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Gastroenterologie up2date 2023; 19(01): 77-95
DOI: 10.1055/a-1950-5126
Darm/Anorektum

Untere und mittlere gastrointestinale Blutung

Mid and Lower Gastrointestinal Bleeding
Jörg G. Albert
,
Kira Grün
,
Christoph Sarrazin
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Zusammenfassung

Blutungen aus dem Gastrointestinaltrakt werden in obere, mittlere und untere gastrointestinale Blutung unterschieden. Die Diagnostik kann eine Herausforderung sein und ist eine Domäne der Koloskopie, der Kapselendoskopie oder der flexiblen Enteroskopieverfahren. Als endoskopische Therapieoptionen stehen die Injektionstherapie, Metallclips, eine thermische Behandlung sowie die Gummibandligatur zur Verfügung, eine chirurgische Resektion ist nur selten erforderlich.

Abstract

Acute lower gastrointestinal bleeding (GI) is the reason in about 20 to 40% of patients who present with clinical signs of intestinal bleeding. The frequency of upper GI seems to decrease and the incidence of upper and lower GI bleeding are approaching. The classification is based on the anatomical landmarks Treitzʼ ligament and Bauhinʼs valve and delimited from a clinical point of view with corresponding epidemiological, diagnostic and therapeutic relevance. Mid and lower GI bleeding manifests overt as hematochezia, visible tarry stools and intermittent blood smearing during defecation, or occult as a positive stool blood test and unexplained iron deficiency anemia. Common sources of bleeding in the colon are diverticula, angiectasias, neoplasias and inflammatory bowel diseases of various origins. In the small intestine, angiectasias, ulcers or erosions associated with the use of NSAIDs or, more rarely, Crohnʼs disease, tumors, metastases and diverticula are found to be the cause of bleeding. Diagnostics is a domain of colonoscopy and capsule endoscopy or flexible enteroscopy methods (balloon enteroscopy or spiral enteroscopy). If the endoscopy does not find the source of the bleeding or does not allow it to be treated, high-resolution angio-CT, optionally with subsequent interventional angiography, can help. Very rarely, scintigrafic procedures are useful. Only rarely, a surgical resection is necessary and can be combined with an intraoperative enteroscopy within the same session.

Kernaussagen

  • Entsprechend der Lokalisation kann eine obere, eine mittlere und eine untere gastrointestinale Blutung unterschieden werden. Hierbei wird die Einteilung an den anatomischen Landmarken Treitzʼsches Band und Bauhinʼsche Klappe festgemacht und aus klinischer Sicht mit entsprechender epidemiologischer, diagnostischer und therapeutischer Relevanz abgegrenzt.

  • Die mittlere und untere gastrointestinale Blutung manifestieren sich

    • overt als Hämatochezie, sichtbarer Teerstuhl und intermittierendes „Blutschmieren“ beim Stuhlgang oder

    • okkult als positiver Stuhlbluttest und als unerklärte Eisenmangelanämie.

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

  • Die Diagnostik ist eine Domäne der Koloskopie und der Kapselendoskopie oder der flexiblen Enteroskopieverfahren (Ballonenteroskopie oder Spiralenteroskopie).

  • Wenn die Endoskopie die Blutungsquelle nicht finden oder nicht behandeln lässt, kann die hochauflösende Angio-CT, ggf. mit nachfolgender interventioneller Angiografie, weiterhelfen. Sehr selten sind szintigrafische Verfahren hilfreich.

  • Eine chirurgische Resektion, ggf. in gleicher Sitzung mit einer intraoperativen Enteroskopie, ist nur selten erforderlich.

