内镜在Dieulafoy病诊断与治疗中的价值

目的探讨内镜在Dieulafoy病诊断与治疗中的价值. 方法回顾性分析我院1994年6月～2002年6月21例引起上消化道出血的Dieulafoy病的内镜下特征、治疗方法与效果. 结果 21例中15例(71.4%)为1次检查确诊,6例为2次或2次以上检查确诊.17例经内镜止血成功,首次治疗成功14例(66.7%),3例经2次内镜止血成功(14.3%);4例外科手术治疗(19.0%). 结论 Dieulafoy病的诊断与治疗,内镜为首选方法.     

肾上腺素黏膜下注射治疗内镜下乳头括约肌切开术并发出血

目的探讨肾上腺素黏膜下注射技术治疗内镜下乳头括约肌切开术(endoscopic sphincterotomy,EST)并发出血的效果。方法回顾性分析2015年1月～2017年12月2个内镜中心行1562例EST的病例资料,45例(2. 9%)发生EST相关出血,其中即刻出血43例(95. 6%),迟发出血2例(4. 4%);渗血42例(93. 3%),搏动性出血3例(6. 7%);少量出血44例(97. 8%),中等量出血1例(2. 2%),无大量出血病例。均采用内镜下肾上腺素黏膜下注射技术止血。结果内镜下肾上腺素黏膜下注射治疗均止血成功,无需要血管栓塞或手术止血,无死亡。结论内镜下肾上腺素黏膜下注射治疗EST并发出血效果显著,并且操作简单,成本低。     

23例Dieulafoy病的内镜诊断和治疗

目的探讨Dieulafoy病内镜下诊断和治疗的方法。方法回顾分析我科临床诊断明确的23例Dieulafoy病伴消化道出血患者的临床资料。结果急诊胃镜确诊19例,急诊肠镜确诊2例,血管造影检查确诊1例,剖腹探查术确诊1例。19例病变位于近端胃,1例位于胃窦,1例位于十二指肠,2例位于直肠。21例内镜确诊的患者行金属钛夹钳夹成功止血,血管造影确诊的患者经动脉内持续灌注垂体后叶素止血,剖腹探查术确诊的患者行单纯血管缝扎术止血。结论急诊内镜检查是诊断Dieulafoy病的首选方法,内镜下钛夹的合理使用是治疗本病的主要手段。     

Dieulafoy病变致急性消化道大出血的综合治疗

目的 探讨Dieulafoy病变致急性消化道大出血的多学科综合治疗及外科治疗方式的选择.方法 回顾性分析2007年4月至2012年4月48例Dieulafoy病变合并消化道大出血患者的临床资料.结果 本组最常见的出血部位是胃体(40例),其次是贲门(4例)、十二指肠(2例)和空肠(2例),且多发生在胃上部胃食管交界处6 cm以内.胃镜明确诊断有46例,急诊剖腹探查确诊2例.18例胃镜明确诊断的患者首先行局部肾上腺素注射和止血夹治疗;6例胃镜明确诊断的患者仅用止血夹治疗;2例十二指肠降部Dieulafoy病变出血内镜治疗失败的患者,行血管X线造影检查并栓塞,结果均成功.23例行手术治疗.47例治愈,1例死于低血容量性休克及多器官功能衰竭,平均住院时间是(10.8±2.5)d.结论 Dieulafoy病变发生率低但易导致凶险出血,可首先尝试内镜下肾上腺素局部注射联合止血夹治疗及介入治疗,多数患者最终需要外科治疗.     

不同内镜止血方法治疗老年消化性溃疡出血的效果比较

目的：评价不同内镜止血方法治疗老年消化性溃疡出血的效果。方法回顾性分析2008年1月～2013年12月在北京大学首钢医院住院并接受内镜治疗的80例老年消化性溃疡出血患者的临床及内镜检查资料,病变出血征象采用Forrest分级。内镜止血治疗方法包括内镜下肾上腺素注射（54例）和金属钛夹治疗（26例）。结果进行内镜治疗的病变均为Forrest Ⅰa～Ⅱb级。与内镜下肾上腺素注射组相比,金属钛夹治疗组的内镜治疗成功率更高（96.2％与87.0％）,再出血发生率更低（7.7％与14.8％）,临床症状消失时间更短[（2.3±0.6）d与（3.4±1.1）d],住院天数更短[（7.8±0.9）d与（11.5±2.4）d],差异均有统计学意义。结论内镜下金属钛夹止血治疗老年消化性溃疡出血的有效性和安全性均优于肾上腺素注射治疗。     

