Skip to main content
SpringerLink
Log in

Gastrointestinale Blutungen bei Intensivpatienten

Von der Prävention zur Therapie

Gastrointestinal bleeding in intensive care patients

From prevention to treatment

  • Leitthema
  • Published:
Intensivmedizin und Notfallmedizin

Zusammenfassung

Die gastrointestinale Blutung ist eine gefürchtete Komplikation bei Patienten auf der Intensivstation. Sie ist mit einer erhöhten Morbidität und Mortalität vergesellschaftet. Hauptrisikofaktoren für das Auftreten einer klinisch bedeutsamen „Stressblutung“ sind die Notwendigkeit zur mechanischen Ventilation über mindestens 48 h oder das Vorliegen einer Koagulopathie (PTT >2-Fache der Norm, INR >1,5, Thrombozyten <50.000/µl). Durch die Gabe von H2-Rezeptorantagonisten oder Protonenpumpenhemmern lässt sich die Häufigkeit einer klinisch bedeutsamen Blutung bei Risikopatienten senken. Diese medikamentöse Prophylaxe wird jedoch viel zu häufig eingesetzt. Des Weiteren fehlt bisher der Nachweis, dass diese Medikamente die Mortalität und/oder die Liegezeit der Patienten verringern. Die Behandlungsstrategien bei Auftreten einer gastrointestinalen Blutung unterscheiden sich nicht zwischen Intensivpatienten und Nicht-Intensivpatienten. Patienten mit Lebervorerkrankung scheinen bei Auftreten einer Blutung auf der Intensivstation besonders vital gefährdet. Die Zukunft muss zeigen, ob gerade bei diesen Patienten besondere Früherkennungsmaßnahmen zu einem besseren Überleben führen.

Abstract

Gastrointestinal bleeding is a dreaded complication in intensive care unit (ICU) patients and is associated with increased morbidity and mortality. The main risk factors for clinically important bleedings are (1) mechanical ventilation >48 h and (2) coagulopathy (PTT >2 times the upper limit of normal, INR >1.5, thrombocyte count <50000/µl). H2-receptor antagonists and proton pump inhibitors reduce the frequency of clinically important bleeding in patients at risk. These drugs are frequently used, although there is no evidence that mortality and/or the length of hospital stay are reduced. There is no difference in the strategies to treat bleeding episodes in ICU and non-ICU patients. ICU patients who suffer from liver disorders are at high risk of death when bleeding. Future studies have to elucidate whether specialized screening programs are needed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2

Literatur

  1. Bajaj JS, Zadvornova Y, Heuman DM et al (2009) Association of proton pump inhibitor therapy with spontatneous bacterial peritonitis in cirrhotic patients with ascites. Am J Gastroenterol 104:1130–1134

    Article  CAS  PubMed  Google Scholar 

  2. Barnert J, Messmann H (2009) Diagnosis and management of lower gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol 6:637–646

    Article  PubMed  Google Scholar 

  3. Cheon JH, Kim JS, Ko SJ et al (2007) Risk factors for upper gastrointestinal bleeding in critically ill patients. Hepatogastroenterology 54:766–769

    PubMed  Google Scholar 

  4. Conrad SA, Gabrielli A, Margolis B et al (2005) Randomized, double-blind comparison of immediate-release omeprazole oral suspension versus intravenous cimetidine for the prevention of upper gastrointestinal bleeding in critically ill patients. Crit Care Med 33:760–765

    Article  CAS  PubMed  Google Scholar 

  5. Cook DJ, Fuller HD, Guyatt GH et al (1994) Risk factors for gastrointestinal bleeding in critically ill patients. N Engl J Med 330:377–381

    Article  CAS  PubMed  Google Scholar 

  6. Cook DJ, Griffith LE, Walter SD et al (2001) The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients. Crit Care 5:368–375

    Article  CAS  PubMed  Google Scholar 

  7. Cook D, Guyatt G, Marshall J et al (1998) A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. N Engl J Med 338:791–797

    Article  CAS  PubMed  Google Scholar 

  8. Cook DJ, Reeve BK, Guyatt GH et al (1996) Stress ulcer prophylaxis in critically ill patients: resolving discordant meta-analyses. JAMA 275:308–312

    Article  CAS  PubMed  Google Scholar 

  9. Dial S, Delaney JA, Schneider V, Suissa S (2006) Proton pump inhibitor use and risk of community-acquired Clostridium difficile-associated disease defined by prescription for oral vancomycin therapy. CMAJ 175:745–748

    PubMed  Google Scholar 

  10. Faisy C, Guerot E, Diehl JL et al (2003) Clinically significant gastrointestinal bleeding in critically ill patients with and without stress-ulcer prophylaxis. Intensive Care Med 29:1306–1313

    Article  PubMed  Google Scholar 

  11. Farrell CP, Mercogliano G, Kuntz CL (2009) Overuse of stress ulcer prophylaxis in the critical care setting and beyond. J Crit Care (Epub ahead of print)

  12. Fischbach W, Malfertheiner P, Hoffmann JC et al (2009) S3-Leitlinie „Helicobacter pylori und gastroduodenale Ulkuskrankheit“ der Deutschen Gesellschaft für Verdauungs- und Stoffwechselkrankheiten (DGVS). Z Gastroenterol 47:68–102

