Skip to main content

Akute gastrointestinale Blutungen

Acute gastrointestinal bleeding

Notfall + Rettungsmedizin volume 13, pages 159–172 (2010)Cite this article

Zusammenfassung

Die akute gastrointestinale Blutung geht mit einer Letalität von 5–10% einher. Obere gastrointestinale Blutungen sind mit 85% häufiger und verlaufen schwerer als untere. Mit der Möglichkeit der endoskopischen Untersuchung des Dünndarms (Kapselendoskopie und Ballonenteroskopie) ist die Entität der mittleren gastrointestinalen Blutung etabliert, welche jedoch noch seltener ist. Anamnestische Hinweise helfen bei der Diagnose der Blutungsart. Die Prognose bzw. das Mortalitätsrisiko wird im Wesentlichen von der Blutungsintensität bestimmt. Zusätzlich beeinflussen Begleiterkrankungen, die Einnahme von Antikoagulanzien und das Alter des Patienten das Letalitätsrisiko, das besonders mit dem Auftreten von Rezidivblutungen steigt. Ein wesentliches Ziel in der Behandlung ist daher das Verhindern von Rezidivblutungen. Goldstandard für die Diagnose ist die Endoskopie, die eine gleichzeitige Therapie ermöglicht. Die Szintigraphie ist im Vergleich zur Angiographie im Nachweis einer Blutung sensitiver, bei der Lokalisation der Blutung ist sie jedoch unterlegen. Zusätzlich bietet die Angiographie auch die Möglichkeit der interventionellen Therapie. Ösophagusvarizenblutungen, die endoskopisch, medikamentös bzw. mittels Sonde nicht zu stillen sind, können mittels transjugulärem Stentshunt versorgt werden. Die Operation sollte bei allen akuten Blutungen nur bei Versagen der übrigen Methoden eingesetzt werden, da sie mit einer hohen Letalität assoziiert ist.

Abstract

Acute gastrointestinal bleeding is a life-threatening disease with a mortality rate of 5–10%. Upper gastrointestinal bleeding occurs more frequently (85%) and has a more severe course compared to lower gastrointestinal bleeding. By the introduction of new diagnostic avenues to examine the small bowel (capsule and balloon enteroscopy) the source of mid-gastrointestinal bleeding can be diagnosed more often, but bleeding of the small bowel is still a rare disease. The medical history may be helpful in the diagnosis of the bleeding source. Prognosis and mortality depend on bleeding intensity, presence of comorbidity, and age of the patient. Furthermore, rebleeding is associated with increased mortality. Therefore, one major goal in the treatment of gastrointestinal bleeding is to avoid rebleeding. Endoscopy is the gold standard in the diagnosis of acute gastrointestinal bleedings and allows endoscopic treatment if possible. Scintigraphy is more sensitive compared to angiography in the detection of the bleeding source; however, the localization of bleeding is more difficult. Furthermore, angiography offers the possibility of treating acute bleeding lesions. With the transjugular stent shunt it is possible to treat acute esophageal variceal bleeding if endoscopic or conservative treatment with drugs or tubes fails. Due to its high mortality rate, surgery is the last resort only if all other methods fail to treat acute bleedings.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

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

Abb. 1
Abb. 2
Abb. 3
Abb. 4
Abb. 5

Literatur

  1. Avgerinos A, Sgouros S, Viazis N et al (2005) Somatostatin inhibits gastric acid secretion more effectively than pantoprazole in patients with peptic ulcer bleeding: A prospective, randomized, placebo-controlled trial. Scand J Gastroenterol 40:515–522

    Article  CAS  PubMed  Google Scholar 

  2. Barnert J, Messmann H (2008) Management of lower gastrointestinal tract bleeding. Best Pract Res Clin Gastroenterol 22:295–312

    Article  CAS  PubMed  Google Scholar 

  3. Busch OR, Delden OM van, Gouma DJ (2008) Therapeutic options for endoscopic haemostatic failures: the place of the surgeon and radiologist in gastrointestinal tract bleeding. Best Pract Res Clin Gastroenterol 22:341–354

