Management von gastrointestinalen Blutungen

Gastrointestinale Blutungen sind ein häufiges Problem in der klinischen Praxis. Die Bandbreite der klinischen Manifestationen reicht von einem positiven Test auf okkultes Blut im Stuhl bis hin zu Hämatochezie. Die Mehrzahl der Ursachen gastrointestinaler Blutungen kann auf wenige Krankheitsentitäten zurückgeführt werden, welche überwiegend im oberen Intestinaltrakt bis einschließlich des Duodenums und im Kolon lokalisiert sind. Zwar eröffnen neu entwickelte diagnostische Verfahren, wie die Kapselendoskopie und die Doppelballonenteroskopie faszinierende neue Einblicke in die frühere „black box” des Dünndarmbereiches zwischen Jejunum und terminalem Ileum. Der Anteil klinisch bedeutsamer intestinaler Blutungen aus diesem Bereich ist jedoch gering.

Gastrointestinal (GI) bleeding is frequently encountered in clinical practice. Symptoms range from clinically overt hematochezia to the incidental finding of a positive fecal occult blood test. The majority of gastrointestinal bleeding can be traced back to a handful of diagnoses. About 90 % of bleeding sites are located in the upper GI tract up to the duodeno-jejunal flexure. Wireless capsule endoscopy and double balloon enteroscopy offer fascinating new aspects into the former „black box” of small bowel diseases. However, small bowel mucosal pathology only accounts for a minority of clinically relevant gastrointestinal bleeding.

Literatur

• 1 Van Leerdam ME, Vreeburg EM, Rauws EA. Acute upper GI bleeding: Did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000.  Am J Gastoenterol. 2003;  98 1494-1499
• 2 Maiden L, Thjodleifsson B, Theodors A. et al. . A quantitative analysis of NSAID-induced small bowel pathology by capsule enteroscopy.  Gastroenterology. 2005;  128 1172-1178
• 3 Barkun A, Bardou M, Marshall JK. Nonvariceal Upper GI Bleeding Consensus Conference Group. Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding.  Ann Intern Med. 2003;  139 843-857
• 4 Garcia LA Rodriguez, Hernandez-Diaz S. Risk of uncomplicated peptic ulcer among users of aspirin and nonaspirin nonsteroidal antiinflammatory drugs.  Am J Epidemiol. 2004;  159 23-31
• 5 Mayer D, Reinshagen M, Mason RA. et al. . Sonographic measurement of thickened bowel wall segments as a quantitative parameter for activity in inflammatory bowel disease.  Z Gastroenterol. 2000;  38 295-300
• 6 Cuellar RE, Gavaler JS, Alexander JA. et al. . Gastrointestinal tract hemorrhage. The value of a nasogastric aspirate.  Arch Intern Med. 1990;  150 1381-1384
• 7 Frossard JL, Spahr L, Queneau PE. et al. . Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial.  Gastroenterology. 2002;  123 17-23
• 8 Ell C, Fischbach W, Keller R. et al. . Hintertux Study Group. A randomized, blinded, prospective trial to compare the safety and efficacy of three bowel-cleansing solutions for colonoscopy (HSG-01*).  Endoscopy. 2003;  35 300-304
• 9 Benz C, Martin WR, Arnold J. et al. . Endoscopic study of the small intestine with push enteroscopy. A prospective Study.  Dtsch Med Wochenschr. 1997;  122 391-395
• 10 Dusold R, Burke K, Carpentier W, Dyck WP. The accuracy of technetium-99m-labeled red cell scintigraphy in localizing gastrointestinal bleeding.  Am J Gastroenterol. 1994;  89 345-348
• 11 Zuckerman DA, Bocchini TP, Birnbaum EH. Massive hemorrhage in the lower gastrointestinal tract in adults: diagnostic imaging and intervention.  AJR Am J Roentgenol. 1993;  161 703-711
• 12 Triester SL, Leighton JA, Leontiadis GI. et al. . A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding.  Am J Gastroenterol. 2005;  100 2407-2418
• 13 Yamamoto H, Sekine Y, Sato Y. et al. . Total enteroscopy with a nonsurgical steerable double-balloon method.  Gastrointest Endosc. 2001;  53 216-220
• 14 Ell C, May A, Nachbar L. et al. . A. Push-and-pull enteroscopy in the small bowel using the double-balloon technique: results of a prospective European multicenter study.  Endoscopy. 2005;  37 613-616
• 15 Clason AE, Macleod DA, Elton RA. Clinical factors in the prediction of further haemorrhage or mortality in acute upper gastrointestinal haemorrhage.  Br J Surg. 1986;  73 985-987
• 16 D'Amico G, Pietrosi G, Tarantino I, Pagliaro L. Emergency sclerotherapy versus vasoactive drugs for variceal bleeding in cirrhosis: a Cochrane meta-analysis.  Gastroenterology. 2003;  124 1277-1291
• 17 Soares-Weiser K, Brezis M, Tur-Kaspa R. et al. . Antibiotic prophylaxis of bacterial infections in cirrhotic patients: A meta-analysis of randomized controlled trials.  Scand J Gastroenterol. 2003;  38 193-200
• 18 Hou MC, Lin HC, Liu TT. et al. . Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: a randomized trial.  Hepatology. 2004;  39 746-753

Anschrift des Verfassers