Novosti u terapiji nevaricealnog krvarenja iz gornjeg gastrointestinalnog trakta

master's thesis

• Title (english): Current developments in therapy of non-variceal upper gastrointestinal bleeding
• Author: Fran Ivan Madunić
• Mentor: Neven Baršić (mentor)
• Committee member: Lucija Virović Jukić (predsjednik povjerenstva)
• Committee member: Jasenka Markeljević (član povjerenstva)
• Committee member: Neven Baršić (član povjerenstva)
• Granter: University of Zagreb; School of Medicine; (Department of Internal Medicine); Zagreb
• Defense date and country: 2022-07-15, Croatia
• Scientific / art field, discipline and subdiscipline: BIOMEDICINE AND HEALTHCARE; Clinical Medical Sciences; Internal Medicine

Abstract

Nevaricealno krvarenje iz gornjeg gastrointestinalnog trakta spada u skupinu čestih hitnih stanja s visokim razinama mortaliteta i morbiditeta. Krvarenje se najčešće razvija u području jednjaka, želuca ili proksimalnog duodenuma, a prezentira se predominantno pojavom hematemeze, melene i/ili hematokezije u slučajevima masivnog krvarenja. Peptička ulkusna bolest nameće se kao glavni uzrok krvarenja, iako doživljava pad u incidenciji uslijed razvoja terapije eradikacije Helicobacter pylori. Liječenje je složeno i može se podijeliti u tri faze: pre-endoskopsku, endoskopsku i post-endoskopsku obradu pacijenta. U sklopu pre-endoskopske obrade, nakon stratifikacije rizika primjenom alata poput Glasgow-Blatchford skale, moguća je upotreba transfuzije koncentrata eritrocita za određene skupine pacijenata, kao i pre-endoskopska medikamentna terapija eritromicinom i inhibitorima protonske pumpe u visokim dozama. Vrijeme od prezentacije simptoma do početka zahvata endoskopije važan je faktor endoskopske obrade, koja kao takva ima svoju ne samo terapijsku već i dijagnostičku ulogu. Preporuke govore u prilog rane (<24h) endoskopije te, ovisno o etiologiji, pristupa se različitim modalitetima terapije koje uključuju injekcijsku, termalnu i mehaničku terapiju. Kao oblik injekcijske terapije najčešći odabir je upotreba epinefrina u kombinaciji s drugim modalitetima, dok su se ranije koristili i sklerozirajući agensi poput etanola. Upotrebom termalnih kontaktnih ili nekontaktnih modaliteta terapije stvara se toplinski efekt koji dovodi do razvoja koagulacije proteina, edema, vazokonstrikcije i aktivacije koagulacijske kaskade indirektnim putem. U skupini termalnih modaliteta mogu se izdvojiti upotreba multipolarnih i termalnih sondi te argon plazma koagulacija. Mehaničku hemostazu moguće je uspostaviti upotrebom endoskopskih OTSC ili TTSC klipsa, omči za podvezivanje ili upotrebom hemostatskog praha kao novijeg rješenja s kratkotrajnim učinkom. Novim modelima prepoznavanja pacijenata visokog rizika nastoji se optimizirati postupak liječenja te smanjiti ekonomski trošak opsežne terapije, dok budućnost nosi usmjerenje ka personaliziranom pristupu u liječenju.

Abstract (english)

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common emergency with a high rate of mortality and morbidity. Hemorrhage usually develops in the esophagus, stomach, or proximal duodenum while the presentation predominantly includes hematemesis, melena and hematochezia in the case of a massive bleeding. Peptic ulcer disease is regarded as the leading cause of hemorrhage, although the incidence is in decline due to the developments in the Helicobacter pylori eradication therapy. NVUGIB treatment is complex and can be divided into three stages: pre-endoscopy, endoscopy, post-endoscopy. During the pre-endoscopy stage, following the risk stratification using tools such as the Glasgow-Blatchford score, a red-blood cell transfusion can be considered with the specific groups of patients alongside with the pre-endoscopic use of erythromycin and high-dose PPI medication. Timing of the endoscopy is an important factor during the endoscopic stage. Endoscopy itself has both therapeutic and diagnostic role. The early form (<24h) of endoscopy is recommended while different etiologies require certain endoscopic modalities of treatment, which include thermal, injection and mechanical therapy. As a form of injection therapy, the most common choice is the use of epinephrine in combination with other modalities while a sclerosing agent, such as pure ethanol, has previously also been used. With the use of thermal contact or non-contact modalities, thermal effect is achieved, which causes protein coagulation, oedema, vasoconstriction and the activation of the coagulation cascade indirectly. Commonly used thermal modalities include multipolar and thermal probes alongside with the argon-plasma coagulation. Mechanical hemostasis can be achieved through the use of OTSC or TTSS endoscopic clips, band ligation devices and with hemostatic powder as a newer way of achieving temporary hemostasis. New models of accurate detection of high-risk patients offer the optimization of treatment with lower costs while the personalization of said treatment seems to be the way of the future.

• Keywords: Nevaricealno krvarenje; Peptička ulkusna bolest; Stratifikacija rizika; Endoskopija; Hemostaza; Injekcijska terapija; Termalna terapija; Mehanička terapija
• Keywords (english): Non-variceal bleeding; Peptic ulcer disease; Risk stratification; Endoscopy; Hemostasis; Injection therapy; Thermal therapy; Mechanical therapy
• Language: croatian
• URN:NBN: urn:nbn:hr:105:945311
• Study programme: Title: Medicine; Study programme type: university; Study level: integrated undergraduate and graduate; Academic / professional title: doktor/doktorica medicine (doktor/doktorica medicine)
• Type of resource: Text
• File origin: Born digital
• Access conditions: Open access
• Created on: 2023-01-17 12:40:40