Page 12 - Gastrointestinal Bleeding (Xuất huyết tiêu hóa)

286 PART III Symptoms, Signs, and Biopsychosocial Issues

*

A B

Fig. 20.7 Endoscopic stigmata of recent
peptic ulcer bleeding. A, Active bleeding
with spurting. B, Visible vessel (arrow)
with adjacent clot. C, Adherent clot. D,
Slight oozing of blood after washing in
C D the center of the ulcer, without clot or a
visible vessel.

100 stigmata, stratify the risk of rebleeding, and confirm completion of
90 90 nonvariceal hemostasis and obliteration of the underlying arterial
80 blood flow. Prior conflicting results have been reported, however,
70 as to whether use of the DEP improves the outcome of endoscopic
A
hemostasis in patients with acute peptic ulcer bleeding.
108,109
60
Risk (%) 50 50 decision-analysis study found that the DEP is the preferred cost-
minimizing strategy over conventional endoscopic therapy alone
40
30 33 in patients with acute peptic ulcer bleeding, 110 The University of
California, Los Angeles (UCLA) Center for Ulcer Research and
20 Education (CURE) Hemostasis Group reported in a randomized
10 10 7 3 controlled trial that rebleeding rates were significantly reduced in
0 the group randomized to DEP compared with the group random-
Active Non- Adherent Oozing Flat Clean ized to standard visually guided hemostasis, and the treatment was
bleeding bleeding clot spot ulcer safe and effective. 111 Rebleeding rates correlated highly with resid-
visible base ual arterial blood flow after endoscopic hemostasis. In another
vessel study, patients with severe nonvariceal UGI bleeding treated
Fig. 20.8 Rebleeding rates without endoscopic therapy or administra- with the DEP by the UCLA CURE group were compared with
tion of a PPI in patients with ulcers demonstrating various stigmata of matched historical controls; rates of rebleeding and surgery were
recent hemorrhage at UCLA CURE. also significantly reduced in the patients treated with the DEP
but not in those treated with standard visually guided endoscopic
CURE, Center for Ulcer Research and Education; UCLA, University of hemostasis (see Fig. 20.7A). 112
California, Los Angeles.
Endoscopic Hemostasis
determine if blood flow is present beneath a stigma in the ulcer
base (Fig. 20.9). 104 DEP has been utilized to risk stratify patients Active Bleeding and Nonbleeding Visible Vessels
with SRH into high risk for rebleeding (active arterial bleeding Many well-conducted randomized controlled trials, meta-
[Forrest FIA], NBVV, [Forrest FIIA], and adherent clot [Forrest analyses, and consensus recommendations have concluded that
FIIB]); intermediate risk (oozing bleeding [Forrest FIA], and endoscopic hemostasis with epinephrine injection or coaptive
flat spots [Forrest FIIC]); and low risk (clean ulcer base [Forrest thermal probe therapy significantly decreases the rates of ulcer
FIII]). 106,107 The presence of a blood flow signal correlates with the rebleeding, urgent surgery, and mortality in patients with high-
risk of rebleeding before and after endoscopic therapy. The DEP risk stigmata such as active arterial bleeding and NBVVs. 22,113-116
has also been used to map the direction of the artery underneath The rebleeding rates for peptic ulcers with various endoscopic