Traitement endoscopique des hémorragies digestives hautes en dehors de l'HTP

Acta Endoscopica - Le traitement endoscopique des hémorragies digestives hautes en dehors de l'HTP est envisageable dans 4 grands groupes d'indications: Pathologie ulcéreuse...     

Enseignement de la prise en charge endoscopique des hémorragies digestives

Gastrointestinal bleeding is an unprevisible and serious event requiring urgent management. Endoscopic hemostasis is defined by the cessation of bleeding and prevention of rebleeding by applying one or more technical endoscopic hemostatic techniques. It is an advanced procedure. Training in endoscopic hemostasis is difficult partly due to the urgent and unpredictable condition of gastrointestinal bleeding. Training by tutoring only (performing clinical cases under the supervision of a trainee) is long and difficult because it depends on the clinical cases seen during fellowship. Endoscopic management of GI hemorrhage includes important knowledge in medical management, in systematic categorization of both source of bleeding and the technique used to control it, and basic knowledge about technical skills to perform endoscopic procedure. Various simulation platforms, including virtual reality simulators, and animal models are available and efficient for training in endoscopic hemostasis. However, validated criteria for obtaining and maintaining procedural competence in endoscopic hemostasis techniques are still lacking.     

��pid��miologie, ��tiologie et ��volution des h��morragies digestives hautes au centre hospitalier universitaire de F��s, Maroc

Background

Acute upper gastrointestinal bleeding (AUGIB) is a common emergency in hepatogastro-enterology. Epidemiology of AUGIB in our country remains unknown. The aim of this study is to evaluate the clinical and etiological characteristics and outcomes of patients with upper gastrointestinal bleeding and to define risk factors of poor prognosis.

Materials and methods

This is a retrospective (2001?C2004) and prospective (2005?C2008) study, including patients with AUGIB who had upper digestive endoscopy in Hassan II University Hospital of Fez.

Results

Thousand three hundred and three cases were included. Eight hundred and twenty-seven were men (63.5%). The mean age was 47.6 ± 17.7 years. The most common causes of AUGIB were ulcer bleeding (46%) and bleeding related to portal hypertension (PH) (23.3%). Prevalence of esophagitis and acute gastritis were 10.9% and 7.3% respectively. The recurrence rate and in-hospital mortality were 8.3% and 6.5% respectively. Portal hypertension-related bleeding, malignancy, advanced age, shock and recurrent bleeding were the main risk factors of mortality in our study.

Conclusion

The patients in our study were young. The most common etiology of AUGIB in our context was ulcer bleeding, which reflects the prevalence of peptic ulcer in our population. Portal hypertension-related bleeding, advanced age and recurrent bleeding were the main risk factors of mortality.     

Prévention des hémorragies digestives hautes de stress en réanimation Révision de la conférence de consensus de 1988

Experts designated by the Société de réanimation de langue française had to audit the 1988 French consensus about upper gastrointestinal bleeding in critically ill patients. In the last decades the incidence of this nosocomial complication has dramatically decreased. A high-risk population has to be defined. H2 antagonists and sucralfate seemed to be more effective than antacids and prostaglandins. Proton pump inhibitors and enteral nutrition could be alternative prophylaxis. The cost-effectiveness ratio wasn't completely defined but implantation of clinical guidelines may reduce costs and limit such treatment for high-risk patients.     

Prise en charge des hémorragies digestives aiguës hautes : utilisation des médicaments à visée hémostatique

Pharmacological treatments such as terlipressin or somatostatin and its analogues are effective in controlling variceal bleeding in patients with cirrhosis. They should be started immediately if cirrhosis is clinically diagnosed, without waiting for endoscopic confirmation of portal hypertension signs. They also improve the efficiency of emergency sclerotherapy.Proton pump inhibitors are probably useful to prevent recurrent bleeding in patients with peptic ulcer, but improvement on survival has not yet been shown. The main benefit is observed in case of ulcer with high risk of recurrent bleeding. If proton pump inhibitors are used, they must be administrated at high dosages and intravenously.New trials are required to determine the optimal duration of the haemostatic pharmacological treatment in patients with cirrhosis and to confirm clinical interest in the use of proton pump inhibitors in case of ulcer bleeding.     

