Management in Peptic Ulcer Hemorrhage:A Dutch National Inquiry

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Abstract
Background and Study Aims: There is no consensus as to what endoscopic hemostatic therapy and pharmacotherapy should be used in peptic ulcer hemorrhage (PUH). We conducted a mail survey to investigate current management of ulcer hemorrhage in the Netherlands. Methods: A questionnaire was sent to gastroenterologists or, if not present, to internists, performing endoscopies, in every hospital in the Netherlands (n = 123). Endoscopic hemostatic therapy, pharmacotherapy, endoscopic reintervention, and management of Helicobacter pylori were evaluated. Results: 90/123 (73 %) questionnaires were returned. Endoscopic hemostatic therapy is given in ulcers classified as Forrest Ia, Ib, IIa, IIb, and IIc by, respectively, 89 %, 93 %, 83 %, 47 %, and 19 % of respondents. Gastroenterologists perform endoscopic therapy more often in Forrest Ib (P = 0.03), IIa (P = 0.002), and IIb (P = 0.001) ulcers when compared with internists. Endoscopic injection therapy is used by 93 % of respondents as first modality. Epinephrine combined with polidocanol is most commonly used (60 %). Pharmacotherapy is given by 97 %. A total of 71 % use proton pump inhibitors (PPIs), and 26 % use H2-receptor antagonists (H2RAs), both mainly initially given intravenously. In case of suspected rebleeding, endoscopic reintervention is performed by 76 %, including a significantly greater percentage of gastroenterologists (89 % of gastroenterologists vs. 60 % of internists, P = 0.005), whereas the others refer the patient directly for surgery. Almost all respondents investigate for H. pylori. Eradication is confirmed by only 64 % (80 % of gastroenterologists vs. 50 % of internists, P = 0.004). Conclusions: There are important differences in management of peptic ulcer hemorrhage between gastroenterologists and internists in the Netherlands. Management is only partly in accordance with evidence-based medicine.

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