Download PDF
Gastroenterologie up2date 2017; 13(02): 179-195
DOI: 10.1055/s-0043-104470
Darm/Anorektum
Georg Thieme Verlag KG Stuttgart · New York

Untere und mittlere gastrointestinale Blutung

Kira Grün
,
Jörg G. Albert
,
Christoph Sarrazin
,
Wolfgang Reuß
Further Information

Publication History

Publication Date:
29 June 2017 (online)

Also available at
    Permissions and Reprints All articles of this category

Update of:

Untere gastrointestinale BlutungGastroenterologie up2date 2010; 6(04): 265-278
DOI: 10.1055/s-0030-1255863

Die gastrointestinale Blutung mit Blutungsquelle im Dünndarm zwischen Treitz-Band und Ileozökalklappe wird als mittlere intestinale Blutung bezeichnet und so von der unteren intestinalen Blutung (Dickdarm) abgegrenzt. Dieser Beitrag zeigt die diagnostischen Möglichkeiten und therapeutischen Optionen bei unteren und mittleren intestinalen Blutungen.
Kernaussagen

  • Bei einer Blutung distal des Treitz-Bandes kann eine mittlere intestinale Blutung mit einer Blutungsquelle im Dünndarm (zwischen Treitz-Band und Bauhin-Klappe) von einer unteren intestinalen Blutung im engeren Sinn (Kolon) aus klinischer Sicht mit entsprechender epidemiologischer, diagnostischer und therapeutischer Relevanz abgegrenzt werden.

  • Die mittlere und untere gastrointestinale Blutung manifestiert sich als positiver okkulter Stuhlbluttest, als unerklärte Eisenmangelanämie, sichtbarer Teerstuhl, ein intermittierendes „Blutschmieren“ beim Stuhlgang oder als aktive Hämatochezie.

  • Häufige Blutungsquellen im Kolon sind Divertikel, Angiektasien, Neoplasien und entzündliche Darmerkrankungen unterschiedlicher Genese. Im Dünndarm werden Angiektasien, Ulzera bzw. Erosionen bei NSAR-Gebrauch oder ein Morbus Crohn, Tumoren, Metastasen und Divertikel gefunden.

  • Die Diagnostik ist eine Domäne der Koloskopie und der neuen Enteroskopieverfahren (Kapselendoskopie, Ballonenteroskopie).

  • Selten sind szintigrafische Verfahren und die Röntgenkontrastdarstellung des Dünndarms hilfreich. Für ausgewählte Patienten im spezialisierten Zentrum stehen die Angiografie und die intraoperative Enteroskopie zur Verfügung. In einigen Fällen kann die hochauflösende CT, ggf. mit Angiografie, weiterhelfen.

  • Die Therapie richtet sich nach dem Befund und ist ebenfalls eine Domäne der Endoskopie, umfasst aber auch radiologische und operative Verfahren.

Schlüsselwörter

Untere gastrointestinale Blutung - mittlere gastrointestinale Blutung - Diagnostik - Therapie
 

