Medical and Endoscopic Treatment in Peptic Ulcer Bleeding: a National German Survey

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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