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Background Patients with high Rockall scores have increased risk of ulcer rebleeding after 3-day esomeprazole infusions. Objective To investigate whether double oral esomeprazole given after a 3-day esomeprazole infusion decreases ulcer rebleeding for patients with high Rockall scores. Design We prospectively enrolled 293 patients with peptic ulcer bleeding who had achieved endoscopic haemostasis. After a 3-day esomeprazole infusion, patients with Rockall scores ≥6 were randomised into the oral double-dose group (n=93) or the oral standard-dose group (n=94) to receive 11 days of oral esomeprazole 40 mg twice daily or once daily, respectively. The patients with Rockall scores <6 served as controls (n=89); they received 11 days of oral esomeprazole 40 mg once daily. Thereafter, all patients received oral esomeprazole 40 mg once daily for two more weeks until the end of the 28-day study period. The primary end point was peptic ulcer rebleeding. Results Among patients with Rockall scores ≥6, the oral double-dose group had a higher cumulative rebleeding-free proportion than the oral standard-dose group (p=0.02, log-rank test). The proportion of patients free from recurrent bleeding during the 4th–28th day in the oral double-dose group remained lower than that of the group with Rockall scores <6 (p=0.03, log-rank test). Among patients with Rockall scores ≥6, the rebleeding rate was lower in the oral double-dose group than in the oral standard-dose group (4th–28th day: 10.8% vs 28.7%, p=0.002). Conclusions Double oral esomeprazole at 40 mg twice daily after esomeprazole infusion reduced recurrent peptic ulcer bleeding in high-risk patients with Rockall scores ≥6. Trial registration number NCT01591083.

Background Critically ill patients in the intensive care unit (ICU) are at risk of clinically important gastrointestinal bleeding, and acid suppressants are frequently used prophylactically. However, stress ulcer prophylaxis may increase the risk of serious adverse events and, additionally, the quantity and quality of evidence supporting the use of stress ulcer prophylaxis is low. The aim of the SUP-ICU trial is to assess the benefits and harms of stress ulcer prophylaxis with a proton pump inhibitor in adult patients in the ICU. We hypothesise that stress ulcer prophylaxis reduces the rate of gastrointestinal bleeding, but increases rates of nosocomial infections and myocardial ischaemia. The overall effect on mortality is unpredictable. Methods/design The SUP-ICU trial is an investigator-initiated, pragmatic, international, multicentre, randomised, blinded, parallel-group trial of stress ulcer prophylaxis with a proton pump inhibitor versus placebo (saline) in 3350 acutely ill ICU patients at risk of gastrointestinal bleeding. The primary outcome measure is 90-day mortality. Secondary outcomes include the proportion of patients with clinically important gastrointestinal bleeding, pneumonia, Clostridium difficile infection or myocardial ischaemia, days alive without life support in the 90-day period, serious adverse reactions, 1-year mortality, and health economic analyses. The sample size will enable us to detect a 20 % relative risk difference (5 % absolute risk difference) in 90-day mortality assuming a 25 % event rate with a risk of type I error of 5 % and power of 90 %. The trial will be externally monitored according to Good Clinical Practice standards. Interim analyses will be performed after 1650 and 2500 patients. Conclusion The SUP-ICU trial will provide high-quality data on the benefits and harms of stress ulcer prophylaxis with a proton pump inhibitor in critically ill adult patients admitted in the ICU. Trial registration ClinicalTrials.gov Identifier: NCT02467621 .

Guidelines for clinical practice are intended to indicate preferred approaches to medical problems as established by scientifically valid research. Double-blind, placebo-controlled studies are preferable, but compassionate use reports and expert review articles are used in a thorough review of the literature conducted through Medline with the National Library of Medicine. Only when data that will not withstand objective scrutiny are available is a recommendation identified as a consensus of experts. Guidelines are applicable to all physicians who address the subject, without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only, acceptable approach to a specific problem. Guidelines are intended to be flexible and must be distinguished from standards of care, which are inflexible and rarely violated. Given the wide range of specifics in any health-care problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. These guidelines were developed under the auspices of the American College of Gastroenterology by a committee of experts in the field, reviewed by its Practice Parameters Committee, and approved by the Board of Trustees. The recommendations of these guidelines are therefore considered valid at the time of production based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at an established time and indicated at publication to assure continued validity. Owing to the volume of new data on the subject of non-steroidal anti-inflammatory drug (NSAID)-related injury to the upper gastrointestinal tract, i.e., the advent of cyclooxygenase (COX)-2 inhibitors, new data on interactions between these agents, as well as traditional NSAIDs, with aspirin and H. pylori, it was elected by the Committee to confine these guidelines to upper gastrointestinal (GI) injury and to leave post-duodenal injury as the subject of a separate guideline.

Endoscopic treatment is effective for bleeding peptic ulcers, but bleeding recurs in 15 to 20 percent of patients. The mortality rate in these patients is high. In vitro studies have shown that a high intragastric pH could facilitate platelet aggregation. 1 Thus, inhibition of gastric acid to maintain a neutral pH should stabilize clots and prevent recurrent bleeding. However, the role of acid suppression in the management of bleeding peptic ulcers, particularly after endoscopic treatment, remains unclear. Evidence of the effectiveness of histamine H 2 –receptor antagonists in bleeding peptic ulcers is conflicting. In a meta-analysis of 27 randomized trials, Collins . . .

