Neue Methoden zur endoskopischen Blutstillung: Fokus auf die nicht variköse Blutung

Zusammenfassung

Die gastrointestinale Blutung (GIB) ist eine der am häufigsten vorkommenden gastroenterologischen Notfälle in der klinischen praktischen Tätigkeit. Während die Inzidenz und die Mortalität der GIB in vielen Ländern abnimmt, steigt die Zahl der endoskopischen Untersuchungen und Eingriffe. Die endoskopische Therapie von nicht varikösen gastrointestinalen Blutungen basiert derzeit auf den „klassischen“ Methoden wie die Injektion von vasoaktiven Substanzen (z. B. Epinephrin) oder Fibrinkleber, der Applikation von sog. „Through-the-scope“-Clips (TTSCs), der Argonplasmakoagulation (APC) oder der bipolaren Koagulation. Gerade für die nicht variköse Blutung sind in den letzten Jahren neue endoskopische Techniken entwickelt worden, die das Therapierepertoire bereichert haben. Die „Over-the-scope“-Clips (OTSCs) weisen eine größere Verschlussfläche auf als die TTSCs und werden zunehmend erfolgreich für die Blutstillung von ausgewählten Patienten mit schweren Ulkusblutungen eingesetzt. Hämostasepulver scheinen bei diffusen Blutungen eine Blutstillung zu erzielen. Neben einer kurzen Darstellung von etablierten „klassischen“ Methoden fokussiert sich diese Übersichtsarbeit auf neue epidemiologischen Daten und neue endoskopischen Techniken zur Blutstillung von nicht varikösen gastrointestinalen Blutungen.

Abstract

Gastrointestinal bleeding is a frequent emergency in daily clinical practice of a gastroenterologist. While incidence and mortality of gastrointestinal bleeding are decreasing in many countries, numbers of endoscopic procedures are increasing. Endoscopic therapy of non-variceal gastrointestinal bleeding is still mainly based on “classical” procedures like injection of vasoactive drugs (i. e. epinephrine) or blood derivates, application of through-the-scope hemoclips (TTSC), Argon plasma coagulation and bipolar coagulation. However, in the last years new endoscopic techniques especially for non-variceal gastrointestinal bleedings have become available and enriched our endoscopic equipment. For example, over-the-scope clips (OTSCs) surpass the size of TTSCs and have been successfully established for treatment of gastrointestinal bleeding and leak closure of fistulas and perforations. In addition, hemostatic powders were shown to achieve primary hemostasis in several cases of gastrointestinal bleeding. Besides a brief overview of “classical” endoscopic procedures for hemostasis of non-variceal gastrointestinal bleeding, this review focuses on new epidemiological data and uprising methods for endoscopic hemostasis.

Schlüsselwörter

obere gastrointestinale Blutung - untere gastrointestinale Blutung - Ulcus ventriculi - gastrointestinale Blutung - chronische gastrointestinale Blutung

Key words

upper gastrointestinal bleeding - lower gastrointestinal bleeding - gastric ulcer - gastrointestinal bleeding - chronic gastrointestinal bleeding

