Hemorragia digestiva alta: estado actual del diagnóstico y tratamiento / Upper gstrointestinal bleending: present status of the diagnosis and treatment

RESUMEN

Se actualiza la metodología diagnóstica y la conducta y tratamiento más aceptados de las dos causas más frecuentes de hemorragia digestiva alta de carácter grave. En la úlcera péptica, gástrica o duodenal, después de la reposición inicial del primer y principal método diagnóstico y terapéutico es la endoscopía digestiva alta. La cirugía sólo está indicada cuando fracasa el intento de hemostasia endoscópica. En la hemorragia varicel las sustancias vasoactivas, en especial, la somastotatina o sus derivados, se emplean como tratamiento inicial mientras se realiza la reposición de la volemia. En la urgencia la hemostasia endoscópica con esclerosis o bandas elásticas es el tratamiento de primera línea y el más empleado para controlar la hemorragia y prevenir la recidiva. Controlado el episodio inicial, el alto riesgo de resangrado obliga a un tratamiento definitivo como profilaxis de la recidiva hemorrágica, puede ser endoscópico para erradicación de las várices, farmacológico con bloqueadores beta o quirúrgico, incluyendo el trasplante hepático.

ABSTRACT

Upper gastrointestinal (GI) bleending is a common clinical problem that requires frequent hospitalization, and sometimes originates a life-frequent hospitalization, and sometimes originates a life-threatening condition. The mortality rate, estimated to be 5 % to 10 %, has been relatively stable. In view of the aging population and the higher mortality of bleeding in the elderly, this may represent a slight improvement in mortality. In tis report, the authors describe the diagnostic methodology, the management and treatment most commonly accepted of the bleeding. For the peptic ulcer - gastric or duodenal - following the initial replacement of blood volumen, the first and main diagnostic and therapeutic procedure is the upper GI endoscopy. Surgery is only suggested when the endoscopic hemostasia fails. For variceal hemorrhages, vasoactive drugs, mainly somatostatin or their derivates, are employed as the initial treatment, meanwhile the transfusion requirements are used for restoration of blood volume. Continued bleeding or recurrent bleeding are indications for endoscopic therapy. Early surgical treatment should be considered for patients with persistent or recurrent bleending from ulcers that have failed endoscopic therapy. Variceal bleending has a high mortality. The patient's condition must be stabilized and requires replacement of blood volume. Acute bleending may be managed by endoscopic sclerotherapy, vasopressin infusion, compression of varices thanshepatically, or by emergency surgery. Once varice have stopped bleeding, a definitive procedure is in order to prevent recurrence of hemorrhage with the use of pharmacologic agents, B-andrenergic blockade or surgical, including liver transplantation. The indications for urgent surgery in GI bleending have remained essentially the same, except that now endoscopic therapy may be tried as the first approach.