    Article  PubMed  Google Scholar 

  4. De Franchis R (2005) Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 43:167–176

    Article  Google Scholar 

  5. Ell C, Hagenmüller F, Schmitt W et al (1995) Multizentrische prospektive Untersuchung zum aktuellen Stand der Therapie der Ulcusblutung in Deutschland. Dtsch Med Wochenschr 120:3–9

    Article  CAS  PubMed  Google Scholar 

  6. Ell C, May A (2006) Mid-gastrointestinal bleeding: capsule endoscopy and push-and-pull enteroscopy give rise to a new medical term. Endoscopy 38:73–75

    Article  CAS  PubMed  Google Scholar 

  7. Elmunzer BJ, Young SD, Inadomi JM et al (2008) Systematic review of the predictors of recurrent hemorrhage after endoscopic hemostatic therapy for bleeding peptic ulcers. Am J Gastroenterol 103:2625–2632

    Article  PubMed  Google Scholar 

  8. Gevers AM, De Goede E, Simoens M et al (2002) A randomized trial comparing injection therapy with hemoclip and with injection combined with hemoclip for bleeding ulcers. Gastrointest Endosc 55:466–469

    Article  PubMed  Google Scholar 

  9. Gisbert JP, Khorrami S, Carballo F et al (2004) H. pylori eradication therapy vs. antisecretory non-eradication therapy (with or without long-term maintenance antisecretory therapy) for the prevention of recurrent bleeding from peptic ulcer. Cochrane Database Syst Rev CD004062

  10. Hebert PC, Wells G, Blajchman MA et al (1999) The transfusion requirements in critical care investigators for the canadian critical care trials group. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 340:409–417

    Article  CAS  PubMed  Google Scholar 

  11. Iddan G, Meron G, Glukhovsky A, Swain P (2000) Wireless capsule endoscopy. Nature 405:417

    Article  CAS  PubMed  Google Scholar 

  12. Jensen DM, Machicado GA, Jutabha R, Kovacs TO (2000) Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 342:78–82

    Article  CAS  PubMed  Google Scholar 

  13. Kovacs TO, Jensen DM (2008) The short-term medical management of non-variceal upper gastrointestinal bleeding. Drugs 68:2105–2111

    Article  CAS  PubMed  Google Scholar 

  14. Lau JYW, Sung JJY, Chan ACW et al (1997) Stigmata of hemorrhage in bleeding peptic ulcers: an interobserver agreement study among international experts. Gastrointest Endosc 46:33–36

    Article  CAS  PubMed  Google Scholar 

  15. Lau JYW, Sung JJY, Lam YH et al (1999) Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med 340:751–756

    Article  CAS  PubMed  Google Scholar 

  16. Levacher S, Letoumelin P, Pateron D et al (1995) Early administration of terlipressin plus glyceryl trinitrate to control active upper gastrointestinal bleeding in cirrhotic patients. Lancet 346:865–868

    Article  CAS  PubMed  Google Scholar 

  17. Liou TC, Chang WH, Wang HY et al (2007) Large-volume endoscopic injection of epinephrine plus normal saline for peptic ulcer bleeding. J Gastroenterol Hepatol 22:996–1002

    Article  CAS  PubMed  Google Scholar 

  18. Lo CC, Hsu PI, Lo GH et al (2006) Comparison of hemostatic efficacy for epinephrine injection alone and injection combined with hemoclip therapy in treating high-risk bleeding ulcers. Gastrointest Endosc 63:767–773

    Article  PubMed  Google Scholar 

  19. Longstreth GF (1997) Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 92:419–424

    CAS  PubMed  Google Scholar 

  20. Messmann H, Schaller P, Andus T et al (1998) Effect of programmed endoscopic follow-up examinations on the rebleeding rate of gastric or duodenal peptic ulcers treated by injection therapy: a prospective, randomized controlled trial. Endoscopy 30:583–589

