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Three Part Question

Does [intravenous omeprazole] lead to [a decrease in the rebleeding rate] for [patients with suspected gastrointestinal bleeding in the emergency department]?

Clinical Scenario

A 55 year-old woman presents to the emergency department with fresh malaena. She is haemodynamically unstable. You wonder whether early use of intravenous omeprazole (prior to endoscopy) could reduce her rebleeding rate after emergency upper gastrointestinal endoscopy.

Search Strategy

Medline searched from 1997 to May week 1 2008 using the OVID interface:
[exp Omeprazole/] AND [exp Gastrointestinal Hemorrhage/ OR exp Peptic Ulcer/ OR exp Stomach Ulcer/] AND [exp Endoscopy/ OR exp Endoscopy, Gastrointestinal/ OR exp Endoscopy, Digestive System/] LIMIT to humans (adults>18 years) AND English AND randomized controlled trial.

Search Outcome

87 papers found of which 86 were irrelevant or of insufficient quality for inclusion. The one relevant paper is shown as follows. No additionally relevant reports were found in the Cochrane Library or the Database of Abstracts of Reviews of Effects.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
JY Lau et al 2007 HKSAR	638 GIB patients divided into two groups before endoscopy, omeprazole (bolus of 80mg omeprazole followed by infusion of 8mg/hr until endoscopy) vs placebo	Double-blinded RCT (level of evidence 1+)	Need for endoscopic haemostasis	19.1% vs 28.4% (P=0.007)	Relatively high-risk patients are excluded, no formal cost analysis performed
			Recurrent bleeding rate	3.5% vs 2.5% (P=0.49)

Comment(s)

This single study is from Hong Kong which may limit its potential usefulness in other global regions. Intravenous omeprazole does not reduce the rebleeding rate and there is no evidence that it improves mortality. It does appear to reduce the hospital length of stay and accelerates resolution of stigmata of bleeding in ulcers and it reduced the requirement for endoscopic therapy.

Clinical Bottom Line

High dose intravenous omeprazole, when used before endoscopic haemostasis in patients with upper gastrointestinal haemorrhage, does not decrease rebleeding or mortality. There is currently insufficient evidence to support the routine use of intravenous omeprazole pre-endoscopy.

References

1. Lau JY, Leung WK, Wu JC, Chan FK, Wong VW, Chiu PW, Lee VW, Lee KK, Cheung FK, Siu P, Ng EK, Sung JJ Omeprazole before endoscopy in patients with gastrointestinal bleeding New England Journal of Medicine 2007;356:1631-40