Non-Variceal Bleeds

Proton Pump Inhibitors (PPIs)

PPIs such as omeprazole are widely used. Theoretically they reduce bleeding by increasing the pH of the normally acidic gastric environment, leading to clot stability.

Post-endoscopy they have been shown to reduce the rebleeding rate and need for surgery but have no effect on overall mortality. [11]

Evidence for their use before endoscopy is conflicting. A Cochrane review found treatment probably reduced the need for endoscopic treatment of bleeding but had no effect on mortality or other outcomes. [12]

NICE advise that PPI therapy should not be given pre-endoscopy. [1]

Learning Bite

Whilst PPIs are commonly used in the management of upper GI bleeds, there is little evidence to support their use in the emergency department.

Antifibrinolytic Therapy

The HALT-IT trial was published in 2020 and looked at the effectives of high-dose 24-hour infusion of tranexamic acid (TXA) in patients with acute HI bleeding. 12,009 patients were randomised to TXA or placebo. They found no difference between the groups in the primary outcome of death from bleeding within 5 days, and no significant differences in any of the secondary outcomes, other than an increase in venous thromboembolic events in the TXA group. [13]

It’s important to remember though that only patients where the treating clinician was uncertain as to the benefits of TXA were enrolled, and so TXA could still be considered in patients with massive haemorrhage in line with local practice.