Older Man With Epigastric Pain and Melena
A 64-year-old man has experienced melena 4 or 5 times in the previous
24 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 less melena. He underwent endoscopy and was told he had ulcers but no tumor. Since then, he has taken H2-blockers intermittently, particularly when he experiences epigastric discomfort. He takes an angiotensin-converting enzyme inhibitor and a diuretic daily for essential hypertension. He smokes cigars occasionally and does not drink alcohol(.PHYSICAL EXAMINATION
The patient appears pale; he is afebrile. Supine heart rate is 104 beats per 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 is clear. Tachycardia and a summation gallop are noted. Bowel sounds are audible. Deep palpation reveals moderate epigastric tenderness but no rebound; there is 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. Hemoglobin is 9.2 g/dL with normal mean corpuscular volume. Liver function tests and prothrombin time are normal. ECG reveals sinus tachycardia and left ventricular hypertrophy 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 complications is the patient's age.B. Aggressive, early, high-dose H2-receptor antagonist therapy effectively prevents rebleeding in the first 72 hours.C. Endoscopy to assess the appearance of the ulcer can reveal prognostic features that aid in acute management.D. Gastric lavage neither stops active bleeding nor prevents recurrent bleeding.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 episodes of upper GI tract hemorrhage. The prognosis for most patients with peptic ulcer disease (PUD) is good. Yet despite advances in the knowledge of pathophysiology (ie, the discovery of H pylori as a causative agent) and the use of endoscopy for diagnosis, prognosis, and therapy, mortality from the disease remains little changed at 6% to 7%.1This man's GI hemorrhage manifested as melena, which occurs in about 20% of patients with bleeding peptic ulcers. Another 30% have hematemesis, while the remaining 50% present with both conditions.1 This patient's history of recurrence is typical and was common before effective therapy to eradicate H pylori was introduced. Clinical features remain the most important indicators of poor outcomes (eg, the need for urgent surgery, death) in patients with PUD. This patient has several of these indicators: severe bleeding that requires urgent endoscopy, hemodynamic instability, and low hemoglobin level. Even so, the most important prognostic indicator here is the patient's age-64 years (choice A). Patients older than 60 years are significantly more likely to have a poor outcome. In a large study of more than 700 patients with bleeding ulcers, mortality in patients under and over 60 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 ulcer size greater than 1 to 2 cm, stigmata of recent hemorrhage (eg, an adherent clot or pigment spots), and visible vessels that are associated with an increased risk of rebleeding and death. These findings can thus guide decisions regarding use of endoscopic epinephrine( and coagulation, intensive care placement, and discharge (choice C). The time-honored maneuver of gastric lavage helps determine whether hemorrhage is proximal to the ligament of Treitz and can confirm severe bleeding and a high risk of rebleeding-which are indicated by failure to clear. However, gastric lavage does not stop bleeding or prevent recurrences (choice D). Treatment of risk factors diminishes the recurrence of PUD and, by inference, reduces bleeding complications as well. The most prevalent and reversible risk factors for PUD are NSAID use and H pylori infection. NSAIDs should be discontinued; if H pylori infection is detected by endoscopic testing, it should be eradicated (choice E).4Surprisingly, H2-receptor antagonists are not effective in preventing rebleeding in patients with acute bleeding PUD. The reduction in gastric acidity that these agents promote was thought to constitute significant local therapy in such patients because a pH of more than 6 appears to be necessary for platelet aggregation and fibrin clot formation. Yet many studies have failed to show that H2-receptor antagonists significantly decrease rebleeding in the traditional 72-hour window.5 Thus, H2-receptor antagonist therapy is not indicated for prevention of rebleeding (and, by inference, death) in this setting, although its use for long-term healing is appropriate. Recent studies have shown that parenteral proton pump inhibitors (PPIs) are effective in acute management, perhaps because these agents work faster than H2-receptor antagonists and raise gastric pH to high levels.5 The effectiveness of oral PPIs available in the United States is being studied. Outcome of this case. Urgent endoscopy revealed an 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 symptoms or bleeding.
