Gastrointestinale Blutungen

Gastrointestinale Blutungen sind häufig und können anhand der Anamnese und mithilfe klinischer und laborchemischer Untersuchungen schnell diagnostiziert werden. Die weitere Behandlung sollte dann endoskopisch unter stationären Bedingungen erfolgen. Dieser CME-Artikel gibt eine detaillierte Übersicht zum klinischen Management und stellt verschiedene endoskopische Vorgehensweisen in Abhängigkeit von der Blutungslokalisation vor.

Abstract

Gastrointestinal bleeding Gastrointestinal bleeding occurs frequently in clinical practice. The presence of gastrointestinal bleeding usually is suspected by typical clinical history and results of clinical examination and laboratory findings. Endoscopic treatment of gastrointestinal bleeding is associated with high success rates over 90%. Different techniques for endoscopic hemostasis are available and for most indications, a combination of two modalities is recommended. Endoscopic management of recurrent or persistent bleeding is technically more challenging and associated with increased mortality (up to 10%, especially in patients with high age and comorbidities). In this situation, endoscopic hemostasis using an over-the-scope clip has shown to be superior to standard treatment for recurrent peptic ulcer bleeding in the upper gastrointestinal tract. Recent studies also have shown superiority for first-line over-the-scope clip treatment of non-variceal upper gastrointestinal bleeding in high-risk patients. In this review, management of gastrointestinal bleeding is summarized based on current guidelines and current literature.

Kernaussagen

• Das Auftreten gastrointestinaler Blutungen ist im klinischen Alltag häufig.

• Das Management gastrointestinaler Blutungen erfolgt endoskopisch unter stationären Bedingungen.

• Die Spiral-Enteroskopie ist ein neues Verfahren zur endoskopischen Intervention im Dünndarm.

• Der OTSC ist den Standardclips bei der Rezidiv-Ulkusblutung im oberen GI-Trakt überlegen.

• Die variköse obere Gastrointestinalblutung muss früh von der nicht varikösen Blutung abgegrenzt werden.

• Beim Management gastrointestinaler Blutungen kann ein interdisziplinäres Vorgehen erforderlich sein.

