A cost-effective approach to the patient with peptic ulcer bleeding

The average hospital cost to manage patients hospitalized at Virginia Mason Hospital who bleed from a peptic ulcer is approximately $5000 per patient in our series of 30 patients. Because there are 150,000 admissions per year in the United States for peptic ulcer bleeding, the total hospital cost can be estimated to be $750 million. The actual cost may be higher because our 30 patients had minimal complications and were discharged on average in less than 4 days. The majority of hospital cost is incurred by the intensive care unit or the hospital nursing floor. There is a close to linear relation between the length of stay and the total hospital cost. Upper gastrointestinal endoscopy is a major advance in the treatment of peptic ulcer bleeding. It can provide significant cost savings by identifying some patients with bleeding peptic ulcers who have clean bases on endoscopy who are then eligible for prompt discharge from the hospital. In addition, endoscopic thermal therapy (with multipolar electrocautery or heater probe) and injection therapy cost less than $50 in incremental cost and can reduce further bleeding by 43%, reduce the need for urgent surgery by 63%, and reduce the mortality rate by 60%. Some patients still require urgent surgical intervention, which is substantially more costly than endoscopic hemostasis but is highly effective. Preliminary studies show promise in predicting further bleeding, with clinical scoring systems such as the Baylor Bleeding Score and with the use of Doppler ultrasonography. Better prediction of further bleeding should guide the choice of durable hemostasis early in the hospitalization. Additional studies should clarify the role of NSAID avoidance and H. pylori eradication in the long-term prevention of recurrent peptic ulcer bleeding.