Download PDF
Z Gastroenterol 2014; 52(5): 441-446
DOI: 10.1055/s-0034-1366210
Kasuistik
© Georg Thieme Verlag KG Stuttgart · New York

Obere gastrointestinale Blutung mit hämorrhagischem Schock am Ende einer Urlaubsreise: Präklinische und innerklinische Versorgung eines gastrointestinalen Notfalls

Upper Gastrointestinal Bleeding and Haemorrhagic Shock at the End of the Holidays: Pre-Hospital and In-Hospital Management of a Gastrointestinal Emergency
M. Nguyen-Tat
1   First Medical Department, University Medical Center Mainz, Johannes Gutenberg University Mainz
,
A. Hoffman
2   Department of Internal Medicine, St. Mary’s Hospital Frankfurt
,
J. U. Marquardt
1   First Medical Department, University Medical Center Mainz, Johannes Gutenberg University Mainz
,
H. Buggenhagen
3   Department of Anesthesiology, University Medical Center Mainz, Johannes Gutenberg University Mainz
,
T. Münzel
4   Second Medical Department, University Medical Center Mainz, Johannes Gutenberg University Mainz
,
W. Kneist
5   Department for General, Visceral and Transplant Surgery, University Medical Center Mainz, Johannes Gutenberg University Mainz
,
P. R. Galle
1   First Medical Department, University Medical Center Mainz, Johannes Gutenberg University Mainz
,
R. Kiesslich
2   Department of Internal Medicine, St. Mary’s Hospital Frankfurt
,
J. W. Rey
2   Department of Internal Medicine, St. Mary’s Hospital Frankfurt
› Author Affiliations
Further Information

Publication History

29 November 2013

16 February 2014

Publication Date:
13 May 2014 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Nach der Rückkehr aus dem Urlaub wurde ein 55-jähriger Patient mit Teerstuhl und hämorrhagischem Schock im Zugabteil eines InterCity der Deutschen Bahn notfallmedizinisch versorgt und in ein Krankenhaus der Maximalversorgung eingeliefert. Hier erfolgte zunächst die weitere notfallmedizinische Behandlung, in deren Rahmen in der internistischen Notaufnahme in interdisziplinärer Zusammenarbeit eine Stabilisierung der Hämodynamik sowie die Sicherung der Atemwege und Atemfunktion erfolgten. Anschließend wurde eine Notfall-Endoskopie des oberen Gastrointestinaltrakts durchgeführt. Ursächlich für das hämorrhagische Schockgeschehen war eine arteriell spritzende, endoskopisch nicht zu stillende Blutung im Duodenum. Die definitive Blutungsstillung gelingt schließlich im Rahmen einer notfallmäßigen Laparatomie. Durch ein an die Versorgung traumatologischer Patienten angelehntes, aber für gastroenterologische Patienten mit Schockgeschehen nicht regelhaft vorhandenes Schockraum-Management konnte im vorliegenden Falle eines hochgradig instabilen Patienten durch die spontane Übernahme von etablierten Algorithmen aus der interdisziplinären Versorgung von Trauma-Patienten eine adäquate Kreislaufstabilisierung sowie Blutungskontrolle erreicht werden. Auch wenn ein Großteil der oberen gastrointestinalen Blutungen spontan sistieren, sollte wie für hier berichtete internistische Notfälle mit hämorrhagischem Schockgeschehen eine notfallmedizinische Versorgung nach Algorithmen entwickelt und implementiert werden. Am vorliegenden Fall wird ein mögliches beispielhaftes Vorgehen diskutiert sowie ein Vorschlag für ein mögliches Schockraum-Protokoll für diese Patientengruppe entwickelt.