Schlüsselwörter

gastrointestinale Blutung - Endoskopie - Koloskopie

Key words

intestinal bleeding - endoscopy - colonoscopy


Publication History

Article published online:
08 March 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • 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
    PubMedGoogle 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 Götz M, Biecker E, Dechêne A. et al. Addendum zur S2k-Leitlinie Gastrointestinale Blutungen der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). Z Gastroenterol 2022; 60: 1139-1145 DOI: 10.1055/a-1788-3501.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Triantafyllou K, Gkolfakis P, Gralnek IM. et al. Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53: 850-868 DOI: 10.1055/a-1496-8969.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Strate LL, Gralnek IM. ACG Clinical Guideline: management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol 2016; 111: 459-474 DOI: 10.1038/ajg.2016.41.
    CrossrefPubMedGoogle Scholar
  • 8 Cea Soriano L, Lanas A, Soriano-Gabarró M. et al. Incidence of upper and lower gastrointestinal bleeding in new users of low-dose aspirin. Clin Gastroenterol Hepatol 2019; 17: 887-895.e6 DOI: 10.1016/j.cgh.2018.05.061.
    CrossrefPubMedGoogle Scholar
  • 9 Oakland K, Kothiwale S, Forehand T. et al. External validation of the oakland score to assess safe hospital discharge among adult patients with acute lower gastrointestinal bleeding in the US. JAMA Netw Open 2020; 3: e209630 DOI: 10.1001/jamanetworkopen.2020.9630.
    CrossrefPubMedGoogle Scholar
  • 10 Oakland K, Jairath V, Uberoi R. et al. Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study. Lancet Gastroenterol Hepatol 2017; 2: 635-643 DOI: 10.1016/S2468-1253(17)30150-4.
    CrossrefPubMedGoogle Scholar
  • 11 Villanueva C, Colomo A, Bosch A. et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013; 368: 11-21 DOI: 10.1056/NEJMoa1211801.
    CrossrefPubMedGoogle Scholar
  • 12 HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet 2020; 395(10241): 1927-1936 DOI: 10.1016/S0140-6736(20)30848-5.
    CrossrefPubMedGoogle Scholar
  • 13 Albert J G, Sarrazin C, Zeuzem S. Untere gastrointestinale Blutung. Gastroenterologie up2date 2010; 6: 265-278 DOI: 10.1055/s-0030-1255863.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 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
  • 15 Fry LC, Bellutti M, Neumann H. et al. Incidence of bleeding lesions within reach of conventional upper and lower endos- copes in patients undergoing double-balloon enteroscopy for obscure gastrointestinal bleeding. Aliment Pharmacol Ther 2009; 29: 342-343
    CrossrefPubMedGoogle Scholar
  • 16 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
  • 17 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
  • 18 Wong SK, Ho YH, Leong AP. et al. Clinical behavior of complicated right-sided and left-sided diverticulosis. Dis Colon Rectum 1997; 40: 344-348 DOI: 10.1007/BF02050427.
    CrossrefPubMedGoogle Scholar
  • 19 Mohammed Ilyas MI, Szilagy EJ. Management of diverticular bleeding: evaluation, stabilization, intervention, and recurrence of bleeding and indications for resection after control of bleeding. Clin Colon Rectal Surg 2018; 31: 243-250 DOI: 10.1055/s-0037-1607963.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 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
  • 21 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
  • 22 Grün K, Albert J G, Sarrazin C. et al. Untere und mittlere gastrointestinale Blutung. Gastroenterologie up2date 2017; 13: 179-195 DOI: 10.1055/s-0043-104470.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Setoyama T, Ishii N, Fujita Y. Enodoscopic band ligation (EBL) is superior to endoscopic clipping for the treatment of colonic diverticular hemorrhage. Surg Endosc 2011; 25: 3574-3578
    CrossrefPubMedGoogle Scholar
  • 24 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
  • 25 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
  • 26 Loscalzo J. From clinical observation to mechanism-Heydeʼs syndrome. N Engl J Med 2012; 367: 1954-1956 DOI: 10.1056/NEJMcibr1205363.
    CrossrefPubMedGoogle Scholar
  • 27 Gill JC, Wilson AD, Endres-Brooks J. et al. Loss of the largest von Willebrand factor multimers from the plasma of patients with congenital cardiac defects. Blood 1986; 67: 758-761
    CrossrefPubMedGoogle Scholar
  • 28 Tsai HM, Sussman II, Nagel RL. Shear stress enhances the proteolysis of von Willebrand factor in normal plasma. Blood 1994; 83: 2171-2179
    CrossrefPubMedGoogle Scholar
  • 29 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 DOI: 10.1160/TH09-06-0391.
    Article in Thieme ConnectPubMedGoogle 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 Brown C, Subramanian V, Wilcox CM. et al. Somatostatin ana- logues in the treatment of recurrent bleeding from gastro- intestinal vascular malformations: an overview and systematic review of prospective observational studies. Dig Dis Sci 2010; 55: 2129-2134
    CrossrefPubMedGoogle Scholar
  • 32 Ge ZZ, Chen HM, Gao YJ. et al. Efficacy of thalidomide for refractory gastrointestinal bleeding from vascular malformation. Gastroenterology 2011; 141: 1629-1637.e1–4 DOI: 10.1053/j.gastro.2011.07.018.
    CrossrefPubMedGoogle Scholar
  • 33 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
  • 34 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 quiz 45 DOI: 10.1038/ajg.2014.395.
    CrossrefPubMedGoogle Scholar
  • 35 Koulaouzidis A, Rondonotti E, Giannakou A. et al. Diagnostic yield of small-bowel capsule endoscopy in patients with iron-deficiency anemia: a systematic review. Gastrointest Endosc 2012; 76: 983-992 DOI: 10.1016/j.gie.2012.07.035.
    CrossrefPubMedGoogle Scholar
  • 36 Dray X, Battaglia G, Wengrower D. et al. Radiofrequency ablation for the treatment of radiation proctitis. Endoscopy 2014; 46: 970-976 DOI: 10.1055/s-0034-1377756. Epub 2014 Oct 7. PMID: 25290097
    Article in Thieme ConnectPubMedGoogle Scholar