Orpen-Palmer Josh, Stanley Adrian J
Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK.
BMJ Med. 2022 Sep 28;1(1):e000202. doi: 10.1136/bmjmed-2022-000202. eCollection 2022.
Upper gastrointestinal bleeding is a common emergency presentation requiring prompt resuscitation and management. Peptic ulcers are the most common cause of the condition. Thorough initial management with a structured approach is vital with appropriate intravenous fluid resuscitation and use of a restrictive transfusion threshold of 7-8 g/dL. Pre-endoscopic scoring tools enable identification of patients at high risk and at very low risk who might benefit from specific management. Endoscopy should be carried out within 24 h of presentation for patients admitted to hospital, although optimal timing for patients at a higher risk within this period is less clear. Endoscopic treatment of high risk lesions and use of subsequent high dose proton pump inhibitors is a cornerstone of non-variceal bleeding management. Variceal haemorrhage results in higher mortality than non-variceal haemorrhage and, if suspected, antibiotics and vasopressors should be administered urgently, before endoscopy. Oesophageal variceal bleeding requires endoscopic band ligation, whereas bleeding from gastric varices requires thrombin or tissue glue injection. Recurrent bleeding is managed by repeat endoscopic treatment. If uncontrolled bleeding occurs, interventional radiological embolisation or surgery is required for non-variceal bleeding or transjugular intrahepatic portosystemic shunt placement for variceal bleeding.
上消化道出血是一种常见的急症表现，需要迅速进行复苏和处理。消化性溃疡是导致这种情况的最常见原因。采用结构化方法进行全面的初始处理至关重要，包括适当的静脉液体复苏以及使用7 - 8 g/dL的限制性输血阈值。内镜检查前的评分工具能够识别出可能从特定处理中获益的高风险和极低风险患者。对于入院患者，应在就诊后24小时内进行内镜检查，不过在此期间高风险患者的最佳检查时机尚不太明确。对高风险病变进行内镜治疗以及随后使用高剂量质子泵抑制剂是非静脉曲张性出血处理的基石。静脉曲张出血导致的死亡率高于非静脉曲张出血，如果怀疑有静脉曲张出血，应在内镜检查前紧急给予抗生素和血管加压药。食管静脉曲张出血需要内镜下套扎术，而胃静脉曲张出血则需要注射凝血酶或组织胶。复发性出血通过重复内镜治疗进行处理。如果出血无法控制，非静脉曲张出血需要进行介入放射栓塞或手术，静脉曲张出血则需要进行经颈静脉肝内门体分流术。
