早期内镜诊治应用于老年急性非静脉曲张性上消化道大出血患者的价值分析

目的探讨早期内镜在老年急性非静脉曲张性上消化道大出血(ANVUGIB)患者的诊断和治疗中的价值。方法回顾分析该院2015年1月-2015年9月150例老年ANVUGIB的患者早期内镜和择期内镜的诊疗结果,分析上消化道大出血的原因,比较两组患者在内镜病因检出率、首次出血止血成功率、再出血率、外科手术率、平均止血时间、输血量、平均住院时间和平均住院费用的差别。采用诺丁汉健康调查问卷(NHP)比较两组患者出院3个月后生活质量的差别。结果老年ANVUGIB出血患者中,消化性溃疡、胃癌和急性糜烂出血性胃炎是最常见的出血原因。与择期内镜组相比,早期内镜组病因检出率、首次出血止血成功率明显增高(P0.05),再出血率、外科手术率明显降低,患者输血量减少,平均住院时间缩短,平均住院费用降低(P0.05),两组差异有统计学意义,早期内镜组患者出院3个月后生活质量明显高于择期内镜组患者(P0.05)。结论老年ANVUGIB患者进行早期内镜检查及治疗安全,效果确切,能尽快明确出血原因,减少患者住院费用,值得推广。     

内镜治疗急性非静脉曲张性上消化道出血的临床价值

目的：探讨经内镜治疗急性非静脉曲张消化道出血的临床价值。方法：回顾分析2007年3月—2009年12月81例急性非静脉曲张消化道出血患者的临床资料。结果：81例患者中即时止血成功78例（96.3%）;48h内再出血5例,再次内镜下止血成功4例（80%）。共4例治疗无效,均转外科手术治疗,内镜治疗总有效率为95.1%（77/81）。结论：内镜治疗急性非静脉曲张消化道出血是一种安全、有效的方法。     

The effect of endoscopic hemostasis with alcohol on the mortality rate of nonvariceal upper gastrointestinal hemorrhage. A randomized prospective study

One hundred and forty-five patients with nonvariceal upper GI hemorrhage, active or with stigmata (Forrest I and II) were divided into two groups according to the day of the week on which emergency endoscopy was performed: group A (78 patients) in which conventional treatment was applied (blood transfusions, antacids, cimetidine, pirenzepine), and group B (65 patients) in which endoscopic hemostasis with absolute alcohol (Asaki's method) was performed. The two groups were comparable as regards age, sex distribution and type of hemorrhage (after Forrest). Emergency surgery was performed in both groups if the bleeding did not stop or if it recurred. Twenty patients (11 in group A and 9 in group B) were operated on some time after the bleeding episode (5-18 days) to prevent new episodes. Absolute alcohol injection achieved hemostasis in all the cases of active hemorrhage (Forrest I) and prevented recurrence in 24 out of 25 cases with a clot or visible vessels (Forrest II), so that emergency surgery was not necessary in any of the patients of group B. Mortality rate was significantly lower in group B than in group A (10 deaths in group A, 2 in group B, p less than 0.05) being explained mainly by the reduced post-operative mortality (18% in group B), due to the small number of the operated patients (28 in groups A, 10 in B; p less than 0.02), especially of those operated on as an emergency (one in the endoscopic hemostasis group as compared with 17 in the conventional treatment group; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

内镜止血联合埃索美拉唑治疗急性非静脉曲张性上消化道出血的临床分析

目的评价内镜下止血联合埃索美拉唑治疗急性非静脉曲张性上消化道出血的临床效果。方法对比分析内镜联合埃索美拉唑治疗组(68例)与单用埃索美拉唑治疗组(70例)的止血时间、再出血率、剖腹手术率、平均输血量、住院时间等。结果内镜联合药物组的止血时间、再出血率、剖腹手术率、平均输血量及住院时间均少于单用药物组(P<0.01),且内镜下止血未发生医源性穿孔病例。结论内镜下止血联合埃索美拉唑治疗急性非静脉曲张性上消化道出血安全可靠,值得临床推广。     

