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Antisecretory therapy
PPIs are recommended as firstline
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therapy and are superior to H 2 antagonists in terms of reducing the | ||||
risk of bleeding. 38 | ||||
A PPI is recommended until the | ||||
time of endoscopy for all patients who | ||||
present acutely with suspected upper | ||||
gastrointestinal bleed secondary to a |
potential peptic ulcer. The PPI therapy is an 80mg IV bolus of either esomeprazole, omeprazole or pantoprazole administered over 15-30 minutes followed by an ongoing 8mg / hour infusion. 39 Intermittent IV dosing is also possible, though the optimal regimen for this is less established. 38, 39 IV therapy is preferred over oral therapy |
Figure 9. An excavated 10mm duodenal ulcer with a visible central vessel and oedematous edge. This is Forrest grade 2A in a patient with gastrointestinal bleeding. |
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because it results in a faster increase in |
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intragastric pH. 40
The duration of IV therapy is contingent on the endoscopic findings. The Forrest classification is used to grade ulcers based on their macroscopic appearance, with grade 1A representing the most severe bleeding( see table 1). 41 High-dose PPI therapy following index endoscopy is recommended in patients who have grade 1A to 2B ulcers. Highdose PPI therapy is defined as 80mg or more daily for three or more days, with this typically administered IV as an ongoing infusion or intermittent dosing, in an inpatient setting. This typically
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Table 1. Forrest classification for ulcers
Grade
1A
1B
2A( see figure 9)
2B
2C
Description
Active spurting
Active oozing
Non-bleeding visible vessel
Adherent clot
Flat pigmented spot
3 Clean ulcer base
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is followed by oral PPI therapy administered as an outpatient. 38 In contrast, patients with grade 2C or 3 ulcers may be transitioned to oral PPI therapy alone following endoscopic evaluation. 38
The overall duration and dosing of PPI therapy is dependent on the underlying aetiology of the ulcer, its location and the presence of complications.
Duration of PPI therapy
In patients with complicated peptic
ulcers associated with bleeding and perforation, high-dose PPI therapy is recommended for eight weeks,
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with suitable regimens including esomeprazole 20mg orally twice daily or pantoprazole 40mg orally twice daily. 39
In patients with uncomplicated duodenal ulcers who are positive for H. pylori, PPI therapy given for 14 days as part of triple therapy is typically
36, 42 sufficient to induce healing.
For uncomplicated NSAID induced ulcers, a once daily dose of PPI therapy, such as esomeprazole 20mg or pantoprazole 40mg, is recommended for 8-12 weeks. 43 In those with an ongoing need to remain on
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NSAIDs, once daily maintenance antisecretory therapy can reduce the risk of ulcer complications and recurrence. 44 Eight weeks of PPI therapy is recommended for all patients with gastric ulcers, though guidelines are unclear on the dosing regimen in uncomplicated H. pylori cases. 36
Endoscopic therapy
Endoscopic evaluation by gastroscopy
is the initial stage of management of a bleeding peptic ulcer. Ulcers that are not bleeding do not require endoscopic management. The
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