·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬∑’Ë¡“¥â«¬¿“«–‡≈◊Õ¥ÕÕ°„π∑“߇¥‘πÕ“À“√ à«πµâπ„πª√–‡∑»‰∑¬                       ®“°°“√ª√–™ÿ¡        2...
○       ○   ○                            ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬   ○   ○   ○                            ·π«∑“ß°“√¥Ÿ·≈√—°...
○   ○   ○                                                          Upper GI bleeding   ○   ○   ○                          ...
○       ○   ○                            ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬   ○   ○   ○                                   ¡“§¡·æ∑¬å...
○    ○      ○                                                                                      Upper GI bleeding      ...
○○○                                                                                                                    ○○ ...
Yes                                        No       8                           Ulcer bleeding                          Va...
○○○                                                                                                                    ○○ ...
○       ○       ○                                                                                           Upper GI bleed...
○       ○   ○                            ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬   ○   ○   ○                                     - Red b...
○   ○   ○                                                      Upper GI bleeding   ○   ○   ○      or -     Clinical cirrho...
○       ○   ○                            ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬   ○   ○   ○                                    followed...
○   ○   ○                                                         Upper GI bleeding    ○   ○   ○21. If hemostasis fail    ...
○       ○   ○                            ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬    ○       ○       ○                                   ...
○   ○   ○                                                                             Upper GI bleeding                   ...
○       ○   ○                            ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬                ○   ○       ○                           ...
