单光子发射型计算机断层扫描在下消化道出血诊断中的应用

目的 探讨单光子发射型计算机断层扫描（SPECT）显像在下消化道出血中的诊断价值。方法 回顾性分析24例下消化道出血患者SPECT显像资料。行异位胃黏膜显像者16例，行^99mTc－植酸钠（PHA）显像者4例，行^99mTc－红细胞（RBC）显像者4例，所有患者均接受手术并进行病例检查。结果 异位胃黏膜显像的阳性率为100％（16／16），特异性为93．7％（15／16）；^99mTc-PHA显像和^99mTc-RBC显像的阳性率分别为75．0％（3／4）和75．0％（3／4），但诊断缺乏特异性。结论 SPECT在美克尔憩室的诊断中有很高的灵敏度和特异性；对不明原因下消化道出血进行^99mTc-PHA显像或^99mTc-RBC显像可为临床提供出血灶定位参考。     

胶囊内镜在小肠疾病诊断中的价值

目的探讨胶囊内镜对小肠疾病的诊断价值。方法2002年9月至2007年3月间对155例患者所进行的159例次胶囊内镜检查进行回顾性研究。记录胶囊内镜在胃和小肠的平均运行时间,评价患者的耐受性、胶囊内镜完成检查情况及胶囊内镜下病变的检出情况等。结果155例患者中,不明原因的消化道出血97例,腹痛42例,腹部不适6例,腹泻4例,体检6例。93．1％的患者（148／159）完成了全小肠摄影。所有患者在检查过程中未诉特殊不适。胶囊内镜胃内平均停留时间为65．5（1～335）min,小肠平均停留时间为282．2（45～524）min。胶囊内镜病变检出率为78．6％（125／159）。胶囊内镜发现血管病变43．4％（69／159）,小肠炎性病变28．3％（45／159）,黏膜下结节10．1％（16／159）,小肠憩室8．2％（13／159）,小肠肿物5．7％（9／159）以及小肠息肉、小肠异物、小肠寄生虫等。不明原因消化道出血病变检出率为89．7％（87／97）,腹痛查因病变检出率为73．8％（31／42）。结论胶囊内镜检查安全性较高,患者容易接受。胶囊内镜对小肠疾病、尤其消化道不明原因出血者具有重要的诊断价值。     

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目的 探讨急性疑难下消化道出血部位的术中定位方法。方法 对12例 术前检查、术中探查不能确定出血部位的下消化道出血病人，行分段肠道灌洗后内镜检查。结果 9例发现出血部位，3例未明。结论 术中灌洗内镜检查有助于术中出血部位的准确定位，操作简便，直观有效。     

胶囊内镜初筛联合术中内镜诊断老年不明原因消化道出血

目的 探讨胶囊内镜初筛联合术中内镜对老年不明原因消化道出血的诊断.方法 回顾性分析2005年1月至2006年7月收治的23例老年患者不明原因消化道出血的胶囊内镜及术中内镜检查结果,分析小血病因.结果 23例中,胶囊内镜初筛检出小肠病变22例,胶囊内镜与术中探查及内镜诊断的符合率为91%(21/23).结论 胶囊内镜初筛联合术中内镜是诊断老年患者不明原因消化道出血的有效方法.     

小肠出血的检查方法和手术时机

目的 探讨小肠出血的检查方法和手术时机.方法 回顾性分析1999年1月至2009年1月成都军区总医院收治的132例小肠出血患者的临床资料.根据患者的病情,选择性地行小肠气钡双重造影、选择性肠系膜动脉造影、胶囊内镜、剖腹探查、术中内镜检查、全消化道钡餐及螺旋CT检查.不同检杳方法阳性率比较采用x2检验.结果 术中内镜检查和剖腹探查阳性率最高,两者比较,差异无统计学意义(x2=0.006,P>0.05).术中内镜检查和剖腹探查分别与小肠气钡双重造影、选择性肠系膜动脉造影、胶囊内镜、全消化道钡餐、螺旋CT检查阳性率比较,差异有统计学意义(x2=4.080、3.840、4.470、5.070、7.300,4.170、3.920、4.550、5.210、7.310,P<0.05).112例急诊手术患者中76例病灶位于积血上缘,36例位于积血下缘.术后127例痊愈、4例复发、1例因出血量过大死亡.结论 术中内镜检查和剖腹探查是发现小肠出血病灶的最佳方法.急性大出血时是不明原因小肠出血患者的最佳手术时机.     

