© Borgis - Postępy Nauk Medycznych 1/2014, s. 5-8
*Maciej Rupiński, Władysław Januszewicz
Ostre krwawienie z wrzodu trawiennego – aktualne standardy postępowania
Current standards in the management of acute peptic ulcer bleeding
Department of Gastroenterology and Hepatology, Medical Center of Postgraduate Education and Department of Gastroenterological Oncology, The Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Warszawa
Head of Department: prof. Jarosław Reguła, MD, PhD
Streszczenie
Ostre krwawienie z wrzodu trawiennego pozostaje jednym z częstszych stanów nagłych w chorobach wewnętrznych, z istotnym ryzykiem zgonu i wystąpienia ciężkich powikłań. Odpowiednio zorganizowane, zespołowe postępowanie w tej grupie pacjentów, oparte na dobrze udokumentowanych algorytmach, ułatwia opanowanie sytuacji klinicznej i chroni chorych przed niekorzystnymi konsekwencjami krwotoku. Należy zwrócić uwagę na kluczowe znaczenie badania endoskopowego, które wykonane w odpowiednim czasie i optymalnych warunkach stanowi podstawę dla planowania dalszego postępowania, pomaga w określeniu rokowania oraz umożliwia wykonanie w większości przypadków skutecznego tamowania krwawienia.
W artykule zawarto najważniejsze informacje dotyczące aktualnie rekomendowanych na świecie standardów postępowania z pacjentami z ostrym krwawieniem z wrzodu trawiennego, w oparciu o bieżące zalecenia przyjęte i opublikowane w 2012 r. przez American College of Gastroenterology (1). Część z tych wiadomości jest zawarta w wytycznych polskiej grupy roboczej konsultanta krajowego w dziedzinie gastroenterologii, opublikowanych w 2008 roku (2).
Summary
Acute peptic ulcer bleeding remains one of the most frequent medical emergency in internal medicine, with significant risk of mortality and severe complications. Appropriately organized multidisciplinary management, based on clinically proven algorithms, helps to control this clinical situation and improve outcomes in this group of patients. It should be noted crucial role of endoscopy, which done in a proper time and under optimal conditions, is the basis for the planning of further procedures, helps in determining prognosis and allows effective control of bleeding.
This paper aims to outline most important recommendations for the management of patients with overt upper gastrointestinal bleeding due to gastric or duodenal ulcers. The recommendations are based on the current practice guidelines, accepted and published by the American College of Gastroenterology (1) in 2012 and Polish guidelines published in 2008 (2).
Introduction
Gastric and duodenal ulcers are the most common cause of acute upper gastrointestinal bleeding (UGIB). Patients with bleeding should be hospitalized and treated under emergency conditions. Despite the broad availability of modern diagnostic and therapeutic procedures such as endoscopy and the use of acid suppressing drugs, it still remains a potentially fatal condition with mortality of up to 10% and high rate of severe complications. Application of clinically proven recommendations leads to diminution of patients mortality and morbidity and improvement in clinical outcomes. These may also result in shorter hospital stay resulting in better cost-effectiveness.
Key issues related to management of patients with overt UGIB presenting with hematemesis, melena and also hematochezia will be discussed in this article.
First section of the article presents initial management of UGIB due to ulcers in patients without suspicion of liver disease associated with esophageal varices. Second part provides information about the role of endoscopic therapy and the third part summarizes post-endosopic management including further treatment, time of hospital stay and re-bleeding prevention.
Multidisciplinary work-up
Health care facilities admitting patients with UGIB should be properly equipped and prepared for diagnostic and therapeutic steps in this condition. It is necessary to organize a collective and synchronized management algorithms within units that may be involved in treating this condition. Such integrated approach should involve Emergency Department, Endoscopy Unit, General or Gastrointestinal Surgical Unit with Operating Room, Intensive Care Unit and General or Gastrointestinal Medicine Unit. Furthermore, the role of other, supporting units including hospital laboratory providing blood products, hospital pharmacy and Radiology Unit is of primary relevance.
