Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA.
VA Connecticut Healthcare System, West Haven, Connecticut, USA.
Am J Gastroenterol. 2021 May 1;116(5):899-917. doi: 10.14309/ajg.0000000000001245.
We performed systematic reviews addressing predefined clinical questions to develop recommendations with the GRADE approach regarding management of patients with overt upper gastrointestinal bleeding. We suggest risk assessment in the emergency department to identify very-low-risk patients (e.g., Glasgow-Blatchford score = 0-1) who may be discharged with outpatient follow-up. For patients hospitalized with upper gastrointestinal bleeding, we suggest red blood cell transfusion at a threshold of 7 g/dL. Erythromycin infusion is suggested before endoscopy, and endoscopy is suggested within 24 hours after presentation. Endoscopic therapy is recommended for ulcers with active spurting or oozing and for nonbleeding visible vessels. Endoscopic therapy with bipolar electrocoagulation, heater probe, and absolute ethanol injection is recommended, and low- to very-low-quality evidence also supports clips, argon plasma coagulation, and soft monopolar electrocoagulation; hemostatic powder spray TC-325 is suggested for actively bleeding ulcers and over-the-scope clips for recurrent ulcer bleeding after previous successful hemostasis. After endoscopic hemostasis, high-dose proton pump inhibitor therapy is recommended continuously or intermittently for 3 days, followed by twice-daily oral proton pump inhibitor for the first 2 weeks of therapy after endoscopy. Repeat endoscopy is suggested for recurrent bleeding, and if endoscopic therapy fails, transcatheter embolization is suggested.
我们进行了系统评价，针对明确的临床问题制定了建议，并采用 GRADE 方法来管理显性上消化道出血患者。我们建议在急诊科进行风险评估，以识别极低风险患者（例如，Glasgow-Blatchford 评分为 0-1），这些患者可以在门诊随访后出院。对于因上消化道出血住院的患者，我们建议在血红蛋白水平降至 7g/dL 时输血。建议在胃镜检查前给予红霉素输注，并在出现症状后 24 小时内进行胃镜检查。建议对有活动性喷血或渗血的溃疡和非出血可见血管进行内镜治疗。建议使用双极电凝、热探头和无水乙醇注射进行内镜治疗，低至极低质量的证据也支持夹闭、氩等离子凝固和软单极电凝；TC-325 止血粉喷雾用于活动性出血的溃疡，对于先前成功止血后再次出现溃疡出血，建议使用过镜夹。内镜止血后，建议连续或间断使用高剂量质子泵抑制剂治疗 3 天，然后在胃镜检查后的前 2 周每天口服质子泵抑制剂 2 次。对于再次出血，建议重复进行内镜检查，如果内镜治疗失败，则建议进行经导管动脉栓塞治疗。