选择性动脉造影诊治隐匿性下消化道出血

作者自1988年1月至1995年1月，对38例经常规检查不明原因的下消化道出血采用选择性动脉造影作定位和／或定性诊断，出血诊断率84％（32／38）。31例手术治疗，送病理检查均明确病因。并提出选择性动脉造影后，动脉内留置导管，术中推注美蓝作定位诊断，确定病变范围，切除出血病变肠段。亦可用于经导管动脉内推注血管收缩性药物，作止血治疗。     

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目的 探讨应用软结肠镜(内镜)对常见下消化道外科疾病的诊治，以提高利用内镜进行诊治的安全性及疗效。方法 回顾1984～2001年37939例行内镜诊治的病人，其中行内镜治疗9039例，包括低位肠梗阻64例、乙状结肠扭转11例、假性结肠梗阻6例、下消化道出血56例、良性肠狭窄23例及肠道息肉8879例。总结操作体会，分析疗效及并发症的原因。结果 低位肠梗阻明确梗阻原因、部位者35例(54．7％，35／64)；乙状结肠扭转复位成功11例(100％，11／11)；假性结肠梗阻经内镜减压，治愈者5例(83．3％，5／6)，急性下消化道出血明确出血原因及部位者37例(66．1％，37／56)，37例中立即经内镜止血成功者36例(97．3％，36／37)；结、直肠吻合口经内镜下扩张均成功(100％，23／23)；内镜下行大肠息肉摘除术8864例，共10105枚，术后出血4例，迟发性穿孔2例；术中经内镜行小肠息肉摘除术15例，共412枚，术后无并发症。结论 内镜提高了下消化道外科疾病的诊治水平，但应严格把握适应证。     

消化道出血的诊治思路

消化道出血诊治重点是准确定位,要重视病史、体检和一般检查的提示作用。特殊检查中,首选纤维内镜。小肠出血可先通过CT、同位素或胶囊内镜初步筛查,再经小肠镜检查并给予止血。消化道大出血首选数字减影血管造影（DSA）检查。对无法明确诊断的病人,可进行手术探查和术中肠镜检查。     

术中内镜在急性下消化道出血中的应用

急性下消化道出血，有时来势凶险，直接威胁病人的生命。如何明确病因，准确判断出血部位，对及时手术治疗极为重要。我院自1996-2003年对术前及术中未能明确诊断的急性下消化道出血11例患者，采用术中内镜检查，取得了良好的效果。现报道如下。     

急性下消化道大出血的诊断和治疗

目的 探讨急性下消化道大出血的诊断和治疗方法。方法 对本院25例急性下消化道大出血的临床表现，特殊检查(如纤维胃镜、结肠镜、气钡结肠造影、急诊选择性腹腔动脉造影以及核素扫描)进行了分析和对比。结果 选择性腹腔动脉造影和核素扫描的阳性诊断率分别为78．6％和86．4％，而气钡结肠造影的阳性率为67%，急诊结肠镜检查的阳性率仅为41％。结论 尽管急性下消化道大出血的最有效的诊断方法是选择性腹腔动脉造影和核素扫描．但急诊肠道镜检查仍应为下消化道大出血的常规检查。如果血管造影疑为肠血管性疾病出血时则应保留导管，术中注入亚甲兰有助于术中的定位诊断，且术中肠道镜检查也可提高诊断率。     

