H. pylori infection and NSAIDs are the major causes of peptic ulcer bleeding in the United States; therefore, preventive strategies should focus on these etiologies. Smoking and alcohol use impair ulcer healing, and patients should be counseled about smoking cessation and moderation of alcohol use. A systematic review of 41 randomized controlled trials of patients taking NSAIDs found that double-dose H 2 receptor antagonists (relative risk [RR] = ) and PPIs (RR = ) significantly reduced the risk of peptic ulcer bleeding. 27 In patients with a history of peptic ulcer bleeding, aspirin, clopidogrel, and NSAIDs should be avoided if possible. In patients taking aspirin who develop peptic ulcer bleeding, aspirin therapy with PPI therapy should be restarted as soon as the risk of cardiovascular complication is thought to outweigh the risk of rebleeding. 1 A Cochrane review of seven studies of 578 patients with peptic ulcer bleeding concluded that eradication of H. pylori infection reduced the long-term rate of rebleeding ( percent) compared with patients in the noneradication group (20 percent; number needed to treat = 7). 28 In patients with peptic ulcer bleeding associated with H. pylori infection, eradication is essential and should be confirmed by urea breath test, stool antigen test, or biopsy urease test. 1 A repeat upper endoscopy in eight to 12 weeks is recommended for patients with peptic ulcer bleeding secondary to gastric ulcers to assess for healing and to exclude malignancy, and for patients with severe esophagitis to exclude Barrett esophagus.
The incidence of MIs and strokes is high in persons 80 years and older, and thus the potential benefit of aspirin is large. The relationship between increasing age and GI bleeding is also well established and thus the potential harms are also large. The net benefit of aspirin use in persons 80 years and older is probably best in those without risk factors for GI bleeding (other than older age) and in those who could tolerate a GI bleeding episode (., those with normal hemoglobin levels, good kidney function, or easy access to emergency care). Physicians should inform patients about the adverse consequences of GI bleeding because these events might be mitigated by early recognition of the signs and symptoms of bleeding (., dark stools, vomiting blood, bright red blood per rectum, syncope, and lightheadedness). If physicians decide to prescribe aspirin in adults 80 years and older, they should do so only after a discussion with the patient that includes the potential harms and uncertain benefits.
Variceal wall tension is probably the main factor that determines variceal rupture. Vessel diameter is one of the determinants of variceal tension. At an equal pressure, a large diameter vessel will rupture while a small diameter vessel will not rupture (37). Besides vessel diameter, one of the determinants of variceal wall tension is the pressure within the varix, which is directly related to the HVPG. Therefore, a reduction in HVPG should lead to a decrease in variceal wall tension, thereby decreasing the risk of rupture. Indeed, variceal hemorrhage does not occur when the HVPG is reduced to <12 mmHg (17, 20). It has also been shown that the risk of rebleeding decreases significantly with reductions in HVPG greater than 20% from baseline (18). Patients whose HVPG decreases to <12 mmHg or at least 20% from baseline levels (“HVPG responders”) not only have a lower probability of developing recurrent variceal hemorrhage (36), but also have a lower risk of developing ascites, spontaneous bacterial peritonitis, and death (21).