  • Literatur

  • 1 Ell C, May A. Mid-gastrointestinal bleeding: capsule endoscopy and push-and-pull enteroscopy give rise to a new medical term. Endoscopy 2006; 38: 73-75
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Zuckerman GR, Prakash C. Acute lower intestinal bleeding: Part I: clinical presentation and diagnosis. Gastrointest Endosc 1998; 48: 606–617. Part II: etiology, therapy, and outcomes. Gastrointest Endosc 1999; 49: 228-238
    CrossrefPubMedGoogle Scholar
  • 3 Waye JD. Diagnostic Endoscopy in lower intestinal Bleeding. In: Sugawa C, Schuman BM, Lucas CE. eds. Gastrointestinal Bleeding. New York: Igaku Shoin Medical Publishers; 1992: 230-241
    Google Scholar
  • 4 ASGE Guideline. The role of endoscopy in the patient with lower GI bledding. Gastrointest Endosc 2014; 79: 875-885
    CrossrefPubMedGoogle Scholar
  • 5 Bramley PN, Masson JW, McKnight G. et al. The role of an open-access bleeding unit in the management of colonic haemorrhage: a 2-year prospective study. Scand J Gastroenterol 1996; 31: 764-769
    CrossrefPubMedGoogle Scholar
  • 6 Longstreth GF. Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 1997; 92: 419-424
    PubMedGoogle Scholar
  • 7 Bounds BC, Kelsey PB. Lower gastrointestinal bleeding. Gastrointest Endosc Clin N Am 2007; 17: 273-288 vi
    CrossrefPubMedGoogle Scholar
  • 8 Farrell JJ, Friedman LS. Gastrointestinal bleeding in the elderly. Gastrointest Endosc Clin N Am 2001; 30: 377-407 viii
    PubMedGoogle Scholar
  • 9 Laine L, Yang H, Chang SC. et al. Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to 2009. Am J Gastroenterol 2012; 107: 1190-1195 quiz 1196
    CrossrefPubMedGoogle Scholar
  • 10 Strate LL, Ayanian JZ, Kotler G. et al. Risk factors for mortality in lower intestinal bleeding. Clin Gastroenterol Hepatol 2008; 6: 1004-1010 quiz 955
    CrossrefPubMedGoogle Scholar
  • 11 Albert JG, Schülbe R, Hahn L. et al. Impact of capsule endoscopy on outcome in mid-intestinal bleeding: a multicenter cohort study in 285 patients. Eur J Gastroenterol Hepatol 2008; 20: 971-977
    CrossrefPubMedGoogle Scholar
  • 12 Rockey DC. Occult gastrointestinal bleeding. N Engl J Med 1999; 341: 38-46
    CrossrefPubMedGoogle Scholar
  • 13 Rockey DC, Koch J, Cello JP. et al. Relative frequency of upper gastrointestinal and colonic lesions in patients with positive fecal occult-blood tests. N Engl J Med 1998; 339: 153-159
    CrossrefPubMedGoogle Scholar
  • 14 Pohl J, Blancas JM, Cave D. et al. Consensus report of the 2nd International Conference on double balloon endoscopy. Endoscopy 2008; 40: 156-160
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Albert JG, Schülbe R, Hahn L. et al. Impact of capsule endoscopy on outcome in mid-intestinal bleeding: a multicentre cohort study in 285 patients. Eur J Gastroenterol Hepatol 2008; 20: 971-977
    CrossrefPubMedGoogle Scholar
  • 16 Fry LC, Bellutti M, Neumann H. et al. Incidence of bleeding lesions within reach of conventional upper and lower endoscopes in patients undergoing double-balloon enteroscopy for obscure gastrointestinal bleeding. Aliment Pharmacol Ther 2009; 29: 342-349
    CrossrefPubMedGoogle Scholar
  • 17 Albert JG, Lübbert C, Surow A. et al. Die Divertikelkrankheit des Dünndarms im Zeitalter der Dünndarmendoskopie. Z Gastroenterol 2009; 47: 674-681
    Article in Thieme ConnectPubMedGoogle Scholar
  • 18 Strate LL, Liu YL, Aldoori WH. et al. Obesity increases the risks of diverticulitis and diverticular bleeding. Gastroenterology 2009; 136: 115-122.e1
    CrossrefPubMedGoogle Scholar
