Page 19 - Gastrointestinal Bleeding (Xuất huyết tiêu hóa)

CHAPTER 20 Gastrointestinal Bleeding 293

obscured the view, technical problems with hemostasis occurred, despite the older age and more serious medical problems of
clinically significant bleeding recurred, or less effective endo- patients treated by angiography. 158,159 These studies suggest 20
scopic techniques such as epinephrine injection alone were used. that angiography can be considered after failure of endoscopic
therapy. If embolization therapy does not control the bleed-
Rebleeding After Endoscopic Treatment ing, surgery remains an option.
A randomized controlled trial has suggested that OTSC
The risk of rebleeding from peptic ulcers, which started bleed- hemoclipping for recurrent peptic ulcer bleeding was more effec-
ing in the outpatient setting and required endoscopic hemosta- tive than standard endoscopic hemostasis (mostly by hemoclip-
sis, is greatest in the first 72 hours after diagnosis and treatment. ping). This new treatment has the potential to reduce the need
Patients should be kept on a PPI in high doses for at least 72 for surgery or angiography for recurrent ulcer bleeding. OTSC
hours following endoscopic hemostasis, after which they can be hemoclipping is also more effective than standard hemostasis in
switched to a standard dose. Before the widespread use of IV eradicating underlying artieral blood flow, which, when present,
PPIs, the rebleeding rate after endoscopic hemostasis of actively correlates with a risk of rebleeding. 106,111 Immediate surgical
bleeding ulcers or those with an NBVV was as high as 30%; with intervention is indicated for patients who have exsanguinating
the use of PPIs and improved endoscopic techniques, the rate is bleeding and those who cannot be medically resuscitated. Sur-
less than 10% in most studies. gery should also be considered if the endoscopist does not feel
The difference between ulcer hemorrhage that starts in the comfortable treating a large or pulsating visible vessel (e.g., one
outpatient setting and hemorrhage that starts in the inpatient set- in a deep, posterior duodenal ulcer that may represent the gas-
ting is substantial (Table 20.7). Owing to the fact that the time troduodenal artery) or if a bleeding malignant ulcerated mass is
to rebleeding can be much longer for inpatient (than outpatient) found on endoscopy.
ulcer hemorrhage and the risk of rebleeding is high, combination
endoscopic hemostasis and high-dose IV PPI administration for Immediate Postendoscopic Management
more than 72 hours should be considered. Further studies are
warranted in this high-risk group to define optimal management. High-Risk Endoscopic Stigmata
If rebleeding from a peptic ulcer is severe, an urgent repeat Patients who have undergone endoscopic hemostasis for active
EGD (rather than immediate surgery) should be performed. A arterial bleeding, an NBVV, or an adherent clot should be
large, well-designed, randomized trial from Hong Kong found observed in the hospital for 72 hours while they receive high-dose
that when endoscopic hemostasis is repeated in patients with IV infusions of a PPI. After successful endoscopic treatment and
hemodynamically significant rebleeding after initial endoscopic recovery from sedation, the patient can be started on a liquid diet,
hemostasis, 73% of patients achieve sustained hemostasis and do with subsequent advancement of the diet. For patients who have
not require surgery. 157 The overall mortality rate was the same been on and need to continue antiplatelet agents or an anticoagu-
in those who achieved and those who did not achieve hemostasis, lant, a cardiologist or vascular physician should be consulted to
but the rate of serious complications was significantly higher in help determine whether, and for how long, these agents can be
the latter group (who required surgery). Factors that predicted held. 116,160 For patients with severe atherosclerotic cardiovascular
failure of endoscopic retreatment included an ulcer size of at least disease who require aspirin, however, a dose of 81 mg/day should
2 cm and hypotension on initial presentation. be started within 7 days.

Angiography, Surgery, and Over-the-Scope Hemoclips Intermediate-Risk Stigmata
Patients with flat spots and arterial blood flow detected under-
Patients with recurrent bleeding despite 2 sessions of endo- neath, those with oozing bleeding from an ulcer and no other
scopic hemostasis can be considered for angiographic embo- stigmata (e.g., spurting, NBVV, clot), and those with severe
lization or surgical therapy. Several retrospective series have comorbidity or shock on presentation should undergo endoscopic
reported no significant differences between angiography with hemostasis. Initiation of a twice-daily oral PPI and observation in
embolization and surgery in rates of rebleeding and mortality, the hospital for 24 to 48 hours after successful endoscopic hemo-
stasis are recommended. Such patients do not benefit from high-
dose IV PPIs after successful endoscopic hemostasis. 106,135
TABLE 20.7 Comparison of the Onset of Peptic Ulcer Bleeding in Low-Risk Endoscopic Stigmata
Outpatients Versus Inpatients
Patients with a clean-based ulcer or flat spot with no arterial
Onset blood flow detected in the ulcer base can generally resume
Parameter Outpatient Inpatient a normal diet immediately, begin an oral PPI once daily,
and be discharged early after endoscopy when stable. 132
Frequency (%) 80-90 10-20
These patients can often avoid hospitalization entirely or
American Society of ≤3 >3 be discharged early. 10,11,74,161 Generally, they are young and
Anesthesiologists Physical hemodynamically stable with no severe coexisting medical
Status score* illnesses, a hemoglobin level higher than 10 mg/dL, normal
Time to rebleeding (%) coagulation parameters, and good social support systems at
≤72 hr 70-80 40-50 home in case bleeding recurs.
4-7 days 10-15 15-20
8-30 days 1-5 15-20 Prevention of Recurrent Ulcer Bleeding
>30 days 0 5-10 Hp Infection
All patients with peptic ulcer bleeding should be tested for Hp
*One point signifies a healthy person; 5 points signifies high likelihood of infection (see earlier) and, if the result is positive, should receive
mortality within 24 hr. standard therapy for Hp infection (see Chapter 52). One caveat
88
Data from the UCLA CURE database.
CURE, Center for Ulcer Research and Education; UCLA, University of is that bleeding can lead to a false-negative rapid urease test result,
California, Los Angeles. and the patient may need to undergo an alternative method of
testing for Hp in this setting. Antibiotic therapy does not have to