Initial assessment
A primary goal in management of a patient with overt UGIB is assessing clinical condition focusing on hemodynamic status. In patients with clinical signs of shock or ongoing bleeding with high risk of hemodynamic collapse resuscitation measures should be immediately initiated. Peripheral venous access (more than one in some cases) enabling transfusion of intravenous fluids should be obtained. Fast transfusion of red blood cells compatible with patient’s original blood group should be required when hemoglobin level is lower than 7 g/dl (3). In patients with cardiovascular comorbidities, like coronary heart disease, blood transfusion may be considered even with higher hemoglobin level (4). It is also necessary to withdraw the blood specimen for respective blood tests (blood group when no documentation is available, complete blood count, routine biochemistry and coagulation panel). It is obligatory to monitor vital parameters such as heart rate, blood pressure, arterial blood saturation and urine output.
After stabilizing the patient it is necessary to assess the risk of bleeding using one of available scoring systems, such as pre-endoscopic Rockall score (range 0-7, higher value indicates higher risk of death and recurrent bleeding). It uses simple clinical data available immediately at presentation: heart rate, systolic blood pressure, patients age and comorbidities (tab. 1). Rockall scoring system facilitates the delivery of the appropriate level of care to patients and may assist in initial decisions such as timing of endoscopy, need for surgical intervention and time of discharge.
Table 1. Pre-endoscopic Rockall scoring system.
| Variable | Score 0 | Score 1 | Score 2 | Score 3 |
| Age | < 60 years | 60-79 years | > 80 years | |
| Blood pressure fall (Shock) | No shock
SBP > 100 and
pulse < 100/min | Tachycardia
SBP > 100 and
pulse > 100/min | Hypotension
SBP < 100 and
pulse > 100/min | |
| Co-morbidity | No major comorbidity | | IHD, HF,
any major comorbidity | Renal or liver failure, disseminated malignancy |
SBP – systolic blood pressure; HF – heart failure; IHD – ischemic heart disease
Total range of the scoring system, which is a summary of particular lines, is between 0 to 7.
First letters of variables arrange in an easy-to-remember ABC scheme.
Thus, patients with the highest score (Rockall score 6-7) should be immediately admitted to Intensive Care Unit, while patients with lower Rockall score values may be treated within General Internal Medicine or Surgical Unit. Those with the lowest score (Rockall score 0-1) may be discharged from the emergency department usually within 24 hours just after receiving necessary evaluation including endoscopy showing no active or recent hemorrhage (5).
Pre-endoscopic medical therapy
Basic pre-endoscopic pharmacologic treatment include acid suppressant agents like proton-pump inhibitors (PPIs). Providing 80 mg omeprazole bolus followed by continuous 8 mg/h infusion is recommended. Such a treatment increases the chances of spontaneous hemostasis, diminishing the risk of early re-bleeding and also the need for endoscopic and surgical intervention (6).
Intravenous infusion of 250 mg erythromycin given approximately 30-minutes before endoscopy may be considered in bleeding patients. The prokinetic effect of this drug accelerates gastric emptying from residual content (blood, clots and remaining food) improving efficiency in localizing the bleeding source, therefore decreasing the need for repeat endoscopy (7-10).
Current recommendations, based on reliable clinical trials, do not support routine application of nasogastric tube or gastric lavage (1).
Endoscopy
Timing of endoscopy
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Piśmiennictwo
1. Laine L, Jensen DM: Management of Patients With Ulcer Bleeding. Am J Gastroenterol 2012; 107: 345-360.
2. Marek T, Baniukiewicz A, Wallner G et al.: Wytyczne postępowania w krwawieniu z górnego odcinka przewodu pokarmowego pochodzenia nieżylakowego. Przegląd Gastroenterologiczny 2008; 3(1): 1-22.
3. Villanueva C, Colomo A, Bosch A et al.: Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013; 368: 11-21.
4. Hebert PC, Wells G, Blajchman MA et al.: A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999; 340: 409-417.
5. Rockall TA, Logan RFA, Devlin HB et al.: Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996; 38: 316-321.
6. Lau JY, Leung WK, Wu JCY et al.: Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med 2007; 356: 1631-1640.
7. Sreedharan A, Martin J, Leontiadis GI et al.: Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev 2010 (7): CD005415.
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