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MANAGEMENT OF ACUTE PEPTIC ULCER BLEEDING: A NATIONWIDE CANADIAN SURVEY
G Sawisky, J Cheung, R Enns, M Byrne, N Marcon, C Wong Department of Medicine, Division of Gastroenterology, University of Alberta, Edmonton, AB
AIM: To determine the current Canadian practice patterns in the management of acute peptic ulcer disease (PUD) bleeding.
METHODS: A survey was mailed out to all gastroenterologists registered with the provincial Royal College of Physicians and Surgeons in February 2007. The survey consisted of demographic questions and questions related to the management of acute peptic ulcer bleeding.
RESULTS: The response rate was 54.4% (N = 288 out of 530). Sixty two percent (62%) were University-affiliated gastroenterologists. For patients presenting with a possible stable PUD bleed, 50% of gastroenterologist would intially treat with IV proton-pump inhibitor (PPI) infusion, while 39.9% would treat with either PO PPI or IV bolus PPI. For patients with possible unstable PUD bleed, 92% would treat with IV PPI infusion. For post-endoscopic therapy acid suppression of high risk ulcers, 93.8% would treat with IV PPI infusion. However, only 68.4% believed that IV PPI infusion was definitely superior to PO PPI post-endoscopic therapy. Many gastroenterologists (43%) routinely use large volume (>10cc) vs small volume (<10cc) during injection therapy. A minority (6.9%) felt that that endoclips were superior to combination injection/coagulation therapy for most lesions and 30.5% for select lesions; while 36.8% felt that it was not superior and 21.9% were unsure. For the management of adherent clots, only 10% would not remove or treat the clot endoscopically. Many gastroenterologist (57%) do not perform routine relook endoscopy on high risk ulcers, but 12.5% do routinely, and 24% do only if there are high risk comorbidities. In the post-myocardial infarction setting, only 8% would restart aspirin (ASA) post-high risk ulcer bleeding within 3days, while 22% would wait 3-7days, 27.5% 1-2 weeks, 13.8% 2-4 weeks, 8.3% >4wks, and 12.1% would repeat endoscopy before restarting ASA.
CONCLUSIONS: Variable practice appears to exist in the management of acid suppression of stable patients presenting with possible ulcer bleeding, the use of large volume of injection therapy, the benefit of endoclip therapy and the timing of restarting aspirin post-high risk ulcer bleeding. Further studies and guidelines may be needed to address these areas.