Buscar en
Gastroenterología y Hepatología
Toda la web
Inicio Gastroenterología y Hepatología Factores asociados al fracaso de la terapéutica endoscópica en la hemorragia d...
Información de la revista
Vol. 26. Núm. 4.
Páginas 227-233 (Enero 2003)
Compartir
Compartir
Descargar PDF
Más opciones de artículo
Vol. 26. Núm. 4.
Páginas 227-233 (Enero 2003)
Acceso a texto completo
Factores asociados al fracaso de la terapéutica endoscópica en la hemorragia digestiva por úlcera gástrica
Factors associated with failure of endoscopic therapy in gastric ulcer bleeding
Visitas
5594
M.V. García Sánchez*, P. López Vallejos, A. González Galilea, C. Gálvez Calderón, A. Naranjo Rodríguez, M.D. Sánchez-Tembleque Zarandona, A. Hervás Molina, J.F. de Dios Vega
Unidad Clínica de Aparato Digestivo. Hospital Universitario Reina Sofía. Córdoba. España
Este artículo ha recibido
Información del artículo
Introducción

La terapéutica endoscópica es una técnica eficaz en el control de la hemorragia por úlcera péptica. Sin embargo, el sangrado persiste o recidiva hasta en el 10-30% de los enfermos. Las úlceras gástricas y duodenales presentan características clínicas y endoscópicas diferentes, por lo que la eficacia del tratamiento endoscópico y los factores asociados a su fracaso deberían estudiarse por separado.

Objetivos

Analizar la eficacia de la terapéutica endoscópica en enfermos con alto riesgo de persistencia o recidiva del sangrado por úlcera gástrica y determinar los factores asociados al fracaso de esta técnica.

Pacientes y método

Se trata de un estudio retrospectivo, basado en un protocolo de actuación clínica, en el que se analizaron los 208 enfermos ingresados por hemorragia secundaria a úlcera gástrica con sangrado activo o estigmas de reciente sangrado, que recibieron terapéutica endoscópica, entre enero de 1992 y diciembre de 2001. Se recogieron variables clínicas, analíticas y endocópicas en el momento del ingreso, así como el tratamiento médico y procedimiento endoscópico aplicado. La endoscopia se realizó dentro de las 12 h siguientes al ingreso. Los enfermos fueron clasificados en función de la respuesta al tratamiento endoscópico: a) pacientes con hemorragia limitada, y b) pacientes con persistencia o recidiva del sangrado por fracaso terapéutico. La pauta de actuación en los enfermos con fallo del tratamiento endoscópico se realizó según un protocolo previamente establecido. Las variables que obtuvieron significación estadística en el análisis univariante se incluyeron en un modelo de regresión logística para identificar aquellas con un valor predictivo independiente para el fracaso de la terapéutica endoscópica.

Resultados

La hemostasia definitiva se logró tras la terapéutica inicial en 181 (87%) de los enfermos. La eficacia de una segunda terapia aumentó el porcentaje de hemostasia a un 91% de los casos. En el modelo de regresión logística, las únicas variables que se asociaron independientemente al fallo terapéutico inicial fueron: la repercusión hemodinámica en el momento del ingreso (p = 0,016; OR = 3,99), la necesidad de transfusión de hemoderivados previos a la endoscopia (p = 0,025; OR = 3,48), la localización alta de la úlcera gástrica (p = 0,050; OR = 3,08) y la terapéutica endoscópica no satisfactoria (p = 0,009; OR = 17,39).

Conclusión

Estas variables podrían identificar de forma temprana a un subgrupo de enfermos, lo que permitiría llevar a cabo una mayor vigilancia médico-quirúrgica, así como ofrecerles otras alternativas terapéuticas.

Introduction

Endoscopic therapy is an effective technique in the control of bleeding due to peptic ulcer. However, bleeding persists or recurs in as many as 10-30% of patients. Gastric and duodenal ulcers present different clinical and endoscopic features and consequently the efficacy of endoscopic therapy and the factors associated with its failure should be studied separately.

Objectives

To analyze the efficacy of endoscopic therapy in patients at high risk of persistent or recurrent bleeding due to gastric ulcer and to identify the factors associated with the failure of this technique.