内镜黏膜下剜除术治疗胃间质瘤

目的探讨内镜黏膜下剜除术(endoscopic submucosal excavation,ESE)治疗胃间质瘤(gastric stromal tumors,GSTs)的疗效及安全性。方法 2012年12月~2014年6月经胃镜、超声内镜诊断为胃固有肌层GISTs 33例,均采用ESE治疗(标记、注射、环形切开、病灶剥离、创面处理)。结果术后病理证实33例均完整切除瘤体,手术时间10~69 min,平均46 min。住院时间7~28 d,平均10.9 d。术后病理活检及免疫组化结果:胃肠平滑肌瘤6例,间质瘤26例,梭形细胞肿瘤1例;根据NIH危险分级,极低危31例,低危2例。3例术中出血,经内镜下热活检钳电凝止血或金属止血夹夹闭后成功止血,出血量50~300 ml,术中出血率9.1%(3/33);1例术后持续黑便,经禁食水,口服肾上腺素盐水及静脉药物止血、抑酸等治疗后缓解,术后出血率3.0%(1/33),总出血率12.1%(4/33)。2例发生穿孔,穿孔率6.1%(2/33),经钛夹成功夹毕,无死亡。术后6~12个月33例均复查全腹部CT,未见肿瘤复发及转移。结论 ESE治疗GST安全、有效。     

Dieulafoy病19例临床分析

目的:探讨Dieulafoy病发病情况、诊断及治疗方法。方法:回顾性分析19例Dieulafoy病的临床表现、诊断、治疗方法及疗效。结果:全部病例均表现突发上消化道大出血。初次胃镜检查确诊12例（63.2%），第2次检查确诊4例（21.1%），术中探查确诊3例（15.8%）；14例经一次内镜下止血成功，1例经二次内镜下止血成功，4例行外科手术止血（包括1例内镜下止血后72h再出血者）。结论:急诊胃镜是诊断Dieulafoy病首选方法；治疗首选内镜下止血，内镜下止血不成功者，应立刻手术治疗。     

透明帽用于消化内镜止血治疗的护理配合

目的探讨透明帽在消化内镜止血治疗中的作用及护理配合方法。方法对86例消化道出血患者实施内镜止血治疗,均于内镜下找到出血点后安装透明帽,其中32例消化道溃疡底部动脉或Dieulafoy病出血者选用带侧孔的透明帽电凝止血,21例贲门黏膜撕裂综合征出血者选用不带侧孔的透明帽以金属夹止血,33例食管胃静脉曲张者选用带侧孔的透明帽注射硬化剂止血,同时加强术前准备、术中配合及术后观察护理。结果 86例均顺利完成内镜治疗并取得较好的止血效果,无相关并发症发生;术后3~6个月内镜复查,出血部位瘢痕形成,2例食管胃静脉曲张患者再出血,第2次给予硬化剂注射联合套扎治疗止血成功;余84例无复发出血。结论透明帽用于消化内镜止血治疗效果好,并发症少,护理人员熟练掌握其性能和操作,能缩短操作时间,提高治疗效果。     

胃镜下消化道止血术应用于活动性消化道出血的临床效果

目的探讨胃镜下消化道止血术治疗活动性消化道出血患者的效果。方法回顾性分析82例活动性消化道出血患者临床诊治和随访情况,其中胃镜下钛夹联合去甲肾上腺素喷洒治疗者41例为观察组,肾上腺素盐水注射(1∶10000)止血治疗者41例为对照组。比较两组首次止血成功率,并记录两组再出血及并发症。结果两组无死亡病例,观察组首次止血成功率为95.12%,明显高于对照组78.05%,χ2=5.14,P=0.02;观察组再出血率为2.44%明显低于对照组19.51%,χ2=6.12,P=0.01。治疗期间均未出现严重性并发症,两组再出血者均经开腹术治疗后好转。结论胃镜下钛夹联合去甲肾上腺素喷洒治疗活动性消化道出血具有较好的止血效果,且术后再出血风险较低、安全性较高。     

心血管介入和手术后食管贲门黏膜撕裂的临床及内镜特点

目的探讨心血管介入和手术后食管贲门黏膜撕裂的临床特点。方法回顾性分析2015年3月~2019年3月经电子胃镜检查诊断为食管贲门黏膜撕裂综合征并出血,且发病前1周内有心脏及大血管介入或手术史24例的临床、内镜资料。发病前均有呕吐的症状,继而出现呕血或胃管内抽出暗红色血。结果内镜下均为纵行撕裂,好发生于贲门部(14例,58. 3%),多见于左侧壁(10例,41. 7%)、后壁(8例,33. 3%),单处撕裂多见(19例,79. 2%)。75. 0%(18/24)有活动性出血(Chung分级Ⅰ级3例,Ⅱ级15例)。2例Chung分级Ⅳ级者无需止血治疗;余22例采用以金属钛夹为基础的联合止血方式,止血成功20例,2例内镜下止血失败者行腹主动脉和腹腔干造影联合胃左动脉栓塞止血。结论心血管介入治疗和手术后出现呕血或胃管内抽出暗红色血的患者应考虑到食管贲门黏膜撕裂并出血的可能,胃镜下止血是有效的治疗方法。     

Is endoscopic band ligation superior to injection therapy for Dieulafoy lesion?