放大内镜下胃食管反流病患者食管乳头内毛细血管环形态学观察

目的探讨胃食管反流病（GERD）患者食管乳头内毛细血管环（IPCL）形态学检查在GERD诊断中的临床价值及护理。方法对非糜烂性食管炎（NERD）患者20例、糜烂性食管炎（EE）患者20例和10例健康志愿者行24h食管pH监测,采用白光和放大内镜窄波成像（NBI）模式观察食管下段黏膜IPCL形态并进行分型,同时配合有效的护理措施。结果3组受检者顺利完成内镜检查。NERD组患者24h食管pH监测阳性率为55％,EE组为90％,健康对照组均为阴性,NERD组低于EE组;放大内镜NBI模式下健康对照组食管IPCL呈茶色规律排列的卷发状、小螺旋状;NERD组85％及EE组100％食管IPCL形态为Ⅱ型,但仍排列规律,与健康对照组比较差异均有统计学意义（P〈0．05）。结论食管ICPL形态特异性改变有助于GERD的内镜诊断;高质量的护理配合对顺利完成内镜检查起到了重要的作用。     

Is early endoscopy in the emergency room beneficial in patients with bleeding peptic ulcer? A "fortuitously controlled" study

BACKGROUND AND STUDY AIMS: In previous randomized trials, early endoscopy improved the outcome in patients with bleeding peptic ulcer, though most of these studies defined "early" as endoscopy performed within 24 hours after admission. Using the length of hospital stay as the primary criterion for the clinical outcome, we compared the results of endoscopy done immediately after admission (early endoscopy in the emergency room, EEE) with endoscopy postponed to a time within the first 24 hours after hospitalization, but still during normal working hours ("delayed" endoscopy in the endoscopy unit, DEU). PATIENTS AND METHODS: We conducted a retrospective analysis of data from 81 consecutive patients with bleeding peptic ulcer admitted in 1997 and 1998 (age range 16 - 90 years). Of these 81 patients, 38 underwent DEU (the standard therapy at the hospital) and 43 underwent EEE. Patients in the two groups were comparable with regard to admission criteria, were equally distributed with respect to their risk of adverse outcome (assessed using the Baylor bleeding score and the Rockall score), and differed only in the treatment they received. Endoscopic hemostasis was performed whenever possible in all patients with Forrest types I, IIa, and IIb ulcer bleeding. RESULTS: We found similar rates in the two groups for recurrent bleeding (16 % in DEU patients vs. 14 % in EEE patients), persistent bleeding (8 % in DEU patients vs. none in EEE patients), medical complications (21 % in DEU patients vs. 26 % in EEE patients), the need for surgery (8 % in DEU patients vs. 9 % in EEE patients), and the length of hospital stay (5.1 days for DEU patients vs. 5.9 days for EEE patients). None of the differences between the two groups in these parameters were statistically significant. None of the patients died. CONCLUSIONS: Early endoscopy in an emergency room did not improve the clinical outcome in our 81 consecutive patients with bleeding peptic ulcer.     

The usefulness of endoscopic hemoclipping for bleeding Dieulafoy lesions

BACKGROUND AND STUDY AIMS: Dieulafoy lesion is a rare cause of massive gastrointestinal hemorrhage, most commonly from the proximal stomach. Surgery was regarded as the treatment of choice in the past, but recently endoscopic management has become the standard approach. However, the effectiveness of various endoscopic modalities in treating bleeding Dieulafoy lesion has been little studied. This study was therefore done to compare the hemostatic efficacy of endoscopic hemoclipping and epinephrine injection therapy. PATIENTS AND METHODS: Between January 1998 and December 2001, a consecutive series of 32 patients with bleeding Dieulafoy lesion underwent endoscopic treatment. They were randomly treated either by endoscopic epinephrine injection therapy (n = 16) or by hemoclipping (n = 16). We compared mortality rate, primary hemostasis rate, and rebleeding rate between two groups. RESULTS: There was no bleeding-related death in either group. There was no significant difference in primary hemostasis rates between the hemoclipping group (93.8 %) and epinephrine injection group (87.5 %, P = 1.00). There was a trend toward a lower rate of need for multiple endoscopic sessions to achieve permanent hemostasis in the hemoclipping group compared with the epinephrine injection group (6.3 % vs. 31.3 %, P = 0.086). Hemoclipping was significantly more effective in preventing recurrent bleeding than epinephrine injection therapy (0 % vs. 35.7 %, P < 0.05). With regard to lesion site, hemoclipping was significantly more effective in preventing recurrent bleeding of gastric body Dieulafoy lesion than epinephrine injection therapy (0 % vs. 50 %, P < 0.05). CONCLUSIONS: Bleeding from Dieulafoy lesion was well controlled by therapeutic endoscopic procedures. Hemoclipping was more effective for Dieulafoy lesion than epinephrine injection therapy, with less need for subsequent endoscopy.     