Patients and methods

We performed a retrospective study based on a clinical intervention protocol. Two hundred eight patients admitted for bleeding secondary to gastric ulcer with active bleeding or stigmas of recent bleeding who received endoscopic therapy between January 1992 and December 2001 were analyzed. Clinical, laboratory and endoscopic variables on admission, as well as the medical treatment and endoscopic procedure applied, were registered. Endoscopy was performed within 12 hours of admission. Patients were classified according to their response to endoscopic therapy: a) patients with limited bleeding, and b) patients with persistent or recurrent bleeding due to therapeutic failure. Intervention in patients with therapeutic failure was performed according to a previously established protocol. Variables that were statistically significant in the univariate analysis were included in a logistic regression model to identify those with an independent predictive value for failure of endoscopic therapy.

Results

Definitive hemostasis was achieved after initial therapy in 181 patients (87%). The efficacy of a second procedure increased the percentage of hemostasis to 91% of the patients. In the logistic regression model, the only variables that were independently associated with initial therapeutic failure were: hemodynamic status on admission (p = 0.016; OR = 3.99), the need for transfusion of blood products prior to endoscopy (p = 0.025; OR = 3.48), upper localization of the gastric ulcer (p = 0.050; OR = 3.08) and unsatisfactory endoscopic therapy (p = 0.009; OR = 17.39).

Conclusion

These variables could contribute to the early identification of a subgroup of patients, which would enable us to increase medical-surgical surveillance and offer them other therapeutic alternatives.