A similar episode occurred 4 years earlier; however, there was less melena. He underwent endoscopy and was told he had ulcers but no tumor. Since then, he has taken H2-blockers intermittently, particularly when he experiences epigastric discomfort. He takes an angiotensin-converting enzyme inhibitor and a diuretic daily for essential hypertension. He smokes cigars occasionally and does not drink alcohol(.PHYSICAL EXAMINATION
The patient appears pale; he is afebrile. Supine heart rate is 104 beats per 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 is clear. Tachycardia and a summation gallop are noted. Bowel sounds are audible. Deep palpation reveals moderate epigastric tenderness but no rebound; there is 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. Hemoglobin is 9.2 g/dL with normal mean corpuscular volume. Liver function tests and prothrombin time are normal. ECG reveals sinus tachycardia and left ventricular hypertrophy 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 complications is the patient's age.B. Aggressive, early, high-dose H2-receptor antagonist therapy effectively prevents rebleeding in the first 72 hours.C. Endoscopy to assess the appearance of the ulcer can reveal prognostic features that aid in acute management.D. Gastric lavage neither stops active bleeding nor prevents recurrent bleeding.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 episodes of upper GI tract hemorrhage. The prognosis for most patients with peptic ulcer disease (PUD) is good. Yet despite advances in the knowledge of pathophysiology (ie, the discovery of H pylori as a causative agent) and the use of endoscopy for diagnosis, prognosis, and therapy, mortality from the disease remains little changed at 6% to 7%.1This man's GI hemorrhage manifested as melena, which occurs in about 20% of patients with bleeding peptic ulcers. Another 30% have hematemesis, while the remaining 50% present with both conditions.1 This patient's history of recurrence is typical and was common before effective therapy to eradicate H pylori was introduced. Clinical features remain the most important indicators of poor outcomes (eg, the need for urgent surgery, death) in patients with PUD. This patient has several of these indicators: severe bleeding that requires urgent endoscopy, hemodynamic instability, and low hemoglobin level. Even so, the most important prognostic indicator here is the patient's age-64 years (choice A). Patients older than 60 years are significantly more likely to have a poor outcome. In a large study of more than 700 patients with bleeding ulcers, mortality in patients under and over 60 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 ulcer size greater than 1 to 2 cm, stigmata of recent hemorrhage (eg, an adherent clot or pigment spots), and visible vessels that are associated with an increased risk of rebleeding and death. These findings can thus guide decisions regarding use of endoscopic epinephrine( and coagulation, intensive care placement, and discharge (choice C). The time-honored maneuver of gastric lavage helps determine whether hemorrhage is proximal to the ligament of Treitz and can confirm severe bleeding and a high risk of rebleeding-which are indicated by failure to clear. However, gastric lavage does not stop bleeding or prevent recurrences (choice D). Treatment of risk factors diminishes the recurrence of PUD and, by inference, reduces bleeding complications as well. The most prevalent and reversible risk factors for PUD are NSAID use and H pylori infection. NSAIDs should be discontinued; if H pylori infection is detected by endoscopic testing, it should be eradicated (choice E).4Surprisingly, H2-receptor antagonists are not effective in preventing rebleeding in patients with acute bleeding PUD. The reduction in gastric acidity that these agents promote was thought to constitute significant local therapy in such patients because a pH of more than 6 appears to be necessary for platelet aggregation and fibrin clot formation. Yet many studies have failed to show that H2-receptor antagonists significantly decrease rebleeding in the traditional 72-hour window.5 Thus, H2-receptor antagonist therapy is not indicated for prevention of rebleeding (and, by inference, death) in this setting, although its use for long-term healing is appropriate. Recent studies have shown that parenteral proton pump inhibitors (PPIs) are effective in acute management, perhaps because these agents work faster than H2-receptor antagonists and raise gastric pH to high levels.5 The effectiveness of oral PPIs available in the United States is being studied. Outcome of this case. Urgent endoscopy revealed an 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 symptoms or bleeding.
References
1. Laine L, Peterson W. Bleeding peptic ulcer. N Engl J Med. 1994;331:717-727.
2. Branicki FJ, Coleman SY, Fok PJ, et al. Bleeding peptic ulcer: a prospective evaluation of risk factors for rebleeding and mortality. World J Surg. 1990;14:262-270.
3. Khuroo MS, Yattoo GN, Javid G, et al. A comparison of omeprazole and placebo for bleeding peptic ulcer. N Engl J Med. 1997;336:1054-1058.
4. Libby ED. Omeprazole to prevent recurrent bleeding after endoscopic treatment of ulcers. N Engl J Med. 2000;343:358-359.
5. Lau JYW, Sung JJY, Lee KKC, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Engl J Med. 2000;343:310-316.