鼻内镜下鼻止血术后再出血的鼻内镜处理

目的：探讨鼻内镜下鼻止血术后再次出血的鼻内镜下处理技巧及疗效。 方法：回顾性分析2014年1月至2021年1月符合入选标准的我科住院行鼻内镜鼻止血术后再出血患者的临床资料，随访3个月，分析患者出血高危因素，观察再次鼻内镜下鼻止血效果，总结技术要点。 结果：共入选53例鼻内镜下鼻止血术后再出血患者，年龄31~79岁，平均58.6岁；女性10例（18.87%），男性43例（81.13%）。再出血发生于首次鼻内镜下止血后0.5 h~23 d；其中出血发生于24 h 内25例（47.18%），24~72 h12例（22.64%），72 h~7 d 8例（15.09%），7~30 d 8例（15.09%）。所有患者均再次接受经鼻内镜下鼻止血术，术后即刻止血成功率100%，术后随访3个月2例发生间断少量出血，对症治疗后出血停止，其余患者未再有活动性出血。 结论：鼻内镜下鼻止血术后再出血采用鼻内镜再次处理有效。     

内镜套扎术联合组织胶注射治疗食管胃底静脉曲张破裂出血疗效观察

目的观察内镜套扎术联合组织胶注射治疗食管胃底静脉曲张破裂出血的疗效。方法选择73例食管胃底静脉曲张破裂出血的患者,药物+内镜(生长抑素+内镜套扎术联合组织胶注射)治疗组34例,内科保守治疗(生长抑素+普洛奈尔)组39例,观察两组止血有效率和再出血率。结果药物+内镜治疗组止血有效率94.12%,再出血率5.88%;内科保守治疗止血有效率74.36%,再出血率27.27%。两组止血有效率差异无统计学意义(P>0.05),药物+内镜治疗组再出血率发生率明显低于内科保守治疗组,差异有统计学意义(P<0.05)。结论内镜下套扎术联合组织胶注射治疗食管胃底静脉曲张破裂出血安全有效。     

Overlooked lesions at emergency endoscopy for acute nonvariceal upper gastrointestinal bleeding

BACKGROUND AND STUDY AIMS: Excessive blood covering the examination field is a frequent cause of diagnostic failure in emergency endoscopy for acute upper gastrointestinal bleeding. The implications and outcome in these patients have not been well described. PATIENTS AND METHODS: The records for 1459 consecutive patients who presented at our medical center with acute nonvariceal upper gastrointestinal bleeding during a 15-month period were reviewed. All of the patients underwent emergency endoscopy within 24 h of initial presentation. Patients in whom an identifiable bleeding source was not found in spite of an overtly bloody lumen were designated as having a failure of diagnosis, and these cases were analyzed further. RESULTS: Diagnosis failed in 25 patients (1.7 %), 16 of whom underwent repeat endoscopy or surgical intervention. Bleeding vessels were identified in 13 of these patients. Gastric and duodenal ulcers were the most commonly overlooked lesions, with locations in the cardia (n = 3), fundus (n = 2), posterior wall of the antrum (n = 1), duodenal bulb (n = 3), second part of the duodenum (n = 2), and in the stoma of a Billroth II gastrectomy (n = 2). The rates for endoscopic complications, recurrent bleeding, surgery, and mortality were significantly higher in the group with diagnostic failure than in patients with acute upper gastrointestinal bleeding in whom diagnosis did not fail (8 % vs. 0.4 %; 20 % vs. 3.1 %; 16 % vs. 2.9 %; and 20 % vs. 3.6 %, respectively). CONCLUSIONS: In acute nonvariceal upper gastrointestinal bleeding, diagnostic failure is associated with higher morbidity and mortality. The data from this study emphasize the importance of good preparation before the procedure and adequate removal of blood during emergency endoscopy procedures.     

