Üst gastrointestinal sistem kanamalarında erken endoskopinin mortalite ve morbiditeye etkisi
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Date
2014
Authors
Hafızoğlu, Merve
Journal Title
Journal ISSN
Volume Title
Publisher
Uludağ Üniversitesi
Abstract
Üst gastrointestinal sistem (ÜGİS) kanamaları özofagusun üst kısmı ile Treitz ligamanı arasındaki herhangi bir yerden lümen içine olan kanamaları kapsar. ÜGİS kanaması olan hasta acil servise hematemez, melena veya hematokezya ile başvurabilir. Amerika Birleşik Devletleri ve Avrupa'da ÜGİS kanama nedeni ile hastaneye başvurma oranı %0.1 iken, mortalite oranı %10'dur. ÜGİS kanamasının sebepleri arasında en sık peptik ülser, eroziv hastalıklar ve özofagogastrik varisler görülür. GİS kanamalarına yaklaşımda en önemli nokta hastanın hemodinamik durumunun değerlendirilmesidir. Daha sonra ise kanama sebebinin saptanması ve gerekli tedavi yaklaşımlarını uygulayarak yeniden kanamanın önlenmesi gerekmektedir. Acil endoskopi ve hemostatik girişimsel işlemlerle sıklıkla kanama kontrolu sağlanmaktadır. Kanama devam ettiği takdirde tekrar girişimsel işlem kararı, avantaj ve dezavantajlar göz önünde bulundurularak erkenden verilmelidir. Akut ÜGİS kanamalı hastalara ilk 24 saat içinde endoskopi uygulamak standart yaklaşımdır. Bununla birlikte erken endoskopinin tanımı konusunda ortak bir görüş yoktur. Çeşitli çalışmalara göre bu tanım acil servise başvurudan sonra 2 saat ile 24 saat arasında çeşitlilik gösterir. Bizim çalışmamızda ÜGİS kanaması ile acil servise başvuran 115 hasta alındı. Hastalar endoskopi yapılma sürelerine göre 3 gruba ayrıldığında (<8 saat, 8-24 saat, >24 saat) gruplar arasında endoskopik bulgu, forrest sınıflandırması, endoskopik veya cerrahi tedavi ihtiyacı, replasman ihtiyacı, takiplerde tekrarlayan kanama, tekrarlayan endoskopi ihtiyacı ve hastaların akıbeti konusunda anlamlı fark saptanmamıştır. Bunun sebebi grupların demografik ve klinik özelliklerinin birbirine benzer olması ve her iki gruptaki hastaların da genel olarak stabil hastalardan oluşması olabilir. Bizim çalışmamızda hastaların acil servise başvurusundan sonra 8 saatten kısa sürede uygulanan endoskopinin 8-24 saat arasında uygulanan endoskopiye oranla kesin bir faydası görülmemiştir. Sonuç olarak üst gastrointestinal sistem kanamalarında erken endoskopinin tanımı, ilk 24 saat içinde ne zaman yapılacağı ve faydaları konusunda ortak bir görüş yoktur, yapılan prospektif randomize çalışmalar da erken endoskopinin kar zarar oranını belirlemede göz önünde bulundurulmalıdır.
Upper gastrointestinal system (UGS) bleeding includes hemorrhages located anywhere between upper region of the oesophagus and the Treitz ligament into the lumen. Patients with UGS bleeding can be admitted to the emergency service with signs of haematemesis, melena or haematochezia. Admittion rates to the hospital is 0.1% and mortality rate is 10% due to UGS bleeding in United States of America (USA) and Europe, respectively. Causes of the UGS bleeding are most commonly peptic ulcer, erosive diseases and oesophagogastric varices. The keystone of the approach to the UGS bleeding is evaluation of the hemodynamic situation of the patient. Then, the cause of bleeding must be determined and rebleeding must be prevented by administration of the appropriate treatment. Urgent endoscopy and hemostatic interventions generally provide adequate bleeding control. Re-intervention decision must be made swiftly with evaluation of advantages and disadvantages if the bleeding continues. Endoscopic intervention in the initial 24 hour is the standart treatment of patients with acute UGS bleeding. However, there is no consensus about description of the early endoscopic intervention. In various studies, this description varies between 2 and 24 hours later from admittion to the emergency service. In our study, 115 patients who were admitted to the emergency service with UGS bleeding were enrolled. Cut-off value was determined as 8 hours. Then, patients were classified into 3 group according to time of endoscopy (<8 hours, 8-24 hours, >24 hours) and there were no significant difference between these groups in terms of endoscopic results, classification of forrest, need of endoscopic or surgical treatment, need of replacment, rebleeding in monitoring period, need of endoscopic re-intervention and the outcome of the patients. These results may be due to the similarity of these groups in terms of demographic and clinical properties; or the stability of the majority of the patients in these groups. In our study, there were no definitive benefits in endoscopy performed less than 8 hours later over 8-24 hours later from admittion. In conclusion, there is no consensus about the definition of the early endoscopic intervention, exact time of it in the initial 24 hours and the benefits of it. Prospective studies which were performed must be considered in estimation of benefit/harm ratio of the early endoscopic intervention.
Upper gastrointestinal system (UGS) bleeding includes hemorrhages located anywhere between upper region of the oesophagus and the Treitz ligament into the lumen. Patients with UGS bleeding can be admitted to the emergency service with signs of haematemesis, melena or haematochezia. Admittion rates to the hospital is 0.1% and mortality rate is 10% due to UGS bleeding in United States of America (USA) and Europe, respectively. Causes of the UGS bleeding are most commonly peptic ulcer, erosive diseases and oesophagogastric varices. The keystone of the approach to the UGS bleeding is evaluation of the hemodynamic situation of the patient. Then, the cause of bleeding must be determined and rebleeding must be prevented by administration of the appropriate treatment. Urgent endoscopy and hemostatic interventions generally provide adequate bleeding control. Re-intervention decision must be made swiftly with evaluation of advantages and disadvantages if the bleeding continues. Endoscopic intervention in the initial 24 hour is the standart treatment of patients with acute UGS bleeding. However, there is no consensus about description of the early endoscopic intervention. In various studies, this description varies between 2 and 24 hours later from admittion to the emergency service. In our study, 115 patients who were admitted to the emergency service with UGS bleeding were enrolled. Cut-off value was determined as 8 hours. Then, patients were classified into 3 group according to time of endoscopy (<8 hours, 8-24 hours, >24 hours) and there were no significant difference between these groups in terms of endoscopic results, classification of forrest, need of endoscopic or surgical treatment, need of replacment, rebleeding in monitoring period, need of endoscopic re-intervention and the outcome of the patients. These results may be due to the similarity of these groups in terms of demographic and clinical properties; or the stability of the majority of the patients in these groups. In our study, there were no definitive benefits in endoscopy performed less than 8 hours later over 8-24 hours later from admittion. In conclusion, there is no consensus about the definition of the early endoscopic intervention, exact time of it in the initial 24 hours and the benefits of it. Prospective studies which were performed must be considered in estimation of benefit/harm ratio of the early endoscopic intervention.
Description
Keywords
Üst gastrointestinal sistem kanamaları, Üst gastrointestinal sistem kanamalı hastaya yaklaşım, Erken endoskopi, Upper gastrointestinal system bleeding, Approach to the upper gastrointestinal bleeding, Early endoscopy
Citation
Hafızoğlu, M. (2014). Üst gastrointestinal sistem kanamalarında erken endoskopinin mortalite ve morbiditeye etkisi. Yayınlanmamış uzmanlık tezi. Uludağ Üniversitesi Tıp Fakültesi.