MKSAP: 50-year-old man with a large bleeding gastric ulcer

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 50-year-old man is evaluated in follow-up after hospitalization 6 months ago for a large bleeding gastric ulcer. Tests performed for Helicobacter pylori infection at that time were negative. However, for the 3 months before hospitalization he had been taking ibuprofen for chronic back pain. He was discharged from the hospital on omeprazole, and his ibuprofen was discontinued. Owing to the large size of the ulcer and increased suspicion for underlying malignancy, follow-up upper endoscopy was performed 3 months later and showed complete ulcer healing; the omeprazole was stopped. He has not found any other treatment as effective as ibuprofen for his back pain, and he wishes to restart the ibuprofen. He does not have cardiovascular disease and is at low risk for developing cardiovascular disease.

Physical examination is unremarkable.

Which of the following is the most appropriate management?

A: Celecoxib
B: Celecoxib and omeprazole
C: Ibuprofen
D: Ibuprofen and sucralfate

MKSAP Answer and Critique

The correct answer is B: Celecoxib and omeprazole.

The most appropriate management is celecoxib and omeprazole. Patients such as this with a history of an NSAID-associated bleeding ulcer have a substantial risk for developing recurrent ulcer bleeding. A series of randomized clinical trials in a Hong Kong population illustrated the relative effectiveness of the various treatment strategies in the secondary prevention of NSAID-induced bleeding ulcer disease. Despite endoscopic documentation of complete ulcer healing, the reinitiation of NSAID therapy without a proton pump inhibitor (PPI) resulted in a recurrent ulcer bleeding rate of nearly 20% over a 6-month time frame. The addition of a PPI along with the NSAID lowered the recurrent ulcer bleeding rate to nearly 5% in the same 6-month time frame. Use of the cyclooxygenase-2 (COX-2) selective NSAID celecoxib resulted in a similar 6-month bleeding rate of nearly 5%. Additionally, co-therapy with sucralfate is ineffective in preventing NSAID- or aspirin-related gastric or duodenal ulceration. The most effective treatment strategy in the prevention of recurrent ulcer bleeding was use of celecoxib plus twice-daily PPI therapy, which had a 12-month rebleeding rate of 0%. Therefore, patients with a previous NSAID-associated bleeding ulcer who must remain on NSAIDs should receive a COX-2 selective NSAID plus PPI therapy to maximize risk reduction for a recurrent ulcer bleed.

Key Point

  • A series of randomized clinical trials showed that the most effective treatment strategy in the prevention of recurrent ulcer bleeding was the use of celecoxib plus twice-daily proton pump inhibitor therapy.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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