Advertisement

Digestive Diseases and Sciences

, Volume 63, Issue 11, pp 3033–3040 | Cite as

The Use of Higher Dose Steroids Increases the Risk of Rebleeding After Endoscopic Hemostasis for Peptic Ulcer Bleeding

  • Yutaka Kondo
  • Waku Hatta
  • Tomoyuki Koike
  • Yasushi Takahashi
  • Masahiro Saito
  • Takeshi Kanno
  • Kiyotaka Asanuma
  • Naoki Asano
  • Akira Imatani
  • Atsushi Masamune
Original Article
  • 79 Downloads

Abstract

Background

Previous studies have shown that several factors such as hemodynamic instability at admission are risk factors for rebleeding of peptic ulcer bleeding. However, whether steroid use increases the risk of rebleeding remains elusive.

Aims

This study aimed to clarify the risk factors for rebleeding after endoscopic hemostasis for peptic ulcer bleeding.

Methods

A total of 185 patients who underwent endoscopic hemostasis for peptic ulcer bleeding at our institution between 2005 and 2017 were retrospectively analyzed. We evaluated factors, including comorbid conditions, in-hospital onset, and steroid use, associated with rebleeding by logistic regression analysis. In addition, we investigated the association between the dose of steroids and rebleeding.

Results

The rebleeding rate after endoscopic hemostasis for peptic ulcer bleeding was 14.6%. In the multivariate analysis, the independent risk factors for rebleeding were steroid use (odds ratio 4.56, p = 0.015), multiple ulcers (4.43, p = 0.005), number of comorbidities ≥ 3 3.18, p = 0.026), hemodynamic instability (3.06, p = 0.039), and number of comorbidities ≥ 3 (2.93, p = 0.047). Furthermore, the use of higher dose steroids (≥ 20 mg per day in prednisolone; 10.55, p = 0.002), but not lower dose (< 20 mg per day in prednisolone), was an independent risk factor for rebleeding in the multivariate analysis. The relationship between steroid use and rebleeding was observed in a dose-dependent manner (p for trend = 0.002).

Conclusions

This study first revealed that using higher dose steroids was an independent risk factor for rebleeding after endoscopic hemostasis for peptic ulcer bleeding, with a dose-response relation.

Keywords

Steroid Rebleeding Peptic ulcer bleeding Dose-dependent relation 

Abbreviations

PUB

Peptic ulcer bleeding

NSAIDs

Nonsteroid antiinflammatory drugs

GI

Gastrointestinal

PPI

Proton pump inhibitor

ASA

American Society of Anesthesiologists

PSL

Prednisolone

IQR

Interquartile range

ORs

Odds ratios

PEG

Percutaneous endoscopic gastrostomy

ENBD

Endoscopic naso-biliary drainage

CI

Confidence interval

Notes

Compliance with ethical standards

Conflict of interest

All authors have no conflicts to declare.