Background  Dieulafoy lesion is a rare but serious cause of gastrointestinal system bleeding. An aberrant submucosal artery, which was described in 1884, causes the bleeding. The lesion can be located anywhere in the gastrointestinal tract but is most commonly found in the proximal stomach up to 6 cm from the gastroesophageal junction. Increased experience in endoscopy has led to an increased frequency of its proper diagnosis. Various methods are used to achieve successful hemostasis by endoscopy in Dieulafoy lesion; however, comparative studies about the success rates of these methods are still needed. In this study, we compared two of these endoscopic hemostatic methods: band ligation, and injection therapy in Dieulafoy lesions. Methods  In this prospective study, 18 patients admitted to the Emergency Surgical Unit between January 2002 and December 2005 with upper gastrointestinal bleeding diagnosed as Dieulafoy lesion were included. Diagnose of Dieulafoy lesion was made at initial or second-look endoscopy. Patients were randomized in two groups according to therapy method: injection therapy and band ligation groups. Therapy was applied immediately after recognizing the lesion at the same endoscopic procedure. Two groups were compared regarding demographical data, presence of comorbid diseases, history of medication and previous gastrointestinal system bleeding, hemodynamic status, laboratory values, need for transfusion, endoscopic findings, success rate of the treatment method, mean hospital stay, complications, and recurrence of bleeding. Results  Of 588 patients admitted with upper gastrointestinal hemorrhage, Dieulafoy lesion was recognized in 18 cases (3.1%) at initial or second-look endoscopy. All patients were men with a mean age of 62.8 (range, 30–80) years. Band ligation was applied to ten patients and the remaining eight were treated by injection therapy. During the follow-up period, rebleeding occurred in six of the patients (75%) with injection therapy, whereas no rebleeding occurred for the patients in the band ligation group. The rebleeding rate and mean hospital stay was significantly higher for the injection therapy group. Conclusions  Our study suggests that of the endoscopic treatment methods, band ligation is superior to injection therapy for the treatment Dieulafoy lesions. Presented at the 15th EAES Congress, July 4–7, 2008 Athens, Greece.     

近端胃切除术治疗断流术后再次上消化道出血的临床疗效分析

目的探讨近端胃切除术（Phemister术）对门静脉高压症行脾切除加贲门周围血管离断术术后再次出血的临床疗效。方法对我院肝胆外科2009年6月至2014年1月收治的26例断流术后再次上消化道出血的患者行近端胃切除术的临床资料及术后随访资料进行分析。结果26例均取得满意的止血效果,其中5例急诊手术,1例行术中胃镜下食管中上段曲张静脉套扎术（EVL）并空肠造瘘留置肠内营养管。2例术后吻合口出血,经输血、药物止血、抑酸及护胃等治疗止血;1例吻合口瘘,经肠外营养及通畅引流等治愈;5例出现大量腹水,经营养、补充白蛋白、利尿等治疗好转。随访中4例发现食管静脉曲张并行EVL,1例于术后13个月因上消化道出血死亡。结论对于门静脉高压症断流术后再出血患者经药物、内镜或介入（TIPS）等非手术治疗效果不满意者,近端胃切除术治疗效果确切。     