Role of contrast CT in acute lower gastrointestinal bleeding

OBJECTIVE: To evaluate the role of CT abdomen in the localization of acute lower gastrointestinal bleeding. SUMMARY BACKGROUND DATA: The source of bleed in acute lower gastrointestinal bleeding is often difficult to localize. The role of CT in the evaluation of this group of patients has not been clearly addressed. METHODS: A retrospective review of all patients with acute lower gastrointestinal bleeding over a 3-year period was carried out. When endoscopy failed to localize the source and bleeding continued, angiography and/or scintigraphy were carried out. In contrast, those who had normal endoscopies and had clinically stopped bleeding, underwent CT abdomen. RESULTS: CT done in 7 patients with no evidence of active bleed identified a lesion in 6 (86%). CONCLUSIONS: CT may be useful in acute lower gastrointestinal bleeding where endoscopy fails to localize a lesion and bleeding has stopped temporarily.     

Surgical approach to occult gastrointestinal bleeding.

In 5% of patients with gastrointestinal bleeding, standard evaluation fails to reveal the source of the bleeding. We describe the management of 71 patients treated for obscure gastrointestinal bleeding at the Mount Sinai Medical Center, New York, New York, from 1985 to 1991. There were 38 men (54%) and 33 women (46%). The mean age was 60 years. The patients had bleeding episodes for a mean period of 26 months and required an average of 20 units of blood prior to surgical treatment. All had undergone an extensive diagnostic workup including barium contrast studies, endoscopies, and angiographies. Some had multiple bleeding scans, Meckel scans, and surgical explorations. Three patients were found to have "watermelon stomach" on endoscopy and had an antrectomy. Sixty-eight (96%) patients underwent a preoperative small bowel enteroscopy, which revealed the precise diagnosis in 50 (70%) of the patients. All patients underwent surgery. In 30 (42%) patients in whom the bleeding site was not apparent at exploration, intraoperative enteroscopy was performed. Two actively bleeding patients had intraoperative enteroscopy, which failed to localize the bleeding site, and intraoperative scintigraphy was utilized. The bleeding was found to originate in small bowel arteriovenous malformation (AVM) (28 patients), leiomyoma (8 patients), primary small bowel malignancies (11 patients), and other causes (24 patients). Fifty-six patients (80%) had no further bleeding; 9 with multiple small bowel AVM have experienced rebleeding and are alive. Six patients died of recurrent bleeding, and six died of metastatic cancer. An aggressive approach should be applied in patients in whom standard evaluation fails to localize the source of gastrointestinal bleeding. Enteroscopy, surgical exploration with additional intraoperative enteroscopy, and occasional intraoperative scintigraphy can achieve an excellent yield and allow resection and potential cure.     

Intraoperative fiberoptic endoscopy

Conventional endoscopy is an indispensable tool in the diagnosis and management of many patients with gastrointestinal disease. Intraoperative use of the fiberoptic endoscope permits direct visualization of the mucosal surface, eliminating the need for enterotomy in many cases. Over a 4.5-year period, 32 patients underwent gastrointestinal endoscopy during laparotomy for a wide variety of surgical problems. In 15 cases, obscure or unknown sites of upper and lower gastrointestinal bleeding were localized. Replacement of percutaneously placed biliary drainage tubes was facilitated in four cases. In three patients artifactual lesions suggested by gastrointestinal (GI) contrast studies were excluded with intraoperative endoscopy at the time of exploratory laparotomy, and in four cases, retained foreign bodies were recovered easily without the need for enterotomy. In six additional patients intraoperative endoscopy was used to localize nonpalpable colon polyps or to determine the extent of mucosal ulceration. The average time for an intraoperative fiberoptic endoscopic examination was 20 minutes. No complications resulted from this technique. In summary, intraoperative fiberoptic endoscopy is of definite value in assessing selected patients with difficult GI surgical problems encountered during laparotomy. This technique enhances the surgeon's ability to identify and treat inaccessible and occult GI lesions.     

