Other Treatments for Bleeding Ulcers

In the early part of the 20th century, when stress and diet were judged to be important factors for peptic ulceration, patients with peptic ulcers were treated with hospitalization, bed rest, and the prescription of “bland” diets. By the 1950s, investigators and clinicians had focused their attention primarily on the role of gastric acid, and antacid therapy had become the treatment of choice for peptic ulcer disease. Antacids given at very high doses healed about 80% of duodenal ulcers after 4 weeks of therapy.

The histamine H2 receptor blockers cimetidine became available for clinical use in 1977. H2 receptor antagonists produced good ulcer healing rates, ranging from 80% to 95%, after 6 to 8 weeks of therapy. Subsequently other H2 receptor blockers like ranitidine, famotidine and nizatidine were used. With the advent of proton pump inhibitors (PPIs) in the 1980s, even more potent acid suppression and higher rates of ulcer healing could be achieved. Although most acute peptic ulcerations healed with acid suppression therapy, the majority of patients experienced recurrences within 1 year of discontinuing treatment with antacids or antisecretory agents alone.

The discovery of the link between Helicobacter pylori and peptic ulcer by Marshall and Warren in the mid-1980s led to another revolution in ulcer therapy. Now there is overwhelming evidence to support H. pylori infection as the most important cause of duodenal and gastric ulcers worldwide. Curing the infection not only heals peptic ulcer but also prevents ulcer relapse.

Although hospitalizations for uncomplicated peptic ulcers in western countries had begun to decline by the 1950s, there was an increase in admissions for ulcer hemorrhage and perforation among the elderly. This increase has been attributed to the greater use of non-steroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin. In the United States, use of prescription NSAIDs accounts for about 25% of all reported adverse drug reactions. Cotherapy with antiulcer drugs and the replacement of NSAIDs with cyclooxygenase-2 (COX-2) inhibitors have become acceptable treatments for patients who are at risk for peptic ulcer disease.

Endoscopic therapy has been shown to reduce rebleeding, surgery and death among patients with bleeding peptic ulcers. Saline injection, epinephrine and thermal coagulation are used during endoscopic therapy to treat bleeding peptic ulcers. Between 5% and 10% of patients who present with acute upper gastrointestinal bleeding will require surgery because of continued or recurrent bleeding.