上消化道出血(出血）.pptx

UGI Bleeding
Epidemiology of Upper GI Bleeding
・ Bleeding from a source above the ligament of Treitz
・ 1 case/1,000 py
• Surgical therapy
• Pharmacologic therapy
Endoscopic Therapy
・ Perform early (ideally within 24 h)
・ Indications for haemostatic therapy:
• (1) +/-Adherent clot, (2) Nonbleeding visible vessel, (3) Active bleeding (oozing, spurting) (Laine, Peterson. 1 994)
・ Heater probe, bipolar electrocoagulation or injection therapy
・ Decreases in rebleeding, surgery and
m ortality (Cook, et al. 1992, Sacks, et al. 1990)
Surgical Therapy
・ Endoscopic management failure
・ Other extenuating circumstances
・ Patient survival improved by optimal timing
・ Individualized by clinical context, endoscopic and surgical expertise
Surgical Therapy
Surgery
Complications
15%
10%
P=
18%
"3 36%
11
Mortality
Endoscopic retreatment group (n=48) ■ Surgery group (n=44)
Pharmacologic Therapy
• Splanchnic blood pressure modifiers
・ vasopressin, somatostatin, octreotide
• Anti-fibrinolytic agents
・ tranexamic acid
• Acid suppressing agents
-H2-receptor antagonists (H2RAs), proton pump inhibitors (PPIs)
S omatostatin/Octreotide
・ Effects:
-Lowers splanchnic blood pressure
• Decreases gastric acid secretion
• Increases duodenal bicarbonate secretion
・ Meta-analysis: (Imperial©, Birgisson, 1997)
• 14 trials (n= 1,829); SOM (12 trials), OCT (2 trials)
- risk of rebleeding vs. H2RAs
• RR= among investigator-blinded trials
• Studies did not control for confounders, ., endoscopic therapy
Acid Suppressing Agents
• H2-receptor antagonists (H2RAs)
・ Cimetidine, ranitidine, famotidine, nizatidine
• Proton pump inhibitors (PPIs)
・ Pantoprazole, omeprazole (oral, IV)
-Esomeprazole (Nexium) (oral)
・ Lansoprazole (oral)
Role of Acid in Hemostasis
• Impairs clot formation
・ Impairs platelet aggregation & causes disaggregation
• Accelerates clot lysis
・ Predominantly acid-stimulated pepsin
• May impair integrity of mucus/bicarbonate barrier
Figure 21. Endosco