A 58-year-old man is hospitalized after having three black, loose stools in 1 day. He has no other medical conditions, takes no medications, and does not drink alcohol.
On physical examination, vital signs are normal. The patient appears comfortable, with a normal abdominal examination. Anorectal examination shows a small amount of black tarry stool in the rectal vault. The remainder of the examination is normal.
Upper endoscopy reveals a 1.5-cm gastric ulcer with a nonbleeding visible vessel, which is treated with endoscopic clips. Biopsy of the ulcer is performed, and results of testing for Helicobacter pylori infection are pending.
Which of the following is the most appropriate immediate treatment?
A. Broad-spectrum antibiotics
B. Esomeprazole, intravenously twice daily
C. Octreotide, intravenously by continuous infusion
D. Omeprazole, orally once daily
MKSAP Answer and Critique
The correct answer is B. Esomeprazole, intravenously twice daily. This content is available to MKSAP 19 subscribers as Question 88 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.
The most appropriate treatment is esomeprazole, a proton pump inhibitor (PPI), intravenously twice daily for 72 hours (Option B). Upper endoscopy should be performed within 24 hours in patients with acute upper gastrointestinal bleeding (UGIB). In this patient, endoscopy revealed a nonbleeding visible vessel within the ulcer base, which is classified as an ulcer with high risk for rebleeding. After endoscopy, patients with UGIB and ulcers with high risk for rebleeding (active bleeding, nonbleeding visible vessel, or adherent clot) should receive continuous-infusion PPI therapy for 72 hours or a PPI intravenously twice daily for 72 hours and remain in the hospital during that time. Intravenous PPI therapy is followed by an oral PPI twice daily for 2 weeks, followed by once daily for an additional 6 weeks. The risk for rebleeding in patients with high-risk ulcers that are successfully treated endoscopically is similar for patients who receive twice-daily intravenous PPI and those who receive continuous PPI infusion. Because of the higher costs associated with continuous infusion, twice-daily PPI is preferable given the similar clinical efficacy.
Initiation of broad-spectrum antibiotics for 7 days is recommended in all patients with cirrhosis and gastrointestinal bleeding even in the absence of ascites. This patient does not have cirrhosis; therefore, treatment with broad-spectrum antibiotics (Option A) is not indicated.
Octreotide (Option C) is an analogue of somatostatin that decreases splanchnic blood flow and lowers portal pressure; it should be initiated before endoscopic evaluation and continuously infused for 3 to 5 days after variceal hemorrhage. Octreotide is not routinely used in nonvariceal UGIB.
Patients with low-risk stigmata following recent UGIB (i.e., flat pigmented spot, clean-based ulcer) should receive once-daily oral PPI therapy, such as omeprazole (Option D), for 8 weeks. Following endoscopy, these patients can be fed within 24 hours and discharged from the hospital. This patient has a high-risk ulcer; after 72 hours of intravenous PPI treatment, he will require treatment with PPI orally twice daily for 2 weeks followed by once daily for an additional 6 weeks.
- Patients with ulcers at high risk for rebleeding (active bleeding, nonbleeding visible vessel, or adherent clot) should receive intravenous proton pump inhibitor (PPI) therapy for 72 hours, followed by an oral PPI twice daily for 8 weeks.
- Because of the higher costs associated with continuous infusion, twice-daily intravenous PPI therapy is preferable given the similar clinical efficacy for upper gastrointestinal bleeding.