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Transcript of "Guideline%20 upper%20gi%20bleeding"

  1. 1. ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬∑’Ë¡“¥â«¬¿“«–‡≈◊Õ¥ÕÕ°„π∑“߇¥‘πÕ“À“√ à«πµâπ„πª√–‡∑»‰∑¬ ®“°°“√ª√–™ÿ¡ 2004 Consensus for Clinical Practice Guideline for the management of Upper GI Bleeding ®—¥∑”‚¥¬ °≈ÿà¡«‘®—¬‚√§°√–‡æ“–Õ“À“√  ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬
  2. 2. ○ ○ ○ ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ ○ ○ ○ ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ ∑’Ë¡“¥â«¬¿“«–‡≈◊Õ¥ÕÕ°„π∑“߇¥‘πÕ“À“√ à«πµâπ„πª√–‡∑»‰∑¬ ‚¥¬°≈ÿà¡«‘®—¬‚√§°√–‡æ“–Õ“À“√  ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬ æ‘¡æå§√—Èß·√° ∏—𫓧¡ 2547 ISBN 974-92027-2-4 §≥–ºŸâ®—¥∑” ∑’˪√÷°…“ : πæ.∫—≠™“ ‚Õ«“∑Ó√æ√ : æ≠.«‚√™“ ¡À“™—¬ ª√–∏“π : πæ.Õÿ¥¡ §™‘π∑√ ‡≈¢“πÿ°“√ : æ≠.‚©¡»√’ ‚¶…‘µ™—¬«—≤πå °√√¡°“√ : æ≠.™ÿµ¡“ ª√–¡Ÿ≈ ‘π∑√—æ¬å ‘ : πæ.æ‘»“≈ ‰¡â‡√’¬ß : æÕ.πæ. ÿ√æ≈ ™◊Ëπ√—µπ°ÿ≈ : πæ. ‘√‘«—≤πå Õπ—πµæ—π∏ÿåæß»å : πæ.ÕßÕ“® ‰æ√ ≥±√“ß°Ÿ√ ÕÕ°·∫∫·≈–®—¥∑”√Ÿª‡≈à¡‚¥¬ ∫√‘…—∑ ¬Ÿ‡π’ˬπ §√’‡Õ™—Ëπ ®”°—¥ 240/37 ∂. ®√—≠ π‘∑«ß»å Õ.∫“ß°Õ°πâÕ¬ °∑¡. 10700 ‚∑√. 0-2866-3002-3 ·øì°´å. 0-2412-5320○ ○ ○ ○ ○ ○ 2
  3. 3. ○ ○ ○ Upper GI bleeding ○ ○ ○ §”π” ○ ○ ○ ¿“«–‡≈◊Õ¥ÕÕ°„π∑“߇¥‘πÕ“À“√ à«πµâπ‡ªìπ¿“«–∑’Ëæ∫∫àÕ¬·≈–¡’§«“¡ ”§—≠„π‡«™ªØ‘∫—µ‘ ‡π◊ËÕß®“°‡ªìπ¿“«–∑’Ë¡’Õ—µ√“µ“¬∂÷ß√âÕ¬≈– 10-15 ‚¥¬ à«π„À≠ຟâªÉ«¬¡—°‡ ’¬‡ ’¬™’«‘µ„π™à«ß·√°∑’Ë¡“æ∫·æ∑¬åÀ√◊Õ¡“∂÷ß‚√ß欓∫“≈ ºŸâªÉ«¬∑’Ë¡“¥â«¬¿“«–‡≈◊Õ¥ÕÕ°„π∑“߇¥‘πÕ“À“√ à«πµâπ®÷ß¡’§«“¡®”‡ªìπ∑’Ë®–µâÕ߉¥â√—∫°“√¥Ÿ·≈√—°…“Õ¬à“ß√«¥‡√Á« ∂Ÿ°µâÕß ·≈–‡À¡“– ¡ ‚¥¬‡©æ“–„π°“√ª√–‡¡‘𧫓¡√ÿπ·√ß·≈–°“√∑” resuscitation ºŸâªÉ«¬ „πªí®®ÿ∫—π‰¥â¡’°“√æ≤π“„π¥“π°“√¥·≈√°…“ºª«¬ ‚¥¬‡©æ“–°“√„™¬“„π°≈¡ antisecretory ·≈– — â Ÿ — Ÿâ É â ÿà°“√√°…“∑“ß endoscopy ´ß¡∫∑∫“∑ ”§≠·≈–π¬¡„™‡æ¡¢πÕ¬“ß¡“° ª√–°Õ∫ — ÷Ë ’ — ‘ â ‘Ë ÷È à°—∫¬—߉¡à‡§¬¡’°“√®—¥∑”·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬∑’Ë¡“¥â«¬¿“«–‡≈◊Õ¥ÕÕ°„π∑“߇¥‘πÕ“À“√ à«πµâπ„πª√–‡∑»‰∑¬¡“°àÕπ °≈ÿ¡«‘®¬‚√§°√–‡æ“–Õ“À“√  ¡“§¡ à —·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬ ‰¥â‡≈Á߇ÀÁπ∂÷ߧ«“¡ ”§—≠„π‡√◊ËÕßπ’È®÷߉¥â®—¥ª√–™ÿ¡ consensus ‡√◊ËÕß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬∑’Ë¡“¥â«¬¿“«–‡≈◊Õ¥ÕÕ°„π∑“߇¥‘πÕ“À“√ à«πµâπ·≈–‰¥â¢âÕ √ÿª‡ªìπ·π«∑“ß„π°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬∑’Ë¡“¥â«¬¿“«–‡≈◊Õ¥Õ°„π∑“߇¥‘πÕ“À“√ à«πµâπ ‚¥¬·æ∑¬åºŸâ‡¢â“√à«¡ª√–™ÿ¡ª√–°Õ∫¥â«¬Õ“¬ÿ√·æ∑¬å¥â“π√–∫∫∑“߇¥‘πÕ“À“√ »—≈¬·æ∑¬å Õ“¬ÿ√·æ∑¬å∑—Ë«‰ª ·≈–·æ∑¬å‡«™ªØ‘∫—µ‘∑—Ë«‰ª º≈°“√ª√–™ÿ¡‰¥â¢âÕ √ÿª·≈–π”¡“„™â „π°“√®—¥∑”·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬¥—ß°≈à“« ‚¥¬‡πâπ¢âÕ¡Ÿ≈ π—∫ πÿπ∑’ˇªìπ evidence-based ·≈–„Àâ·æ∑¬å∑’ËÕ¬Ÿà „π‚√ß欓∫“≈∑ÿ°√–¥—∫ “¡“√∂π”·π«∑“ß°“√¥Ÿ·≈√—°…“¥—ß°≈à“«‰ªªØ‘∫—µ‘‰¥â®√‘ß  ¡“§¡®–¡’°“√µ‘¥µ“¡·≈–ª√–‡¡‘πº≈À≈—ß®“°∑’Ë·æ∑¬å ‰¥â „™â·π«∑“ß°“√√—°…“ºŸâªÉ«¬∑’Ë¡“¥â«¬‡≈◊Õ¥ÕÕ°„π∑“߇¥‘πÕ“À“√ à«πµâππ’È·≈â« 1-2 ªï À√◊Õ‡¡◊ËÕ¡’¢âÕ¡Ÿ≈∑’ˇªìπÀ≈—°∞“πÕ—π„À¡à ®–¡’°“√·°â ‰¢·π«∑“ß°“√¥Ÿ·≈√—°…“¥—ß°≈à“«„Àâ¡’§«“¡‡À¡“– ¡·≈–¥’¬‘Ëߢ÷Èπ 3 ○ ○ ○ ○ ○ ○
  4. 4. ○ ○ ○ ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ ○ ○ ○  ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬ ¢Õ¢Õ∫§ÿ≥·æ∑¬å ∑ÿ°∑à“π∑’Ë „À⧫“¡√à«¡¡◊ÕÕ¬à“ߥ’¬‘Ëß ‚¥¬‰¥â ≈–‡«≈“𔧫“¡√Ÿâ·≈–ª√– ∫°“√≥å ‡æ◊ËÕ√à«¡„π°“√®—¥∑”·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬∑’Ë¡“¥â«¬¿“«–‡≈◊Õ¥ÕÕ°„π∑“ß ‡¥‘πÕ“À“√ à«πµâπ ·≈–¢Õ¢Õ∫§ÿ≥ ∫√‘…—∑ ‡™Õ√‘Ëß-æ≈“« ®”°—¥, ∫√‘…—∑ ∑“‡§¥“ (ª√–‡∑»‰∑¬) ®”°¥, ∫√…∑‚π«“√µ  (ª√–‡∑»‰∑¬) ®”°¥, ∫√…∑ ‡∫Õ√≈π ø“√¡“ — ‘ — å’ — ‘ — å‘ å ´Ÿµ‘§Õ≈ Õ‘π¥— µ√’È ®”°—¥ ∫√‘…—∑, ∫√‘…—∑ ¬Ÿ´’∫’ ø“√å¡“ (‰∑¬·≈π¥å) ®”°—¥, ∫√‘…—∑  ¬“¡ø“√å¡“´Ÿµ‘§Õ≈ ®”°—¥, ∫√‘…—∑ ‡Õ‰´ (ª√–‡∑»‰∑¬) ¡“√凰Áµµ‘Èß ®”°—¥, ∫√‘…—∑ ·Õä∫∫Õµ ≈“∫Õ·√µÕ√’  ®”°—¥, ∫√‘…—∑ ·Õ µ√Ⓡ´π‡π°â“ (ª√–‡∑»‰∑¬) ®”°—¥ ∑’˙૬ π—∫ πÿπ°“√®—¥°“√ª√–™ÿ¡‚¥¬‰¡à¡’‡ß◊ËÕπ‰¢„¥Ê∑”„Àâß“π ”‡√Á®≈ÿ≈à«ß‰ª‰¥â ¥â«¬¥’ ¡§«“¡¡ÿàßÀ¡“¬ √».πæ.∫—≠™“ ‚Õ«“∑Ó√æ√ 𓬰 ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬○ ○ ○ ○ ○ ○ 4
  5. 5. ○ ○ ○ Upper GI bleeding ○ ○ ○·ºπ¿Ÿ¡‘°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬∑’Ë¡“¥â«¬¿“«–‡≈◊Õ¥ÕÕ°„π∑“߇¥‘πÕ“À“√ à«πµâπ‡©’¬∫æ≈—π  ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬ 1 Hematemesis / Melena 2 Initial Assessment and Resuscitation 3 Risk Stratification 3 A Low Risk 3 B High Risk PPI for Suspected Samotostain for 6 Non-variceal Suspected Variceal 7 4 Supportive Treatment and Monitoring Bleeding Bleeding Endoscopy Available 5 Elective Endoscopy Yes No 8 Ulcer bleeding Variceal Bleeding Others Refer 9 High risk 10 Low risk 16 Pharmacologic Therapy Endoscopic Hemostasis (Somatostatin or analogue) for Major Stigmata Hemorrhage 