J Med Assoc Thai 2016; 99 (9):988

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Comparison of High Dose and Standard Dose Proton Pump Inhibitor before Endoscopy in Patients with Non-Portal Hypertension Bleeding
Rattanasupar A Mail, Sengmanee S

Background: Gastrointestinal bleeding with non-portal hypertension bleeding (non-PHT) is the most common cause of gastrointestinal emergencies with high mortality rate. The majority of non-PHT patient stem from acid related disease. The practice guideline recommends using pre-endoscopic proton pump inhibitors (PPIs). However, the dose and route of PPIs administration were still unclear according to the Association for Gastroenterology.

Objective: To compare the efficiency of PPIs between high dose and standard dose before endoscopy in patients suffering with gastrointestinal bleeding due to non-PHT.

Material and Method: The present study was designed as a prospective, randomized controlled trial. The patients were randomly categorized into two groups, the first group received intravenous pantoprazole 80 mg bolus then continuously drip 8 mg per hour (high dose group) and the other group received intravenous pantoprazole 40 mg twice daily before endoscopy (standard dose group). Baseline characteristics, Blatchford score, endoscopic findings, morbidity, and other complications were recorded.

Results: One hundred thirteen patients were recruited. Fifty-eight patients were in the high dose group and 55 patients in the standard dose group. Blatchford scores in the high dose group were slightly higher than the standard dose group but there was no statistically significant difference (12.49+3.29 and 12.38+4.06, respectively, p = 0.876). Twenty-two patients were high-risk for peptic ulcer bleeding from endoscopy. There were significantly less numbers of patient who were high-risk of peptic ulcer bleeding in the high dose group compared to the standard dose group (10 patients [17.24%] and 12 patients [21.82%], respectively, p = 0.025). There was no difference between the two groups in average time of hospital stay (3.03 and 2.89 days, respectively, p>0.05), mean unit of blood transfusion (1.79 and 1.63 units, respectively, p>0.05), and the complications after endoscopy such as recurrent bleeding (0 and 1 patient, respectively, p>0.05), recurrent bleeding and death (0 and 1 patient, respectively, p>0.05). The Blatchford score greater than 10, 11, and 12 showed high sensitivity of 100%, 95%, and 95% respectively with negative predictive values (NPV) of 100%, 97%, and 97% respectively, in predicting high-risk peptic ulcer bleeding.

Conclusion: The high dose of PPIs administration before endoscopy reduced the chance of high-risk peptic ulcer bleeding compared to the standard dose. Both high dose and standard dose of PPIs did not affect the time of hospital stay, unit of blood transfusion, the complications after endoscopy, and mortality rate. Standard dose PPIs can be considered using in patients with Blatchford scores lower than 10. High dose PPIs would be beneficial in patients who have Blatchford scores between 10 and 12. For patients who have Blatchford scores greater than 12, high dose PPIs are recommended.

Keywords: Peptic ulcer bleeding, Proton pump inhibitors before endoscopy, Blatchford score

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