上消化道出血诊治

Characteristicofuppergastrointestinalbleeding

amonggeriatricpatientsDepartmentofGeriatricsFirstAffiliatedHospitalofNanjingMedicalUniversityWei-HaoSunweihaosun@

.CriteriaofWHOelderlyindividual:thoseover65yearsofageelderlysociety:Itismorethan7%thatthepercentageratioofelderlypopulationtototalpopulationintheareaoracountry.ChinesepopulationisalsoagingUGIbleedingApproximately30%declineinrateoverlast15years

150,000admissionsperyear

Over$1,000,000,000annually

AssociatedwithNSAIDuseUGIbleedingMortalityrate8-10%

>65nowcompriseover30%

Pepticulcerstillmostcommoncause

SurgerynowplaysanadjunctiveroleEpidemiology103:100000adultsperyearShiftinageofpopulationatriskIncreasinguseofNSAIDs&anticoagulantsIncreasingincidenceofin-hospitalbleedingAetiologyPUD50%Acutegastricerosions20%Esophagealvarices10%Tumor5%-10%AVM6%Mallory-Weisstear5%Deiulafoy1%DrugsEstablishedriskfactorsAspirin&NSAIDsWarfarinAlcoholPossibleassociationCalciumchannelblockersSelectiveserotoninuptakeinhibitors- (antidepressant)PepticUlcerDisease:

NSAIDSNSAIDsmaycausebothduodenalorgastriculcersNSAIDsinhibitprostaglandinproductionandcausebreakdownoftheprotectivebarrierofthegastricmucosaPepticUlcerDisease:

NSAIDSComplicationsofNSAIDtherapyusuallyoccurwithinthefirstmonthNSAIDsnotonlyinduceulcersbutmayincreasethechanceofbleedinginpatientswhohaveunderlyingulcerdiseaseVIGOR-SummaryofGIEndpoints†p<0.001.*p=0.005.012345ConfirmedClinical

UpperGIEventsConfirmed

Complicated

UpperGIEventsAllClinicalGIBleedingRR:0.46†(0.33,0.64)RR:0.43*(0.24,0.78)RR:0.38†(0.25,0.57)Ratesper100Patient-YearsRofecoxibNaproxen()=95%CI.Source:Bombardier,etal.NEnglJMed.2000.ReducingtheRiskofUGIToxicitiesinPatientsRequiringChronicNSAIDTherapyRiskDefinitionSuggestedManagementLow<65yr,noaspirin,nopriorulcerorGIcomplicationNonselectiveNSAIDaloneModerateOnetotworiskfactors

(e.g.,age>65yr,high-doseNSAIDs,low-doseaspirin)PartiallyselectiveNSAIDplus

PPIormisoprostol;selective

COX-2inhibitorHigh>3riskfactorsorconcomitantaspirin,corticosteroidsorwarfarinSelectiveCOX-2inhibitorplusPPIormisoprostolVeryhighPriorulcerorulcer-relatedcomplicationSelectiveCOX-2inhibitorplusPPIormisoprostol*;consideravoidingnonselectiveNSAIDsandselectiveCOX-2inhibitorsPresentationHaematemesisMelaenaFrankrectalbleedingSignsandsymptomsofhypovolaemiaAnaemiaEndoscopyDiagnosticTherapeuticPrognosticEndoscopicHaemostasisWidelyacceptedasmosteffectivemethodInjectionwithadrenaline,saline,sclerotherapy

Laser,diathermy,heaterprobe

EndoscopicclipapplicationProducesinitialcontrolofbleedingReducesrebleedingDecreasesneedforsurgeryMeta-analysis-maysignificantlyreducemortality

ClinicalCourseEndoscopy+/EndoscopicHaemostasis

Nomorebleeding -Rxulcer,eradicateHPContinuingbleeding -surgeryRebleed -surgery

-(repeatEH?)Lifethreateningmassivebleed-endoscopyintheatre,proceedtosurgery+/angiographyRiskscoring-Rockall 0 1 2 3age <60 60-79 >80shock no pulse>100 BP<100

comorbidity no CCF,IHD RF,LF maligDiagnosis nil,noSRHallelse UGICa

MajorSRH nil blood,clot visiblevesselRiskscore-RockallMax.score-7(beforeendoscopy),11(afterendoscopy)GoodindexofprognosisMortalityincreasesinstepwisefashionasscoreincreasesValuableinauditasriskstandardisedmortalitycanbecalculatedLackofstandardizeddefinitions,especiallyinstigmata

Complications:rebleeding,20%;perforation,1%

Costsnotdefined

Roleofrepeatendoscopy:plannedvs.rebleedingEndoscopicTherapy-QuestionsFutureEndoscopicTherapiesCryotherapy

Clips

Argonplasmacoagulation

Sewing“Modern”Managementof

UGIHemorrhageResuscitationHighdoseprotonpumpinhibitors

80mgbolusinjectionofomeprazoleplus8mg/hrinfusionEarlyendoscopywiththerapeuticinterventionRepeatendoscopyin2hoursforhighriskpatientsConcomitantdecisionbysurgeryandgastroenterologyregardingoperationMostdeathsstillduetorepeatedepisodesofshock“Modern”Managementof

UGIHemorrhageRe-bleeding-criteriaFreshhaematemesisormelaenaFallinBPtolessthan100orby50mmHgFallinHbby2gm/dlNeedforcontinuoustransfusionIfindoubt-repeatOGDIndicationsforSurgeryFailedEHRe-bleedafterEH1episodeinpt>60yrsorotherhighriskfactor2episodesinptswithnohighriskfactors-?unsafeTransfusiongreaterthan4units/24hrsEndoscopicre-treatmentControversialReducesneedforsurgeryafterre-bleedingwithoutincreasingtheriskofdeath.Lauetal1999NEJM(RCT)Routineendoscopyin24hrs&retreatment-