急性小肠出血的诊断分析

目的　探讨急性小肠出血的诊断方法。方法　对 17例急性小肠出血病人分别采用X线钡餐检查 ,99mTc标记的红细胞核素扫描 (ECT) ,选择性肠系膜血管造影 (DSA ) ,术中肠镜检查 ,比较各种诊断方法对判断出血部位的优劣。结果　对出血部位的定位阳性率 :ECT为 ( 7/14 )5 0 % ;DSA为 ( 8/12 ) 66.7% ,X线钡餐为 ( 3 /8) 3 7.5 %。术前不能确诊的 5例病人 ,术中肠镜均明确出血部位 ( 10 0 % )。结论　ECT和DSA有较高的诊断价值。对于术前辅助检查不能明确出血部位的病人 ,剖腹探查结合术中内镜检查是确定出血部位的关键。     

Small bowel exploration and resection using single‐port surgery: a safe and feasible approach

Aim The aim of this study is to demonstrate the efficacy of wireless capsule endoscopy for preoperative identification of bleeding sources and/or small bowel tumours in surgical patients and to evaluate the feasibility of single‐port surgery in the treatment of such pathologies. Method Five patients presenting with obscure gastrointestinal bleeding or/and mild small bowel obstruction were investigated to diagnose and localize the bleeding source or tumour using capsule endoscopy imaging, and, if necessary, with other investigative modalities. All patients were operated on using single‐port surgery for small bowel exploration, lesion confirmation, small bowel resection and anastomosis. Results Small bowel pathology was successfully detected by video capsule endoscopy in three of four patients, and was further substantiated by contrast CT, double‐balloon endoscopy or enteroclysis. Complete small bowel exploration, intra‐operative identification and oncological resection of the involved segment and anastomosis (intracorporeal and extracorporeal) was successfully performed in all five patients using single‐port access without any complication, morbidity or mortality. Conclusion This study demonstrates the feasibility and safety of single‐port small bowel resection performed after a high‐quality preoperative localization of the tumour.     

下消化道出血11例诊治体会

目的探讨不明原因下消化道出血的手术诊治体会。方法回顾性分析10年间经内镜、血管造影、增强CT扫描及核素扫描均不能明确下消化道出血部位及原因、由于反复出血或出血凶猛而采用剖腹探查诊治者11例的临床资料。结果最常见的出血原因是血管发育不良或畸形(5例),其次,小肠憩室2例,小肠平滑肌瘤1例,3例原因不明。最终的手术方式主要是右半结肠切除(7例),其他有病变小肠段切除3例及结肠次全切除1例。死亡率27.3%,再出血率18.2%。结论原因不明的下消化道出血,多数病人可以通过剖腹探查明确诊断及治疗,应及时手术。     

Use of technetium-labeled red blood cell scintigraphy in the detection and management of gastrointestinal hemorrhage

The effectiveness of technetium 99m-labeled red blood cell scintigraphy in localizing hemorrhage, directing surgical intervention, and screening patients for arteriography was determined in 103 patients. The radionuclide scan result was compared to the bleeding site determined by arteriography, endoscopy, or surgery. Eighty-five patients had a bleeding site identified; 18 patients did not and were excluded. Thirty-one scans were performed in 29 patients for upper gastrointestinal hemorrhage. Five positive scans incorrectly localized an upper gastrointestinal bleeding site, although two scans localized the site, for a scan sensitivity of 8%. Fifty-nine scans were performed in 56 patients with lower gastrointestinal bleeding. Fifteen scans were positive, three incorrectly localizing the hemorrhage. Seventy-four percent of the patients with lower gastrointestinal hemorrhage documented by arteriography, endoscopy, or surgery had negative scans for bleeding. The radionuclide scan sensitivity for lower gastrointestinal bleeding was 23%. Surgery was required in 18 patients for bleeding, 11 of whom had negative scans for bleeding. In seven surgical patients with positive scans, in no instance did the scan direct the surgical intervention. Eighteen patients underwent scintigraphy and arteriography; nearly one half of the patients with negative scans for bleeding had positive localizing arteriograms, although almost one half of the patients with positive scans for bleeding had negative arteriograms. Scintigraphy failed to localize hemorrhage in 85% of the patients. Technetium 99m-labeled red blood cell scintigraphy did not direct surgical intervention, nor did it adequately screen patients for arteriography.     

