上消化道出血诊治.ppt

Characteristic of upper gastrointestinal bleeding among geriatric patients,Department of Geriatrics First Affiliated Hospital of Nanjing Medical University Wei-Hao Sun ,.,Criteria of WHO,elderly individual: those over 65 years of age elderly society: It is more than 7% that the percentage ratio of elderly population to total population in the area or a country.,Chinese population is also aging,UGI bleeding,Approximately 30% decline in rate over last 15 years 150,000 admissions per year Over $1,000,000,000 annually Associated with NSAID use,UGI bleeding,Mortality rate 8-10% 65 now comprise over 30% Peptic ulcer still most common cause Surgery now plays an adjunctive role,Epidemiology,103:100 000 adults per year Shift in age of population at risk Increasing use of NSAIDs & anticoagulants Increasing incidence of in-hospital bleeding,Aetiology,PUD 50% Acute gastric erosions 20% Esophageal varices 10% Tumor 5%-10% AVM 6% Mallory-Weiss tear 5% Deiulafoy 1%,Drugs,Established risk factors Aspirin & NSAIDs Warfarin Alcohol Possible association Calcium channel blockers Selective serotonin uptake inhibitors- (antidepressant),Peptic Ulcer Disease: NSAIDS,NSAIDs may cause both duodenal or gastric ulcers NSAIDs inhibit prostaglandin production and cause breakdown of the protective barrier of the gastric mucosa,Peptic Ulcer Disease: NSAIDS,Complications of NSAID therapy usually occur within the first month NSAIDs not only induce ulcers but may increase the chance of bleeding in patients who have underlying ulcer disease,VIGOR - Summary of GI Endpoints,p 0.001.,* p = 0.005.,0,1,2,3,4,5,Confirmed Clinical Upper GI Events,Confirmed Complicated Upper GI Events,All Clinical GI Bleeding,RR: 0.46 (0.33, 0.64),RR: 0.43* (0.24, 0.78),RR: 0.38 (0.25, 0.57),Rates per 100 Patient-Years,Rofecoxib,Naproxen,( ) = 95% CI.,Source: Bombardier, et al. N Engl J Med. 2000.,Reducing the Risk of UGI Toxicities in Patients Requiring Chronic NSAID Therapy,Presentation,Haematemesis Melaena Frank rectal bleeding Signs and symptoms of hypovolaemia Anaemia,Endoscopy,Diagnostic Therapeutic Prognostic,Endoscopic Haemostasis,Widely accepted as most effective method Injection with adrenaline, saline, sclerotherapy Laser, diathermy, heater probe Endoscopic clip application Produces initial control of bleeding Reduces rebleeding Decreases need for surgery Meta-analysis - may significantly reduce mortality,Clinical Course,Endoscopy +/ Endoscopic Haemostasis No more bleeding - Rx ulcer, eradicate HP Continuing bleeding - surgery Rebleed - surgery - (repeat EH?) Life threatening massive bleed - endoscopy in theatre, proceed to surgery +/ angiography,Risk scoring - Rockall,0 1 2 3 age 80 shock no pulse100 BP100 comorbidity no CCF, IHD RF, LF malig Diagnosis nil, no SRH all else UGI Ca Major SRH nil blood, clot visible vessel,Risk score - Rockall,Max. score - 7 (before endoscopy), 11 (after endoscopy) Good index of prognosis Mortality increases in stepwise fashion as score increases Valuable in audit as risk standardised mortality can be calculated,Lack of standardized definitions, especially in stigmata Complications: rebleeding, 20%; perforation, 1% Costs not defined Role of repeat endoscopy: planned vs. rebleeding,Endoscopic Therapy - Questions,Future Endoscopic Therapies,Cryotherapy Clips Argon plasma coagulation Sewing,“Modern” Management of UGI Hemorrhage,Resuscitation High dose proton pump inhibitors 80 mg bolus injection of omeprazole plus 8 mg/hr infusion Early endoscopy with therapeutic intervention Repeat endoscopy in 2 hours for high risk patients,Concomitant decision by surgery and gastroenterology regarding operation Most deaths still due to repeated episodes of shock,“Modern” Management of UGI Hemorrhage,Re-bleeding - criteria,Fresh haematemesis or melaena Fall in BP to less than 100 or by 50 mm Hg Fall in Hb by 2 gm / dl Need for continuous transfusion If in doubt - repeat OGD,Indications for Surgery,Failed EH Re-bleed after EH 1 episode in pt 60 yrs or other high risk factor 2 episodes in pts with no high risk factors - ? unsafe Transfusion greater than 4 units / 24 hrs,Endoscopic re-treatment,Controversial Reduces need for surgery after re-bleeding without increasing the risk of death. Lau et al 1999 NEJM (RCT) Routine endoscopy in 24 hrs & retreatment - no benefit Messman 1998 NEJM (