11 Endoscopy Feasible 15 Antisecretory 11 Endoscopy Feasible Therapeutic therapy Therapeutic 18 Yes No Yes No Continue Pharmacologic Therapy 13 17 EVL/EIS 19 SB 24-48 hrs Fail Success 12 Endoscopic Hemostasis Consult Surgeon or Refer Bleeding Stop Ongoing Bleed 22 20 21 Success Fail Success Fail OR Re-endoscopy Rebleed SB 24-48 hrs TIPS or Surgery 23 and Hemostasis or Refer 14 OR Pharmacologic Therapy and Re-endoscopy Fail Monitoring Rebleed OR EVL/EIS Success Rebleed 5 ○ ○ ○ ○ ○ ○
  6. 6. ○○○ ○○ ○○○ ○6 1 Hematemesis / Melena 2 Initial Assessment and Resuscitation ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ ○ 3 Risk Stratification ○ ○ 3 A Low Risk 3 B High Risk PPI for Suspected Samotostain for 6 Non-variceal Suspected Variceal 7 4 Supportive Treatment Bleeding Bleeding and Monitoring Endoscopy Available 5 Elective Endoscopy Yes No 8
  7. 7. Yes No 8 Ulcer bleeding Variceal Bleeding Others Refer 9 High risk 10 Low risk Pharmacologic Therapy Endoscopic Hemostasis 16 (Somatostatin or analogue) for Major Stigmata Hemorrhage Therapeutic 15 Antisecretory 11 Therapeutic 11 Endoscopy Feasible therapy Endoscopy Feasible ○ ○ 18 ○ Yes No Yes No Continue Pharmacologic Therapy 13 Endoscopic Consult Surgeon 17 EVL/EIS 19 SB 24-48 hrs Fail Success 12 Hemostasis or Refer7 Upper GI bleeding ○○○ ○○ ○○○○
  8. 8. ○○○ ○○ ○○○ ○8 13 Endoscopic Consult Surgeon 17 EVL/EIS 19 SB 24-48 hrs Fail Success 12 Hemostasis or Refer Bleeding Stop Ongoing Bleed 22 ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ 20 21 ○ ○ Success Fail Success Fail ○ OR Re-endoscopy Rebleed SB 24-48 hrs TIPS or Surgery 23 and Hemostasis or Refer 14 OR Pharmacologic Re-endoscopy Fail Therapy and OR EVL/EIS Monitoring Rebleed Success Rebleed
  9. 9. ○ ○ ○ Upper GI bleeding ○ ○ ○ §”Õ∏‘∫“¬‡æ‘Ë¡‡µ‘¡µ“¡·ºπ¿Ÿ¡‘ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○1. ·ºπ¿Ÿ¡‘π’È „™â‡©æ“– ”À√—∫ºŸâªÉ«¬∑’Ë¡“¥â«¬¿“«–‡≈◊Õ¥ÕÕ°„π∑“߇¥‘πÕ“À“√  à«πµâπ‡©’¬∫æ≈—π ∑’ˇ°‘¥¢÷Èπ¿“¬„π 48 ™—Ë«‚¡ß‡∑à“π—Èπ ‚¥¬ºŸâªÉ«¬Õ“®¡“¥â«¬ Õ“°“√Õ“‡®’¬π‡ªìπ‡≈◊Õ¥ À√◊Õ∂à“¬ melena2. Initial Assessment and Resuscitation ë Supportive Treatment a. Maintain airway b. History and physical examination for assessment of severity and causes c. NG