Division of Gastroenterology, Montreal General Hospital Site, McGill University Health Centre, Montreal, Quebec, Canada.
Ann Intern Med. 2010 Jan 19;152(2):101-13. doi: 10.7326/0003-4819-152-2-201001190-00009.
A multidisciplinary group of 34 experts from 15 countries developed this update and expansion of the recommendations on the management of acute nonvariceal upper gastrointestinal bleeding (UGIB) from 2003.
The Appraisal of Guidelines for Research and Evaluation (AGREE) process and independent ethics protocols were used. Sources of data included original and published systematic reviews; randomized, controlled trials; and abstracts up to October 2008. Quality of evidence and strength of recommendations have been rated by using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.
Recommendations emphasize early risk stratification, by using validated prognostic scales, and early endoscopy (within 24 hours). Endoscopic hemostasis remains indicated for high-risk lesions, whereas data support attempts to dislodge clots with hemostatic, pharmacologic, or combination treatment of the underlying stigmata. Clips or thermocoagulation, alone or with epinephrine injection, are effective methods; epinephrine injection alone is not recommended. Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended. Preendoscopy proton-pump inhibitor (PPI) therapy may downstage the lesion; intravenous high-dose PPI therapy after successful endoscopic hemostasis decreases both rebleeding and mortality in patients with high-risk stigmata. Although selected patients can be discharged promptly after endoscopy, high-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis. For patients with UGIB who require a nonsteroidal anti-inflammatory drug, a PPI with a cyclooxygenase-2 inhibitor is preferred to reduce rebleeding. Patients with UGIB who require secondary cardiovascular prophylaxis should start receiving acetylsalicylic acid (ASA) again as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days); ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding.
来自 15 个国家的 34 名多学科专家共同制定了本指南，对 2003 年版急性非静脉曲张性上消化道出血（UGIB）管理推荐意见进行了更新和扩充。
使用评估指南研究与评价（AGREE）方法和独立的伦理方案。数据来源包括原始研究和发表的系统评价、随机对照试验和截至 2008 年 10 月的摘要。使用推荐意见评估、制定与评价（GRADE）标准对证据质量和推荐意见强度进行分级。
推荐意见强调了早期风险分层，可使用经验证的预后评分和早期内镜检查（24 小时内）。对于高危病变仍推荐进行内镜止血，对于已明确的出血征象可尝试通过止血、药物或联合治疗去除血栓。夹子或热凝治疗，单独或联合肾上腺素注射，都是有效的方法；不推荐单独使用肾上腺素注射。对某些高危患者行再次内镜检查可能有益，但不常规推荐。内镜检查前质子泵抑制剂（PPI）治疗可能使病变降级；成功内镜止血后静脉给予大剂量 PPI 治疗可降低高危征象患者的再出血率和死亡率。虽然某些患者在内镜检查后可迅速出院，但高危患者在接受内镜止血后应至少住院 72 小时。对于需要非甾体类抗炎药的 UGIB 患者，建议使用 PPI 加环氧化酶-2 抑制剂，以降低再出血风险。需要二级心血管预防的 UGIB 患者应在心血管风险超过胃肠道风险时（通常在 7 天内）重新开始服用阿司匹林（ASA）；ASA 加 PPI 治疗较单独使用氯吡格雷可降低再出血风险。
