What are the WSES guidelines for the diagnosis and treatment of bleeding peptic ulcers?

Updated: Apr 26, 2021
  • Author: BS Anand, MD; Chief Editor: Philip O Katz, MD, FACP, FACG  more...
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Answer

Bleeding peptic ulcer clinical practice guidelines were released in January 2020 by the World Society of Emergency Surgery. [68]

The recommended biochemical and imaging/procedural investigations in the diagnosis of suspected bleeding peptic ulcer are as follows:

  • Blood-typing; hemoglobin, hematocrit, and electrolyte values; and coagulation assessment

  • Performing endoscopy as soon as possible, particularly in high-risk patients (Management decisions can be guided based on the damage noted from recent hemorrhage during endoscopy, as this can help predict further bleeding risk.)

The recommended parameters for evaluation at emergency department referral and the criteria for defining an unstable patient are as follows:

  • Rapid, careful medical/surgical evaluation to prevent further bleeding and reduce mortality

  • Upon emergency department referral, evaluation of signs, symptoms, and laboratory findings to assess stability versus instability

  • Evaluation according to Rockall and Glasgow-Blatchford scoring systems to assess disease severity and guide therapy

The recommended nonoperative and endoscopic strategies in patients with bleeding peptic ulcer are as follows:

  • Nonoperative management as first-line management after endoscopy

  • Endoscopic treatment to achieve hemostasis and to help prevent rebleeding, the need for surgery, and mortality

  • Administration of pre-endoscopy erythromycin

  • Initiation of proton-pump inhibitor therapy as soon as possible

  • Post successful endoscopic hemostasis, high-dose proton-pump inhibitor therapy as a continuous infusion for the first 72 hours

  • Proton-pump inhibitor therapy for 6-8 weeks following endoscopic treatment (Long-term proton-pump inhibitor therapy is not recommended except in patients with ongoing NSAID use.)

Indications for surgical treatment and the appropriate approach for surgery in patients with bleeding peptic ulcer are as follows:

  • Surgical hemostasis, or, if equipment and qualified personnel are available, angiographic embolization, after failure of repeated endoscopy

  • Refractory bleeding peptic ulcer: Surgical intervention with open surgery

  • Intraoperative endoscopy to facilitate localization of the bleeding site

Indications for antimicrobial therapy and for Helicobacter pylori testing in patients with bleeding peptic ulcer are as follows:

  • Empirical antimicrobial therapy not recommended

  • H pylori testing in all patients

  • If positive for H pylori, eradication therapy recommended

  • First-line eradication therapy: Standard triple therapy (ie, amoxicillin, clarithromycin, proton-pump inhibitor)

  • First-line therapy if high clarithromycin resistance detected: Ten-day sequential therapy with four drugs (ie, amoxicillin, clarithromycin, metronidazole, proton-pump inhibitor)

  • Second-line therapy if first-line failed: Ten-day levofloxacin-amoxicillin triple therapy

  • Start standard triple therapy after 72-96 hours of intravenous proton-pump inhibitor, for 14-day duration


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