irrigation d. Fluid resuscitation e. Blood for CBC, cross-match blood group for blood transfusionÀ¡“¬‡Àµÿ : √“¬≈–‡Õ’¬¥°“√¥Ÿ·≈√—°…“„Àâª√—∫µ“¡§«“¡‡À¡“– ¡¢ÕߺŸâªÉ«¬ ·µà≈–√“¬·≈–µ“¡ ¿“槫“¡æ√âÕ¡¢Õß ∂“π欓∫“≈3. Risk Stratification 3A Low clinical risk factors 3B High clinical risk factors include ë Host factors - Age > 60 years - Co-morbid conditions e.g. renal failure, cirrhosis, cardio- vascular disease, COPD - Hemodynamic instability e.g. orthostatic hypotension, pulse >100 /min, systolic BP < 100 mmHg - Coagulopathy including drug-related ë Bleeding character - Continuous red blood from NG after irrigation 9 ○ ○ ○ ○ ○ ○
  10. 10. ○ ○ ○ ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ ○ ○ ○ - Red blood per rectum ë Patient course - Need blood transfusion - Rebleeding - Hemodynamic instability Note: In special circumstances, patientsû referral may be considered if - The patient has rare blood group (group AB, Rh negative) - Taking more than 1 hr to the nearest referral hospital - Blood transfusion is not available 4. Supportive Treatment and Monitoring ë Supportive treatment as 2 ë Oral PPI double dose until endoscopy 5. Elective Endoscopy ë Every patient should have endoscopy done if available ë If endoscopy is not available, consider patientûs referral 6. Suspected non-variceal bleeding ë Continuous IV infusion or bolus PPI or oral PPI double dose ë If endoscopy is available with in 8 hr, PPI may not be needed Note: - Continuous IV infusion PPI: Omeprazole or Pantoprazole 80 mg v bolus then infusion drip 8 mg/hr - Bolus PPI: Omeprazole or Pantoprazole 40 mg v twice daily 7. Suspected variceal bleeding ë Clinical signs include - Previous documented of esophageal varices or gastric varices or - Signs of portal HT e.g. splenomegaly, ascites, hepatic en- cephalopathy, dilated superficial vein○ ○ ○ ○ ○ ○ 10
  11. 11. ○ ○ ○ Upper GI bleeding ○ ○ ○ or - Clinical cirrhosis with thrombocytopenia and/or spleno- megaly ë Medication: Somatostatin 250 microgram bolus followed with somatostatin 250 microgram/hour IV or Octreotide 50 micro- gram bolus followed with octreotide 50 microgram/hour IV ë If endoscopy can be performed urgently, somatostatin or its analogue may not