Abstract

Upon returning from holidays, a 55-year-old patient presenting with melena and haemorrhagic shock was admitted to a University hospital after receiving first emergency medical care in a German InterCity train. In an interdisciplinary effort, haemodynamics were stabilised and the airway and respiratory function were secured. Under emergency care conditions the patient then underwent an emergency upper GI endoscopy where a spurting arterial upper gastrointestinal bleeding (Forrest 1a) was found. While the bleeding could not be controlled with endoscopic techniques, definitive haemostasis was achieved with a surgical laparotomy. While not commonly established for patients with severe GI bleeding, by spontaneous implementation of an interdisciplinary trauma room approach following established trauma algorithms the team was able to achieve stabilisation of vital functions and final control of bleeding in this highly unstable patient. Although the majority of upper gastrointestinal bleedings spontaneously cease, emergency care algorithms should be developed and implemented for patients with severe gastrointestinal bleedings in shock. Following the case vignette, we discuss a potential approach and develop an exemplary protocol for shock room management in this patient subgroup.

Schlüsselwörter

obere gastrointestinale Blutung - hämorrhagischer Schock - Schockraum - Notfallendoskopie

Key words

upper gastrointestinal bleeding - haemorrhagic shock - shock room - emeregency endoscopy
 

  • Literatur

  • 1 Rixen D, Steinhausen E, Dahmen J et al. S3 guideline on treatment of polytrauma/severe injuries. Initial surgical phase: significance – possibilities – difficulties?. Der Unfallchirurg 2012; 115: 22-29
    CrossrefPubMedGoogle Scholar
  • 2 Ellinger K, Genzwürker H. Kursbuch Notfallmedizin. Köln: Deutscher Ärzteverlag; 2011. 2. Auflage: 922
    Google Scholar
  • 3 Peura DA, Lanza FL, Gostout CJ et al. The American College of Gastroenterology Bleeding Registry: preliminary findings. The American journal of gastroenterology 1997; 92: 924-928
    PubMedGoogle Scholar
  • 4 Cappell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. The Medical clinics of North America 2008; 92: 491-509 , xi
    CrossrefPubMedGoogle Scholar
  • 5 Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. The American journal of gastroenterology 1995; 90: 206-210
    PubMedGoogle Scholar
  • 6 Rupp T, Singh S, Waggenspack W. Gastrointestinal hemorrhage: The prehospital recognition, assessment & management of patients with a GI bleed. JEMS: a journal of emergency medical services 2004; 29: 80-81 , 83–95; quiz 96–87
    PubMedGoogle Scholar
  • 7 Nakamura S, Matsumoto T, Sugimori H et al. Emergency endoscopy for acute gastrointestinal bleeding: Prognostic value of endoscopic hemostasis and the AIMS65 score in Japanese patients. Digestive endoscopy: official journal of the Japan Gastroenterological Endoscopy Society 2013; DOI: 10.1111/den.12187.
    CrossrefPubMedGoogle Scholar
  • 8 Chandra S. AIMS65 score predicts short-term mortality but not the need for intervention in acute upper GI bleeding. Gastrointestinal endoscopy 2013; 78: 381-382
    CrossrefPubMedGoogle Scholar
  • 9 Saltzman JR, Tabak YP, Hyett BH et al. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointestinal endoscopy 2011; 74: 1215-1224
    CrossrefPubMedGoogle Scholar
  • 10 Pericleous M, Murray C, Hamilton M et al. Using an “action set” for the management of acute upper gastrointestinal bleeding. Therapeutic advances in gastroenterology 2013; 6: 426-437
    CrossrefPubMedGoogle Scholar
  • 11 Wang CY, Qin J, Wang J et al. Rockall score in predicting outcomes of elderly patients with acute upper gastrointestinal bleeding. World journal of gastroenterology: WJG 2013; 19: 3466-3472
