Peptic ulcer disease - Mucosal Immunology · 6 Peptic ulcer disease Bible class 08.23.2017,...

Peptic ulcer disease

Benjamin Heimgartner, OA Gastroenterologie

Universitätsklinik für Viszerale Chirurgie und Medizin, Inselspital

Bible class

08.23.2017

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Bible class 08.23.2017, Gastroenterologie Inselspital

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What is the initial most important

step in patients with suspected

GI-bleeding?

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Hemodynamic status should be assessed immediately upon

presentation and resuscitative measures begun as needed

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When do you prescribe blood

transfusions?

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When do you prescribe blood

transfusions?

Blood transfusions should target hemoglobin ≥ 7 g/ dl, with

higher hemoglobins targeted in patients with clinical evidence of

intravascular volume depletion or comorbidities such as

coronary artery disease

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6 weeks mortality

5% vrs 9%

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What are the limits of thrombocytes

and INR (NICE guidelines)?

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Thrombocyten > 50 G/L

What are the limits of thrombocytes

and INR (NICE guidelines)?

•INR < 1.5

• Thrombocyten > 50 G/L

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Which scores of risk assessments

do you know and what are the

clinical implications?

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Which medication should be

considered before active bleeding?

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Which medication should be

considered before active bleeding?

-Erythromycin 250 mg i.v.

(NNT 9 patients => Diagnosis)

Barkun AN et al.: Prokinetics in acute upper GI bleeding: a meta-analysis.

Gastrointest Endosc 2010: 1138 – 45 .

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What about PPI before and after

endoscopy?

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PPI before endoscopy

Lau et al. NEJM 2008; 1631-40

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PPI-Therapie after endoscopy

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What about nasogastric tube?

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What about nasogastric tube?

-Up 18% to upper GI bleeding

missed

-To low negativ predictive value

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Timing of the endoscopy?

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Timing of the endoscopy?

- first resuscitative efforts

- usually within 24 hours

- within 12 hours:- tachycardia, hypotension, bloody emesis or NG aspirate

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•Is endotracheal intubation

recommended?

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•Is endotracheal intubation

recommended?

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Classification of peptic ulcers?

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Classification of peptic ulcers?

Forrest classification

- 1: Active bleeding

- 2: Evidence of recent hemorrhage

- 3: Clean base

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Why this is important?

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90%Spritzend Blutung Ia 10%

Sickernde Blutung Ib 10%

50%

25-30%

Gefässstumpf IIa 25%

Koagelbedeckt IIb 10%

Hämatinbelag IIc 10%

Fibrinbelag III 35%

Katschinski B et al. Dig Dis Sci. 1994; 706-12.

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Sickernde Blutung Ib 10% 10-20%

50%

25-30%



Hämatinbelag IIc 10%

Fibrinbelag III 35%


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Sickernde Blutung Ib 10% 10-20%

50%

25-30%



Hämatinbelag IIc 10% 7-10%

Fibrinbelag III 35% 3-5%


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How do you use Adrenaline?

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How do you use Adrenaline?

-Adrenaline not used alone

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• What treatment options exists?

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• What treatment options exists?

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•Second look endoscopy?

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-Not as a matter of routine

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•Rebleeding after second

endoscopic attempt?

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•Rebleeding after second

endoscopic attempt?

- Consider surgery or angiography

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Risk factors for rebleeding

Aliment Pharmacol Ther 2011; 888–900

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•Nutrition after endoscopy?

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-Usually clear fluid immediatly

-If clean based regular diet

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•Duration of hospitalisation?

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•Duration of hospitalisation?

- Usually 3 days in high risk patients

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Prevention of rebleeding

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Prevention of rebleeding

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•Is every ulcer due to peptic

disease?

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•Is every ulcer due to peptic

disease?

-Cancer

- Infectious

- Ischemic

-Chronic inflammatory disease

-Acute inflammatory

Consider CT

Document healing!!!

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• Whats the problem with H. pylori

testing in bleeding patients?

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Peptic ulcer disease - Mucosal Immunology · 6 Peptic ulcer disease Bible class 08.23.2017,...

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