三腔二囊管与内镜联合治疗食管胃底静脉曲张破裂出血

目的探讨三腔二囊管与内镜联合治疗食管胃底静脉曲张破裂出血的疗效,及三腔二囊管压迫止血后,内镜介入时机的选择。方法 87例食管胃底静脉曲张破裂出血患者,随机分为2组,观察组：三腔二囊管压迫后,胃管抽出胃液提示无明显活动性出血,患者生命体征平稳后,即行内镜下曲张静脉治疗;对照组：传统方法三腔二囊管压迫止血（即：三腔二囊管气囊压迫止血,每8~12 h放松气囊1次,出血停止24~48 h后,先放出气囊空气,再观察24 h,如无再出血则拔管）,再行内镜治疗。结果两组患者均顺利完成了内镜下治疗,未因活动性出血或胃腔积血影响内镜操作或治疗效果。但观察组缩短了既往三腔二囊管压迫至内镜治疗的间隙期,减轻了患者痛苦,减少了气囊压迫并发症,避免了观察期内反复出血而延误内镜治疗时机,乃至死亡的可能。结论三腔二囊管与内镜联合治疗食管胃底静脉曲张破裂出血疗效佳,观察组内镜治疗的时机,兼具了内镜急诊止血与择期治疗预防再出血的优点,值得推广。     

康复新液联合奥美拉唑治疗老年人非静脉曲张性上消化道出血疗效观察

目的观察康复新液联合奥美拉唑治疗老年人非静脉曲张性上消化道出血的疗效。方法将胃镜检查确诊为非静脉曲张性上消化道出血56例患者按随机数字表法分为2组：治疗组32例,口服康复新液10 mL,tid;奥美拉唑40 mg加入生理盐水100 mL中静脉滴注,bid。对照组24例,奥美拉唑40 mg加入生理盐水100 mL中静脉滴注,bid。2组均5 d为1个疗程。对2组的疗效及止血时间进行比较。结果治疗组总有效率为96.9%,对照组总有效率为79.2%,2组比较差异有统计学意义（P〈0.05）。治疗组止血时间明显低于对照组（P〈0.05）。2组患者用药期间无不良反应,均有良好的耐受性。结论康复新液联合奥美拉唑可有效地治疗老年人非静脉曲张性上消化道出血。     

Endoscopic hemostasis by injection therapy and electro-hydro-coagulation in high-risk patients with active gastroduodenal bleeding ulcer

For the purpose of arresting hemorrhage from bleeding gastric or duodenal ulcers we developed, in 28 high-risk patients, a new method of endoscopic local injection of epinephrine (1:10,000) followed by electro-hydro monopolar coagulation and injection of Polidocanol (1%). Nine patients had signs of shock at the time of admission. The average blood requirements were 3.9 units in the first 24 hours. All patients had important factors militating against surgery, namely age and serious primary disease. In 26 out of 28 patients (92.8%) hemostasis was accomplished during endoscopy. Three patients (10.7%) rebled within the first 36 hours, requiring emergency surgery. Thus definitive hemostasis was achieved in 23 patients (82.1%). There were no complications as a result of endoscopic treatment.     

微孔多聚糖止血材料在消化性溃疡出血内镜治疗中的疗效及安全性观察

目的 探讨微孔多聚糖止血材料在消化性溃疡出血内镜治疗中的疗效及安全性。方法 收集内镜下诊断为消化性溃疡伴出血患者25例（观察组）,内镜下止血治疗方法为常规止血方法（机械止血、电凝止血）联合微孔多聚糖止血材料进行电动正压喷洒止血治疗,对比同期采用常规止血方法治疗的消化性溃疡伴出血患者25例（对照组）,比较2组患者5min...     

床边急诊胃镜诊治致死性非静脉曲张性上消化道大出血

目的探讨床边急诊胃镜在急性重症非静脉曲张性上消化道大出血诊治中的作用。方法154例致死性非静脉曲张性上消化道大出血病人，入院后即刻行床边急诊胃镜明确病因、部位及出血情况后胃镜下注射肾上腺素-利多卡因-高渗盐水止血。结果急诊诊断率94．2％，总有效率92．9％，再出血率9．0％，无不良反应。结论床边急诊胃镜能有效诊断急性致死性非静脉曲张性上消化道大出血，内镜下注射肾上腺素-利多卡因-高渗盐水能有效止血，安全、简便。     

63例非静脉曲张性上消化道出血的内镜治疗分析

目的探讨内镜治疗急性非静脉曲张性上消化道出血的疗效。方法回顾性分析2008年9月—2011年5月行内镜治疗的63例急性非静脉曲张性上消化道出血患者的临床资料。内镜治疗包括药物喷洒、注射、氩气等离子体电凝、金属钛夹等方法。结果 63例患者中,注射治疗31例,联合氩气治疗17例,联合钛夹15例。63例患者中即时止血成功60例(96.3%),48 h内再出血4例,再次内镜下止血成功3例。共4例治疗无效,均转外科手术治疗,内镜治疗总有效率为93.65%(59/63)。结论内镜治疗急性非静脉曲张性上消化道出血是一种安全、有效的方法。     

