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

  • Endoscopie Thérapeutique
  • Published:
Acta Endoscopica

Résumé

Le traitement endoscopique des hémorragies digestives hautes en dehors de l'HTP est envisageable dans 4 grands groupes d'indications:

Pathologie ulcéreuse (ulcères gastro-duodénaux—Dieulafoy—Mallory-Weiss):

Le traitement doit être basé sur le pronostic clinique et endoscopique des hémorragies ulcéreuses. Malgré ses imperfection (définition des stigmates hémorragiques — concordance interobservateur des signes endoscopiques), la classification de Forrest reste l'élément majeur de la décision thérapeutique. A côté des techniques endoscopiques «classiques» (photo, thermo ou électrocoagulation et injections), les techniques plus récentes (électrocoagulation par plasma argon — hémoclip — ligature élastique — colles biologiques) ont fait la preuve de leur efficacité dans le contrôle de l'hémorragie d'ulcères à haut risque (Forrest Ia/b et IIa) et son risque de récidive ainsi que dans la diminution du besoin chirurgical. Les associations thérapeutiques et le retraitement endoscopique (combinaison adrénaline — thermo ou électrocoagulation) diminuent le besoin chirurgical sans augmenter le risque de mortalité au prix de complications moindres. En revanche, le retraitement programmé n'est pas recommandé lorsque les critères de sélection se basent sur ceux de Forrest.

Des recommandations sont proposées:

  • - apprécier le pronostic en tenant compte des éléments cliniques et endoscopiques (Score de Baylor);

  • - laver abondamment les caillots des lésions Forrest IIb;

  • - traiter les stades Ia, Ib, IIa de Forrest;

  • - associer injection (adrénaline) et thermocoagulation (APC, ou Gold probe);

  • - surveiller en milieu intensif pendant les trois jours suivant le traitement initial des malades stades Ia, Ib et IIa de Forrest;

  • - préférer un retraitement endoscopique en présence d'une RH à un retraitement programmé;

  • - ne pas traiter les stades IIc et III de Forrest (possibilité de sortie dans les 24 heures).

Pathologie tumorale: la conduite d'essais comparatifs est difficile et justifie l'attitude pragmatique guidée par le type de lésion retrouvée et les conditions locales sachant que quelle que soit la technique utilisée, les résultats habituels sont mauvais à moyen terme.

Pathologie vasculaire (angiodysplasie — ectasies vasculaire antrale): les traitements endoscopiques ont fait état de leur efficacité. Préférer les méthodes thermiques par balayage (APC) pour les lésions diffuses et la ligature élastique pour les lésions localisées.

Pathologie iatrogène (hémorragie de la sphinctérotomie endoscopique — de la mucosectomie — de la polypectomie): le meilleur traitement est préventif en respectant des règles simples basées sur des éléments cliniques et biologiques. L'électrocoagulation mono-ou multipolaire et l'adrénaline doivent être disponibles de même qu'une technique de coagulation (APC) et/ou de clippage.

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  1. Département d'hépatogastroentérologie, Centre Hospitalier du Mans, 194, avenue Rubillard, 72037, Le Mans Cedex 1, France

    B. Bour

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Bour, B. Traitement endoscopique des hémorragies digestives hautes en dehors de l'HTP. Acta Endosc 29 (Suppl 2), 343–350 (1999). https://doi.org/10.1007/BF03019314

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