• Literatur

• 1 Raju GS, Gerson L, Das A et al. American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding. Gastroenterology 2007; 133: 1697-1717
• 2 Itoi T, Nageshwar Reddy D, Sofuni A et al. Clinical evaluation of a prototype multi-bending peroral direct cholangioscope. Digestive endoscopy 2014; 26: 100-107
• 3 Jairath V, Martel M, Logan RFA et al. Why do mortality rates for nonvariceal upper gastrointestinal bleeding differ around the world? A systematic review of cohort studies. Canadian journal of gastroenterology 2012; 26: 537-543
• 4 Ahsberg K, Ye W, Lu Y et al. Hospitalisation of and mortality from bleeding peptic ulcer in Sweden: a nationwide time-trend analysis. Alimentary pharmacology and therapeutics 2011; 33: 578-584
• 5 van Leerdam ME, Vreeburg EM, Rauws EAJ et al. Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000. The American journal of gastroenterology 2003; 98: 1494-1499
• 6 Yang J, Lee T, Montez-Rath ME et al. Trends in acute nonvariceal upper gastrointestinal bleeding in dialysis patients. Journal of the American Society of Nephrology 2012; 23: 495-506
• 7 Loperfido S, Baldo V, Piovesana E et al. Changing trends in acute upper-GI bleeding: a population-based study. Gastrointestinal endoscopy 2009; 70: 212-224
• 8 Abougergi MS, Travis AC, Saltzman JR. The in-hospital mortality rate for upper GI hemorrhage has decreased over 2 decades in the United States: a nationwide analysis. Gastrointestinal endoscopy 2015; 81: 882-888.e1
• 9 Barkun AN, Bardou M, Kuipers EJ et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Annals of internal medicine 2010; 152: 101-113
• 10 Cooper GS, Kou TD, Wong RCK. Use and impact of early endoscopy in elderly patients with peptic ulcer hemorrhage: a population-based analysis. Gastrointestinal endoscopy 2009; 70: 229-235
• 11 Navaneethan U, Njei B, Venkatesh PGK et al. Timing of colonoscopy and outcomes in patients with lower GI bleeding: a nationwide population-based study. Gastrointestinal endoscopy 2014; 79: 297-306.e12
• 12 Laine L, McQuaid KR. Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials. Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 2009; 7: 33-47 ; quiz 1-2
• 13 El Ouali S, Barkun AN, Wyse J et al. Is routine second-look endoscopy effective after endoscopic hemostasis in acute peptic ulcer bleeding? A meta-analysis. Gastrointestinal endoscopy 2012; 76: 283-292
• 14 Lanas A, Garcia-Rodriguez LA, Polo-Tomas M et al. Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice. Am J Gastroenterol 2009; 104: 1633-1641
• 15 Cook DJ, Guyatt GH, Salena BJ et al. Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Gastroenterology 1992; 102: 139-148
• 16 Sung JJY, Chan FKL, Lau JYW et al. 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 2003; 139: 237-243
• 17 Vergara M, Bennett C, Calvet X et al. Epinephrine injection versus epinephrine injection and a second endoscopic method in high-risk bleeding ulcers. The Cochrane database of systematic reviews 2014; 10: CD005584
• 18 Repici A, Arezzo A, De Caro G et al. Clinical experience with a new endoscopic over-the-scope clip system for use in the GI tract. Dig Liver Dis 2009; 41: 406-410
• 19 Albert JG, Friedrich-Rust M, Woeste G et al. Benefit of a clipping device in use in intestinal bleeding and intestinal leakage. Gastrointest Endosc 2011; 74: 389-397
• 20 Kirschniak A, Subotova N, Zieker D et al. The Over-The-Scope Clip (OTSC) for the treatment of gastrointestinal bleeding, perforations, and fistulas. Surg Endosc 2011; 25: 2901-2905
• 21 Manta R, Galloro G, Mangiavillano B et al. Over-the-scope clip (OTSC) represents an effective endoscopic treatment for acute GI bleeding after failure of conventional techniques. Surgical endoscopy 2013; 27: 3162-3164
• 22 Chan SM, Chiu PWY, Teoh AYB et al. Use of the Over-The-Scope Clip for treatment of refractory upper gastrointestinal bleeding: a case series. Endoscopy 2014; 46: 428-431