    Article  CAS  PubMed  Google Scholar 

  13. Frattaroli FM, Casciani E, Spoletini D et al (2009) Prospective sutdy comparing multi-detector row CT and endoscopy in acute gastrointestinal bleeding. World J Surg 33:2209–2217

    Article  PubMed  Google Scholar 

  14. García-Rodríguez LA, Ruigómez A, Panés J (2007) Use of acid-suppressing drugs and the risk of bacterial gastroenteritis. Clin Gastroenterol Hepatol 5:1418–1423

    Article  PubMed  Google Scholar 

  15. Heidelbaugh JJ, Inadomi JM (2006) Magnitude and economic impact of inappropriate use of stress ulcer prophylaxis in non-ICU hospitalized patients. Am J Gastroenterol 101:2200–2205

    Article  PubMed  Google Scholar 

  16. Hubmann R, Bodlaj G, Czompo M et al (2006) The use of self-expanding metal stents to treat acute esophageal variceal bleeding. Endoscopy 38:896–901

    Article  CAS  PubMed  Google Scholar 

  17. Jaeckle T, Stuber G, Hoffmann MH et al (2008) Detection and localization of acute upper and lower gastrointestinal (BI) bleeding with arterial phase multi-detector row helical CT. Eur Radiol 18:1406–1413

    Article  CAS  PubMed  Google Scholar 

  18. Kantorova I, Svoboda P, Scheer P et al (2004) Stress ulcer prophylaxis in critically ill patients: a randomized controlled trial. Hepatogastroenterology 51:757–761

    PubMed  Google Scholar 

  19. Kim BC, Cheon JH, Kim TI, Kim WH (2008) Risk factors and the role of bedside colonoscopy for lower gastrointestinal hemorrhage in critically ill patients. Hepatogastroenterology 55:2108–2111

    PubMed  Google Scholar 

  20. Klebl F, Langgartner J, Bregenzer N et al (2002) Charakterisierung der oberen gastrointestinalen Blutung bei Intensivpatienten. Intensivmed 39:233–239

    Article  Google Scholar 

  21. Klebl F, Messmann H (2010) Akute gastrointestinale Blutungen. In: Burchardi H, Larsen R, Muhl E et al (Hrsg) Die Intensivmedizin, 11. Aufl. Springer, Berlin Heidelberg New York Tokyo (im Druck)

  22. Klebl FH, Schölmerich J (2007) Therapy insight: prophylaxis of stress-induced gastrointestinal bleeding in critically ill patients. Nat Clin Pract Gastroenterol Hepatol 4:562–570

    Article  PubMed  Google Scholar 

  23. Laine L, Takeuchi K, Tarnawski A (2008) Gastric mucosal defense and cytoprotection: bench to bedside. Gastroenterology 135:41–60

    Article  CAS  PubMed  Google Scholar 

  24. Lowe DO, Mamdani MM, Kopp A et al (2006) Proton pump inhibitors and hospitalization for Clostridium difficile-associated disease: a population-based study. Clin Infect Dis 43:1272–1276

    Article  CAS  PubMed  Google Scholar 

  25. Asensio NA, Barrientos RR, Castro ZP et al (2002) Utilizacion de supresores de la secrecion acida en pacientes hospitalizados. An Med Interna 19:557–560

    Google Scholar 

  26. Ojiako K, Shingala H, Schorr C, Gerber DR (2008) Famotidine versus pantoprazole for preventing bleeding in the upper gastrointestinal tract of critically ill patients receiving mechanical ventilation. Am J Crit Care 17:142–147

    PubMed  Google Scholar 

  27. Parente F, Cucino C, Gallus S et al (2003) Hospital use of acid-suppressive medications and its fall-out on prescribing in general practice: a 1-month survey. Aliment Pharmacol Ther 17:1503–1506

    Article  CAS  PubMed  Google Scholar 

  28. Robertson MS, Wilson SJ, Cade JF (2008) Acute stress ulceration prophylaxis: point prevalence surveys in intensive care units in Victoria, 1997 and 2005. Crit Care Resusc 10:18

    PubMed  Google Scholar 

  29. Villanueva C, Colomo A, Aracil C, Guarner C (2008) Current therapy of variceal bleeding. Best Pract Res Clin Gastroenterol 22:261–278

    Article  PubMed  Google Scholar 

  30. Zedtwitz-Liebenstein K, Wenisch C, Patruta S et al (2002) Omeprazole treatment diminishes intra- and extracellular neutrophil reactive oxygen production and bactericidal activity. Crit Care Med 30:1118–1122

    Article  CAS  PubMed  Google Scholar 

  31. Klebl FH, Schölmerich J (2008) Future expectations in the prophylaxis of intestinal bleeding. Best Pract Res Clin Gastroenterol 22(2):373–387

    Article  CAS  PubMed  Google Scholar 

Download references

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

  1. Klinik und Poliklinik für Innere Medizin I, Klinikum der Universität Regensburg, 93042, Regensburg, Deutschland

    F.H. Klebl

Authors
  1. F.H. Klebl
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to F.H. Klebl.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Klebl, F. Gastrointestinale Blutungen bei Intensivpatienten. Intensivmed 47, 260–265 (2010). https://doi.org/10.1007/s00390-009-0158-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00390-009-0158-5

Schlüsselwörter

Keywords

Search

Navigation