be needed8. Patient should be referred if ë High risk of bleeding including recurrent bleeding and no endo- scopic treatment or no surgical treatment available ë Rare blood group ë No blood transfusion available 9. High endoscopic risks ë Arterial bleeding; spurting, oozing ë Non-bleeding visible vessel ë Adherent clot10. Low endoscopic risks ë Hematin spot ë Clean-based ulcer ë Gastritis11. Therapeutic endoscopy feasible ë Defined as ability to do any of therapeutic modalities (even 1 modality)12. Endoscopic hemostasis ë Spurting : injection with adrenaline and followed with thermal coagulation or hemoclips ë Clot adherent : injection with adrenaline then removal of clot, 11 ○ ○ ○ ○ ○ ○
  12. 12. ○ ○ ○ ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ ○ ○ ○ followed with thermal coagulation or hemoclips ë Non bleeding visible vessel : thermal coagulation, fibrin sealant or hemoclips 13. Consult surgeon as soon as possible or refer if no surgeon available 14. Pharmacologic therapy ë Drugs : oral or IV infusion PPI is either used depending on patients severity and physicianûs judgement 15. Antisecretory therapy ë Drugs : oral or IV infusion PPI is either used depending on patients severity and physicianûs judgement ë In NSAID user including low dose ASA - PPI is recommended in ongoing NSAIDs use - H2RA is as effective as PPI if NSAIDs are stopped 16. Pharmacologic therapy in variceal bleeding ë Somatostatin 250 microgram bolus, followed with somatosta- tin 250 microgram/hour IV or Octreotide 50 microgram bolus, followed with octreotide 50 microgram/hour IV ë If the patient already received somatostatin or its analogue before endoscopy, bolus dose is not needed 17. Endoscopic variceal ligation (EVL) or Endoscopic injection sclero- therapy (EIS) depends on the experiences of the endoscopist 18. Continue pharmacologic therapy for 5 days 19. Sengstaken Blakemore tube (SB) insertion 20. Hemostatic success means bleeding stopped ë May consider discharge somatostatin or its analogue if the EVL or EIS is completely performed○ ○ ○ ○ ○ ○ 12
