上消化道出血诊治.ppt

Characteristic of upper gastrointestinal bleeding among geriatric patients Department of Geriatrics First Affiliated Hospital of Nanjing Medical University Wei-Hao Sun .Criteria of WHO n nelderly individual:those over 65 years of age n nelderly society:It is more than 7%that the percentage ratio of elderly population to total population in the area or a country.Chinese population is also aging UGI bleedingn nApproximately 30%decline in rate over last 15 yearsn n150,000 admissions per yearn nOver$1,000,000,000 annuallyn nAssociated with NSAID useUGI bleedingn nMortality rate 8-10%n n65 now comprise over 30%n nPeptic ulcer still most common causen nSurgery now plays an adjunctive roleEpidemiologyn n103:100 000 adults per yearn nShift in age of population at riskn nIncreasing use of NSAIDs&anticoagulantsn nIncreasing incidence of in-hospital bleedingAetiologyn nPUD 50%n nAcute gastric erosions 20%n nEsophageal varices 10%n nTumor 5%-10%n nAVM 6%n nMallory-Weiss tear 5%n nDeiulafoy 1%Drugsn nEstablished risk factors Aspirin&NSAIDs Warfarin Alcoholn nPossible association Calcium channel blockers Selective serotonin uptake inhibitors-(antidepressant)Peptic Ulcer Disease:NSAIDSn nNSAIDs may cause both duodenal or gastric ulcersn nNSAIDs inhibit prostaglandin production and cause breakdown of the protective barrier of the gastric mucosaPeptic Ulcer Disease:NSAIDSn nComplications of NSAID therapy usually occur within the first monthn nNSAIDs not only induce ulcers but may increase the chance of bleeding in patients who have underlying ulcer diseaseVIGOR-Summary of GI Endpointsp 0.001.*p=0.005.012345Confirmed Clinical Upper GI EventsConfirmedComplicated Upper GI Events All ClinicalGI BleedingRR:0.46(0.33,0.64)RR:0.43*(0.24,0.78)RR:0.38(0.25,0.57)Rates per 100 Patient-YearsRofecoxibNaproxen()=95%CI.Source:Bombardier,et al.N Engl J Med.2000.Reducing the Risk of UGI Toxicities in Patients Reducing the Risk of UGI Toxicities in Patients Requiring Chronic NSAID Therapy Requiring Chronic NSAID Therapy RiskRiskDefinitionDefinitionSuggested ManagementSuggested ManagementLowLow65 65 yr,high-dose(e.g.,age 65 yr,high-dose NSAIDs,low-dose aspirinNSAIDs,low-dose aspirin)Partially selective NSAID plus Partially selective NSAID plus PPI or misoprostol;selectivePPI or misoprostol;selectiveCOX-2 inhibitor COX-2 inhibitor HighHigh 3 3 risk factors or concomitant risk factors or concomitant aspirin,corticosteroids or aspirin,corticosteroids or warfarinwarfarinSelective COX-2 inhibitor plus Selective COX-2 inhibitor plus PPI or misoprostolPPI or misoprostolVery highVery highPrior ulcer or ulcer-related Prior ulcer or ulcer-related complicationcomplicationSelective COX-2 inhibitor plus Selective COX-2 inhibitor plus PPI or misoprostol*;consider PPI or misoprostol*;consider avoiding nonselective NSAIDs avoiding nonselective NSAIDs and selective COX-2 inhibitorsand selective COX-2 inhibitorsPresentationn nHaematemesisn nMelaenan nFrank rectal bleedingn nSigns and symptoms of hypovolaemian nAnaemiaEndoscopyn nDiagnosticn nTherapeuticn nPrognosticEndoscopic Haemostasisn nWidely accepted as most effective methodWidely accepted as most effective methodn nInjection with adrenaline,saline,sclerotherapy n nLaser,diathermy,heater probe n nEndoscopic clip applicationn nProduces initial control of bleedingn nReduces rebleedingn n Decreases need for surgery Decreases need for surgeryn nMeta-analysis-may significantly reduce mortality Clinical Coursen nEndoscopy+/Endoscopic Haemostasisn nNo more bleeding-Rx ulcer,eradicate HPn nContinuing bleeding-surgeryn nRebleed-surgery-(repeat EH?)n nLife threatening massive bleed-endoscopy in theatre,proceed to surgery+/angiography Risk scoring-Rockall0 01 12 23 3ageage608080shockshocknonopulse100pulse100BP100BP60 yrs or other high risk factor 2 episodes in pts with no high risk factors-?unsafen nTransfusion greater than 4 units/24 hrsEndoscopic re-treatmentn nControversialn nReduces need for surgery after re-bleeding without increasing the risk of death.Lau et al 1999 NEJM(RCT)n nRoutine endoscopy in 24 hrs&retreatment-no benefit Messman 1998 NEJM(RCT)ConclusionMajority of the patients with acute UGI bleed are high risk elderly patients and should undergo the minimum operation to secure haemostasis at the first sign of clinical re-bleed following therapeutic endoscopy.