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Introduction

In the context of proper proton pump inhibitors (PPI) use, over-prescription is commonly criticized. Conversely, few studies have assessed the consequences of not prescribing PPIs in patients with a recognized indication for prophylactic treatment. This study aims to compare, in a cohort of patients with upper gastrointestinal bleeding (UGB), those with and without PPI at bleeding onset and in particular patients who are considered at high risk for UGB.

Aims & Methods

We undertook a post-hoc analysis of data from a prospective multicenter observational study (1) conducted in 46 French medical centers, which included all consecutive UGB cases that occurred between November 2017 and October 2018. Data about patients’ demographics, clinical, endoscopic and prognostic features were collected. First, we explored bleeding etiology in patients with and without PPI at the time of bleeding. Then, we calculated the rate of prophylactic PPI prescription in patients having an UGB related to peptic ulcer disease (PUD) and notably in those considered at higher risk of bleeding according to international guidelines (2, 3). In patients who had peptic ulcer bleeding, we compared those with and without PPI upon bleeding onset, in terms of baseline demographics and bleeding severity. We then analyzed the predictors of severe UGB defined by a Glasgow Blatchford score (GBS)≥11. We included PPI prophylaxis in our analysis to determine its role in reducing bleeding severity.

Results

A total of 2,498 patients with UGB were included, of whom 777 (31%) were on PPI at the time of bleeding. UGB related to PUD was significantly less prevalent in patients with PPI than in those without PPI (28% vs 46%, respectively; p< 0.0001). No difference was observed in the frequency of bleeding related to portal hypertension nor to esophagitis between the two groups (P=0.64 and 0.26, respectively) whereas hemorrhagic angiodysplasias were more common in the group with PPI (p<0.0001).
Of the 893 patients who had UGB related to PUD, only 21.5% were on PPI. These patients, compared to those without PPI, were older (74 vs 69 years; p<0.0001) and had more comorbidities (defined by a Charlson score≥3) (p<0.0001), notably at cardiovascular level. Ulcer was more likely to be located in the stomach in patients with PPI and in the duodenum in those without PPI (p=0.002). Helicobacter Pylori prevalence and Forrest classification were comparable in both groups (p=0.11 and 0.18, respectively). There was no statistically significant difference in terms of severity measured by mean GBS, blood transfusions or 6-week mortality and rebleeding rates (p>0.05).
In patients at high risk for UGB, we noted an under-prescription of PPI prophylaxis (Table 1). Independent predictors for severe bleeding according to multivariate analysis were the following: age≥65years (p=0.001), in-hospital bleeding (p=0.012), Charlson score≥3 (p<0.0001) and dual anti-platelets use (p=0.031). The absence of PPI prophylaxis did not affect bleeding severity (p=0.5).

Table 1: PPI prescription rates in high risk patients*:
	PUD-related UGB	High Risk patients	PPI-prescription rate
NSAIDS	112	74	20%
AP	312	122	35%
OAC	178	89	34%
Dual-AP	46	16	50%
OAC+AP	50	7	29%
NSAIDS: non-steroidal anti-inflammatory drugs, AP: anti-platelets, OAC: oral anti-coagulants, PUD: peptic ulcer disease, UGB: upper gastrointestinal bleeding, PPI: proton pump inhibitor, * Risk stratification according to European Society of Cardiologist (2) and American college of Gastroenterology guidelines (3).

Conclusion

In this cohort of patients with UGB, peptic ulcer bleeding occurred less frequently in patients on PPI. However, PPI treatment did not affect bleeding severity which was mainly determined by patients’ age and comorbidities. Most importantly, we noted a significant under-prescription of prophylactic PPI in high-risk groups having a well-recognized indication for gastric protection. This finding must be highlighted when discussing proper prescribing practices.

References

(1) Quentin V, Remy AJ, Macaigne G et al. Prognostic factors associated with upper gastrointestinal bleeding based on the French multicenter SANGHRIA trial. Endosc Int Open 2021; 09: E1504–E1511 DOI 10.1055/a-1508-5871
(2) Marco Roffi etal. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation, European Heart Journal (2016) 37, 267–31
(3) Lanza FL, Chan FKL, Quigley EMM. Practice Parameters Committee of the American College of Gastroenterology. Guidelines for prevention of NSAID-related ulcer com- plications. Am J Gastroenterol 2009;104:728–738.