El Texto completo está disponible en PDF
Bibliografía
[1.]
G. Miño, J.L. Jaramillo, C. Gálvez, C. Carmona, A. Reyes, M. De la Mata.
Análisis de una serie general prospectiva de 3.270 hemorragias digestivas altas.
Rev Esp Enferm Dig, 82 (1992), pp. 7-15
[2.]
Consensus conference.
Therapeutic endoscopy and bleeding ulcers.
JAMA, 262 (1989), pp. 1369-1372
[3.]
J.L. Jaramillo, C. Gálvez, C. Carmona, J.L. Montero, G. Miño.
Prediction of further hemorrhage in bleeding peptic ulcer.
Am J Gastroenterol, 89 (1994), pp. 2135-2138
[4.]
C. Sugawa, A.L. Joseph.
Endoscopic interventional management of bleeding duodenal and gastric ulcers.
Surg Clin North Am, 72 (1992), pp. 317-334
[5.]
H.S. Sacks, T.C. Chalmers, A.L. Blum, J. Berrier, D. Pagano.
Endoscopic hemostasis. An effective therapy for bleeding peptic ulcers.
JAMA, 264 (1990), pp. 494-499
[6.]
D.J. Cook, G.H. Guyatt, B.J. Salena, L.A. Laine.
Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: ameta-analysis.
Gastroenterology, 102 (1992), pp. 139-148
[7.]
J. Balanzo, S. Sainz, J. Such, J.C. Espinos, C. Guarner, X. Cusso, et al.
Endoscopic hemostasis by local injection of epinephrine and polidocanol in bleeding ulcer. A prospective randomized trial.
Endoscopy, 20 (1988), pp. 289-291
[8.]
J. Panes, J. Viver, M. Forne, E. García-Olivares, C. Marco, J. Garau.
Controlled trial of endoscopic sclerosis in bleeding peptic ulcers.
Lancet, 2 (1987), pp. 1292-1294
[9.]
L. Laine, W.L. Peterson.
Bleeding peptic ulcer.
N Engl J Med, 331 (1994), pp. 717-727
[10.]
D.M. Jensen.
Management of severe ulcer rebleeding.
N Engl J Med, 340 (1999), pp. 799-801
[11.]
M. Moreto, M. Zaballa, M.J. Suárez, S. Ibáñez, E. Ojembarrena, J.M. Castillo.
Endoscopic local injection of ethanolamine oleate and thrombin as an effective treatment for bleeding duodenal ulcer: a controlled trial.
Gut, 33 (1992), pp. 456-459
[12.]
S.Y. Song, J.B. Chung, Y.M. Moon, J.K. Kang, I.S. Park.
Comparison of the hemostatic effect of endoscopic injection with fibrin glue and hypertonic saline-epinephrine for peptic ulcer bleeding: a prospective randomized trial.
Endoscopy, 29 (1997), pp. 827-833
[13.]
Z.A. Saeed.
Second thoughts about second-look endoscopy for ulcer bleeding?.
Endoscopy, 30 (1998), pp. 650-652
[14.]
C. Villanueva, J. Balanzo, X. Torras, G. Soriano, S. Sainz, F. Vilardell.
Value of second-look endoscopy after injection therapy for bleeding peptic ulcer: a prospective and randomized trial.
Gastrointest Endosc, 40 (1994), pp. 34-39
[15.]
H. Messmann, P. Schaller, T. Andus, G. Lock, W. Vogt, V. Gross, et al.
Effect of programmed endoscopic follow-up examinations on the rebleeding rate of gastric or duodenal peptic ulcers treated by injection therapy: a prospective, randomized controlled trial.
Endoscopy, 30 (1998), pp. 583-589
[16.]
Z.A. Saeed, R.A. Cole, F.C. Ramirez, F.E. Schneider, K.S. Hepps, D.Y. Graham.
Endoscopic retreatment after successful initial hemostasis prevents ulcer rebleeding: a propective randomized trial.
Endoscopy, 28 (1996), pp. 288-294
[17.]
C. Villanueva, J. Balanzo, J.C. Espinos, J.M. Domenech, S. Sainz, J. Call, et al.
Prediction of therapeutic failure in patients with bleeding peptic ulcer treated with endoscopic injection.
Dig Dis Sci, 38 (1993), pp. 2062-2070
[18.]
E. Brullet, R. Campo, X. Calvet, D. Coroleu, E. Rivero, D.J. Simo.
Factors related to the failure of endoscopic injection therapy for bleeding gastric ulcer.
Gut, 39 (1996), pp. 155-158
[19.]
E. Brullet, X. Calvet, R. Campo, M. Rue, L. Catot, L. Donoso.
Factors predicting failure of endoscopic injection therapy in bleeding duodenal ulcer.
Gastrointest Endosc, 43 (1996), pp. 111-116
[20.]
Z.A. Saeed, C.B. Winchester, P.A. Michaletz, K.L. Woods, D.Y. Graham.
A scoring system to predict rebleeding after endoscopic therapy of nonvariceal upper gastrointestinal hemorrhage, with a comparison of heat probe and ethanol injection.
Am J Gastroenterol, 88 (1993), pp. 1842-1849
[21.]
S.K. Wong, L.M. Yu, J.Y. Lau, Y.H. Lam, A.C. Chan, E.K. Ng, et al.
Prediction of therapeutic failure after adrenaline injection plus heater probe treatment in patients with bleeding peptic ulcer.
Gut, 50 (2002), pp. 322-325
[22.]
I.K. Chung, E.J. Kim, M.S. Lee, H.S. Kim, S.H. Park, M.H. Lee, et al.
Endoscopic factors predisposing to rebleeding following endoscopic hemostasis in bleeding peptic ulcers.
