonpump inhibitors (PPIs) are effective in acute management,perhaps because these agents work faster than H₂-receptorantagonists and raise gastric pH to high levels.⁵ Theeffectiveness of oral PPIs available in the United States isbeing studied.Outcome of this case. Urgent endoscopy revealedan 8-mm ulcer in the duodenum but no active bleeding.Biopsy of the ulcer was negative for tumor but positive forH pylori. An appropriate regimen for H pylori was initiated.At 6 months, the patient had no recurrent PUD symptomsor bleeding.

References:

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Laine L, Peterson W. Bleeding peptic ulcer. N Engl J Med. 1994;331:717-727.

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Branicki FJ, Coleman SY, Fok PJ, et al. Bleeding peptic ulcer: a prospective evaluationof risk factors for rebleeding and mortality. World J Surg. 1990;14:262-270.

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Khuroo MS, Yattoo GN, Javid G, et al. A comparison of omeprazole andplacebo for bleeding peptic ulcer. N Engl J Med. 1997;336:1054-1058.

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Libby ED. Omeprazole to prevent recurrent bleeding after endoscopic treatmentof ulcers. N Engl J Med. 2000;343:358-359.

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Lau JYW, Sung JJY, Lee KKC, et al. Effect of intravenous omeprazole onrecurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Engl JMed. 2000;343:310-316.