  13. 13. ○ ○ ○ Upper GI bleeding ○ ○ ○21. If hemostasis fail ë Somatostatin or its analogue should be continued ë Consider options according to healthcare resources, experi- ences of the endoscopist and the patientûs conditions - Consult for surgery or Transcutaneous intrahepatic porto- systemic shunt (TIPS) with or without temporary tampon- ade with Sengstaken Blakemore tube - Temporary tamponade with Sengstaken Blakemore tube and re-endoscopy after 24-48 hr22. If bleeding is still ongoing more than 24-48 hour surgery or TIPS is needed23. The surgeon should be capable for shunt surgery otherwise refer to the center that has more equipped facilities À¡“¬‡Àµÿ: °≈ÿà¡«‘®—¬‚√§°√–‡æ“–Õ“À“√  ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘π Õ“À“√·Ààߪ√–‡∑»‰∑¬ ‰¥â®—¥∑” Statement ‡√◊ËÕß·π«∑“ß°“√¥Ÿ·≈ √—°…“ºŸâªÉ«¬∑’Ë¡“¥â«¬¿“«–‡≈◊Õ¥ÕÕ°„π∑“߇¥‘πÕ“À“√ à«πµâπ ´÷Ëß®–¡’√“¬ ≈–‡Õ’¬¥√«¡∑—ß¡’‡Õ° “√Õâ“ßՑ߇æ◊Õ„™âª√–°Õ∫°—∫ guideline „πÀπ—ß ◊Õ‡≈à¡π’È È Ë ·≈–‰¥â àßµàÕ‰ª¬—ß√“™«‘∑¬“≈—¬Õ“¬ÿ√·æ∑¬å·Ààߪ√–‡∑»‰∑¬, °√–∑√«ß  “∏“√≥ ¢·≈– ∂“∫πæ≤π“·≈–√∫√Õߧ≥¿“æ‚√ß欓∫“≈ (æ√æ) ‡æÕ ÿ — — — ÿ Ë◊ ‡º¬·æ√àµàÕ‰ª ∑à“π “¡“√∂À“√“¬≈–‡Õ’¬¥‰¥â „π®ÿ≈ “√ ¡“§¡·æ∑¬å √–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬,  “√√“™«‘∑¬“≈—¬Õ“¬ÿ√·æ∑¬å·Ààß ª√–‡∑»‰∑¬ ·≈– www.thaigastro.org 13 ○ ○ ○ ○ ○ ○
  14. 14. ○ ○ ○ ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ ○ ○ ○ √“¬π“¡ºŸâ‡¢â“ª√–™ÿ¡ —¡¡π“ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Consensus for Clinical Practice Guideline for the management of Upper GI Bleeding 24-26  ‘ßÀ“§¡ 2546 ≥ ÀâÕߪ√–™ÿ¡‚√ß·√¡√–¬Õß√’ Õ√å∑ ®.√–¬Õß πæ.‡°√¬ß‰°√ Õ§√«ß»å ’ — √æ. ¡µ‡«™ ‘‘ °√߇∑æœÿ æ≠.‚©¡»√’ ‚¶…µ™¬«≤πå ‘ — — √“¡“∏∫¥’ ‘ °√߇∑æœ ÿ π∑.πæ. ™π«µ√  ∑∏«π“ ‘ — ÿ ‘ √æ.¿¡æ≈œ Ÿ‘ °√߇∑æœ ÿ æ≠.™ÿµ‘¡“ ª√–¡Ÿ≈ ‘π∑√—æ¬å √æ.√“¡“∏‘∫¥’ °√ÿ߇∑æœ πæ.™Ÿ™“µ‘ §Ÿ»‘√‘«—≤πå √æ.Õÿµ√¥‘µ∂å Õÿµ√¥‘µ∂å πæ.‡µ¡™¬ ‰™¬π«µ‘ ‘ — ÿ— √æ.»√√“™ ‘‘ °√߇∑æœ ÿ πæ.‰µ√®°√ ´π¥Ÿ — — √æ.¡À“√“™π§√‡™¬ß„À¡à ’ ‡™¬ß„À¡à ’ πæ.∑«’ √—µπ™Ÿ‡Õ° √æ.√“™«‘∂’ °√ÿ߇∑æœ πæ.∑Õߥ’ ™¬æ“π™ — ‘ √æ. ¡µ‡«™ ‘‘ °√߇∑æœ ÿ πæ.∏πæ≈ ‰À¡·æß √æ. ß¢≈“π§√π∑√å ‘  ß¢≈“ πæ.∏‡π» ®—¥«—≤π°ÿ≈ √æ. ¡‡¥Á®æ√–∫√¡√“™‡∑«’ ≥ »√’√“™“ ™≈∫√’ ÿ πæ.∏‡π» ™µ“æπ“√°…å ‘ — √æ.¡À“√“™π§√‡™¬ß„À¡à ’ ‡™¬ß„À¡à ’ πæ.∏«—™™—¬ Õ—§√«‘æÿ∏ √æ.»‘√‘√“™ °√ÿ߇∑æœ πæ.∫—≠™“ ‚Õ«“∑Ó√æ√ √æ. ß¢≈“π§√‘π∑√å  ß¢≈“ πæ.∫—π‡∑‘ß ‡¬“«å«—≤π“πÿ°ÿ≈ √æ.æπ— π‘§¡ ™≈∫ÿ√’ πæ.ª√–¡«≈ ‰∑¬ß“¡»‘≈ªá √æ.°“à‘π∏ÿå °“à‘π∏ÿå πæ.æ—≤π“ ‡∫â“ “∑√ √æ.§√∫ÿ√’ π§√√“™ ’¡“ πæ.æπ® °≈≈–«≥™¬å ‘ ‘ ÿ ‘ √æ.®Ã“≈ß°√≥å ÿ °√߇∑æœ ÿ πæ.æ‘»“≈ ‰¡â‡√’¬ß √æ.»√’π§√‘π∑√å ¢Õπ·°àπ πæ.摇»… 摇»…æß…“ √æ.¡À“√“™π§√‡™’¬ß„À¡à ‡™’¬ß„À¡à πæ.¿—∑√“¬ÿ  ÕÕª√–¬Ÿ√ √æ.æ√–ª°‡°≈â“ ®—π∑∫ÿ√’ πæ.¡°√‡∑æ ‡∑æ°“≠®π“ √æ.√—™¥“-∑à“æ√– °√ÿ߇∑æœ○ ○ ○ ○ ○ ○ 14