  • 19 Akutsu D, Narasaka T, Wakayama M. et al. Endoscopic detachable snare ligation: a new treatment method for colonic diverticular hemorrhage. Endoscopy 2015; 47: 1039-1042
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 Polese L, DʼInca R, Angriman I. et al. Gastrointestinal telangiectasia: a study by EGD, colonoscopy, and capsule endoscopy in 75 patients. Endoscopy 2008; 40: 23-29
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Heyde EC. Gastrointestinal bleeding in aortic stenosis. N Engl J Med 1958; 259: 196
    PubMedGoogle Scholar
  • 22 Gill JC, Menitove JE, Anderson PR. et al. HTLV-III serology in hemophilia: relationship with immunologic abnormalities. Blood 1986; 67: 758-761
    CrossrefPubMedGoogle Scholar
  • 23 Salzmann EW, Weinstein MJ, Weintraub RM. et al. Treatment with desmopressin acetate to reduce blood loss after cardiac surgery. A double-blind randomized trial. N Engl J Med 1986; 314: 1402-1406
    CrossrefPubMedGoogle Scholar
  • 24 Panzer S, Badr Eslam R, Schneller A. et al. Loss of high-molecular-weight von Willebrand factor multimers mainly affects platelet aggregation in patients with aortic stenosis. Thromb Haemost 2010; 103: 408-414
    Article in Thieme ConnectPubMedGoogle Scholar
  • 25 Tsai HM, Sussman II, Nagel RL. et al. Shear stress enhances the proteolysis of von Willebrand factor in normal plasma. Blood 1994; 83: 2171-2179
    PubMedGoogle Scholar
  • 26 Crawley JT, de Groot R, Xiang Y. et al. Unraveling the scissile bond: how ADAMTS13 recognizes and cleaves von Willebrand factor. Blood 2011; 118: 3212-3221
    CrossrefPubMedGoogle Scholar
  • 27 von Herrath D, Ludwig WD, Schuler J. DER ARZNEIMITTELBRIEF. Gastrointestinale Blutungen bei Aortenstenose – das Heyde-Syndrom. AMB 2012; 46: 96
    PubMedGoogle Scholar
  • 28 Swanson E, Mahgoub A, MacDonald R. et al. Medical and endoscopic therapies for angiodysplasia and gastric antral vascular ectasia: a systematic review. Clin Gastroenterol Hepatol 2014; 12: 571-582
    CrossrefPubMedGoogle Scholar
  • 29 Brown C, Subramanian V, Wilcox CM. et al. Somatostatin analogues in the treatment of recurrent bleeding from gastrointestinal vascular malformations: an overview and systematic review of prospective observational studies. Dig Dis Sci 2010; 55: 2129-2134
    CrossrefPubMedGoogle Scholar
  • 30 Junquera F, Feu F, Papo M. et al. A multicenter, randomized, clinical trial of hormonal therapy in the prevention of rebleeding from gastrointestinal angiodysplasia. Gastroenterology 2001; 121: 1073-1079
    CrossrefPubMedGoogle Scholar
  • 31 Lock G. Ischämische Kolitis. In: Messmann H. Hrsg. Klinische Gastroenterologie. Stuttgart: Thieme; 2012
    Google Scholar
  • 32 Davila RE, Rajan E, Adler DG. et al. ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding. Gastrointest Endosc 2005; 62: 656-660
    CrossrefPubMedGoogle Scholar
  • 33 Brandt LJ, Feuerstadt P, Longstreth GF. et al. ACG clinical guideline: epidemiology, risk factors, patterns of presentation, diagnosis, and management of colon ischemia (CI). Am J Gastroenterol 2015; 110: 18-44
    CrossrefPubMedGoogle Scholar
  • 34 Montoro MA, Brandt LJ, Santolaria S. et al. Clinical patterns and outcomes of ischaemic colitis: results of the Working Group for the Study of Ischaemic Colitis in Spain (CIE study). Scand J Gastroenterol 2011; 46: 236-246
    CrossrefPubMedGoogle Scholar
  • 35 Looker AC, Dallman PR, Carroll MD. et al. Prevalence of iron deficiency in the United States. JAMA 1997; 277: 973-976
    CrossrefPubMedGoogle Scholar
  • 36 Martí M, Artigas JM, Garzón G. et al. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology 2012; 262: 109-116
    CrossrefPubMedGoogle Scholar
