Upper Gastrointestinal Bleeding, An issue of Gastroenterology Clinics of North America (eBook)

Ian M. Gralnek (Autor)

eBook Download: EPUB

2014 | 1. Auflage
100 Seiten
Elsevier Health Sciences (Verlag)
978-0-323-32651-3 (ISBN)

Infos

Upper Gastrointestinal Bleeding, An issue of Gastroenterology Clinics of North America,

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This issue of Gastroenterology Clinics of North America is all about acute upper GI bleeding and is divided into two distinct sections: section I is devoted to nonvariceal upper GI bleeding and section II is devoted to variceal upper GI bleeding. Acute nonvariceal upper GI bleeding may originate from the esophagus, stomach, or duodenum, essentially anywhere proximal to the Ligament of Treitz. In Section I, Dr Gianluca Rotondano, Hospital Maresca, Torre del Greco, Italy, begins with a review of the epidemiology and diagnosis of acute nonvariceal upper GI bleeding. We then turn to patient presentation, risk stratification, and how to initially medically manage these bleeding patients. I am pleased to have one of our emergency medicine colleagues, Dr Andrew Meltzer, Department of Emergency Medicine, George Washington University, contribute this important article and provide a unique viewpoint from the emergency department where most of these patients initially present. As we all know, endoscopic hemostasis is the accepted standard of care for patients with acute nonvariceal upper GI bleeding. Moreover, peptic ulcer bleeding is the most common nonvariceal cause of acute upper GI bleeding; thus, Drs Yidan Lu, Yen-I Chen, and Alan Barkun from McGill University, Montreal, Canada, provide an in-depth review of the endoscopic management of peptic ulcer bleeding. Drs Eric Tjwa, I. Lisanne Holster, and Ernst Kuipers from the Erasmus Medical Center University Hospital, Rotterdam, The Netherlands, review the endoscopic management of all other causes of acute nonvariceal upper GI bleeding, and in addition, Drs Louis Wong Kee Song and Michael Levy from the Mayo Clinic, Rochester, Minnesota discuss emerging endoscopic hemostasis treatments, such as topical sprays and over-the-scope clipping devices. Although endoscopic hemostasis is very highly effective, there are unfortunately cases where bleeding is unable to be controlled or when significant rebleeding occurs that is not amenable to endoscopic therapy. Therefore, I have included two articles that provide insight into the question...what if endoscopic hemostasis fails? The first article, written by Drs Philip Wai Yan Chiu and James Yun Wong Lau, from Prince of Wales Hospital, The Chinese University of Hong Kong, focuses on tried and true surgical treatment options. The second article, by Dr Sujal Nanavati, University of California at San Francisco, Department of Radiology and Biomedical Imaging, addresses the alternative treatment strategy of angiographic embolization, which has now emerged as the often preferred salvage treatment strategy.

Textauszug

Epidemiology and Diagnosis of Acute Nonvariceal Upper Gastrointestinal Bleeding

Gianluca Rotondano, [e-mail],     Division of Gastroenterology & Digestive Endoscopy, Hospital Maresca, ASLNA3sud, Via Montedoro, Torre del Greco 80059, Italy

Acute upper gastrointestinal bleeding (UGIB) is a common gastroenterological emergency. A vast majority of these bleeds have nonvariceal causes, in particular gastroduodenal peptic ulcers. Nonsteroidal antiinflammatory drugs, low-dose aspirin use, and Helicobacter pylori infection are the main risk factors for UGIB. Current epidemiologic data suggest that patients most affected are older with medical comorbidit. Widespread use of potentially gastroerosive medications underscores the importance of adopting gastroprotective pharamacologic strategies. Endoscopy is the mainstay for diagnosis and treatment of acute UGIB. It should be performed within 24 hours of presentation by skilled operators in adequately equipped settings, using a multidisciplinary team approach.

Keywords

Nonvariceal bleeding

Epidemiology

Diagnosis

Risk factors

Peptic ulcer

Endoscopy

Timing

Key points

• There is a trend toward a decrease in the overall incidence and hospitalization for nonvariceal upper gastrointestinal bleeding (UGIB) worldwide. Peptic ulcer is still the most common cause of hemorrhage.

• The changing epidemiology is characterized by an aging population, with multiple comorbidities and increased use of aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), or other antiplatelets/anticoagulants.

• Mortality for UGIB is still approximately 5% and is usually related to multiorgan failure, cardiopulmonary conditions, and end-stage malignancy.

• Endoscopy is the mainstay in the management of UGIB, allowing for proper diagnosis, risk stratification, and treatment of the bleeding lesion.

• Unless contraindicated, endoscopy should be performed within 24 hours of patient presentation to maximize benefits and improve economic outcomes.

Epidemiology of acute nonvariceal upper gastrointestinal bleeding

UGIB is predominantly nonvariceal in origin and remains one of the most common challenges faced by gastroenterologists and endoscopists in daily clinical practice. Despite major advances in the approach to the management of nonvariceal UGIB over the past 2 decades, including prevention of peptic ulcer bleeding, optimal use of endoscopic therapy, and adjuvant high-dose proton pump inhibitors (PPIs), it still carries considerable morbidity, mortality, and health economic burden.