This randomized, controlled trial compared treatment with celecoxib and treatment with diclofenac plus omeprazole in patients with arthritis and ulcer bleeding. The rates of recurrent ulcer bleeding during six months of follow-up were similar in the two groups (4.9 percent in the celecoxib group and 6.4 percent in the diclofenac-plus-omeprazole group). Treatment with a COX-2–selective NSAID was not inferior to treatment with a nonselective NSAID plus a proton-pump inhibitor. Nonsteroidal antiinflammatory drugs (NSAIDs) are one of the most widely prescribed classes of drugs worldwide, with nearly $2 billion spent in the United States yearly on prescription NSAIDs alone. 1 Gastrointestinal toxic effects induced by NSAIDs are common. In the United States, an estimated 107,000 patients are hospitalized and 16,500 die each year as a result of NSAID-related ulcer complications. 2 Patients with a history of ulcer bleeding who use NSAIDs are at the highest risk for ulcer complications. 3 , 4 Current evidence indicates that concurrent therapy with NSAIDs and proton-pump inhibitors or misoprostol reduces the risk of ulcers 5 , 6 and ulcer complications. . . .

The use of low-dose aspirin as prophylaxis against cardiac events or stroke and the presence of Helicobacter pylori infection are both risk factors for upper gastrointestinal tract bleeding from ulcers. In this study, patients taking low-dose aspirin who had both bleeding from ulcers and H. pylori infection had the latter eradicated and were then randomly assigned to receive lansoprazole (62 patients) or placebo (61 patients) and were followed for a median of 12 months while the low-dose aspirin treatment was continued. There was one recurrence of ulcer complications in the lansoprazole group and nine in the placebo group (P=0.008). After the eradication of H. pylori infection, low-dose aspirin therapy can be continued more safely if lansoprazole is added to the therapeutic regimen. The efficacy of low-dose aspirin (less than 325 mg daily) in the prevention of cardiovascular and cerebrovascular diseases is well established. 1 Patients who are taking low-dose aspirin, however, have an increased risk of ulcer complications, 2 and some of these patients should be given prophylactic treatment. One of the available options for preventing these ulcer complications is the simultaneous use of proton-pump inhibitors, which reduce gastric acidity substantially. In a recent epidemiologic study, the use of a proton-pump inhibitor was found to be associated with a decrease of 80 percent in the risk of gastrointestinal bleeding in subjects taking low-dose aspirin. . . .

Currently, no consensus exists on optimal treatment for post-endoscopic submucosal dissection (ESD) gastric ulcer. This study aims to compare rebamipide and tegoprazan combination therapy with tegoprazan monotherapy for post-ESD ulcer healing. Between May 2022 and September 2023, 140 patients (141 lesions) who underwent ESD for gastric epithelial neoplasms at five tertiary hospitals were randomly assigned to tegoprazan monotherapy or combination therapy groups. The size, stage and healing quality of the post-ESD ulcers were assessed at weeks 4 and 8. Modified intention-to-treat (mITT) and per-protocol analyses included 132 and 121 lesions, respectively. The ulcer healing rate at week 4 was significantly higher in the combination therapy group than in the tegoprazan monotherapy group (96.4% vs. 93.6%, P  = 0.02 in mITT). Combination therapy significantly predicted higher-than-average ulcer healing at week 4 (odds ratio 2.28, 95% confidence interval 1.04–5.02, P  = 0.04). The proportion of flat ulcer scar at week 8 was significantly higher in the combination group than in the tegoprazan monotherapy group (73.8% vs. 48.4%, P  = 0.007). Combination treatment with rebamipide and tegoprazan led to faster ulcer healing and the development of high-quality post-ESD scars compared to tegoprazan monotherapy.

Patients with acute upper gastrointestinal bleeding were assigned to receive endoscopy within 6 hours or between 6 and 24 hours after gastroenterologic consultation. Mortality at 30 days was 8.9% in the former group and 6.6% in the latter group; earlier endoscopy did not lower mortality.

Background and GoalsPeptic ulcer disease is the most frequent cause of upper gastrointestinal bleeding. We sought to establish the epidemiology and hemostasis success rate of the different treatment modalities in this setting.MethodsRetrospective cohort study using the National Inpatient Sample. Non-elective adult admissions with a principal diagnosis of ulcer bleeding were included. The primary outcome was endoscopic, radiologic and surgical hemostasis success rate. Secondary outcomes were patients’ demographics, in-hospital mortality and resource utilization. On subgroup analysis, gastric and duodenal ulcers were studied separately. Confounders were adjusted for using multivariate regression analysis.ResultsA total of 136,425 admissions (55% gastric and 45% duodenal ulcers) were included. The mean patient age was 67 years. The majority of patients were males, Caucasians, of lower income and high comorbidity burden. The endoscopic, radiological and surgical therapy and hemostasis success rates were 33.6, 1.4, 0.1, and 95.1%, 89.1 and 66.7%, respectively. The in-hospital mortality rate was 1.9% overall, but 2.4% after successful and 11.1% after failed endoscopic hemostasis, respectively. Duodenal ulcers were associated with lower adjusted odds of successful endoscopic hemostasis, but higher odds of early and multiple endoscopies, endoscopic therapy, overall and successful radiological therapy, in-hospital mortality, longer length of stay and higher total hospitalization charges and costs.ConclusionsThe ulcer bleeding endoscopic hemostasis success rate is 95.1%. Rescue therapy is associated with lower hemostasis success and more than a ten-fold increase in mortality rate. Duodenal ulcers are associated with worse treatment outcomes and higher resource utilization compared with gastric ulcers.