    CrossrefPubMedGoogle Scholar
  • 12 Church NI, Dallal HJ, Masson J et al. Validity of the Rockall scoring system after endoscopic therapy for bleeding peptic ulcer: a prospective cohort study. Gastrointestinal endoscopy 2006; 63: 606-612
    CrossrefPubMedGoogle Scholar
  • 13 Srygley FD, Gerardo CJ, Tran T et al. Does this patient have a severe upper gastrointestinal bleed?. JAMA: the journal of the American Medical Association 2012; 307: 1072-1079
    CrossrefPubMedGoogle Scholar
  • 14 Baradarian R, Ramdhaney S, Chapalamadugu R et al. Early intensive resuscitation of patients with upper gastrointestinal bleeding decreases mortality. The American journal of gastroenterology 2004; 99: 619-622
    CrossrefPubMedGoogle Scholar
  • 15 Villanueva C, Colomo A, Bosch A et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013; 368: 11-21
    CrossrefPubMedGoogle Scholar
  • 16 Wen Y, Yang H, Wei W et al. The outcomes of 1120 severe multiple trauma patients with hemorrhagic shock in an emergency department: a retrospective study. BMC emergency medicine 2013; 13 (Suppl. 01) S6
    CrossrefPubMedGoogle Scholar
  • 17 Theusinger OM, Madjdpour C, Spahn DR. Resuscitation and transfusion management in trauma patients: emerging concepts. Current opinion in critical care 2012; 18: 661-670
    CrossrefPubMedGoogle Scholar
  • 18 Fort E, Sautereau D, Silvain C et al. A randomized trial of terlipressin plus nitroglycerin vs. balloon tamponade in the control of acute variceal hemorrhage. Hepatology 1990; 11: 678-681
    CrossrefPubMedGoogle Scholar
  • 19 Gluud LL, Klingenberg SL, Langholz E. Tranexamic acid for upper gastrointestinal bleeding. The Cochrane database of systematic reviews 2012; 1 CD006640
    PubMedGoogle Scholar
  • 20 Vu EN, Schlamp RS, Wand RT et al. Prehospital use of tranexamic acid for hemorrhagic shock in primary and secondary air medical evacuation. Air medical journal 2013; 32: 289-292
    CrossrefPubMedGoogle Scholar
  • 21 Stagnitti F. Uncontrolled bleeding in patients with major abdominal trauma. Annali italiani di chirurgia 2013; 84: 365
    PubMedGoogle Scholar
  • 22 Waye JD. Intubation and sedation in patients who have emergency upper GI endoscopy for GI bleeding. Gastrointestinal endoscopy 2000; 51: 768-771
    CrossrefPubMedGoogle Scholar
  • 23 Rehman A, Iscimen R, Yilmaz M et al. Prophylactic endotracheal intubation in critically ill patients undergoing endoscopy for upper GI hemorrhage. Gastrointestinal endoscopy 2009; 69: e55-e59
    CrossrefPubMedGoogle Scholar
  • 24 Schacher GM, Lesbros-Pantoflickova D, Ortner MA et al. Is early endoscopy in the emergency room beneficial in patients with bleeding peptic ulcer? A "fortuitously controlled" study. Endoscopy 2005; 37: 324-328
    Article in Thieme ConnectPubMedGoogle Scholar
  • 25 Bjorkman DJ, Zaman A, Fennerty MB et al. Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study. Gastrointestinal endoscopy 2004; 60: 1-8
    CrossrefPubMedGoogle Scholar
  • 26 Wysocki JD, Srivastav S, Winstead NS. A nationwide analysis of risk factors for mortality and time to endoscopy in upper gastrointestinal haemorrhage. Aliment Pharmacol Ther 2012; 36: 30-36
    CrossrefPubMedGoogle Scholar
  • 27 Tsoi KK, Chiu PW, Chan FK et al. The risk of peptic ulcer bleeding mortality in relation to hospital admission on holidays: a cohort study on 8,222 cases of peptic ulcer bleeding. The American journal of gastroenterology 2012; 107: 405-410
    CrossrefPubMedGoogle Scholar
  • 28 Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in gastrointestinal bleeding. Lancet 1974; 2: 394-397
    CrossrefPubMedGoogle Scholar
  • 29 Ahmed A, Stanley AJ. Acute upper gastrointestinal bleeding in the elderly: aetiology, diagnosis and treatment. Drugs & aging 2012; 29: 933-940
    CrossrefPubMedGoogle Scholar