Schlüsselwörter

gastrointestinal - Blutung - endoskopisch - Management - Clip

Keywords

gastrointestinal - bleeding - endoscopic - management - clip

Publikationsverlauf

Artikel online veröffentlicht:
23. Januar 2023

• Literatur

• 1 Gralnek IM, Dumonceau JM, Kuipers EJ. et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: a1-46
• 2 Lau JY, Sung JJ, Lam YH. et al. Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med 1999; 340: 751-756
• 3 Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000; 356: 1318-1321
• 4 Cheng DW, Lu YW, Teller T. et al. A modified Glasgow Blatchford Score improves risk stratification in upper gastrointestinal bleed: a prospective comparison of scoring systems. Aliment Pharmacol Ther 2012; 36: 782-789
• 5 Brunk T, Schmidt A, Hochberger J. et al. Telemetric capsule-based upper gastrointestinal tract – blood detection – first multicentric experience. Minim Invasive Ther Allied Technol 2022; 31: 704-711
• 6 Villanueva C, Colomo A, Bosch A. et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013; 368: 11-21
• 7 Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med 2014; 174: 1755-1762
• 8 Seshasai SRK, Wijesuriya S, Sivakumaran R. et al. Effect of aspirin on vascular and nonvascular outcomes: meta-analysis of randomized controlled trials. Arch Intern Med 2012; 172: 209-216
• 9 Côté R, Zhang Y, Hart RG. et al. ASA failure: does the combination ASA/clopidogrel confer better long-term vascular protection?. Neurology 2014; 82: 382-389
• 10 Gu ZC, Wei AH, Zhang C. et al. Risk of Major Gastrointestinal Bleeding With New vs Conventional Oral Anticoagulants: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2020; 18: 792-799
• 11 Hansen ML, Sørensen R, Clausen MT. et al. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med 2010; 170: 1433-1441
• 12 Götz M, Anders M, Biecker E. et al. S2k Guideline Gastrointestinal Bleeding – Guideline of the German Society of Gastroenterology DGVS [S2k-Leitlinie Gastrointestinale Blutung]. Z Gastroenterol 2017; 55: 883-936
• 13 Gralnek IM, Stanley AJ, Morris AJ. et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021. Endoscopy 2021; 53: 300-332
• 14 Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012; 107: 345-360; quiz 361
• 15 Marmo R, Rotondano G, Piscopo R. et al. Dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers: a meta-analysis of controlled trials. Am J Gastroenterol 2007; 102: 279-289; quiz 469
• 16 Barkun AN, Martel M, Toubouti Y. et al. Endoscopic hemostasis in peptic ulcer bleeding for patients with high-risk lesions: a series of meta-analyses. Gastrointest Endosc 2009; 69: 786-799
• 17 Chung IK, Ham JS, Kim HS. et al. Comparison of the hemostatic efficacy of the endoscopic hemoclip method with hypertonic saline-epinephrine injection and a combination of the two for the management of bleeding peptic ulcers. Gastrointest Endosc 1999; 49: 13-18
• 18 Ljubicic N, Budimir I, Biscanin A. et al. Endoclips vs large or small-volume epinephrine in peptic ulcer recurrent bleeding. World J Gastroenterol 2012; 18: 2219-2224
• 19 Schmidt A, Gölder S, Goetz M. et al. Over-the-Scope Clips Are More Effective Than Standard Endoscopic Therapy for Patients With Recurrent Bleeding of Peptic Ulcers. Gastroenterology 2018; 155: 674-686
• 20 Jensen DM, Kovacs T, Ghassemi KA. et al. Randomized Controlled Trial of Over-the-Scope Clip as Initial Treatment of Severe Nonvariceal Upper Gastrointestinal Bleeding. Clin Gastroenterol Hepatol 2021; 19: 2315-2323.e2
• 21 Meier B, Wannhoff A, Denzer U. et al. Over-the-scope-clips versus standard treatment in high-risk patients with acute non-variceal upper gastrointestinal bleeding: a randomised controlled trial (STING-2). Gut 2022; 71: 1251-1258
• 22 Cahyadi O, Bauder M, Meier B. et al. Effectiveness of TC-325 (Hemospray) for treatment of diffuse or refractory upper gastrointestinal bleeding - a single center experience. Endosc Int Open 2017; 5: E1159-1164
• 23 Chen YI, Wyse J, Lu Y. et al. TC-325 hemostatic powder versus current standard of care in managing malignant GI bleeding: a pilot randomized clinical trial. Gastrointest Endosc 2020; 91: 321-328.e1
• 24 Ofosu A, Ramai D, John F. et al. The Efficacy and Safety of Hemospray for the Management of Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2021; 55: e37-45
• 25 Alzoubaidi D, Hussein M, Rusu R. et al. Outcomes from an international multicenter registry of patients with acute gastrointestinal bleeding undergoing endoscopic treatment with Hemospray. Dig Endosc 2020; 32: 96-105
• 26 Escorsell À, Pavel O, Cárdenas A. et al. Esophageal balloon tamponade versus esophageal stent in controlling acute refractory variceal bleeding: A multicenter randomized, controlled trial. Hepatology 2016; 63: 1957-1967
• 27 Beyna T, Arvanitakis M, Schneider M. et al. Total motorized spiral enteroscopy: first prospective clinical feasibility trial. Gastrointest Endosc 2021; 93: 1362-1370
• 28 Beyna T, Moreels T, Arvanitakis M. et al. Motorized Spiral Enteroscopy: Results of an international, multicenter, prospective observational clinical study on patients with normal and altered gastrointestinal anatomy. Endoscopy 2022;
• 29 Nagata N, Niikura R, Ishii N. et al. Cumulative evidence for reducing recurrence of colonic diverticular bleeding using endoscopic clipping versus band ligation: Systematic review and meta-analysis. J Gastroenterol Hepatol 2021; 36: 1738-1743