Intraoperative gastrointestinal endoscopy.

A four year experience with the adaptation of the flexible fiberoptic endoscope to the intraoperative environment is presented in 30 patients. The technique of intraoperative endoscopy was utilized in a wide variety of difficult gastrointestinal surgical problems to include the location of the site and cause of bleeding of obscure etiology; resolution of intraoperative dilemmas without the necessity of opening abdominal viscera; resection of lesions during operations conducted for other pathological processes; and enhancement of diagnosis at laparotomy. There were no complications from the use of intraoperative endoscopy and the technique was beneficial in 28 of the 30 patients (93.3%). Limiting factors in the full utilization of the endoscope at celiotomy were dense adhesions with a shortened mesentery and massive hemorrhage with blood obscuring the intestinal lumen.     

Cinematic nuclear scintigraphy reliably directs surgical intervention for patients with gastrointestinal bleeding

HYPOTHESIS: Cinematic technetium Tc 99m red blood cell ((99m)Tc-RBC) scans, in which real-time scanning is performed and analyzed, can accurately localize gastrointestinal bleeding and thus direct selective surgical intervention. DESIGN: Retrospective medical record review with historical controls. SETTING: Large, university-affiliated public hospital in urban setting. PATIENTS: Twenty-six patients presenting with upper and lower gastrointestinal hemorrhage who underwent cinematic (99m)Tc-RBC scan examinations between 1990 and 1997 and required surgical intervention to control the bleeding. INTERVENTIONS: All patients with gastrointestinal bleeding underwent open surgical procedures to provide cessation of bleeding and resection of appropriate abnormalities. MAIN OUTCOME MEASURES: Patient outcome was based on correlation between preoperative RBC scans and intraoperative findings, surgical pathology, and postoperative clinical course. RESULTS: Twenty-five (96%) of 26 scans were interpreted as positive for gastrointestinal bleeding. In 22 of these 25 scans, the site of bleeding was correctly identified for a sensitivity of 88%. One or more additional diagnostic tests were performed on 19 (73%) of 26 patients, and included angiography and flexible endoscopy. The most common operation performed to control bleeding was a hemicolectomy (14/26). Diverticulosis was the most prevalent diagnosis (46%). Two patients (8%) experienced rebleeding after operation. The overall mortality rate was 19% (5/26). CONCLUSIONS: Cinematic (99m)Tc-RBC scintigraphy is a sensitive, noninvasive alternative to mesenteric angiography for accurately localizing the site of gastrointestinal hemorrhages. As such, this technique can be reliably used to direct selective surgical intervention.     

Role of intraoperative enteroscopy in the management of obscure gastointestinal bleeding at the time of video-capsule endoscopy

Background

This study aimed at evaluating the role of intraoperative enteroscopy (IOE) for the management of obscure gastrointestinal (GI) bleeding in patients who had been preoperatively explored by video-capsule endoscopy (VCE).

Methods

Eighteen patients who underwent IOE for obscure GI bleeding were prospectively recorded between November 2000 and January 2007. The bleeding site was preoperatively localized by VCE in the small bowel in 15 patients, but the origin of bleeding remained unknown in 3 patients.

Results

In the 3 patients with negative VCE, IOE was normal, but intraoperative conventional endoscopy identified gastric (n = 1) and colonic (n = 2) lesions. Among the 15 patients with VCE positive for small-bowel lesions, laparotomy and IOE yielded localization and treatment (surgical n = 11 and endoscopic n = 2) guidance for 13 of 15 (87%) lesions. At median 19-month follow-up, 3 bleeding recurrences (3 of 15 [20%]) were recorded, resulting in a 73% therapeutic efficacy of IOE.

Conclusions

IOE remains useful for the management of obscure GI bleeding when preoperative VCE is positive for small-bowel lesions that are not reachable by nonoperative enteroscopy. When VCE is negative, new conventional endoscopy should be proposed instead of IOE.