A 52-year-old man with a history of peptic ulcer disease presents with coffee-ground vomitus and haemodynamic instability. Upper endoscopy reveals a bleeding duodenal ulcer with an adherent clot. After endoscopic haemostasis, what is the drug of choice for preventing rebleeding?

Explanation

## Peptic Ulcer Bleeding: Post-Endoscopic Pharmacological Management **Key Point:** High-dose intravenous proton pump inhibitor (PPI) infusion is the drug of choice after endoscopic haemostasis of peptic ulcer bleeding to prevent rebleeding. ### Rationale for High-Dose IV PPI After successful endoscopic therapy (injection, cautery, or clip placement), high-dose IV PPI is mandatory to: 1. Maintain intragastric pH > 6.0 (optimal for clot stability and platelet aggregation) 2. Reduce gastric acid secretion by >90% 3. Prevent rebleeding in the first 72 hours (critical window) 4. Reduce mortality and need for surgery ### PPI Dosing Regimen **Standard regimen for peptic ulcer bleeding:** - **Bolus:** 80 mg IV over 30 minutes - **Infusion:** 8 mg/hour for 72 hours (or until oral intake resumes) - **Transition:** Switch to oral PPI (e.g., omeprazole 20 mg daily) after 72 hours **Evidence:** This regimen reduces rebleeding from ~20% to ~5–10% and is supported by major guidelines [cite:Harrison 21e Ch 297]. ### Comparison of Agents for Peptic Ulcer Bleeding | Agent | Route | Mechanism | Role in Acute Bleeding | Evidence | | --- | --- | --- | --- | --- | | **Pantoprazole/Omeprazole (IV)** | IV | PPI; ↓ acid secretion >90% | **Gold standard** post-endoscopy | Strong; reduces rebleeding & mortality | | **Famotidine (IV)** | IV | H₂RA; ↓ acid secretion ~60% | Inferior to PPI; rarely used now | Weak; higher rebleeding rates | | **Sucralfate** | Oral | Mucosal protectant | No proven benefit in acute bleeding | Weak; not recommended | | **Misoprostol** | Oral | Prostaglandin analogue | Used for NSAID-induced ulcer prevention, not acute bleeding | Not indicated for acute haemorrhage | **High-Yield:** The **80 mg bolus followed by 8 mg/h infusion** is the standard regimen taught in NEET PG. Memorise this dosing. **Mnemonic:** **"80-8 Rule"** — 80 mg bolus, 8 mg/hour infusion for peptic ulcer bleeding post-endoscopy. **Clinical Pearl:** Even if the patient is on chronic PPI therapy at home, the acute bleeding episode requires **escalation to IV high-dose PPI** for 72 hours; oral dosing is insufficient in the acute phase. **Warning:** Do not confuse: - ~~H₂ receptor antagonists (famotidine, ranitidine)~~ — inferior efficacy; rarely used now for acute bleeding - ~~Sucralfate~~ — mucosal protectant, no acid suppression; no role in acute bleeding - ~~Misoprostol~~ — used for NSAID ulcer prophylaxis, not acute bleeding