Peptic Ulcer Bleeding in Patients With or Without Cirrhosis
Peptic Ulcer Bleeding in Patients With or Without Cirrhosis
Background Physiopathology and prognosis of peptic ulcer bleeding (PUB) have never been described in cirrhotic patients.
Aim To assess risk factors and outcome of PUB in two groups of patients with PUB with or without cirrhosis.
Methods We included prospectively all patients with PUB referred to our ICU of Hepatology and Gastroenterology between January 2008 and March 2011. All patients were treated according to international recommendations. Diagnosis of cirrhosis was based on clinical, biological and morphological exams. Aetiologies, characteristics and outcomes of PUB were compared in cirrhotic vs. noncirrhotic patients.
Results A total of 203 patients with PUB were included prospectively. Twenty-nine patients had cirrhosis (group Cirr+), and 174 patients had no cirrhosis (group Cirr−). Demographic data were similar between the two groups except for age and alcohol consumption. Aetiology of cirrhosis was alcohol in 97% of cirrhotic patients. Characteristics of PUB were not different between the two groups. Ninety-three per cent of patients with cirrhosis had endoscopic portal hypertension. Aetiology of PUB was different between the group Cirr+ and Cirr− (Helicobacter pylori = 10.3% vs. 48.8%, P < 0.0001; NSAID's = 17.2% vs. 54.0%, P < 0.0001; idiopathic PUB = 79.3% vs. 23.8%, P < 0.0001). Outcome was comparable concerning re-bleeding (7.0% vs. 6.9%, P = 0.31), need for arterial embolisation (10.3 vs. 8.6%, P = 0.76), need for salvage surgery (0 vs. 1.7%, P = 0.31) and mortality (3.0% vs. 1.1%, P = 0.87).
Conclusions Physiopathology of PUB seems to be different in patients with cirrhosis. In cirrhotic patients, PUB occurs almost only in alcoholics. In our series, prognosis was similar to general population. PUB in cirrhosis might be related to portal hypertension and/or alcohol.
Peptic ulcer bleeding (PUB) is the most common cause of upper gastrointestinal bleeding in the world. In general population, PUB is usually related either to Helicobacter pylori infection or to nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin. Peptic ulcer neither due to H. pylori nor to NSAIDs is habitually called 'idiopathic ulcers', and accounts for 4% of cases. High-risk PUB is defined by endoscopic features, on the basis of Forrest classification. High-risk lesions include ulcers with active bleeding (i.e. spurting or oozing haemorrhage, Forrest IA and IB respectively), with a nonbleeding visible vessel (Forrest IIA) and with an adherent clot (Forrest IIB). In a recent meta-analysis, major predictors for re-bleeding in patient with PUB were haemodynamic instability, active bleeding at endoscopy, large ulcer size, haemoglobin value and the need for transfusion. The reference treatment for high-risk PUB includes therapy with high-dose proton pump inhibitors (PPIs) started as soon as possible combined with a double endoscopic treatment. However, recent data suggest that a standard-dose regimen may be as effective as a high-dose regimen of PPIs after initial endoscopic therapy.
Many data are now available to indicate arterial embolisation in patients with PUB when medical and endoscopic treatment fails, and for some authors, surgery should be confined to arterial embolisation failure. Despite recent improvement in PUB management, mortality of PUB remains high, ranging from 5 to 10%.
Peptic ulcer bleeding accounts for 30% of causes of gastrointestinal bleeding in patients with cirrhosis, and for 50% of nonvariceal upper gastrointestinal bleeding. However, as opposed to variceal bleeding, physiopathology, treatment and prognosis of PUB have never been described in cirrhotic patients. In an observational study, the role of H. pylori infection seemed controversial in cirrhotic patients. Because cirrhosis is generally an exclusion criterion in randomised controlled trials concerning management of PUB, the efficacy of standard of care needs to be assessed in cirrhotic patients. Moreover, large studies describing prognosis of PUB treated according to actual recommendations are lacking.
Our 10-bed ICU of hepato-gastroenterology is devoted to patients with gastrointestinal bleeding, with or without cirrhosis. Treatment of PUB is standardised according to recent guidelines, and does not differ between cirrhotic and noncirrhotic patients. Therefore, the aim of this prospective study was to compare aetiologies and prognosis of PUB in patients with and without cirrhosis treated with the standard of care.
