Wee E
Gastroenterology, Department of General Medicine, Khoo Teck Puat Hospital, Singapore.
J Postgrad Med. 2011 Apr-Jun;57(2):161-7. doi: 10.4103/0022-3859.81868.
Nonvariceal upper gastrointestinal bleeding is unique from variceal bleeding in terms of patient characteristics, management, rebleeding rates, and prognosis, and should be managed differently. The majority of nonvariceal upper gastrointestinal bleeds will not rebleed once treated successfully. The incidence is 80 to 90% of all upper gastrointestinal bleeds and the mortality is between 5 to 10%. The causes include nonacid-related ulceration from tumors, infections, inflammatory disease, Mallory-Weiss tears, erosions, esophagitis, dieulafoy lesions, angiodysplasias, gastric antral vascular ectasia, and portal hypertensive gastropathy. Rarer causes include hemobilia, hemosuccus pancreaticus, and aortoenteric fistulas. Hematemesis and melena are the key features of bleeding from the upper gastrointestinal tract, but fresh per rectal bleeding may be present in a rapidly bleeding lesion. Resuscitation and stabilization before endoscopy leads to improved outcomes. Fluid resuscitation is essential to avoid hypotension. Though widely practiced, there is currently insufficient evidence to show that routine red cell transfusion is beneficial. Coagulopathy requires correction, but the optimal international normalized ratio has not been determined yet. Risk stratification scores such as the Rockall and Glasgow-Blatchford scores are useful to predict rebleeding, mortality, and to determine the urgency of endoscopy. Evidence suggests that high-dose proton pump inhibitors (PPI) should be given as an infusion before endoscopy. If patients are intolerant of PPIs, histamine-2 receptor antagonists can be given, although their acid suppression is inferior. Endoscopic therapy includes thermal methods such as coaptive coagulation, argon plasma coagulation, and hemostatic clips. Four quadrant epinephrine injections combined with either thermal therapy or clipping reduces mortality. In hypoxic patients, endoscopy masks allow high-flow oxygen during upper gastrointestinal endoscopy. The risk of rebleeding reduces after 72 hours. In rebleeding, repeat endoscopy is useful and persistent failure of endoscopic therapy mandates either embolization or surgery. In this review, we analyze the management of nonvariceal upper gastrointestinal bleeding with evidence from the currently published clinical trials.
非静脉曲张性上消化道出血在患者特征、治疗、再出血率和预后方面与静脉曲张性出血不同，应采取不同的治疗方法。大多数非静脉曲张性上消化道出血一旦成功治疗就不会再出血。其发病率占所有上消化道出血的80%至90%，死亡率在5%至10%之间。病因包括肿瘤、感染、炎症性疾病引起的非酸相关性溃疡、马洛里-魏斯撕裂、糜烂、食管炎、Dieulafoy病变、血管发育异常、胃窦血管扩张和门静脉高压性胃病。罕见病因包括胆道出血、胰管出血和主动脉肠瘘。呕血和黑便是上消化道出血的关键特征，但快速出血病变可能出现新鲜直肠出血。内镜检查前的复苏和稳定病情可改善预后。液体复苏对于避免低血压至关重要。尽管广泛应用，但目前尚无足够证据表明常规红细胞输血有益。凝血功能障碍需要纠正，但最佳国际标准化比值尚未确定。诸如罗卡尔和格拉斯哥-布拉奇福德评分等风险分层评分有助于预测再出血、死亡率，并确定内镜检查的紧迫性。有证据表明，在内镜检查前应静脉输注高剂量质子泵抑制剂（PPI）。如果患者不耐受PPI，可给予组胺-2受体拮抗剂，尽管其抑酸作用较差。内镜治疗包括热凝法，如套扎凝血、氩离子凝固术和止血夹。四象限肾上腺素注射联合热凝治疗或夹闭术可降低死亡率。对于低氧患者，内镜检查面罩可在上消化道内镜检查期间提供高流量氧气。72小时后再出血风险降低。对于再出血，重复内镜检查有用，而内镜治疗持续失败则需要进行栓塞或手术。在本综述中，我们根据目前发表的临床试验证据分析非静脉曲张性上消化道出血的治疗方法。
