Neue Epidemiologie der akuten gastrointestinalen Blutung

[Endoscopy, angiography, surgery: diagnostic and therapeutic algorithms for diverticular bleeding]

Diverticular bleeding is a complication of diverticular disease but in contrast to diverticulitis, publications concerning diverticular bleeding are less common. Diverticular bleeding is the cause of approximately 20-50% of cases of lower gastrointestinal bleeding and in rare cases can be life-threatening. The main symptom of diverticular hemorrhage is painless hematochezia and the German guidelines recommend that further diagnostics of suspected diverticular bleeding should be performed in hospital. Interdisciplinary diagnostic and therapeutic algorithms recommend primary endoscopy in acute as well as chronic recurrent diverticular bleeding. If endoscopy fails to provide an exact localization of the origin of bleeding, angiography or computed tomography (CT) angiography can be performed. The ^99mTc erythrocyte scintigraphy should only be performed if endoscopy and angiography are unable to identify the localization of the bleeding source. More than 90% of diverticular hemorrhages stop spontaneously; however, it is general agreed that an active diverticular bleeding detected during colonoscopy should be immediately treated endoscopically. Alternative radiological techniques for hemostasis are rarely needed and attention must be paid to the complications. In the rare case of severe bleeding that cannot otherwise be stopped or if the bleeding vessel cannot be located, laparotomy and total colectomy can be recommended. If the diverticular bleeding has definitely been identified or recurrent bleeding causes chronic anemia, segmental or total colectomy may be undertaken; however, the advantages and disadvantages of both types of surgery have to be thoroughly explained to the patient.

Changing trends in acute upper-GI bleeding: a population-based study

BACKGROUND

Advances in medical practice in recent decades have influenced the etiology and management of acute upper-GI bleeding (UGIB), but their impact on the incidence and mortality is unclear.

OBJECTIVE

To analyze the time trends of UGIB in 2 different management eras.

DESIGN

Prospective observational study.

SETTING

General university-affiliated hospital.

PATIENTS AND INTERVENTIONS

A total of 587 patients who presented with UGIB during the 1983-to-1985 period were compared with 539 patient in the 2002-to-2004 period.

RESULTS

The overall incidence of UGIB decreased from 112.5 to 89.8 per 100,000/y, which corresponds to a 35.5% decrease after adjustment for age (95% CI, 24.2%-46.8%). The age standardized incidence of ulcer bleeding decreased by 41.6% (95% CI, 27.2%-56%); the decrease occurred only in people younger than 70 years of age. The rate of history of peptic ulcer disease decreased from 32.7% in the 1983-to-1985 period versus 19.5% in the 2002-to-2004 period (P < .001). The mean age increased from 61.0 to 68.7 years (P < .001), and the male:female ratio decreased from 2.7 to 1.8 (P = .002). The comorbidities increased from 69% to 75% (P = .01), the use of nonsteroidal anti-inflammatory drugs from 40.0% to 46.4% (P = .03), and the cases of bleeding occurring during hospitalization from 10.4% to 17.1% (P < .001). In the 1983-to-1985 cohort, the endoscopy was solely diagnostic, and antisecretory therapy consisted of H2-antagonists drugs. In the second period, 39.3% of patients underwent endoscopic therapy, whereas proton pump inhibitors were administered in 47%. Rebleeding rates decreased from 32.5% to 7.4% (P < .001) and surgery from 10.2% to 2.0% (P < .001). Overall mortality decreased from 17.1 to 8.2 per 100,000/y, which corresponded to a 60.8% decrease after adjustment for age (95% CI, 46.5%-75.1%). The age standardized mortality rate for ulcer bleeding decreased by 56.5% (95% CI, 41.9%-71.1%).

LIMITATIONS

A single-center study and a potential lack of generalizability.

CONCLUSIONS

From the 1983-to-1985 period to the 2002-to-2004 period, major changes occurred in the incidence of UGIB, features of patients, management, and outcomes. The incidence and mortality of UGIB overall and ulcer bleeding decreased significantly, and the decline of incidence occurred only in patients younger than 70 years old.

Dedicated bleed units: should they be advocated?

BACKGROUND

Upper gastrointestinal haemorrhage (UGIH) is a common emergency, however, dedicated bleed units only exist in selected hospitals in the UK.

OBJECTIVE

To evaluate the rebleeding and mortality rate of patients admitted with UGIH to a tertiary centre bleed unit in comparison with the current national standards and earlier unit performance in 1995-1998.

METHODS

A retrospective case note review of demographics, the Rockall scores and final outcome was conducted for all patients admitted to the bleed unit over 24 months.

RESULTS

Two hundred and fifty-five cases were identified with a mean age of 62 years and a median Rockall score of 3. Eighty-two percent of gastroscopies were performed within 24 h. Of these, 29% were undertaken after 5 p.m. Peptic ulcer and varices (15%) were the commonest diagnosis. The rebleeding (12%) and mortality rate (9%) were comparable with that of the units previous audit (P=0.47, 0.51, respectively) and the current national audit (P=0.58, 0.76, respectively). The number of patients requiring surgery has reduced from 6 to 0.4% in our unit over the last 8 years. Preendoscopy and postendoscopy Rockall scores were predictive of rebleeding (P=0.013, 0.045) and mortality (P=0.003, 0.01).

CONCLUSION

This study has shown a consistently low rebleeding and mortality rate in patients with UGIH in a dedicated bleed unit. However there are limitations to the degree of improvements which can be demonstrated due to factors such as age and comorbidity.

Acute upper gastrointestinal hemorrhage: is a radiological interventional approach an alternative to emergency surgery?

The aim of our study was to discuss the option of endovascular treatment compared to surgery for patients with endoscopically unmanageable nonvariceal hemorrhage of the upper gastrointestinal tract. From 2000 to 2006, 23 patients (male, 15 male; female, 8; mean age, 69 years) who failed endoscopic therapy for upper gastrointestinal hemorrhage were retrospectively evaluated. Twelve patients were operated on (SG), whereas 11 patients had an endovascular intervention (IG). Technical and primary clinical success rates and complications rates were calculated. Clinical parameters and comorbidities were related to outcome. The surgical group suffered less frequently from pre-existing pulmonary diseases (SG, 17%; IG, 55%; p = 0.05) and had a higher incidence of shock requiring catecholamines (p < 0.01) or plasma expander therapy (p < 0.01). There was no significant difference in the incidence of recurrent bleeding episodes (SG, 17%; IG, 27%; p = 0.35) and mortality rates (SG, 17%; IG, 27%, p = 0.35). Deaths in the IG were due to recurrent bleeding. In patients with unsuccessful endoscopic control of nonvariceal bleeding of the upper GI tract, surgery remains a very effective treatment. However, in patients with a high surgical risk due to unknown bleeding sources and/or severe pre-existing diseases/comorbidities, endovascular therapy offers an excellent treatment option. These patients should then be operated on as early as possible to minimize the risk of recurrent bleeding episodes, which are associated with high morbidity and mortality.