Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group
Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group
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DOI：
10.7326/m19-1795
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发表时间：
2019-12-03
影响因子：
39.2
通讯作者：
Bardou, Marc
中科院分区：
文献类型：
--
作者：
Barkun, Alan N.;Almadi, Majid;Bardou, Marc
描述：这份对2010年《非静脉曲张性上消化道出血（UGIB）患者管理的国际共识建议》的更新完善了先前的重要陈述，并提出了新的具有临床相关性的建议。
方法：一个国际多学科专家小组制定了这些建议。数据来源包括先前建议中总结的证据，以及对从多个电子文献数据库建库至2018年4月期间进行的一系列文献检索所确定的系统综述和试验。小组成员通过一个反复的过程提出关键问题。两名方法学家根据GRADE（推荐意见分级的评估、制定与评价）方法准备了证据概要并评估了与关键问题相关的证据质量（确定性）。小组成员审查了证据概要，并通过共识过程对建议进行投票，确定建议的强度为强或有条件。
建议：内镜检查前的管理：该小组建议使用格拉斯哥 - 布拉奇福德评分1分或更低来识别再出血风险极低的患者，这些患者可能不需要住院。对于无心血管疾病的患者，建议的输血血红蛋白阈值为低于80 g/L，对于有心血管疾病的患者，阈值应更高。
内镜管理：该小组建议急性上消化道出血患者在就诊后24小时内接受内镜检查。对于有高危征象的患者，推荐热凝固和硬化剂注射进行内镜治疗，并建议使用夹子。对于有活动性出血溃疡的患者，建议使用TC - 325（止血粉）作为临时治疗，但不作为唯一治疗方法。
药物管理：该小组建议有高危征象的出血性溃疡患者在成功进行内镜治疗后接受高剂量质子泵抑制剂（PPI）治疗（静脉负荷剂量后持续输注）3天。对于这些高危患者，建议继续口服PPI治疗，14天内每日两次，之后每日一次，总疗程取决于出血病变的性质。
二级预防：该小组建议对于因心血管预防需要抗血小板或抗凝治疗且既往有溃疡出血的患者进行PPI治疗。
Description: This update of the 2010 International Consensus Recommendations on the Management of Patients With Non-variceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and presents new clinically relevant recommendations.Methods: An international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional.Recommendations: Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.