  • 37 Hartmann D, Schmidt H, Bolz G. et al. A prospective two-center study comparing wireless capsule endoscopy with intra-operative enteroscopy in patients with obscure GI bleeding. Gastrointest Endosc 2005; 61: 826-832
    CrossrefPubMedGoogle Scholar
  • 38 Carey EJ, Leighton JA, Heigh RI. et al. A single-center experience of 260 consecutive patients undergoing capsule endoscopy for obscure gastrointestinal bleeding. Am J Gastroenterol 2007; 102: 89-95
    CrossrefPubMedGoogle Scholar
  • 39 Pennazio M, Santucci R, Rondonotti E. et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 2004; 126: 643-653
    CrossrefPubMedGoogle Scholar
  • 40 Redndo-Cerezo E, Perez-Vigara G, Perez-Sola A. et al. Diagnostic yield and impact of capsule endoscopy on management of patients with gastrointestinal bleeding of obscure origin. Dig Dis Sci 2007; 52: 1376-1381
    CrossrefPubMedGoogle Scholar
  • 41 Ma JJ, Wang Y, Xu XM. et al. Capsule endoscopy and single-balloon enteroscopy in small bowel diseases: Competing or complementary?. World J Gastroenterol 2016; 22: 10625-10630
    CrossrefPubMedGoogle Scholar
  • 42 Fujimori S, Seo T, Gudis K. et al. Diagnosis and treatment of obscure gastrointestinal bleeding using combined capsule endoscopy and double balloon endoscopy: 1-year follow-up study. Endoscopy 2007; 39: 1053-1058
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Kaffes AJ, Siah C, Koo JH. Clinical outcomes after double-balloon enteroscopy in patients with obscure GI bleeding and a positive capsule endoscopy. Gastrointest Endosc 2007; 66: 304-309
    CrossrefPubMedGoogle Scholar
  • 44 Hadithi M, Heine GDN, Jacobs MAJM. et al. A prospective study comparing video capsule endoscopy with double-balloon enteroscopy in patients with obscure gastrointestinal bleeding. Am J Gastroenterol 2006; 101: 52-57
    CrossrefPubMedGoogle Scholar
  • 45 Gay G, Delvaux M, Fassler I. Outcome of capsule endoscopy in determining indication and route for push-and-pull enteroscopy. Endoscopy 2006; 38: 49-58
    Article in Thieme ConnectPubMedGoogle Scholar
  • 46 Nakamura M, Niwa Y, Ohmiya N. et al. Preliminary comparison of capsule endoscopy and double-balloon enteroscopy in patients with suspected small-bowel bleeding. Endoscopy 2006; 38: 59-66
    Article in Thieme ConnectPubMedGoogle Scholar
  • 47 Riccioni ME, Urgesi R, Spada C. et al. Unexplained iron deficiency anaemia: Is it worthwhile to perform capsule endoscopy?. Dig Liver Dis 2010; 42: 560-566
    CrossrefPubMedGoogle Scholar
  • 48 Dray X, Battaglia G, Wengrower D. et al. Radiofrequency ablation for the treatment of radiation proctitis. Endoscopy 2014; 46: 970-976
    Article in Thieme ConnectPubMedGoogle Scholar
  • 49 Richter-Schrag HJ, Glatz T. et al. First-line endoscopic treatment with over-the-scope clips significantly improves the primary failure and rebleeding rates in high-risk gastrointestinal bleeding: A single-center experience with 100 cases. World J Gastroenterol 2016; 22: 9162-9171
    CrossrefPubMedGoogle Scholar
  • 50 Rockey DC, Cello JP. Evaluation of the gastrointestinal tract in patients with iron-deficiency anemia. N Engl J Med 1993; 329: 1691-1695
    CrossrefPubMedGoogle Scholar
  • 51 Kepczyk T, Kadakia SC. Prospective evaluation of gastrointestinal tract in patients with iron-deficiency anemia. Dig Dis Sci 1995; 40: 1283-1289
    CrossrefPubMedGoogle Scholar
  • 52 Zuckerman G, Benitez J. A prospective study of bidirectional endoscopy (colonoscopy and upper endoscopy) in the evaluation of patients with occult gastrointestinal bleeding. Am J Gastroenterol 1992; 87: 62-66
    PubMedGoogle Scholar