Zusammenfassung
Einleitung: Ulzera sind die häufigste Ursache für obere GI-Blutungen. Ziel war die endoskopische
und medikamentöse Therapie der Ulkusblutung in deutschen Akutkrankenhäusern zu erheben
und mit der medizinischen Forschung zu vergleichen. Methoden: Ein strukturierter Fragebogen wurde 3 / 2004 an 1371 Akutkrankenhäuser versandt,
die Patienten mit oberer GI-Blutung versorgen. Der Fragebogen war parallel zu einem
Fragebogen gestaltet, mit dem 2001 eine vergleichbare Erhebung in Frankreich durchgeführt
wurde. Abgefragt wurden in 44 Einzelpunkten Strukturdaten der Kliniken, Organisation
der Notfalltherapie, endoskopische und medikamentöse Behandlung der Ulkusblutung.
Alle Fragebogen, die bis 8 / 2004 zurückgesendet wurden, wurden in die Auswertung
einbezogen. Ergebnisse: Die Rücklaufquote betrug 49 % (675 / 1371). Die mittlere Bettenzahl der Kliniken
betrug im Median 200, zu 49 % waren es Häuser der Grundversorgung. Ein 24-h-Endoskopiedienst
wird von 92 % der Kliniken (620 / 675) gewährleistet. In 75 % steht eine Fachschwester
als Assistenz zur Verfügung. Fiberendoskope werden nur in 15 % verwendet. Im Median
werden 10 ± 12 (0 – 160) Blutungen/Monat davon 6 ± 6 Ulkusblutungen (60 %) behandelt.
In 72 % werden GI-Blutungen sofort nach Stabilisierung behandelt, alle jedoch innerhalb
von 24 h. Die Forrest-Klassifikation wird in 99 % benutzt, dagegen werden Prognosescores
(z. B. Baylor-Rockall) nur in 3 % der Fälle angewendet. Forrest Ia, Ib, IIa, IIb,
IIc, III werden in 99, 99, 90, 58, 4 bzw. 2 % als Indikation zur endoskopischen Therapie
gesehen. Bevorzugte primäre Therapie ist mit Abstand die Injektion (v. a. Adrenalin
1:10 000) und gefolgt von der Clipapplikation. Im Mittel werden 17 ± 13 ml pro Läsion
injiziert. 93 % versuchen im Falle einer Rezidivblutung eine erneute endoskopische
Therapie. Eine programmierte Re-Endoskopie wird in 63 % durchgeführt. Zur Säuresuppression
werden in 99,6 % PPI verwendet, zu 85 % in 2 × täglich Standarddosis. Oralisiert wird
zumeist mit Beginn der Nahrungsaufnahme. Die Indikationsstellung zur Eradikation erfolgt
nach rationellen Prinzipien. Schlussfolgerung: Die medikamentöse und endoskopische Therapie der Ulkusblutung hat einen hohen Standard
erreicht, obwohl einige Therapiestrategien noch der Verbesserung bedürfen. Größere
Kliniken zeigen einen Trend, näher am jeweiligen med. Goldstandard zu behandeln.
Abstract
Objective: Peptic ulcers are the leading cause of upper gastrointestinal (GI) bleeding. The
aim of this study was the evaluation of the recent clinical practice in drug therapy
and endoscopic treatment of ulcer bleedings in Germany and to compare the results
with the medical standard. Methods: A structured questionnaire (cross-sectional study) was sent to 1371 German hospitals
that provide an emergency service for upper GI bleeding. The project was designed
similar to a nationwide inquiry in France in 2001. Forty-four questions concerning
the following topics were asked: hospital organisation, organisation of emergency
endoscopy service, endoscopic and drug therapy of ulcer bleeding, endoscopic treatment
of variceal bleeding. Return of the questionnaires was closed in August 2004. Results: Response rate was 675 / 1371 (49 %). Mean hospitals size was < 200 beds, 49 % (n
= 325) had basic care level. 92 % provided a 24-hour endoscopy service, specialized
nurses were available in 75 %. Fiberscopes were used only in 15 %. A mean of 10 ±
12 (range: 0 – 160) bleeding cases/month were treated, 6 ± 6 cases per month (60 %)
were ulcer bleedings. Endoscopy was performed in 72 % immediately after stabilization
but in all cases within 24 hours. The Forrest classification was used in 99 % whereas
prognostic scores were applied only in 3 %. Forrest Ia,/Ib/IIa/IIb/IIc/III ulcers
were indications for endoscopic therapy in 99 %/ 99 %/ 90 %/ 58 %/ 4 %/ 2 % respectively.
Favoured initial treatment was injection (diluted epinephrine, mean volume 17 ± 13
mL/lesion) followed by clipping. In re-bleedings, 93 % tried endoscopic treatment
again. Scheduled re-endoscopy was performed in 63 %. PPI were used in 99.6 %, 85 %
administered standard dose twice daily. PPI administration was changed from intravenous
to oral with the end of fasting in nearly all hospitals. PPI administration schemes
can be improved. Indications for Helicobacter pylori eradication followed rational
principles. Conclusion: Medical and endoscopic treatment of bleeding ulcers reached a high standard, although
some therapeutic strategies leave room for improvement. Bigger hospitals tend to be
closer to the medical standard.
Schlüsselwörter
gastrointestinale Blutung - obere gastrointestinale Blutung - Ulcus ventriculi
Key words
gastrointestinal bleeding - upper gastrointestinal bleeding - peptic ulcer
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PD Dr. Juergen Maiss
Gastroenterology Clinic Dr. Kerzel/PD Dr. Maiss
Mozartstr. 1
91301 Forchheim
Germany
Phone: ++ 49/91 91/20 75
Fax: ++ 49/91 33/60 26 18
Email: juergen.maiss@uk-erlangen.de or j.maiss@t-online.de