1. Omeprazole before Endoscopy in Patients with Gastrointestinal Bleeding James Y. Lau, M.D., Wai K. Leung, M.D., Justin C.Y. Wu, M.D., Francis K.L. Chan, M.D., Vincent W.S. Wong, M.D., Philip W.Y. Chiu, M.D., Vivian W.Y. Lee, Ph.D., Kenneth K.C. Lee, Ph.D., Frances K.Y. Cheung, M.B., Ch.B., Priscilla Siu, B.Sc., Enders K.W. Ng, M.D., and Joseph J.Y. Sung, M.D. R1 Hwang Eun Jung N Engl J Med 2007;356:1631-40

2. Background High-dose proton-pump inhibitor after hemostasis Reduced recurrent bleeding Improved clinical outcomes The adjuvant use Clot formation over arteries : pH dependent A gastric pH > 6 : platelet aggregation

3. Before endoscopy A lack of evidence Early intravenous infusion of a high-dose proton pump inhibitor before endoscopy Therapeutic effect on bleeding ulcers Reduce the need for endoscopic therapy Improved clinical outcomes

4. Methods Overt signs of upper gastrointestinal bleeding (i.e., melena or hematemesis with or without hypotension) Hypotensive shock SBP ≤90 mm Hg, PR ≥110 beats per minute

5. Exclusion criteria Refractory shock Underwent urgent endoscopy Age <18 years of age : informed consent Pregnant; those with a known allergy to proton-pump inhibitors; Aspirin user regularly for cardiovascular protection

6. Study Procedures Omeprazole (Losec, Astra-Zeneca) or placebo An 80-mg IV bolus injection Continuous infusion of 8 mg per hour until endoscopic examination Urgent endoscopy Without stopping the omeprazole or placebo Ongoing bleeding Fresh hematemesis or hematochezia Hypotensive shock

7. At endoscopy Gastroduodenal ulcers with spurting hemorrhage, oozing hemorrhage, or non bleeding visible vessels → Epinephrine (dilution,1:10,000) Hemostasis Bleeding had stopped Bleeding vessels were flattened or cavitated

8. CLO test histologic examination Helicobacter pylori infection Bleeding esophageal and gastric varice band ligation and injection of a tissue adhesive Vasoactive drugs and intravenous antibiotics

9. Omeprazole (8 mg per hour)72 hours after endoscopy Ulcer hemostasis Recurrent bleeding Vomiting of fresh blood hypotensive shock SBP ≤90 mm Hg or PR≥110 beats/minute with melena after stabilization Hb ↓ >2 g/dL, Hct ↓ > 6% within 24 hours After a transfusion, Hb < 10g/dL

10. Urgent endoscopy Recurrent bleeding Actively bleeding (spurting or oozing hemorrhage) Fresh blood in the stomach A vessel at the ulcer base Clots overlying ulcers were lifted, and the base of the ulcer was examined Endoscopic therapy was repeated Surgical intervention

11. 72 hrs infusion of omeprazole → 40 mg of omeprazole orally per day for 8 weeks Positive rapid urease test for H. pylori 1-week course 20 mg of omeprazole twice daily 500 mg of clarithromycin twice daily 1 g of amoxicillin twice daily 40 mg of omeprazole per day for the remaining 7 weeks

12. End Points Our primary end point The first endoscopic examination. Secondary end points Signs of bleeding Need for urgent endoscopy Duration of hospital stay Transfusion Emergency surgery to achieve hemostasis Rates of recurrent bleeding Death from any cause within 30 days

13. Results

20. Conclusions Infusion of high-dose omeprazole before endoscopy accelerated the resolution of signs of bleeding in ulcers reduced the need for endoscopic therapy