  • 30 Jairath V, Kahan BC, Logan RF et al. National audit of the use of surgery and radiological embolization after failed endoscopic haemostasis for non-variceal upper gastrointestinal bleeding. The British journal of surgery 2012; 99: 1672-1680
    CrossrefPubMedGoogle Scholar
  • 31 Meier R, Wettstein AR. Treatment of acute nonvariceal upper gastrointestinal hemorrhage. Digestion 1999; 60 (Suppl. 02) 47-52
    PubMedGoogle Scholar
  • 32 Chang CF, Chan CY, Lin HJ et al. Endoscopy for upper gastrointestinal bleeding at emergency unit. Zhonghua yi xue za zhi = Chinese medical journal Free China ed 1992; 49: 217-222
    PubMedGoogle Scholar
  • 33 Monig SP, Lubke T, Baldus SE et al. Early elective surgery for bleeding ulcer in the posterior duodenal bulb. Own results and review of the literature. Hepato-gastroenterology 2002; 49: 416-418
    PubMedGoogle Scholar
  • 34 Borgohain B, Khonglah T. Developing and organizing a trauma system and mass casualty management: some useful observations from the israeli trauma model. Annals of medical and health sciences research 2013; 3: 85-89
    CrossrefPubMedGoogle Scholar
  • 35 Hussmann B, Waydhas C, Lendemans S. Emergency trauma room management in severely and most severely injured patients. A multidisciplinary task. Medizinische Klinik, Intensivmedizin und Notfallmedizin 2012; 107: 217-227 ; quiz 228–219
    PubMedGoogle Scholar
  • 36 Thies K, Gwinnutt C, Driscoll P et al. The European Trauma Course – from concept to course. Resuscitation 2007; 74: 135-141
    CrossrefPubMedGoogle Scholar
  • 37 Jutabha R, Jensen DM. Management of upper gastrointestinal bleeding in the patient with chronic liver disease. The Medical clinics of North America 1996; 80: 1035-1068
    CrossrefPubMedGoogle Scholar
  • 38 Barkun AN, Bardou M, Martel M et al. Prokinetics in acute upper GI bleeding: a meta-analysis. Gastrointestinal endoscopy 2010; 72: 1138-1145
    CrossrefPubMedGoogle Scholar
  • 39 Pateron D, Vicaut E, Debuc E et al. Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Annals of emergency medicine 2011; 57: 582-589
    CrossrefPubMedGoogle Scholar
  • 40 Dorward S, Sreedharan A, Leontiadis GI et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. The Cochrane database of systematic reviews 2006; DOI: 10.1002/14651858.CD005415.pub2. CD005415
    CrossrefPubMedGoogle Scholar
  • 41 Imperiale TF, Teran JC, McCullough AJ. A meta-analysis of somatostatin versus vasopressin in the management of acute esophageal variceal hemorrhage. Gastroenterology 1995; 109: 1289-1294
    CrossrefPubMedGoogle Scholar
  • 42 Moitinho E, Planas R, Banares R et al. Multicenter randomized controlled trial comparing different schedules of somatostatin in the treatment of acute variceal bleeding. Journal of hepatology 2001; 35: 712-718
    CrossrefPubMedGoogle Scholar
  • 43 Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. The Cochrane database of systematic reviews 2003; DOI: 10.1002/14651858.CD002147. CD002147
    CrossrefPubMedGoogle Scholar
  • 44 Erkek N, Senel S, Hizli S et al. Terlipressin saved the life of a child with severe nonvariceal upper gastrointestinal bleeding. The American journal of emergency medicine 2011; 29: 133 e135–e136
    PubMedGoogle Scholar
  • 45 Fox JG, Hunt PS. Management of acute bleeding gastric malignancy. The Australian and New Zealand journal of surgery 1993; 63: 462-465
    CrossrefPubMedGoogle Scholar
  • 46 Bulut OB, Rasmussen C, Fischer A. Acute surgical treatment of complicated peptic ulcers with special reference to the elderly. World journal of surgery 1996; 20: 574-577
    CrossrefPubMedGoogle Scholar
  • 47 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
    CrossrefPubMedGoogle Scholar
  • 48 Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000; 356: 1318-1321
    CrossrefPubMedGoogle Scholar