Man With Melena and Epigastric Pain

A 67-year-old man is admitted to the hospital because of melena. During the past 24 hours, he has had 4 or 5 episodes of melena. He complains of moderate epigastric pain, but he has had no emesis.

HISTORY

In the weeks before this episode, he has had similar though less severe epigastric pain. He had a similar event, but with less passage of melena, 4 years earlier. At that time, he underwent endoscopy, and he recalls being told that he had “ulcers but no tumor.”

Since then, he has taken proton pump inhibitors intermittently, particularly when he experiences epigastric discomfort. In addition, he takes an angiotensin-converting enzyme inhibitor and a diuretic daily for long-term essential hypertension. He smokes cigars occasionally and does not drink alcohol.

PHYSICAL EXAMINATION

The patient appears pale. He is afebrile with a supine pulse of 104 beats per minute (bpm) and blood pressure of 95/70 mm Hg, which change to 120 bpm and 80/60 mm Hg when he is upright. There is no scleral icterus, but the mucosae are pale. The chest is clear, and the heart examination reveals tachycardia and a summation gallop.

Bowel sounds are audible. Moderate epigastric tenderness is noted on deep palpation, but there is no rebound. No hepatosplenomegaly is detected. The rectal examination results are normal, but grossly melanotic stool, which is strongly positive for occult blood, is present. The remainder of the physical examination is normal.

LABORATORY AND IMAGING RESULTS

White blood cell count is 14,300/µL; platelet count is normal. Hemoglobin level is 8.9 g/dL with a normal mean corpuscular volume. Liver function test results and prothrombin time are normal. Creatinine level is 1.0 mg/dL, and blood urea nitrogen (BUN) level is 28 mg/dL. An ECG shows sinus tachycardia and left ventricular
hypertrophy by voltage criteria with non-specific ST-T changes in leads I, aVL, and V₄ through V₆.

He is admitted to an ICU setting and receives fluid resuscitation and transfusion of packed red blood cells. An endoscopy is performed within 24 hours, which reveals a 1.5-cm ulcer on the lesser curvature with a visible vessel.

Which of the following statements about this patient’s management is most accurate?

A. Epinephrine injections alone are the optimal initial endoscopic therapy maneuver.

B. He will require endoscopy again at 72 hours, prior to discharge.

C. A regimen of proton pump inhibitors after endoscopy lessens the incidence of rebleeding.

D. Somatostatin therapy is routinely indicated after endoscopy to hasten healing.

(Answer on next page)

Correct Answer: C

This patient exhibits manifestations typical of bleeding peptic ulcer, a common and dramatic condition that accounts for roughly half of all episodes of upper gastrointestinal (GI) hemorrhage. This should be the presumed diagnosis here.

ENDOSCOPIC THERAPIES FOR UPPER GI BLEEDING

The prognosis overall for patients with bleeding peptic ulcer is quite good. Yet, despite all of the gains accrued in the knowledge of pathophysiology (ie, Helicobacter pylori), diagnostics (endoscopy), and therapeutics (proton pump inhibitors and endoscopy), the overall mortality remains little changed at 5% to 10%.^1,2 That said, once initial management (hemodynamic instability and volume issues) and triage and risk stratification using clinical variables have been performed, medical and endoscopic therapy techniques have evolved to prevent rebleeding and possibly address mortality.^2,3

Regarding endoscopic therapies, in addition to identifying “high-risk” lesions, such as spurting vessels, visible vessels, and adherent clots on vessels, the endoscopist is able to provide a variety of techniques to actually treat the lesion. These contemporary endoscopic treatments have been shown to reduce rebleeding rates, need for surgery, and mortality in the subset of high-risk patients. Epinephrine injection to constrict blood vessels (choice A) has been found to be inadequate (although superior to medical measures alone) when compared with clips, thermocoagulation, or sclerosing agents either alone or combined with epinephrine.^2-4 Thus, choice A, the use of epinephrine alone, is not correct here because it is not the optimal endoscopic maneuver.

A routine repeat endoscopy performed 24 hours later or before discharge was commonly done in the past.⁴ However, newer data resulting from the use of current effective medical therapies (see below) and the very effective modern endoscopy therapeutic techniques discussed above have shown essentially no benefit for routine repeat endoscopy in a broad population of patients and is not recommended.⁴ Routine repeat endoscopy also adds great cost. Thus, choice B is not correct.

MEDICAL THERAPIES FOR UPPER GI BLEEDING

In addition to endoscopic therapy techniques, a variety of medical maneuvers have been evaluated in upper GI bleeding. The most effective is the use of modern, high-potency acid suppressive therapy with proton pump inhibitors (eg, pantoprazole). These agents have been shown to decrease the incidence of ulcer rebleeding, need for urgent surgery, and mortality.^2,4,5 The mortality benefit is seen in patients with high-risk stigmata who have received endoscopic therapy, thus reinforcing the primary role of endoscopic therapy in these cases.

Many regimens regarding specific dosages and routes of proton pump inhibitors have been evaluated. A reasonable consensus is that an intravenous bolus followed by continuous infusion acutely (during the endoscopy period) with a daily single-dose oral proton pump inhibitor prescribed at discharge is the optimal regimen, making choice C correct here.

Somatostatin (choice D) reduces gastroduodenal blood flow and is used in variceal bleeding and portal hypertension situations. However, trials in the peptic ulcer setting have not shown additional efficacy to the techniques discussed here.⁶ Thus, choice D is not correct.

OUTCOME OF THIS CASE

During endoscopy, the patient was treated with contact thermal coagulation. He also received intravenous proton pump inhibitor therapy while in the hospital. His hemoglobin level remained stable, and he was discharged on day 4 on a regimen of pantoprazole once daily. At 3 months he was well without recurrent symptoms or bleeding.