Case of severe gastric ulcer bleeding of DES stent wearing patient. Efficacy of proton pump inhibitors on ulcer healing in anti platlet drug treatment

Patient: A 43-years old male patient having gastric ulcer treated with proton pump inhibitor (PPI) and caused by NSAID abuse because of joint pains and LAD DES stent implantation in two-years anamnesis was admitted with gastrointestinal bleeding (melaena) to the Gastroenterology Ward of our clinic. His acute gastrointestinal bleedeng lead to a severe anemia (Hgb: 30g/l) and haemodinamical instability. Urgent gastroscopy recognized a 9cm diamether small-curve gastric ulcer with actual bleeding (Forrest I/C). A haemoclip was placed followed by local adrenaline injection leading to complete hemostasis.

At time of admission patient took standard dose of generic lansoprazole and combined platelet aggregation inhibitor treatment (acetyl salicyl acid and clopidogrel). After gaining stop of bleeding and haemodinamical stabilization we faced dilemmas of treatment strategies. Double-dose of original pantoprazole was given i.v. and effect double-checked with 24-hours pH-metry (EsopHogram™ Reflux Analysis), clopidogrel (75mg) was continued in standard dose and its effect was double-checked with aggregometry (Carat Tx4).

Gastric pH controll was effective (only 23min under pH 5,0 in 24 hours), however platelet aggregation inhibition was ineffective in this combination of treatment even if increasing dose of clopidogrel to 150mg.

Ticlopidin treatment got started leading to therapeutic platelet aggregation inhibition. Healing of gastric ulcer was followed with gastrocopy up to healing (histology proved no malignancy).

Conclusions: Correct choice of PPI and dose and recognition of interactions between drugs and drug ineffectivity in time can provide the necessary balance between gastroprotection and stent protection.