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,*,单击此处编辑母版标题样式,.,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,Characteristic of upper gastrointestinal bleeding among geriatric patients,Department of Geriatrics,First Affiliated Hospital of Nanjing Medical University,Wei-Hao Sun,.,Criteria,of,WHO,elderly individual:those over 65 years of age,elderly society:It is more than 7%that the,percentage ratio of,elderly population,to,total population in the area or a country.,Chinese population is also aging,UGI bleeding,Approximately 30%decline in rate over last 15 years,150,000 admissions per year,Over$1,000,000,000 annually,Associated with NSAID use,UGI bleeding,Mortality rate 8-10%,65 now comprise over 30%,Peptic ulcer still most common cause,Surgery now plays an adjunctive role,Epidemiology,103:100 000 adults per year,Shift in age of population at risk,Increasing use of NSAIDs&anticoagulants,Increasing incidence of in-hospital bleeding,Aetiology,PUD 50%,Acute gastric erosions 20%,Esophageal varices 10%,Tumor 5%-10%,AVM 6%,Mallory-Weiss tear 5%,Deiulafoy 1%,Drugs,Established risk factors,Aspirin&NSAIDs,Warfarin,Alcohol,Possible association,Calcium channel blockers,Selective serotonin uptake inhibitors-(antidepressant),Peptic Ulcer Disease:NSAIDS,NSAIDs may cause both duodenal or gastric ulcers,NSAIDs inhibit prostaglandin production and cause breakdown of the protective barrier of the gastric mucosa,Peptic Ulcer Disease:NSAIDS,Complications of NSAID therapy usually occur within the first month,NSAIDs not only induce ulcers but may increase the chance of bleeding in patients who have underlying ulcer disease,VIGOR-Summary of GI Endpoints,p 0.001.,*,p=0.005.,0,1,2,3,4,5,Confirmed Clinical Upper GI Events,ConfirmedComplicated Upper GI Events,All Clinical,GI Bleeding,RR:0.46,(0.33,0.64),RR:0.43,*,(0.24,0.78),RR:0.38,(0.25,0.57),Rates per 100 Patient-Years,Rofecoxib,Naproxen,()=95%CI.,Source:Bombardier,et al.,N Engl J Med,.2000.,Reducing the Risk of UGI Toxicities in Patients Requiring Chronic NSAID Therapy,Risk,Definition,Suggested Management,Low,65 yr,high-dose NSAIDs,low-dose aspirin,),Partially selective NSAID plus PPI or misoprostol;selectiveCOX-2 inhibitor,High,3,risk factors or concomitant aspirin,corticosteroids or warfarin,Selective COX-2 inhibitor plus PPI or misoprostol,Very high,Prior ulcer or ulcer-related complication,Selective COX-2 inhibitor plus PPI or misoprostol*;consider avoiding nonselective NSAIDs and selective COX-2 inhibitors,Presentation,Haematemesis,Melaena,Frank rectal bleeding,Signs and symptoms of hypovolaemia,Anaemia,Endoscopy,Diagnostic,Therapeutic,Prognostic,Endoscopic Haemostasis,Widely accepted as most effective method,Injection with adrenaline,saline,sclerotherapy,Laser,diathermy,heater probe,Endoscopic clip application,Produces initial control of bleeding,Reduces rebleeding,Decreases need for surgery,Meta-analysis-may significantly reduce mortality,Clinical Course,Endoscopy+/Endoscopic Haemostasis,No more bleeding-Rx ulcer,eradicate HP,Continuing bleeding-surgery,Rebleed-surgery-(repeat EH?),Life threatening massive bleed-endoscopy in theatre,proceed to surgery+/angiography,Risk scoring-Rockall,0123,age80,shocknopulse100BP60 yrs or other high risk factor,2 episodes in pts with no high risk factors-?unsafe,Transfusion greater than 4 units/24 hrs,Endoscopic re-treatment,Controversial,Reduces need for surgery after re-bleeding without increasing the risk of death.,Lau et al 1999 NEJM(RCT),Routine endoscopy in 24 hrs&retreatment-no benefit,Messman 1998 NEJM(RCT),Conclusion,Majority of the patients with acute UGI bleed are high risk,elderly patients,and should undergo the,minimum operation,to secure haemostasis at the first sign of clinical re-bleed following therapeutic endoscopy.,
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