Disclosure

No conflict of interest to disclose in relation to this work

CHARACTERISTICS AND PROGNOSIS OF UPPER GASTROINTESTINAL BLEEDING OCCURRING IN PATIENTS ON PROTON PUMP INHIBITORS: POST-HOC ANALYSIS OF A FRENCH PROSPECTIVE MULTICENTER STUDY

Weam EL HAJJ 1, Stephane Nahon 1, Eddy Fares 1, vincent quentin 2, Denis Grasset 3, Jean-Pierre Arpurt 4, Florence Skinazi 5, Rene-Louis Vitte 6, Laurent Costes 7, Andre-Jean Remy 8, christophe locher 9, gilles macaigne 1

1 Groupe Hosptalier Intercommunal Le Raincy - Montfermeil, Montfermeil, France

2 Centre Hospitalier Yves Le Foll, Saint-Brieuc, France

3 CHBA Service de Gastroentérologie, Vannes, France

4 Centre Hospitalier d'Avignon, Avignon, France, Avignon, France

5 Hôpital Delafontaine, Saint-Denis, France

6 Centre Hospitalier Intercommunal de Poissy, Poissy, France

7 Centre Hospitalier Intercommunal de Créteil, Créteil, France

8 Centre Hospitalier de Perpignan, Perpignan, France

9 Grand Hôpital de l'Est Francilien, Meaux, France

Conference

UEG Week Copenhagen 2023

Topics

Oesophagus

Submission format

Abstract

Session

PP 01 Oesophageal, gastric and duodenal disorders (Posters)

Citation

United European Gastroenterology Journal 2023; 11 (Supplement 8)

Published

2023

UEG Online Course

accredited

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This comprehensive course introduces participants to the transformative role of artificial intelligence in gastroenterology. Designed for healthcare professionals, the course covers fundamental AI concepts, clinical applications, and research perspectives. Key topics include machine learning techniques, AI-assisted diagnostics, and the integration of AI systems in clinical practice. Participants will explore the benefits and challenges of AI adoption, ethical considerations, and the regulatory landscape, with an emphasis on evidence-based decision-making.

The course includes extensive PowerPoint presentations and tailored video lectures. Examples are used to demonstrate real-world applications of the material. The total duration of the course is approximately 50 minutes, with an estimated completion time of 60 minutes, including the final assessment.

A Primer for Artificial Intelligence in Gastroenterology

Cem Simsek, Giulio Antonelli, Alanna Ebigbo

Event

A Primer for Artificial Intelligence in Gastroenterology

Topics

Endoscopy

Accreditation status

accredited

Duration

1 hour

Published

2025

UEG Online Course

accredited

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Acute severe ulcerative colitis (ASUC) remains the most severe form of UC and is sometimes associated with mortality. Adequate evaluation, early and correct intervention, and follow-up with a multidisciplinary approach are crucial in management. A comprehensive approach to ASUC, epidemiology, definition, diagnosis, evaluation, and medical and surgical management are all discussed in this online course by Haluk Tarik Kani, Irene Marafini, Joana Roseira, Wilhelmus A. Bemelman and Fernando Magro.

Target audience
We believe both gastroenterology trainees and early career gastroenterologists and surgeons will find in this online course a thorough and updated review on ASUC management.

Acute Severe Ulcerative Colitis

Fernando Magro, Haluk Tarik Kani, Joana Roseira, Irene Marafini, Wilhelmus A. Bemelman

Event

Acute Severe Ulcerative Colitis

Topics

IBD

Accreditation status

accredited

Duration

1 hour

Published

2025

UEG Presentation

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UTILIZATION OF PROTON PUMP INHIBITORS IN PATIENTS WITH OVERT GASTROINTESTINAL BLEEDING: EFFECTS ON SHORT- AND LONG-TERM MORTALITY AND REBLEEDING

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Introduction

Proton pump inhibitors (PPI) may be over or underutilized in patients with acute gastrointestinal bleeding (AGIB). Further, the effects of their use on short- and long-term outcomes are not clear.

