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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Saturday, November 24, 2012

Ulcus sangrante


Management of Patients With Ulcer Bleeding
Laine L., Jensen D. Am J Gastroenterol 2012; 107: 345-360
"This guideline presents recommendations for the step-wise management of patients with overt upper gastrointestinal bleeding. Hemodynamic status is fi rst assessed, and resuscitation initiated as needed. Patients are risk-stratifi ed based on features such as hemodynamic status, comorbidities, age, and laboratory tests. Pre-endoscopic erythromycin is considered to increase diagnostic yield at fi rst endoscopy. Pre-endoscopic proton pump inhibitor (PPI) may be considered to decrease the need for endoscopic therapy but does not improve clinical outcomes. Upper endoscopy is generally performed within 24 h. The endoscopic features of ulcers direct further management. Patients with active bleeding or non-bleeding visible vessels receive endoscopic therapy (e.g., bipolar electrocoagulation, heater probe, sclerosant, clips) and those with an adherent clot may receive endoscopic therapy; these patients then receive intravenous PPI with a bolus followed by continuous infusion. Patients with fl at spots or clean-based ulcers do not require endoscopic therapy or intensive PPI therapy. Recurrent bleeding after endoscopic therapy is treated with a second endoscopic treatment; if bleeding persists or recurs, treatment with surgery or interventional radiology is undertaken. Prevention of recurrent bleeding is based on the etiology of the bleeding ulcer. H. pylori is eradicated and after cure is documented anti-ulcer therapy is generally not given. Nonsteroidal anti-infl ammatory drugs (NSAIDs) are stopped; if they must be resumed low-dose COX-2-selective NSAID plus PPI is used. Patients with established cardiovascular disease who require aspirin should start PPI and generally re-institute aspirin soon after bleeding eases (within 7 days and ideally 1 – 3 days). Patients with idiopathic ulcers receive long-term anti-ulcer therapy."
Journal Scan: Nasogastric Lavage: Uncomfortable Intervention
without Proven Benefit
Navarro M., Lovato L. Emergency Medicine News: November 2012; 34 (11): 20
..."The American College of Gastroenterology conditionally said nasogastric lavage in patients with upper GI bleeding is not required for diagnosis, prognosis, visualization, or therapeutic effect. (Am J Gastroenterol 2012;107[3]:345.) If the motivation to perform nasogastric lavage is to get your patient to endoscopy sooner, the data from this study could be used to support that practice. It is probably a much better goal, however, to minimize interventions that offer little help in ED decision-making and have no proven clinical benefit..."