Page 11 - 53-Peptic ulcer diseases (Loét dạ dày)

CHAPTER 53 Peptic Ulcer Disease 815

the American Heart Association guidelines. Because the potential intervention or death with an area under the receiver operat-
cardiovascular hazards of COX-2 inhibitors and most nonselec- ing curve (AUROC) of 0.86. A GBS score of 1 appears to be the 53
tive NSAIDs, patients with high cardiovascular risk should avoid threshold for outpatient management. The GBS score, however,
using these drugs, if possible. Ibuprofen can attenuate the cardio- does not define a cutoff value above which urgent endoscopy
protective effect of aspirin, possibly through competitive bind- becomes mandatory. A significant proportion of patients at low-
ing to platelet COX-1, and concomitant use of ibuprofen and to-median scores require endoscopic treatment.
low-dose aspirin, therefore, should be avoided. If an NSAID is At the time of EGD, endoscopic stigmata of bleeding in a
deemed necessary in patients at high cardiovascular risk, current ulcer not only pinpoint PUD as the source of bleeding but are
evidence suggests that either celecoxib at moderate dose (200 mg/ themselves prognostic for patient outcomes (see Chapter 20).
day) or naproxen can be considered. One major drawback of con- The commonly used nomenclature is a version modified from
comitant use of NSAIDs such as naproxen and low-dose aspirin Forrest and Finlayson’s 112 original description. Laine and Jen-
is that the combination will markedly increase the risk of ulcer sen 113 summarized rates of further bleeding, surgery, and mor-
complications; thus, combination of celecoxib and low-dose aspi- tality associated with stigmata of bleeding in prospective trials
rin may be the best available option for patients with high GI and without endoscopic therapy.
high cardiovascular risk who require NSAIDs for long term.
• Type I: Active bleeding:
Because Hp infection increases the risk of ulcer complications
in NSAID users, patients with a history of PUD who require Ia: Spurting hemorrhage (Fig. 53.4)
Ib: Oozing hemorrhage (see Fig. 53.4)
NSAIDs for long term should be tested for Hp and, if present, • Type II: Stigmata of recent hemorrhage:
the infection should be eradicated.
IIa: Nonbleeding visible vessel (see Fig. 53.4)
IIb: Adherent clot (see Fig. 53.4)
COMPLICATIONS AND THEIR TREATMENT IIc: Flat pigmentation (see Fig. 53.4)
• Type III: Clean-base ulcers
Bleeding
Actively bleeding ulcers and ulcers with nonbleeding visible
Acute UGI bleeding, the most common complication of PUD, is vessels (“protuberant discoloration” or a “sentinel clot”) warrant
discussed in detail in Chapter 20. PUD remains the leading cause endoscopic therapy (see Chapter 20).
of acute UGI bleeding. 105 Consensus groups have recommended a Endoscopic therapy of ulcers with “adherent clots” had been
multidisciplinary approach to the care of patients presenting with controversial. The definition of adherent clot varies with the
UGI bleeding. 106 Patients with acute UGI bleeding should be vigor in endoscopic washing. Two randomized controlled stud-
assessed promptly on presentation. Volume resuscitation should ies 114,115 and a meta-analysis 116 compared medical therapy to
take priority and precede endoscopy. Features of liver disease endoscopic treatment in ulcer patients with “adherent clots” and
should call attention to the possibility of bleeding from esophago- concluded that clot removal followed by endoscopic treatment of
gastric varices rather than an ulcer. This distinction has prognostic the vessel underneath lowers the risk of recurrent bleeding from
as well as management implications. Variceal hemorrhage carries 30% to 5%.
a higher death rate than ulcer bleeding. The possibility of variceal The term sentinel clot, is often used synonymously with visible
hemorrhage calls for specific measures prior to endoscopy, such as vessel. 117 It represents a fibrin clot, which plugs the rent in an
the use of vasoactive drugs (e.g., octreotide) and antibiotics (e.g., eroded artery. As the ulcer begins to heal, the clot resolves leav-
cefotaxime) as prophylaxis against infective complications such as ing a flat pigmentation to the ulcer base, which eventually disap-
spontaneous bacterial peritonitis (see Chapters 92 and 93). pears from the ulcer floor. This evolution of a bleeding vessel
usually takes less than 72 hours. Ulcers with a flat pigmentation
Endoscopic Therapy or a clean base do not warrant endoscopic therapy.
Recently, a group from UCLA reported their experience
Early endoscopy is generally defined as EGD performed within with the use of an endoscopic Doppler probe to interrogate
24 hours of the patient’s admission. In patients with signs of the ulcer base. In a prospective cohort of 163 patients with
active UGI bleeding, urgent endoscopy establishes a diagnosis bleeding ulcers and varying endoscopic stigmata or recent
and offers a possible intervention. RCTs demonstrated that early hemorrhage, Doppler signals were found in ulcers with minor
endoscopy in patients at low risk for rebleeding allowed early stigmata (adherent clots, 68.4%, and flat pigmentations,
hospital discharge, reduced resource utilization, and facilitated 40.5%). 118 In a subsequent RCT of 148 patients with bleed-
management as outpatients. 107-109 Meta-analysis of 18 clinical tri- ing peptic ulcers, Jensen and associates 119 compared Doppler
als that compared endoscopic therapy to pharmacotherapy alone endoscopic probe–guided hemostasis to standard endoscopic
showed that endoscopic therapy was superior with regard to the hemostasis. The 30 day re-bleeding rate was lower with the use
rates of further bleeding (odds ratio [OR] 0.35; 95% CI, 0.27 to of a Doppler probe to guide the treatment endpoint (11.1% vs.
0.46), surgery (OR 0.57; 95% CI, 0.41 to 0.81), and, importantly, 26.3%, P =.02).
mortality (OR 0.57; 95% CI, 0.37 to 0.89). 110 Endoscopic therapeutic modalities are discussed in more
An International Consensus group 104 recommended the use detail in Chapter 20, and the methods used are discussed briefly
of a prognostic score to guide patient management. The Rock- here.
all scoring system is a composite score using pre- and posten-
doscopy clinical parameters to predict mortality. The score was Injection Methods
derived from data gathered from the first National UK Audit. 109 Endoscopic injection of diluted epinephrine into a bleeding pep-
The Glasgow Blatchford score (GBS), on the other hand, uses tic ulcer works by volume tamponade and local vasoconstriction.
only clinical parameters to predict the need for intervention and The technique is easy to learn and is not damaging to tissues.
is calculated from patient’s Hgb level and blood urea concentra- Diluted epinephrine, however, does not induce vessel thrombo-
tion, pulse and systolic blood pressure on admission, the presence sis. Recurrent bleeding after injection with diluted epinephrine
or absence of melena or syncope, as well as evidence of cardiac or alone occurs in 20% to 30% of patients. Injection with diluted
hepatic failure. 110 The GBS has been the most widely validated epinephrine allows a clear view of the bleeding vessel and should
score and correlates with clinical outcomes. then be combined with application of either thermal-coagulation
In a multicentre prospective study 111 of 3012 patients, or clips. In a meta-analysis, 120 addition of a second modality after
the GBS score was the best of the 4 at predicting the need for epinephrine injection significantly reduced the rate of recurrent