Page 13 - Gastrointestinal Bleeding (Xuất huyết tiêu hóa)

CHAPTER 20 Gastrointestinal Bleeding 287

TABLE 20.4 Independent Risk Factors for Persistent or Recurrent GI
Tract Bleeding 20
Range of Odds
Ratios for
Risk Factor Increased Risk
CliniCal FaCtors
Health status (ASA class 1 vs. 2-5) 1.94-7.63
Comorbid illness 1.6-7.63
Shock (systolic blood pressure <100 mm Hg) 1.2-3.65
Erratic mental status 3.21
Ongoing bleeding 3.14
Age ≥70 yr 2.23
Age >65 yr 1.3 A
Transfusion requirement N/A
Presentation oF Bleeding
Hematemesis 1.2-5.7
NBVV
Red blood on rectal examination 3.76 Ulcer
base
Melena 1.6
laBoratory FaCtors Doppler
Initial hemoglobin ≤10 g/dL 0.8-2.99 endoscopic
Coagulopathy 1.96 probe
endosCoPiC FaCtors
Ulcer location on superior wall of duodenum 13.9
Ulcer location on posterior wall of duodenum 9.2
Active bleeding 2.5-6.48
Artery underneath
High-risk stigmata 1.91-4.81
NBVV
Ulcer size ≥2 cm 2.29-3.54
Ulcer location high on lesser curve 2.79
B
Diagnosis of gastric or duodenal ulcer 2.7
Clot over ulcer 1.72-1.9 Fig. 20.9 A, Doppler endoscopic probe and control unit. B, Prior to
and after endoscopic treatment, detection of arterial blood flow under-
ASA, American Society of Anesthesiologists; N/A, not applicable.
Data from Barkun A, Bardou M, Marshall JK. Consensus recommenda- neath stigmata of hemorrhage by the Doppler endoscopic probe and
tions for managing patients with nonvariceal upper gastrointestinal the mapping direction of the blood flow in the artery facilitate risk strati-
bleeding. Ann Intern Med 2003;139:843–57. fication, endoscopic hemostasis, and reduction in the rate of rebleeding
(if arterial blood flow is obliterated).
NBVV, nonbleeding visible vessel.
stigmata are shown in Fig. 20.8. These rebleeding rates are
based on studies that were performed before the widespread use
of high-dose PPI infusions and that predominantly used injec-
tion therapy, MPEC therapy, or a combination of injection
and thermal probe therapy. In general, for the lesions with the TABLE 20.5 Endoscopic Stigmata of Recent Ulcer Hemorrhage and
Risk of Rebleeding
highest risk of ongoing bleeding or rebleeding, including active
bleeding (90% risk of ongoing bleeding) or NBVVs (50% risk Endoscopic Risk of Risk of Rebleeding
of ongoing bleeding), endoscopic hemostasis alone decreases Stigma (Forrest Frequency Rebleeding After Endoscopic
the rebleeding rate to approximately 15% to 30% (Table 20.5). Class) (%) (%) Hemostasis (%)*
The adjunctive IV administration of a high-dose PPI (e.g., pan- Active arterial 12 90 15-30
toprazole, 80-mg bolus and 8 mg/hr for 72 hours) decreases this bleeding (IA)
rate even further, as discussed in the next section. IV formula- Nonbleeding visible 22 50 15-30
tions of pantoprazole, lansoprazole, and esomeprazole are avail- vessel (IIA)
able in the USA. Adherent clot (IIB) 10 33 0-5
The most commonly used treatment for ulcer bleeding world-
wide is epinephrine injection therapy; it is widely available, easy Oozing without 14 10-14 † 0-5
to perform, safe, and inexpensive. Therapy with epinephrine stigmata (IB)
alone seems to be more effective when used in high doses (13 to Flat spot (IIC) 10 10-25 † 0
20 mL) than in low doses (5 to 10 mL). 117 Injection of epineph- Clean base (III) 32 3 N/A
rine results in a 5-fold increase in circulating plasma epinephrine
levels but is rarely thought to cause clinically significant cardio- *Reduction in bleeding risk is without the administration of a PPI.
†
vascular events. 118 Numerous studies and meta-analyses have The risk depends on whether arterial blood flow is detected before
endoscopic hemostasis (Refs. 111 and 112).
shown that the addition of a thermal or mechanical hemostatic N/A, Not applicable.
modality further decreases the rates of rebleeding, surgery, and