Üst Gastrointestinal Sistem Kanamalı Hastaya Yaklaşım
Özet
Üst gastrointestinal kanama (ÜGİK), ağızdan Treitz ligamentine kadar olan bölgede meydana gelen ve yüksek hastane maliyetleri ile yatış oranlarına yol açan kritik bir acil tıbbi durumdur. Akut ÜGİK tablosundaki hastalar genellikle hematemez veya melena şikayetleriyle başvurmakta olup, yönetim sürecinin ilk ve en önemli adımını hemodinamik stabilitenin, kanama şiddetinin ve resüsitasyon ihtiyacının hızla değerlendirilmesi oluşturur. Hastanın tıbbi geçmişinde yer alan ülser, karaciğer hastalığı ve özellikle aspirin, NSAİİ veya antikoagülan gibi ilaçların kullanımı, potansiyel kanama kaynaklarının saptanmasında hayati rol oynar. Hemodinamik instabilite gösteren hastalarda geniş çaplı damar yolları açılmalı, sıvı resüsitasyonu başlatılmalı ve hemoglobin düzeyinin 7 g/dL'nin altına düştüğü durumlarda kan transfüzyonu gecikmeden uygulanmalıdır. Tedavi protokolünde, kan pıhtılarının stabilizasyonunu sağlamak amacıyla yüksek doz proton pompa inhibitörleri (PPİ) ve mideyi endoskopiye hazırlamak için prokinetik ajanlar ön plana çıkarken; sirozlu ve varis kanaması şüphesi olan hastalarda vazoaktif ilaçlar ile profilaktik antibiyotik kullanımı mortaliteyi azaltmaktadır. Tanı ve erken dönemde hemostaz sağlanmasında altın standart olan üst endoskopinin resüsitasyon sonrası ilk 24 saat içinde (varis şüphesinde 12 saat içinde) uygulanması, hasta sonuçlarını iyileştiren en etkin yaklaşımdır.
Upper gastrointestinal bleeding (UGIB) encompasses hemorrhages originating from the mouth to the Ligament of Treitz, representing a major clinical emergency associated with substantial healthcare expenditures and high hospitalization rates. Patients routinely present with alarming symptoms such as hematemesis or melena, which demand an immediate and rigorous initial assessment of hemodynamic stability alongside prompt resuscitation efforts. A meticulous evaluation of the patient's medical history—focusing on previous bleeding episodes, liver disease, and the concurrent use of ulcerogenic or antithrombotic medications like NSAIDs and anticoagulants—is essential to pinpoint the underlying etiology. For hemodynamically unstable individuals, securing large-bore intravenous access for aggressive fluid resuscitation and initiating restrictive blood transfusions when hemoglobin levels drop below 7 g/dL are critical life-saving interventions. Pharmacological optimization leverages high-dose proton pump inhibitors (PPIs) to facilitate clot stabilization, combined with prokinetic agents to enhance gastric visualization during subsequent interventions. Furthermore, the integration of vasoactive therapies and prophylactic antibiotics significantly reduces recurrent bleeding and mortality risks in patients with liver cirrhosis. Ultimately, upper endoscopy stands as the definitive diagnostic and therapeutic cornerstone, which should ideally be executed within 24 hours of stabilization to optimize clinical outcomes.
Referanslar
Tielleman T, Bujanda D, Cryer B. Epidemiology and risk factors for upper gastrointestinal bleeding. Gastrointestinal Endoscopy Clinics; 2015;25(3): 415-428. doi.org/10.1016/j.giec.2015.02.010.
Abougergi MS, Travis AC, Saltzman JR. The in-hospital mortality rate for upper GI hemorrhage has decreased over 2 decades in the United States: a nationwide analysis. Gastrointestinal endoscopy; 2015;81(4): 882-888. e881. doi.org/10.1016/j.gie.2014.09.027.
Cappell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. Medical Clinics of North America; 2008;92(3): 491-509. doi.org/10.1016/j.gie.2014.09.027.
Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia: the role of urgent colonoscopy after purge. Gastroenterology; 1988;95(6): 1569-1574. doi.org/10.1016/s0016-5085(88)80079-9.
Palmer ED. The vigorous diagnostic approach to upper-gastrointestinal tract hemorrhage: A 23-year prospective study of 1,400 patients. Jama; 1969;207(8): 1477-1480.
Mortensen P, Nøhr M, Møller-Petersen J, et al. The diagnostic value of serum urea/creatinine ratio in distinguishing between upper and lower gastrointestinal bleeding. A prospective study. Danish medical bulletin; 1994;41(2): 237-240.
Ernst AA, Haynes ML, Nick TG, et al. Usefulness of the blood urea nitrogen/creatinine ratio in gastrointestinal bleeding. The American journal of emergency medicine; 1999;17(1): 70-72. doi.org/10.1016/s0735-6757(99)90021-9.