胰十二指肠切除术后晚期出血的诊断与治疗

目的总结胰十二指肠切除术后晚期出血的诊断与治疗经验。方法回顾性分析2002年1月至2013年2月新疆医科大学第一附属医院收治的246例行胰十二指肠切除术患者的临床资料。胰头及壶腹部恶性肿瘤行标准胰十二指肠切除术或联合脏器切除,良性肿瘤及十二指肠乳头肿瘤行保留幽门的胰十二指肠切除术。消化道吻合采用胰肠或胰胃吻合两种方式。患者术后出血时间〉5d定义为晚期出血。消化道出血为消化道出血组,腹腔出血为腹腔出血组。按出血程度分为轻度和重度出血。采取保守治疗和手术治疗（包括介入和开腹手术治疗）两种方法治疗晚期出血。计数资料组间比较采用Fisher确切概率法。结果246例患者中行标准胰十二指肠切除术224例,行保留幽门的胰十二指肠切除术10例,行胰十二指肠切除联合门静脉切除或置换术9例,行胰十二指肠切除联合肠系膜上静脉置换术1例,行胰十二指肠切除联合肝方叶切除术1例,行胰十二指肠切除联合左半肝切除术1例。246例患者中行改良胰肠端侧吻合127例,行胰胃套入吻合53例,行传统胰肠端端套人吻合39例,行胰管空肠黏膜对黏膜吻合27例。患者围手术期死亡15例,病死率为6．10％（15／246）。术后29例患者发生晚期出血,出血发生率为11．79％（29／246）。其中消化道出血14例,腹腔出血15例。29例出血患者中轻度出血9例（消化道出血5例、腹腔出血4例）;重度出血20例（消化道出血9例、腹腔出血11例）。17例患者术后发生先兆出血,其中消化道出血5例、腹腔出血12例。29例患者均经常规保守治疗,消化道出血组患者保守治疗成功率为8／14,腹腔出血组为2／15,两组比较,差异有统计学意义（P〈0．05）。保守治疗失败患者均中转手术治疗。20例重度出血患者中行手术治疗19例,1例经保守治疗成功。9例轻度出血患者全部行保守治疗,1例因肺部感染死亡,其余均获治愈。29例术后晚期出血患者中死亡10例,病死率为34．5％（10／29）。消化道出血组患者病死率为2／14,腹腔出血组为8／15,两组比较,差异无统计学意义（P〉0．05）。结论胰十二指肠切除术后晚期出血常有先兆出血征象,出血程度多为重度。消化道出血经保守治疗多可治愈,腹腔出血需积极手术治疗。     

Endoscopic hemoclip placement for postsphincterotomy bleeding refractory to injection therapy: report of two cases

Bleeding is a serious complication of patients undergoing endoscopic sphincterotomy and is the most common sphincterotomy-associated cause of death. Two patients presented bleeding after endoscopic sphincterotomy. Despite injection treatment with large amounts of epinephrine (1:10,000), the bleeding was uncontrolled. Hemostasis was achieved by placing 2 and 3 hemoclips, respectively at the bleeding site. Our cases suggest that postsphincterotomy bleeding refractory to injection treatment can be safely and effectively controlled by endoscopic hemoclipping, thereby avoiding surgery.     

Endoscopic hemoclip application in the treatment of nonvariceal gastrointestinal bleeding: short-term and long-term benefits

We conducted an uncontrolled retrospective study to evaluate endoscopic hemoclip application as the first-choice hemostatic treatment of gastrointestinal bleeding lesions from a wide variety of sources. Clinical data, endoscopic findings, complications, and short- and long-term outcomes were also investigated. A total of 52 patients (men/women, 36/16; age, 65 +/- 11.5 years) were included in the study. Hemoclipping was technically successful in 51 cases (98%). The average number of therapeutic endoscopic sessions needed to achieve permanent hemostasis was 1.42 +/- 1.2 (range, 1-4). The number of hemoclips required for hemostasis depended on the nature of bleeding with the average number of hemoclips used being 3.11 +/- 1.12 (range, 2-8). No complications occurred, although 1 patient presented recurrent bleeding and was operated on. No further hemorrhage occurred during a median follow-up period of 17.32 +/- 5.4 months (range, 2-53). Endoscopic hemoclipping provided an effective and safe modality for achieving hemostasis in gastrointestinal bleeding from a wide variety of sources, with long-term benefits.     

Total gastrectomy in the surgical treatment of acute massive hemorrhage caused by Dieulafoy lesion of the gastric fundus

GI bleeding caused by Dieulafoy lesion in the gastric fundus: a case report Dieulafoy lesion is a rare cause of massive gastrointestinal (GI) hemorrhage that can be fatal. It arises from an abnormally large eroded submucosal artery and in more than 75% of cases the lesion is mostly found within 6 cm of the cardia. The severity of bleeding and the site of the lesion render the diagnosis sometimes difficult, more than one endoscopic exam is often required. Surgery was regarded as the treatment of choice in the past, but recently endoscopic management has become the standard approach. We report a case of an 42-year-old man presented with upper GI hemorrhage. Repeated upper GI endoscopies revealed a missed diagnosis of subcardial gastric ulcer and Mallory-Weis lesion. Following conservative treatment, the frequency and amount of haemorrhage decreased and totally stop. 48 hours after admission patient developed sudden massive upper GI bleeding and underwent emergency total gastrectomy. The diagnosis of Dieulafoy lesion was made histologically. The patient recovered uneventfully and discharged on the postoperative day 11th. Therefore, Dieulafoy disease represent a diagnostic and therapeutic challenge. Advances in endoscopic technique have greatly assisted in earlier diagnosis and added options to the treatment regimen for this lesion. The relationship of this anomaly to possible exsanguination makes it essential that both endosopical and surgical approach play an important role in the management of this pathology.