  15. 15. ○ ○ ○ Upper GI bleeding ○ ○ ○πæ.√∞°√ «‰≈™π¡å — ‘ √æ.∏√√¡»“ µ√å ª∑¡∏“π’ ÿæ≠.√µπ“ ∫≠»√®π∑√å — ÿ ‘‘— √æ.«™√欓∫“≈ ‘ °√߇∑æœ ÿπæ.√“«‘π ‚´π’Ë √æ.»Ÿπ¬å≈”ª“ß ≈”ª“ßπæ.«√æ®πå π√ ™“ ÿ √æ. ¡‡¥®æ√–π“߇®“ √°µµÏ‘ Á â ‘‘‘ ™≈∫√’ ÿæµÕ.πæ.«√æπ∏åÿ ‡ “«√  — √æ.µ”√«® °√߇∑æœ ÿæ≠.«‚√™“ ¡À“™¬ — √æ.®Ã“≈ß°√≥å ÿ °√߇∑æœ ÿπæ.«—≤π“¬ÿ∑∏  √√æ“π‘™ √æ.§à“¬ ÿ√ ’Àå °“≠®π∫ÿ√’πæ.«’√¬ÿ∑∏ ‚¶…‘µ °ÿ≈™—¬ √æ.π§√æ‘ß§å ‡™’¬ß„À¡àπæ.»√—≥¬å «√√≥¿“ π’ √æ. √√æ ‘∑∏‘Ϫ√– ß§å Õÿ∫≈√“™∏“π’æ≠.»»ª√–¿“ ∫≠≠æ Ø∞å ‘ ÿ ‘‘ √æ.»√√“™ ‘‘ °√߇∑æœ ÿπæ.»ÿ¿™—¬ »√’»‘√‘√ÿàß √æ.æ≠“‰∑»√’√“™“ ™≈∫ÿ√’πæ. ∂“æ√ ¡“π  ∂µ¬å — ‘ √æ.»√√“™ ‘‘ °√߇∑æœ ÿπæ. ¡∫—µ‘ µ√’ª√–‡ √‘∞ ÿ¢ √æ.‡«™»“ µ√凢µ√âÕπ °√ÿ߇∑æœπæ. ¡Õ“® µ—È߇®√‘≠ √æ.°“à‘π∏ÿå °“à‘π∏ÿåπæ. “«µ√ ‚¶…µ™¬«≤πå ‘ ‘ — — √æ.√“¡“∏∫¥’ ‘ °√߇∑æœÿπæ. ‘√‘«—≤πå Õπ—πµæ—π∏ÿåæß»å √æ.√“™«‘∂’ °√ÿ߇∑æœπæ. ‡®µπå ‡≈»‡Õπ°«≤π“ ÿ ‘ — √æ.ÀπÕߧ“¬ ÀπÕߧ“¬πæ. ÿπ∑√ µ√’ √“πÿ«—≤π“ √æ.‡´Áπ‡¡√’Ë π§√√“™ ’¡“πæ. ÿπ∑√ ™‘πª√– “∑»—°¥‘Ï √æ.π§√√“™ ’¡“ π§√√“™ ’¡“πæ. æ®πå æß»ª√– ∫™¬ ÿ å — √æ.»√√“™ ‘‘ °√߇∑æœ ÿπæ. ÿæ√™—¬ °“≠®π«“ ’ √æ.≈æ∫ÿ√’ ≈æ∫ÿ√’æÕ.πæ. √æ≈ ™π√µπ°≈ÿ Ë◊ — ÿ √æ.æ√–¡ß°Æ‡°≈“ ÿ â °√߇∑æœ ÿæÕ.πæ. √æ≈  √“ߧ»√√∞ÿ ÿ å ’— √æ.æ√–¡ß°Æ‡°≈“ ÿ â °√߇∑æœ ÿπæ.ÕßÕ“® ‰æ√ ≥±√“ß°Ÿ√ √æ.¡À“√“™π§√‡™’¬ß„À¡à ‡™’¬ß„À¡àπæ.Õ”π“® ®µ√«√ππ∑å ‘ — √æ.‡®√≠°√ߪ√–™“√°…å ‘ ÿ — °√߇∑æœ ÿπæ.Õ¥¡ §™π∑√ ÿ ‘ √æ.»√√“™ ‘‘ °√߇∑æœ ÿπæ.‚ÕÓ√ «‘«—≤π“™à“ß √æ.Õÿ¥√∏“π’ Õÿ¥√∏“π’πæ.∏—≠‡¥™ π‘¡¡“π«ÿ≤‘æß…å √æ.»‘√‘√“™ °√ÿ߇∑æœπæ. ¡™“¬ ≈≈“°»≈«ß»å ’ ÿ √æ.»√√“™ ‘‘ °√߇∑æœ ÿ 15 ○ ○ ○ ○ ○ ○
  16. 16. ○ ○ ○ ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ ○ ○ ○ §≥–°√√¡°“√¥”‡π‘πß“π°≈ÿà¡«‘®—¬‚√§°√–‡æ“–Õ“À“√ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○  ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬ «“√– æ.».2546-2547 ª√–∏“π : æ≠.«‚√™“ ¡À“™—¬ ‡≈¢“πÿ°“√ : πæ. ‘√‘«—≤πå Õπ—πµæ—π∏ÿåæß»å ‡À√—≠≠‘° : æÕ.πæ. ÿ√æ≈ ™◊Ëπ√—µπ°ÿ≈ °√√¡°“√ : æ≠.‚©¡»√’ ‚¶…‘µ™—¬«—≤πå : æ≠.™ÿµ‘¡“ ª√–¡Ÿ≈ ‘π∑√—æ¬å : πæ.∫—≠™“ ‚Õ«“∑Ó√æ√ : πæ.æ‘»“≈ ‰¡â‡√’¬ß : πæ.ÕßÕ“® ‰æ√ ≥±√“ß°Ÿ√ : πæ.Õÿ¥¡ §™‘π∑√○ ○ ○ ○ ○ ○ 16

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