Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding

B a c k g r o u n d There is conflicting evidence regarding the clinical efficacy of proton pump inhibitors (PPI) initiated prior to endoscopy in patients with upper gastrointestinal bleeding. O b j e c t i v e s We aimed to systematically review evidence from randomised controlled trials (RCTs) that studied PPI treatment initiated before endoscopy in patients with upper gastrointestinal bleeding. S e a r c h s t r a t e g y A search was undertaken according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model using CENTRAL, ( T h e C o c h r a n e L i b r a r y), MEDLINE, EMBASE and CINAHL databases and major conference proceedings up to September 2005. The literature search was re-run in February 2006. S e l e c t i o n c r i t e r i a T y p e s o f s t u d i e s Randomised controlled trials (RCTs). T y p e s o f p a r t i c i p a n t s Hospitalised patients with unselected upper gastrointestinal bleeding T y p e s o f i n t e r v e n t i o n s Active treatment with a PPI (oral or intravenous) and control treatment with either placebo or an histamine-2 receptor antagonist (H2RA). T y p e s o f o u t c o m e m e a s u r e s Assessed at 30 days: mortality, rebleeding and surgery. Also assessed were stigmata of recent haemorrhage at index endoscopy, length of hospital stay and blood transfusion requirements. D a t a c o l l e c t i o n a n d a n a l y s i s At least two reviewers assessed the eligibility criteria of each study and extracted data regarding outcomes and factors affecting methodological quality. M a i n r e s u l t s Five RCTs were included for review. No further RCTS were identified in an updated literature search. Four trials comprising a total of 1512 patients in total reported data for all randomised patients. There was no statistical heterogeneity among trials for the outcomes of mortality, rebleeding and surgery. There were no statistically significant differences in rates of mortality, rebleeding or surgery between PPI and control treatment. Pooled mortality rates were 6.1% and 5.5% respectively ( odds ratio ( OR) 1.12; 95% CI 0.72 to 1.73).Pooled rebleeding rates were 13.9% and 16.6% respectively (OR 0.81; 95% CI 0.61 to 1.09). Pooled rates for surgery were 9.9% and 10.2% respectively (OR 0.96 95% CI 0.68 to 1.35). PPI treatment compared to control significantly reduced the proportion of patients with stigmata of recent haemorrhage at index endoscopy; pooled rates were 37.2% and 46.5% respectively (OR 0.67; 95% CI 0.54 to 0.84). For the continuous outcomes, namely length of hospital stay and blood transfusion requirements, quantitative analysis could not be performed. A u t h o r s' c o n c l u s i o n s PPI treatment initiated prior to endoscopy in patients with upper gastrointestinal bleeding significantly reduces the proportion of patients with stigmata of recent haemorrhage at index endoscopy. However, there is no evidence that PPI treatment affects clinically important outcomes, namely mortality, rebleeding or need for surgery.