Abstract and Introduction
Abstract
Background Physiopathology and prognosis of peptic ulcer bleeding (PUB) have never been described in cirrhotic patients.
Aim To assess risk factors and outcome of PUB in two groups of patients with PUB with or without cirrhosis.
Methods We included prospectively all patients with PUB referred to our ICU of Hepatology and Gastroenterology between January 2008 and March 2011. All patients were treated according to international recommendations. Diagnosis of cirrhosis was based on clinical, biological and morphological exams. Aetiologies, characteristics and outcomes of PUB were compared in cirrhotic vs. noncirrhotic patients.
Results A total of 203 patients with PUB were included prospectively. Twenty-nine patients had cirrhosis (group Cirr+), and 174 patients had no cirrhosis (group Cirr−). Demographic data were similar between the two groups except for age and alcohol consumption. Aetiology of cirrhosis was alcohol in 97% of cirrhotic patients. Characteristics of PUB were not different between the two groups. Ninety-three per cent of patients with cirrhosis had endoscopic portal hypertension. Aetiology of PUB was different between the group Cirr+ and Cirr− (Helicobacter pylori = 10.3% vs. 48.8%, P < 0.0001; NSAID's = 17.2% vs. 54.0%, P < 0.0001; idiopathic PUB = 79.3% vs. 23.8%, P < 0.0001). Outcome was comparable concerning re-bleeding (7.0% vs. 6.9%, P = 0.31), need for arterial embolisation (10.3 vs. 8.6%, P = 0.76), need for salvage surgery (0 vs. 1.7%, P = 0.31) and mortality (3.0% vs. 1.1%, P = 0.87).
Conclusions Physiopathology of PUB seems to be different in patients with cirrhosis. In cirrhotic patients, PUB occurs almost only in alcoholics. In our series, prognosis was similar to general population. PUB in cirrhosis might be related to portal hypertension and/or alcohol.
Introduction
Peptic ulcer bleeding (PUB) is the most common cause of upper gastrointestinal bleeding in the world. In general population, PUB is usually related either to Helicobacter pylori infection or to nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin. Peptic ulcer neither due to H. pylori nor to NSAIDs is habitually called 'idiopathic ulcers', and accounts for 4% of cases. High-risk PUB is defined by endoscopic features, on the basis of Forrest classification. High-risk lesions include ulcers with active bleeding (i.e. spurting or oozing haemorrhage, Forrest IA and IB respectively), with a nonbleeding visible vessel (Forrest IIA) and with an adherent clot (Forrest IIB). In a recent meta-analysis, major predictors for re-bleeding in patient with PUB were haemodynamic instability, active bleeding at endoscopy, large ulcer size, haemoglobin value and the need for transfusion. The reference treatment for high-risk PUB includes therapy with high-dose proton pump inhibitors (PPIs) started as soon as possible combined with a double endoscopic treatment. However, recent data suggest that a standard-dose regimen may be as effective as a high-dose regimen of PPIs after initial endoscopic therapy.
Many data are now available to indicate arterial embolisation in patients with PUB when medical and endoscopic treatment fails, and for some authors, surgery should be confined to arterial embolisation failure. Despite recent improvement in PUB management, mortality of PUB remains high, ranging from 5 to 10%.
Peptic ulcer bleeding accounts for 30% of causes of gastrointestinal bleeding in patients with cirrhosis, and for 50% of nonvariceal upper gastrointestinal bleeding. However, as opposed to variceal bleeding, physiopathology, treatment and prognosis of PUB have never been described in cirrhotic patients. In an observational study, the role of H. pylori infection seemed controversial in cirrhotic patients. Because cirrhosis is generally an exclusion criterion in randomised controlled trials concerning management of PUB, the efficacy of standard of care needs to be assessed in cirrhotic patients. Moreover, large studies describing prognosis of PUB treated according to actual recommendations are lacking.
Our 10-bed ICU of hepato-gastroenterology is devoted to patients with gastrointestinal bleeding, with or without cirrhosis. Treatment of PUB is standardised according to recent guidelines, and does not differ between cirrhotic and noncirrhotic patients. Therefore, the aim of this prospective study was to compare aetiologies and prognosis of PUB in patients with and without cirrhosis treated with the standard of care.
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