This finding was confirmed in a subsequent meta-analysis which
pooled data from five randomized controlled trials,16 that proton pump inhibitor treatment reduces the proportion of patients with stigmata of recent hemorrhage at index endoscopy. However, there is no evidence that this treatment affects clinically important outcomes. Therefore, this strategy of pre-endoscopy proton pump inhibitor should be evaluated based on the cost-effectiveness Deforolimus analysis. When the cost-effective ratios and incremental cost-effectiveness ratio (ICER) was analyzed using a decision model, it was found that pre-emptive treatment with proton pump inhibitor is more effective and less costly for the management of upper gastrointestinal bleeding.17 The upfront cost of proton pump inhibitor is balanced by the subsequent saving in the shortened duration of hospitalization in these patients. Pre-emptive use of intravenous proton pump inhibitor is therefore considered a cost-effective strategy. Albeit the high success of combined endoscopic and pharmacologic control of upper gastrointestinal bleeding, there are some 10–15% of patients who fail respond to initial hemostatic treatment or develop recurrent bleeding after initial
success in hemostasis. Should these patients be given further attempts of endoscopy or should they be considered for surgery? Cohorts studies indicate that delayed surgery would lead to higher mortality as patients are suffering from prolonged hypovolemia and hemodynamic instability. Would repeated attempts of non-surgical treatment www.selleckchem.com/products/BIBW2992.html deprive patients from the best treatment for bleeding control, namely surgical suturing of the bleeding vessel? This question was addressed by a prospective randomized study from Hong Kong, which randomized patients who failed to respond to initial endoscopic hemostasis or suffered recurrent bleeding within 48 h of endoscopy to receive either
surgery or a second attempt of endoscopic therapy.18 In this study, in which 48 patients received endoscopic re-treatment and 44 patients received ulcer surgery, Pyruvate dehydrogenase the results showed that both approaches have pros and cons. The overall success in endoscopic hemostasis was 75%, lower than that of surgical treatment (93%), while over-enthusiastic endoscopic treatment led to perforations. However, surgically treated patients suffered from more peri-operative complications including complications arising from anesthesia or the surgical wound. Therefore, the study concluded that neither of these two approaches is suitable for all patients. Clinical discretion is important in the management of these patients. However, based on the large clinical cohort in this study, patients with hypotension at presentation, hemoglobin level less than 10 g/dL on admission, fresh blood in the stomach, ulcer larger than 2 cm or with active bleeding are the independent risk factors for recurrent bleeding.