Srygley FD, Gerardo CJ, Tran T, et al. Does this patient have a severe upper gastrointestinal bleed? Jama; 2012;307(10): 1072-1079. doi.org/10.1001/jama.2012.253.
Richards RJ, Donica MB, Grayer D. Can the blood urea nitrogen/creatinine ratio distinguish upper from lower gastrointestinal bleeding? Journal of clinical gastroenterology; 1990;12(5): 500-504. doi.org/10.1097/00004836-199010000-00004.
Karakonstantis S, Tzagkarakis E, Kalemaki D, et al. Nasogastric aspiration/lavage in patients with gastrointestinal bleeding: a review of the evidence. Expert review of gastroenterology & hepatology; 2018;12(1): 63-72. doi.org/10.1080/17474124.2018.1398646.
Gralnek IM, Stanley AJ, Morris AJ, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline–Update 2021. Endoscopy; 2021;53(03): 300-332. doi.org/10.1055/a-1369-5274.
Barkun AN, Almadi M, Kuipers EJ, et al. Management of nonvariceal upper gastrointestinal bleeding: guideline recommendations from the International Consensus Group. Annals of internal medicine; 2019;171(11): 805-822. doi.org/10.7326/M19-1795.
Odutayo A, Desborough MJ, Trivella M, et al. Restrictive versus liberal blood transfusion for gastrointestinal bleeding: a systematic review and meta-analysis of randomised controlled trials. The lancet Gastroenterology & hepatology; 2017;2(5): 354-360. doi.org/10.1016/S2468-1253(17)30054-7.
Baradarian R, Ramdhaney S, Chapalamadugu R, et al. Early intensive resuscitation of patients with upper gastrointestinal bleeding decreases mortality. Official journal of the American College of Gastroenterology| ACG; 2004;99(4): 619-622. doi.org/10.1111/j.1572-0241.2004.04073.x.
Laine L, Jensen DM. Management of patients with ulcer bleeding. Official journal of the American College of Gastroenterology| ACG; 2012;107(3): 345-360. doi.org/10.1038/ajg.2011.480.
Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. New England Journal of Medicine; 2013;368(1): 11-21. doi.org/10.1056/NEJMoa1211801.
Ramos GP, Binder M, Hampel P, et al. Outcomes of endoscopic intervention for overt GI bleeding in severe thrombocytopenia. Gastrointestinal endoscopy; 2018;88(1): 55-61. doi.org/Outcomes of endoscopic intervention for overt GI bleeding in severe thrombocytopenia.
Laine L. Treatment of thrombocytopenic patients with GI bleeding. Gastrointestinal endoscopy; 2018;88(1): 62-65. doi.org/10.1016/j.gie.2018.03.003.
Anderson MA, Ben-Menachem T, Gan SI, et al. Management of antithrombotic agents for endoscopic procedures. Gastrointestinal endoscopy; 2009;70(6): 1060-1070. doi.org/10.1016/j.gie.2009.09.040.
Zakko L, Rustagi T, Douglas M, et al. No benefit from platelet transfusion for gastrointestinal bleeding in patients taking antiplatelet agents. Clinical Gastroenterology and Hepatology; 2017;15(1): 46-52. doi.org/10.1016/j.cgh.2016.07.017.
Acosta RD, Abraham NS, Chandrasekhara V, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointestinal endoscopy; 2016;83(1): 3-16. doi.org/10.1016/j.gie.2015.09.035.
Wolf AT, Wasan SK, Saltzman JR. Impact of anticoagulation on rebleeding following endoscopic therapy for nonvariceal upper gastrointestinal hemorrhage. Official journal of the American College of Gastroenterology| ACG; 2007;102(2): 290-296. doi.org/10.1111/j.1572-0241.2006.00969.x.
Dorward S, Sreedharan A, Leontiadis G, et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. The Cochrane database of systematic reviews; 2006(4): CD005415-CD005415. doi.org/10.1002/14651858.CD005415.pub3.
Gisbert J, Gonzalez L, Calvet X, et al. Proton pump inhibitors versus H2‐antagonists: a meta‐analysis of their efficacy in treating bleeding peptic ulcer. Alimentary pharmacology & therapeutics; 2001;15(7): 917-926. doi.org/10.1046/j.1365-2036.2001.01012.x.
Kaviani M, Hashemi M, Kazemifar A, et al. Effect of oral omeprazole in reducing re‐bleeding in bleeding peptic ulcers: a prospective, double‐blind, randomized, clinical trial. Alimentary pharmacology & therapeutics; 2003;17(2): 211-216. doi.org/10.1046/j.1365-2036.2003.01416.x.
Chan W, Khin L, Chung Y, et al. Randomized controlled trial of standard versus high-dose intravenous omeprazole after endoscopic therapy in high-risk patients with acute peptic ulcer bleeding. Journal of British Surgery; 2011;98(5): 640-644. doi.org/10.1002/bjs.7420.