    Article  CAS  PubMed  Google Scholar 

  21. Moschler O, May AD, Muller MK, Ell C (2008) Complications in double-balloon-enteroscopy: results of the German DBE register. Z Gastroenterol 46:266–270

    Article  CAS  PubMed  Google Scholar 

  22. Pennazio M, Santucci R, Rondonotti E et al (2004) Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 126:643–653

    Article  PubMed  Google Scholar 

  23. Peura DA, Lanza FL, Gostout CJ, Foutch PG (1997) The American college of gastroenterology bleeding registry: preliminary findings. Am J Gastroenterol 92:924–928

    CAS  PubMed  Google Scholar 

  24. Rao SV, Jollis JG, Harrington RA et al (2004) Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. JAMA 292:1555–1562

    Article  CAS  PubMed  Google Scholar 

  25. Regula J, Wronska E, Pachlewski J (2008) Vascular lesions of the gastrointestinal tract. Best Pract Res Clin Gastroenterol 22:313–328

    Article  PubMed  Google Scholar 

  26. Rockall TA, Logan RF, Devlin HB, Northfield TC (1995) Variation in outcome after acute upper gastrointestinal haemorrhage. The national audit of acute upper gastrointestinal haemorrhage. Lancet 346:346–350

    Article  CAS  PubMed  Google Scholar 

  27. Rockall TA, Logan RF, Devlin HB, Northfield TC (1996) Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National audit of acute upper gastrointestinal haemorrhage. Lancet 347:1138–1140

    Article  CAS  PubMed  Google Scholar 

  28. Rutgeerts P, Rauws E, Wara P et al (1997) Randomised trial of single and repeated fibrin glue compared with injection of polidocanol in treatment of bleeding peptic ulcer. Lancet 350:692–696

    Article  CAS  PubMed  Google Scholar 

  29. Stanley AJ, Ashley D, Dalton HR et al (2009) Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Lancet 373:42–47

    Article  CAS  PubMed  Google Scholar 

  30. Sung JJY, Chan FKL, Lau JYW et al (2003) The effect of endoscopic therapy in patients receiving omeprazole for bleeding ulcers with nonbleeding visible vessels or adherent clots: A randomized comparison. Ann Intern Med 139:237–243

    CAS  PubMed  Google Scholar 

  31. Vergara M, Calvet X, Gisbert JP (2007) Epinephrine injection versus epinephrine injection and a second endoscopic method in high risk bleeding ulcers. Cochrane Database Syst Rev CD005584

  32. Veyradier A, Balian A, Wolf M et al (2001) Abnormal von willebrand factor in bleeding angiodysplasias of the digestive tract. Gastroenterology 120:346–353

    Article  CAS  PubMed  Google Scholar 

  33. Yamamoto H, Sekine Y, Sato Y et al (2001) Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 53:216–220

    Article  CAS  PubMed  Google Scholar 

  34. Zuccaro G (2008) Epidemiology of lower gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 22:225–232

    Article  PubMed  Google Scholar 

  35. Zuckerman GR, Prakash C (1998) Acute lower intestinal bleeding: part I: clinical presentation and diagnosis. Gastrointest Endosc 48:606–617

    Article  CAS  PubMed  Google Scholar 

Download references

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

  1. III. Medizinische Klinik, Klinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland

    S.K. Gölder & H. Messmann

Authors
  1. S.K. Gölder
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. H. Messmann
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to S.K. Gölder.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Gölder, S., Messmann, H. Akute gastrointestinale Blutungen. Notfall Rettungsmed 13, 159–172 (2010). https://doi.org/10.1007/s10049-009-1192-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10049-009-1192-3

Schlüsselwörter

  • Gastrointestinale Blutung
  • Hämatemesis
  • Ulkusblutung
  • Ösophagusvarizenblutungen
  • Endoskopische Therapie

Keywords

  • Gastrointestinal bleeding
  • Hematemesis
  • Bleeding ulcer
  • Bleeding esophageal varices
  • Endoscopic therapy