• 23 Farnik H, Driller M, Kratt T et al. Indication for 'Over the scope' (OTS)-clip vs. covered self-expanding metal stent (cSEMS) is unequal in upper gastrointestinal leakage: results from a retrospective head-to-head comparison. PloS one 2015; 10: e0117483
• 24 Holster IL, van Beusekom HMM, Kuipers EJ et al. Effects of a hemostatic powder hemospray on coagulation and clot formation. Endoscopy 2015; 47: 638-645
• 25 Sung JJY, Luo D, Wu JCY et al. Early clinical experience of the safety and effectiveness of Hemospray in achieving hemostasis in patients with acute peptic ulcer bleeding. Endoscopy 2011; 43: 291-295
• 26 Holster IL, Kuipers EJ, Tjwa ETTL. Hemospray in the treatment of upper gastrointestinal hemorrhage in patients on antithrombotic therapy. Endoscopy 2013; 45: 63-66
• 27 Ibrahim M, El-Mikkawy A, Mostafa I et al. Endoscopic treatment of acute variceal hemorrhage by using hemostatic powder TC-325: a prospective pilot study. Gastrointestinal endoscopy 2013; 78: 769-773
• 28 Leblanc S, Vienne A, Dhooge M et al. Early experience with a novel hemostatic powder used to treat upper GI bleeding related to malignancies or after therapeutic interventions (with videos). Gastrointestinal endoscopy 2013; 78: 169-175
• 29 Holster IL, Brullet E, Kuipers EJ et al. Hemospray treatment is effective for lower gastrointestinal bleeding. Endoscopy 2014; 46: 75-78
• 30 Sulz MC, Frei R, Meyenberger C et al. Routine use of Hemospray for gastrointestinal bleeding: prospective two-center experience in Switzerland. Endoscopy 2014; 46: 619-624
• 31 Huang R, Pan Y, Hui N et al. Polysaccharide hemostatic system for hemostasis management in colorectal endoscopic mucosal resection. Digestive endoscopy: official journal of the Japan Gastroenterological Endoscopy Society 2014; 26: 63-68
• 32 Chen Y, Barkun A, Nolan S. Hemostatic powder TC-325 in the management of upper and lower gastrointestinal bleeding: a two-year experience at a single institution. Endoscopy 2015; 47: 167-171
• 33 Fishman DS, Tarnasky PR, Patel SN et al. Management of pancreaticobiliary disease using a new intra-ductal endoscope: the Texas experience. World journal of gastroenterology 2009; 15: 1353-1358
• 34 Draganov PV, Lin T, Chauhan S et al. Prospective evaluation of the clinical utility of ERCP-guided cholangiopancreatoscopy with a new direct visualization system. Gastrointestinal endoscopy 2011; 73: 971-979
• 35 Akutsu D, Narasaka T, Wakayama M et al. Endoscopic detachable snare ligation: a new treatment method for colonic diverticular hemorrhage. Endoscopy 2015; 47: 1039-1042
• 36 Shibata S, Shigeno T, Fujimori K et al. Colonic diverticular hemorrhage: the hood method for detecting responsible diverticula and endoscopic band ligation for hemostasis. Endoscopy 2014; 46: 66-69
• 37 Zepeda-Gomez S, Sultanian R, Teshima C et al. Gastric antral vascular ectasia: a prospective study of treatment with endoscopic band ligation. Endoscopy 2015; 47: 538-540
• 38 Jairath V, Hearnshaw S, Brunskill SJ et al. Red cell transfusion for the management of upper gastrointestinal haemorrhage. The Cochrane database of systematic reviews 2010; 8: CD006613
• 39 Villanueva C, Colomo A, Bosch A et al. Transfusion strategies for acute upper gastrointestinal bleeding. The New England journal of medicine 2013; 368: 11-21
• 40 Restellini S, Kherad O, Jairath V et al. Red blood cell transfusion is associated with increased rebleeding in patients with nonvariceal upper gastrointestinal bleeding. Alimentary pharmacology and therapeutics 2013; 37: 316-322
• 41 Jana T, Thosani N, Fallon MB et al. Radiofrequency ablation for treatment of refractory gastric antral vascular ectasia (with video). Endoscopy international open 2015; 3: E125-E127
• 42 Smith LA, Stanley AJ, Bergman JJ et al. Hemospray application in nonvariceal upper gastrointestinal bleeding: results of the Survey to Evaluate the Application of Hemospray in the Luminal Tract. J Clin Gastroenterol 2014; 48: e89-e92