References

  1. 1.
    Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol. 1995;90:206–210.PubMedGoogle Scholar
  2. 2.
    Gralnek IM, Jensen DM, Gornbein J, et al. Clinical and economic outcomes of individuals with severe peptic ulcer hemorrhage and nonbleeding visible vessel: an analysis of two prospective clinical trials. Am J Gastroenterol. 1998;93:2047–2056.CrossRefGoogle Scholar
  3. 3.
    Cook DJ, Guyatt GH, Salena BJ, Laine LA. Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Gastroenterology. 1992;102:139–148.CrossRefGoogle Scholar
  4. 4.
    Lau JY, Sung JJ, Lee KK, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Engl J Med. 2000;343:310–316.CrossRefGoogle Scholar
  5. 5.
    Kim SB, Lee SH, Kim KO, et al. Risk factors associated with rebleeding in patients with high risk peptic ulcer bleeding: focusing on the role of second look endoscopy. Dig Dis Sci. 2016;61:517–522.  https://doi.org/10.1007/s10620-015-3846-y.CrossRefPubMedGoogle Scholar
  6. 6.
    Jensen DM, Pace SC, Soffer E, Comer GM, Study G. Continuous infusion of pantoprazole versus ranitidine for prevention of ulcer rebleeding: a U.S. multicenter randomized, double-blind study. Am J Gastroenterol. 2006;101:1991–1999. (quiz 2170).CrossRefGoogle Scholar
  7. 7.
    Barkun A, Sabbah S, Enns R, et al. The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE): endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting. Am J Gastroenterol. 2004;99:1238–1246.CrossRefGoogle Scholar
  8. 8.
    Ramsoekh D, van Leerdam ME, Rauws EA, Tytgat GN. Outcome of peptic ulcer bleeding, nonsteroidal anti-inflammatory drug use, and Helicobacter pylori infection. Clin Gastroenterol Hepatol. 2005;3:859–864.CrossRefGoogle Scholar
  9. 9.
    Rockall TA, Logan RF, Devlin HB, Northfield TC. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National Audit of Acute Upper Gastrointestinal Haemorrhage. Lancet. 1996;347:1138–1140.CrossRefGoogle Scholar
  10. 10.
    Simoens M, Rutgeerts P. Non-variceal upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol. 2001;15:121–133.CrossRefGoogle Scholar
  11. 11.
    Chiu PW, Ng EK, Cheung FK, et al. Predicting mortality in patients with bleeding peptic ulcers after therapeutic endoscopy. Clin Gastroenterol Hepatol. 2009;7:311–316. (quiz 253).CrossRefGoogle Scholar
  12. 12.
    Marmo R, Koch M, Cipolletta L, et al. Predicting mortality in non-variceal upper gastrointestinal bleeders: validation of the Italian PNED Score and Prospective Comparison with the Rockall Score. Am J Gastroenterol. 2010;105:1284–1291.CrossRefGoogle Scholar
  13. 13.
    Chung IK, Kim EJ, Lee MS, et al. Endoscopic factors predisposing to rebleeding following endoscopic hemostasis in bleeding peptic ulcers. Endoscopy. 2001;33:969–975.CrossRefGoogle Scholar
  14. 14.
    Guglielmi A, Ruzzenente A, Sandri M, et al. Risk assessment and prediction of rebleeding in bleeding gastroduodenal ulcer. Endoscopy. 2002;34:778–786.CrossRefGoogle Scholar
  15. 15.
    Muller T, Barkun AN, Martel M. Non-variceal upper GI bleeding in patients already hospitalized for another condition. Am J Gastroenterol. 2009;104:330–339.CrossRefGoogle Scholar
  16. 16.
    Garcia-Iglesias P, Villoria A, Suarez D, et al. Meta-analysis: predictors of rebleeding after endoscopic treatment for bleeding peptic ulcer. Aliment Pharmacol Ther. 2011;34:888–900.CrossRefGoogle Scholar
  17. 17.
    Elmunzer BJ, Young SD, Inadomi JM, Schoenfeld P, Laine L. Systematic review of the predictors of recurrent hemorrhage after endoscopic hemostatic therapy for bleeding peptic ulcers. Am J Gastroenterol. 2008;103:2625–2632. (quiz 33).CrossRefGoogle Scholar
  18. 18.
    Sakamoto C, Sugano K, Ota S, et al. Case-control study on the association of upper gastrointestinal bleeding and nonsteroidal anti-inflammatory drugs in Japan. Eur J Clin Pharmacol. 2006;62:765–772.CrossRefGoogle Scholar