Incidence of Acute Upper Gastrointestinal Bleeding

With more than 300,000 hospital admissions annually in the United States,1,2 UGIB is one of the most common gastrointestinal (GI) emergencies. A 2012 update on the burden of GI disease in the United States reports that GI hemorrhage still ranked 7th among the principal GI discharge diagnoses from hospital admissions in 2009, with a 22% increase compared with year 2000, and 10th among causes of death from GI and liver diseases.3

The incidence rates of UGIB demonstrate a large geographic variation, ranging from 48 to 160 cases per 100,000 population per year, with consistent reports of higher incidences among men and the elderly.4–10 Possible explanations for the reported geographic variations in incidence are differences in definition of UGIB in various studies, population characteristics, prevalence of gastroerosive medications, in particular aspirin and NSAIDs, and Helicobacter pylori prevalence.

Some but not all time-trend studies have reported a significant decline in incidence of all-cause acute UGIB, especially peptic ulcer bleeding, in recent years. In the Netherlands, the incidence of UGIB decreased from 61.7/100,000 in 1993/1994 to 47.7/100,000 persons annually in 2000, corresponding to a 23% decrease in incidence after age adjustment.6,7 This was confirmed in a population-based study carried out in Northern Italy in which the overall incidence of UGIB decreased from 112.5 to 89.8/100,000 per year, which corresponds to a 35.5% decrease after adjustment for age.8 Trends for incidence of hospitalization due to GI complications in the United States from 2001 to 2009 confirm decreases in UGIB (78.4–60.6/100,000) and peptic ulcer bleeding (48.7–32.1/100,000).11 The reasons for the observed decrease in hospitalizations due to nonvariceal UGIB are not well defined, but it is reasonable to assume that the use of eradication therapy in patients with ulcer disease and the progressive increase in the implementation of preventive strategies in patients taking aspirin and NSAIDs may have played a role.12–14

Outcome data from multicenter observational registries of UGIB, originating from Italy,15 Canada,16 and the United Kingdom,17 reported a mean age of bleeders over 60 years and a prevalence of UGIB in men. In-hospital bleeding (ie, GI hemorrhage that occurs in patients already hospitalized for another medical-surgical condition) occurs in 10% to 25%.7,18–20

Causes of Acute Upper Gastrointestinal Bleeding

Peptic ulcer bleeding is still the most common cause of nonvariceal UGIB, responsible for approximately 31% to 67% of all cases, followed by erosive disease, esophagitis, malignancy, and Mallory-Weiss tears. In 2% to 8% of cases, uncommon causes, such as Dieulafoy lesion, hemobilia, angiodysplasia, vascular-enteric fistula, and gastric antral vascular ectasia are found (Table 1).6–9,15–17,21–26

Table 1

Causes of upper gastrointestinal bleeding according to recent epidemiologic studies

%

Peptic ulcer

31–67

Erosive disease

7–31

Variceal bleeding

4–20

Esophagitis

3–12

Mallory-Weiss tears

4–8

Malignancy

2–8

Vascular lesions

2–8

None (no lesion identified)

3–19

Data from Refs.8,15–17,24,33

In recent years, there has been an overall decrease in the incidence of UGIB related to bleeding peptic ulcers, at least in subjects under 70 years of age,8 whereas its incidence is stable or even higher among patients of more advanced age.27 A study from Australia on bleeding ulcers over a 10-year period (1997–2007) confirmed that the number of bleeding ulcers remained unchanged despite a decreased incidence of uncomplicated peptic ulcer.28 Gastric ulcers increased significantly in both bleeding and nonbleeding patients whereas the proportion of duodenal ulcers fell significantly. The proportion of bleeding ulcers related to NSAIDs or aspirin increased significantly over 10 years, from 51% to 71%. Gastroduodenal ulcers are also the most frequent causes of nonvariceal bleeding in cirrhotic patients (48%–51%).29,30

Nonvariceal UGIB is not just about peptic ulcers. According to different registries, nonvariceal nonulcer bleeding accounts for 34% to 64% of all presenting cases of nonvariceal UGIB.15–17 Recent data from Italy31 show that patients with Dieulafoy lesions have high rebleeding rates (19.1%); although rare causes of nonvariceal UGIB, they can cause torrential bleeding and can be difficult to locate. Patients with Dieulafoy lesions were more likely to present with hematemesis, shock, syncope, and a lower hemoglobin concentration and require blood transfusion compared with patients presenting with other endoscopic diagnoses. Of greater concern was the reported rebleeding rate for Mallory-Weiss tears (6.3%), traditionally considered benign, low-risk, and self-limiting lesions. It is possible that this may represent endoscopic undertreatment because of the perceived low-risk nature of Mallory-Weiss tears but also raises questions regarding uniform diagnostic criteria.

The source and outcomes of UGIB in oncologic patients are poorly investigated. The causes of UGIB in oncologic patients seem to be different from those in the general population. Retrospective data on 324 patients with cancer referred for endoscopy due to UGIB32 showed that tumor was the most common cause of bleeding (23.8%), followed by varices (19.7%), peptic ulcer (16.3%), and gastroduodenal erosions (10.9%). If considering only patients with tumors outside the GI tract, however, the most common causes of UGIB are similar to those in the general population, that is, peptic ulcer, gastroduodenal erosions, and varices. On the other hand, even in patients with tumors...

Produkt-Details

• Erscheint lt. Verlag: 8.2.2015
• Sprache: englisch
• Themenwelt: Medizinische Fachgebiete ► Innere Medizin ► Gastroenterologie
• ISBN-10: 0-323-32651-X / 032332651X
• ISBN-13: 978-0-323-32651-3 / 9780323326513