Épidémiologie, physiopathologie et classification des traumatismes du poignet

Osseous and ligamentous lesions of the wrist are very common and must be treated early to avoid the occurrence of a secondary osteoarthritis. Knowledge of the mechanisms and use of a suitable classification system make it possible to know where to look for lesions, assess the likely prognosis and suggest suitable treatment.     

Place de l’imagerie dans la prise en charge des hémorragies digestives aigu?s

Objectives

To evaluate the role of diagnosis and interventional radiology in acute upper and lower gastrointestinal bleeding (excluding variceal bleeding) in case of failure of endoscopic treatment.

Methods

Review of literature of the past 15 years, referring to the endoscopic, radiological and surgical management in acute gastrointestinal bleeding.

Results

Because of its success (85?C90%), endoscopic treatment confirmed its leading role. When endoscopical first attempt for hematemesis fails, a second one should be attempted, and when possible ??tagging?? the site with a surgical hemostatic clip. Embolization or surgery are then emphazised and guided by the findings of angio-CT. Their results are similar, in retrospective series, as the population embolized was of high surgical risk due to comorbidity and coagulopathy. Embolization should reach the site of bleeding and close the feeding artery. It should consider the whole anastomosic arterial network, to prevent recurrence. Close post-embolization monitoring should screen ischemic complications.

Conclusion

The combination of angio-CT and embolization is successful in targeting and treating persistent or recurrent bleeding after endoscopic management. Technical improvements using microcatheters, increases the embolization??s effectiveness and reduces morbidity. Embolization has a major role and should be preferred in patients with surgical risk.     

Diagnostic et prise en charge des hémorragies coliques diverticulaires

Colonic diverticular bleeding is the most common cause of lower gastrointestinal bleeding representing 35% of cases. It is predominantly a disease of the elderly. Bleeding stops spontaneously in the majority of cases (90%), but sometimes it can be severe and requires specific treatment and blood transfusion. Diverticular bleeding can be life-threatening with a mortality rate of up to 5% of cases. Early colonoscopy is the main examination for diagnosis and treatment of diverticular bleeding. Recurrence occurs in up to 25% of cases within 4 years. Risk factors for recurrence are not clearly understood. Treatment of diverticular bleeding is not clearly codified: serum adrenaline injection, endoclips or endoscopic band ligation have been proposed with a high rate of initial success. Supra-selective embolization is an effective alternative treatment in case of failure of endoscopic treatment. Colectomy to control bleeding is uncommon and should be discussed if bleeding is uncontrolled by endoscopic treatment and/or radiological procedure and if possible after locating bleeding site.     

Épidémiologie des traumatismes crâniocérébraux chez l’enfant

Severe traumatic brain injury (TBI) is a frequent cause of death and long-term disabilities. The epidemiology of severe TBI is not well-known due to variations in TBI definitions among the studies. Population based-studies are scarce, mostly including hospitalization data and rarely deaths on the scene. The annual incidence of severe TBI in the developed countries varies from 2.3 to 17 per 100,000 if based on Glasgow coma scale and reaches 46 per 100,000 if based on others classifications. Severe TBI represents 3 to 10% of all TBIs. The annual mortality rate of severe TBI varies from 2.5 to 9 per 100,000. The most frequent cause of severe TBI and TBI-related death in children is road accidents, falls being less frequent. Percentages of fall, child abuse, and direct hit by objects are higher in infants. Inflicted TBI, probably underestimated, belong to severe TBI and represent one quarter of severe TBI-related deaths in infants of less than one year. The case-fatality rate of severe TBI is around 15–20%. The rate of long-term disabilities varies according to the type of assessed disability and the tools used for its measurement. It is higher following an inflicted TBI. Among children with severe TBI, one third develops psycho-behavioral disorders, 20 to 30% disabilities and cognitive disorders and 60–70% fatigue, behavioral and concentration disorders. In more than 50% of TBI cases, familial dysfunctions occur.