Aims & Methods

We examined utilization of PPI in patients with AGIB and its effect on short- and long-term rebleeding and mortality in a prospective study of patients admitted with AGIB to a tertiary referral center between Jan. 2013 and Aug. 2023. We determined intake of PPI on admission and on discharge, and intake of antithrombotics [antiplatelets (AP) only, anticoagulants (AC) only or both AP and AC] on admission and on discharge. Univariate analysis was done to compare patients using PPI on admission or on discharge to patients not using PPI. Multivariate analysis was done to determine independent predictors of mortality and rebleeding.

Results

846 patients with AGIB (462 had upper GIB) were admitted and followed-up for a median of 59 (29-88) months. 385 were admitted already taking PPI. 623 patients were discharged on PPI and 150 were discharged off PPI (73 patients died in hospital). 49% of patients admitted on PPI and 27% of patients discharged on PPI did not have a clear indication for their use. The overall PPI overutilization rate was 36%. 25% of patients discharged off PPI had at least one clear indication for their use.
Compared to patients admitted off PPI, those admitted on PPI were older (66 vs 70 years, p<0.001), had higher Charlson Comorbidity Index (CCI) (2.4 vs 3.2, p<0.001), were more likely to be on antithrombotics (56% vs 70%, p<0.001) and to require blood transfusion (54% vs 64%, p=0.003). They also had higher 1-month mortality (8% vs 16%, p<0.001). However, they had less stigmata of recent hemorrhage (SRH) (39% vs 30%, p=0.022) and were less likely to require endoscopic therapy (25% vs 15%, p=0.002). Compared to patients discharged off PPI, patients discharged on PPI were more likely to have had in-hospital re-bleeding (1.3% vs 5.3%, p=0.036) but had similar short- and long-term mortality (4.7% vs 2.9%, p= 0.301 and 37% vs 44%, p=0.122, respectively).
On multivariate analysis, PPI on admission was not an independent predictor of 1-month mortality or re-bleeding [OR 1.46 (0.83, 2.57), p= 0.187 and 0.91 (0.51, 1.59), p=0.730], respectively. Predictors of 1-month mortality were CCI [OR 1.13 (1.04,1.22), p=0.002], severe bleeding [OR 2.48 (1.21, 5.10), p=0.013], blood transfusion [OR 2.72 (1.20, 6.15), p=0.017], and SRH [OR 2.53 (1.40, 4.59), p=0.002]. Predictors of 1-month re-bleeding were AC only on admission [OR 2.30 (1.20, 4.42), p= 0.012], severe bleeding [OR 1.96 (1.03, 3.73), p=0.041], and SRH [OR 2.03 (1.16, 3.54), p=0.013]. PPI on discharge was not a predictor of long-term mortality or re-bleeding (table 1). Being on AC only on discharge was a predictor of long-term mortality, while being on AP only on discharge was protective against long-term re-bleeding (table 1).

	Variables	OR (95% CI)	p-value		Variables	OR (95% CI)	p-value
Long-term Mortality**	PPI on discharge	1.38 (0.85, 2.26)	0.194	Long-term Re-bleeding**	PPI on discharge	1.26 (0.76, 2.07)	0.375
	Age-related CCI	1.53 (1.41, 1.67)	<0.001		AP only on discharge	0.45 (0.28, 0.72)	0.001
	Blood transfusion	1.72 (1.18, 2.51)	0.005		AC only on discharge	0.91 (0.54, 1.56)	0.741
	AP only on discharge	0.85 (0.55, 1.32)	0.479		AP and AC on discharge	0.56 (0.29, 1.10)	0.095
	AC only on discharge	2.51 (1.45, 4.36)	0.001		Severe bleeding*	1.53 (1.03, 2.25)	0.034
	AP and AC on discharge	0.91 (0.50, 1.7)	0.749		SRH	1.78 (1.21, 2.64)	0.004
Table 1: Multivariate analysis showing predictors of long-term mortality and re-bleeding in patients with acute GIB. AP: antiplatelets; AC: anticoagulants; Hb: Hemoglobin level; CCI: Charlson Comorbidity Index; Severe bleeding is defined as: Hb drop ≥ 2 units, blood transfusions ≥ 2 units, or systolic blood pressure on admission ≤ 100 mmHg. * long term mortality and re-bleeding are defined as mortality or re-bleeding by the end of follow-up.

Conclusion

There is marked overutilization and underutilization of PPI in patients with GIB, without a significant effect on short- or long-term mortality or rebleeding. A PPI utilization stewardship program is needed to decrease health care costs and potential PPI related side effects.