Green Jr FW, Kaplan MM, Curtis LE, et al. Effect of acid and pepsin on blood coagulation and platelet aggregation: a possible contributor to prolonged gastroduodenal mucosal hemorrhage. Gastroenterology; 1978;74(1): 38-43.
Altraif I, Handoo FA, Aljumah A, et al. Effect of erythromycin before endoscopy in patients presenting with variceal bleeding: a prospective, randomized, double-blind, placebo-controlled trial. Gastrointestinal endoscopy; 2011;73(2): 245-250. doi.org/10.1016/j.gie.2010.09.043.
Pateron D, Vicaut E, Debuc E, et al. Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Annals of emergency medicine; 2011;57(6): 582-589. doi.org/10.1016/j.annemergmed.2011.01.001.
Adang RP, Vismans JFF, Talmon JL, et al. Appropriateness of indications for diagnostic upper gastrointestinal endoscopy: association with relevant endoscopic disease. Gastrointestinal endoscopy; 1995;42(5): 390-397. doi.org/10.1016/s0016-5107(95)70037-4.
Jensen DM. Management of upper gastrointestinal bleeding in the patient with chronic liver disease. Medical Clinics of North America; 1996;80(5): 1035-1068. doi.org/10.1016/s0025-7125(05)70479-x.
Forrest JH, Finlayson N, Shearman D. Endoscopy in gastrointestinal bleeding. The Lancet; 1974;304(7877): 394-397. doi.org/10.1016/s0140-6736(74)91770-x.
Tsoi KK, Ma TK, Sung JJ. Endoscopy for upper gastrointestinal bleeding: how urgent is it? Nature Reviews Gastroenterology & Hepatology; 2009;6(8): 463-469. doi.org/10.1038/nrgastro.2009.108.
Wysocki J, Srivastav S, Winstead N. A nationwide analysis of risk factors for mortality and time to endoscopy in upper gastrointestinal haemorrhage. Alimentary pharmacology & therapeutics; 2012;36(1): 30-36. doi.org/10.1111/j.1365-2036.2012.05129.x.
Garg SK, Anugwom C, Campbell J, et al. Early esophagogastroduodenoscopy is associated with better outcomes in upper gastrointestinal bleeding: A nationwide study. Endoscopy International Open; 2017;5(05): E376-E386. doi.org/10.1055/s-0042-121665.
Lau JY, Yu Y, Tang RS, et al. Timing of endoscopy for acute upper gastrointestinal bleeding. New England Journal of Medicine; 2020;382(14): 1299-1308. doi.org/10.1056/NEJMoa1912484.
Sarin N, Monga N, Adams PC. Time to endoscopy and outcomes in upper gastrointestinal bleeding. Canadian Journal of Gastroenterology; 2009;23(7): 489-493. doi.org/10.1155/2009/604639.
Bjorkman DJ, Zaman A, Fennerty MB, et al. Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study. Gastrointestinal endoscopy; 2004;60(1): 1-8. doi.org/10.1016/s0016-5107(04)01287-8.
Kumar NL, Cohen AJ, Nayor J, et al. Timing of upper endoscopy influences outcomes in patients with acute nonvariceal upper GI bleeding. Gastrointestinal endoscopy; 2017;85(5): 945-952. e941. doi.org/10.1016/j.gie.2016.09.029.
Laursen SB, Leontiadis GI, Stanley AJ, et al. Relationship between timing of endoscopy and mortality in patients with peptic ulcer bleeding: a nationwide cohort study. Gastrointestinal endoscopy; 2017;85(5): 936-944. e933. doi.org/10.1016/j.gie.2016.08.049.
Balderas V, Bhore R, Lara LF, et al. The hematocrit level in upper gastrointestinal hemorrhage: safety of endoscopy and outcomes. The American journal of medicine; 2011;124(10): 970-976. doi.org/10.1016/j.amjmed.2011.04.032.
Gralnek I, Ching J, Maza I, et al. Capsule endoscopy in acute upper gastrointestinal hemorrhage: a prospective cohort study. Endoscopy; 2013;45(01): 12-19. doi.org/10.1055/s-0032-1325933.
Meltzer AC, Ali MA, Kresiberg RB, et al. Video capsule endoscopy in the emergency department: a prospective study of acute upper gastrointestinal hemorrhage. Annals of emergency medicine; 2013;61(4): 438-443. e431. doi.org/10.1016/j.annemergmed.2012.11.008.
Sung JJ, Tang RS, Ching JY, et al. Use of capsule endoscopy in the emergency department as a triage of patients with GI bleeding. Gastrointestinal endoscopy; 2016;84(6): 907-913. doi.org/10.1016/j.gie.2016.04.043.