Endoscopy, 33 (2001), pp. 969-975
[23.]
H.J. Lin, G.Y. Tseng, W.C. Lo, F.Y. Lee, C.L. Perng, F.Y. Chang, et al.
Predictive factors for rebleeding in patients with peptic ulcer bleeding after multipolar electrocoagulation: a retrospective analysis.
J Clin Gastroenterol, 26 (1998), pp. 113-116
[24.]
K.C. Thomopoulos, J.A. Mitropoulos, E.C. Katsakoulis, C.E. Vagianos, K.P. Mimidis, M.N. Hatziargiriou, et al.
Factors associated with failure of endoscopic injection haemostasis in bleeding peptic ulcers.
Scand J Gastroenterol, 36 (2001), pp. 664-668
[25.]
C.P. Choudari, C. Rajgopal, R.A. Elton, K.R. Palmer.
Failures of endoscopic therapy for bleeding peptic ulcer: an analysis of risk factors.
Am J Gastroenterol, 89 (1994), pp. 1968-1972
[26.]
E. Brullet, R. Campo, G. Bedos, S. Barcons, J.M. Gubern, J.M. Bordas.
Site and size of bleeding peptic ulcer. Is there any relation to the efficacy of hemostatic sclerotherapy?.
Endoscopy, 23 (1991), pp. 73-75
[27.]
Z.A. Saeed, F.C. Ramírez, K.S. Hepps, R.A. Cole, D.Y. Graham.
Prospective validation of the Baylor bleeding score for predicting the likelihood of rebleeding after endoscopic hemostasis of peptic ulcers.
Gastrointest Endosc, 41 (1995), pp. 561-565
[28.]
P. Hebert, G. Wells, M. Blajahman, J. Marshall, C. Martin, G. Paglianello, et al.
A multicenter, randomized, controlled clinical trial of transfusion requerement in critical care.
N Engl J Med, 340 (1999), pp. 409-417
[29.]
D.N. Foster, K.J. Miloszewski, M.S. Losowsky.
Stigmata of recent haemorrhage in diagnosis and prognosis of upper gastrointestinal bleeding.
Br Med J, 1 (1978), pp. 1173-1177
[30.]
P. Swain.
What should be done when initial endoscopic therapy for bleeding peptic ulcer fails?.
Endoscopy, 27 (1995), pp. 321-328
[31.]
K.R. Palmer, C.P. Choudari.
Endoscopic intervention in bleeding peptic ulcer.
Gut, 37 (1995), pp. 161-164
[32.]
F.J. Branicki, S.Y. Coleman, T.C. Lam, D. Schroeder, H.H. Tuen, W.L. Cheung, et al.
Hypotension and endoscopic stigmata of recent haemorrhage in bleeding peptic ulcer: risk models for rebleeding and mortality.
J Gastroenterol Hepatol, 7 (1992), pp. 184-190
[33.]
E.D. Palmer.
The sources of upper gastrointestinal bleeding.
Nebr State Med J, 52 (1967), pp. 490
[34.]
C.P. Swain.
Does ulcer position influence presentation or prognosis of upper gastrointestinal bleeding?.
Gut, 27 (1986), pp. 632
[35.]
H.J. Lin, F.Y. Lee, Y.T. Tsai, S.D. Lee, C.H. Lee.
What kind of nonbleeding visible vessel in a peptic ulcer needs aggressive therapy?.
Long-term clinical observation. Endoscopy, 22 (1990), pp. 8-11
[36.]
J. Jhonston.
Comparation of endoscopic lasers, electrosurgery and the heater probe in coagulation of canine arteries.
Gastrointest Endosc, 1984 (1984), pp. 154
[37.]
W. Gorisch.
Heat induced contracion of blood vessels.
Lasers Surg Med, 2 (1982), pp. 1-13
[38.]
B. Kohler, J.F. Rieman.
Does Doppler ultrasound improve the prognosis of acute ulcer bleeding?.
Hepatogastroenterology, 41 (1994), pp. 51-53
[39.]
M.L. Freeman, O.W. Cass, C.J. Peine, G.R. Onstad.
The non-bleeding visible vessel versus the sentinel clot: natural history and risk of rebleeding.
Gastrointest Endosc, 39 (1993), pp. 359-366
[40.]
J.Y. Lau, J.J. Sung, Y.H. Lam, A.C. Chan, E.K. Ng, D.W. Lee, et al.
Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers.
N Engl J Med, 340 (1999), pp. 751-756
[41.]
S.C. Chung.
Preventing ulcer rebleeding: the role of second-look endoscopy.
Can J Gastroenterol, 13 (1999), pp. 409-411
[42.]
J.J. Kolkman, S.G. Meuwissen.
A review on treatment of bleeding peptic ulcer: a collaborative task of gastroenterologist and surgeon.
Scand J Gastroenterol Suppl, 218 (1996), pp. 16-25
[43.]
T.A. Rockall, R.F. Logan, H.B. Devlin, T.C. Northfield.
Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage.
BMJ, 311 (1995), pp. 222-226
[44.]
W. Pimpl, O. Boeckl, H.W. Waclawiczek, M. Heinerman.
Estimation of the mortality rate of patients with severe gastroduodenal hemorrhage with the aid of a new scoring system.
Endoscopy, 19 (1987), pp. 101-106
[45.]
X. Mueller, J.M. Rothenbuehler, A. Amery, F. Harder.
Factors predisposing to further hemorrhage and mortality after peptic ulcer bleeding.
J Am Coll Surg, 179 (1994), pp. 457-461
Copyright © 2003. Elsevier España, S.L.. Todos los derechos reservados
Opciones de artículo
Herramientas
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos