Page 15 - 53-Peptic ulcer diseases (Loét dạ dày)

CHAPTER 53 Peptic Ulcer Disease 819

53

Fig. 53.6 A through-the-scope dila-
tion of an obstructed pylorus caused
by an ulcer. The procedure was per-
formed under fluoroscopic guidance.
A dual-channel endoscope with a 3.7
mm therapeutic channel was used.
A, The stricture was first traversed
with a biliary-type guidewire (arrow-
head). A through-the-scope balloon
was passed over the guidewire across
the stricture. B, A waist, representing
the stricture (arrow), was observed
and was nearly abolished on balloon A B C
inflation (C).

through-the-scope balloon is then passed over the guidewire, and clinically overt GI bleeding. In a cohort study 151 of 2252 ICU
dilation can be seen through the endoscope. The use of a balloon patients, only 1.5% developed clinically important bleeding.
is preferred because its inflation produces a uniform radial force, Respiratory failure (OR 15.6) and coagulopathy (OR 4.3) were
which has a theoretical advantage over the longitudinal shearing independent predictive factors for bleeding stress ulcers. In
force associated with the use of conventional dilators. The pro- 2015, a prospective study 152 of 1034 patients admitted to ICUs
cedure is typically performed with fluoroscopic guidance. A regi- was published; clinically important GI bleeding occurred in
men of gradual dilation over 2 or 3 sessions seems sensible. The 2.6% of patients. Those with 3 or more comorbid illnesses,
targeted diameter is unclear; many authorities recommend dila- liver disease, receiving renal replacement therapy, and with
tion to 15 mm, which is often associated with relief of symptoms. a high organ failure score were at risk. Patients in the ICU
The presence of gastric atony also contributes to symptoms. The with traumatic brain injuries and burns also belong to a high-
risk of perforation increases with the size of balloon. Endoscopic risk group of developing GI bleeding. Across different studies,
series reported immediate relief of obstruction in 78% to 100% there appears to be different candidate predictors for bleeding.
of cases. In a small series of Hp-infected patients, balloon dilation The use of enteral nutrients buffers acid and protects against
followed by Hp eradication led to sustained symptom relief. 150 bleeding.
PPI, H2RA and sucralfate are drugs used for stress ulcer
Surgical Therapy prophylaxis. In a network meta-analysis of 57 RCTs (n = 7293),
Alhazzani and associates 153 showed that PPIs were more effec-
A variety of operations have been described for obstructing DUs, tive for preventing clinically important bleeding than H2RA (OR
pyloric channel ulcers, and pre-pyloric ulcers. They include 0.38), sucralfate (OR 0.30), or placebo (OR 0.24). PPIs, how-
vagotomy with either a drainage procedure (gastrojejunostomy ever, increased the risk of nosocomial pneumonia compared with
or pyloroplasty) or an antrectomy. In the unusual event of an H2RA (OR 1.27), sucralfate (OR 1.65), and placebo (OR 1.52).
obstructing prepyloric GU, an antrectomy followed by a Billroth There is concern that acid suppression predisposes patients to
type I gastroduodenostomy is the procedure of choice. nosocomial infection probably linked to gut dysbiosis. 154 A Euro-
pean multicenter study randomized 3298 ICU patients to receive
STRESS ULCERS 40 mg of intravenous PPI or placebo and found that deaths by 90
days were similar between groups (31.1% vs. 30.4%). The rate
Stress-related gastric and duodenal mucosal injury (stress of composite adverse events (gastrointestinal bleeding, Clostrid-
ulcers) is an illness of the critically ill who are typically cared ium difficile infection, pneumonia, or myocardial ischemia) were
for in an ICU. The etiology of stress ulceration is probably comparable (21.9 vs. 22.6%). There were fewer clinically impor-
related to mucosal ischemia and splanchnic hypo-perfusion tant bleeding events in the PPI group (2.5 vs. 4.2%). 155
from shock or low cardiac output. Fortunately, only a small
proportion of patients with stress-related mucosal lesions have Full references for this chapter can be found onwww�expertconsult�com