  19. 19.
    Weisman SM, Graham DY. Evaluation of the benefits and risks of low-dose aspirin in the secondary prevention of cardiovascular and cerebrovascular events. Arch Intern Med. 2002;162:2197–2202.CrossRefGoogle Scholar
  20. 20.
    Lanas A, Wu P, Medin J, Mills EJ. Low doses of acetylsalicylic acid increase risk of gastrointestinal bleeding in a meta-analysis. Clin Gastroenterol Hepatol. 2011;9:e6.CrossRefGoogle Scholar
  21. 21.
    Messer J, Reitman D, Sacks HS, Smith H Jr, Chalmers TC. Association of adrenocorticosteroid therapy and peptic-ulcer disease. N Engl J Med. 1983;309:21–24.CrossRefGoogle Scholar
  22. 22.
    Narum S, Westergren T, Klemp M. Corticosteroids and risk of gastrointestinal bleeding: a systematic review and meta-analysis. BMJ Open. 2014;4:e004587.CrossRefGoogle Scholar
  23. 23.
    Conn HO, Blitzer BL. Nonassociation of adrenocorticosteroid therapy and peptic ulcer. N Engl J Med. 1976;294:473–479.CrossRefGoogle Scholar
  24. 24.
    Conn HO, Poynard T. Corticosteroids and peptic ulcer: meta-analysis of adverse events during steroid therapy. J Intern Med. 1994;236:619–632.CrossRefGoogle Scholar
  25. 25.
    Park SJ, Park H, Lee YC, et al. Effect of scheduled second-look endoscopy on peptic ulcer bleeding: a prospective randomized multicenter trial. Gastrointest Endosc. 2018;87:457–465.CrossRefGoogle Scholar
  26. 26.
    Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in gastrointestinal bleeding. Lancet. 1974;2:394–397.CrossRefGoogle Scholar
  27. 27.
    Lu Y, Chen YI, Barkun A. Endoscopic management of acute peptic ulcer bleeding. Gastroenterol Clin North Am. 2014;43:677–705.CrossRefGoogle Scholar
  28. 28.
    Wong SK, Yu LM, Lau JY, et al. Prediction of therapeutic failure after adrenaline injection plus heater probe treatment in patients with bleeding peptic ulcer. Gut. 2002;50:322–325.CrossRefGoogle Scholar
  29. 29.
    Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5:649–655.CrossRefGoogle Scholar
  30. 30.
    American Society of Anesthesiologists Task Force on S, Analgesia by N-A. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96:1004–1017.CrossRefGoogle Scholar
  31. 31.
    Cheng HC, Wu CT, Chen WY, Yang EH, Chen PJ, Sheu BS. Risk factors determining the need for second-look endoscopy for peptic ulcer bleeding after endoscopic hemostasis and proton pump inhibitor infusion. Endosc Int Open. 2016;4:E255–E262.CrossRefGoogle Scholar
  32. 32.
    Luo JC, Shin VY, Liu ES, et al. Dexamethasone delays ulcer healing by inhibition of angiogenesis in rat stomachs. Eur J Pharmacol. 2004;485:275–281.CrossRefGoogle Scholar
  33. 33.
    Carpani de Kaski M, Rentsch R, Levi S, Hodgson HJ. Corticosteroids reduce regenerative repair of epithelium in experimental gastric ulcers. Gut. 1995;37:613–616.CrossRefGoogle Scholar
  34. 34.
    Asayama N, Oka S, Tanaka S. Polyglycolic acid sheet application for intractable acute hemorrhagic rectal ulcer. Dig Endosc. 2016;28:689.CrossRefGoogle Scholar
  35. 35.
    Dorff TB, Crawford ED. Management and challenges of corticosteroid therapy in men with metastatic castrate-resistant prostate cancer. Ann Oncol. 2013;24:31–38.CrossRefGoogle Scholar
  36. 36.
    Auchus RJ, Yu MK, Nguyen S, Mundle SD. Use of prednisone with abiraterone acetate in metastatic castration-resistant prostate cancer. Oncologist. 2014;19:1231–1240.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Yutaka Kondo
    • 1
  • Waku Hatta
    • 1
  • Tomoyuki Koike
    • 1
  • Yasushi Takahashi
    • 1
  • Masahiro Saito
    • 1
  • Takeshi Kanno
    • 1
  • Kiyotaka Asanuma
    • 1
  • Naoki Asano
    • 1
  • Akira Imatani
    • 1
  • Atsushi Masamune
    • 1
  1. 1.Division of GastroenterologyTohoku University Graduate School of MedicineSendaiJapan

Personalised recommendations