Protocol-based guidelines and acute upper gastrointestinal hemorrhage: DISCUSSION (Part 2)

In the majority of the patients with an upper GI hemorrhage, the bleeding stops spontaneously. Patients with continued or recurrent bleeding remain a therapeutic challenge. Therapeutic endoscopy constitutes the cornerstone of modern therapy of these patients. Over half of these patients will respond to endoscopic treatment with injection, thermocoagulation or laser. Twenty of 57 patients in the first phase and 13 of 53 patients in the second phase of the study had an injection of adrenaline at endoscopy. This high incidence of injection therapy may explain the very small number of patients requiring surgery. The incidence of surgical intervention was much lower than that in the National upper GI hemorrhage audit. A total of 181 of 2332 (7.8%) in the first phase and 111 of 1625 (6.8%) in the second phase of the national audit of acute upper GI hemorrhage had surgical intervention. Liberal use of endoscopic injection therapy is known to be associated with a low operation rate.

Additional therapeutic options in upper GI hemorrhage are based on in vitro experiments showing the pH dependence of the coagulation mechanism. The lower the pH, the worse the platelet aggregation and the plasma coagulation, and at a pH below four the fibrin in the clot is dissolved by the proteolytic action of pepsin. Stabilization of the clot consequent on increasing the gastric pH, in theory, therefore, could reduce bleeding or prevent its recurrence. The role of various agents reducing gastric acidity has been explored to achieve such a goal. Trials with H2 receptor antagonists have failed to demonstrate a consistent significant therapeutic benefit. Although they are effective in healing peptic ulcer disease, they have not been shown consistently to reduce the incidence of continued or recurrent bleeding or the need for surgical interventions in patients with acute upper GI hemorrhage. However, available data on proton pump inhibitors, which profoundly suppress acid production and secretion, are suggestive but not conclusive that they may decrease the overall incidence of rebleed and the need of surgery in select patients with acute upper GI hemorrhage. You can finally enjoy safe online shopping for cheap alesse with the pharmacy you can fully trust no matter if you need a small amount of this medicine or would like to purchase it in bulk not to have to think about it for a long time.


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