Pre-Endoscopic Rockall and Blatchford Scores to Identify Which Emergency Department Patients with Suspected Gastrointestinal Bleed Do Not Need Endoscopic Hemostasis

Background

The pre-endoscopic Rockall Score (RS) and the Glasgow-Blatchford Scores (GBS) can help risk stratify patients with upper gastrointestinal bleed who are seen in the Emergency Department (ED). The RS and GBS have yet to be validated in a United States patient population for their ability to discriminate which ED patients with upper gastrointestinal bleed do not need endoscopic hemostasis.

Objective

We sought to determine whether patients who received a score of zero on either score (the lowest risk) in the ED still required upper endoscopic hemostasis during hospitalization.

Methods

Retrospective electronic medical record chart review was performed during a 3-year period (2007–2009) to identify patients with suspected upper gastrointestinal bleed by ED final diagnosis of gastrointestinal hemorrhage and related terms at a single urban academic ED. The RS and GBS were calculated from ED chart abstraction and the hospital records of admitted patients were queried for subsequent endoscopic hemostasis.

Results

Six hundred and ninety patients with gastrointestinal bleed were identified and 86% were admitted to the hospital. One hundred and twenty-two patients had an RS equal to zero; 67 (55%; 95% confidence interval [CI] 46–63%) of these patients were admitted to the hospital and 11 (16%; 95% CI 9–27%) received endoscopic hemostasis. Sixty-three patients had a GBS equal to zero; 15 (24%; 95% CI 15–36%) were admitted to the hospital and 2 (13%; 95% CI 4–38%) received endoscopic hemostasis.

Conclusions

Some patients who were identified as lowest risk by the GBS or RS still received endoscopic hemostasis during hospital admission. These clinical decision rules may be insufficiently sensitive to predict which patients do not require endoscopic hemostasis.     

Adrenocortical Dysfunction Following Etomidate Induction in Emergency Department Patients

OBJECTIVE: To assess adrenocortical function following intravenous etomidate use in emergency department (ED) patients requiring intubation. METHODS: This was a prospective, randomized, controlled trial of consecutive patients presenting to the ED requiring intubation. Patients were randomized to receive a single bolus induction dose of either 0.05-0.1 mg/kg midazolam (control group) or 0.3 mg/kg etomidate (etomidate group) during a standardized rapid-sequence intubation (RSI) with succinylcholine. The primary outcome variable was adrenocortical function at 4, 12, and 24 hours post-induction as assessed by measured serum cortisol response to exogenous cosyntropin (cosyntropin stimulation test, CST). Fisher's exact test was used to compare CST results between groups. RESULTS: Thirty-one patients were enrolled: 8 control, 10 etomidate, and 13 excluded from analysis for either incomplete data or steroid use during the study period. The 4-hour CST results were significantly different between study groups, with a normal response in 100% of control patients vs 30% of etomidate patients (p = 0.004). The 12- and 24-hour CSTs did not differ significantly between groups: normal CST in 100% of control patients at 12 and 24 hours vs 100% and 90% among etomidate patients at 12 and 24 hours, respectively (p = 1.0 at 12 and 24 hours). Measured cortisol levels of patients with abnormal CSTs remained within normal laboratory reference ranges. CONCLUSION: Use of etomidate in ED patients requiring RSI results in adrenocortical dysfunction. However, cortisol levels remain within normal laboratory levels during this period of dysfunction. Adrenocortical dysfunction appears to resolve within 12 hours of a single bolus dose of 0.3 mg/kg etomidate.     

Urgent bedside endoscopy for clinically significant upper gastrointestinal hemorrhage after admission to the intensive care unit

Objective To investigate the sources of hemorrhage and use of endoscopic hemostasis in patients with clinically significant upper gastrointestinal (UGI) hemorrhage after admission to the intensive care unit (ICU).Design and setting Prospective study, 123 beds of ICU in a 1,629-bed medical center.Measurements and results Of the 9,512 consecutive admissions over a 2-year period 105 UGI hemorrhage patients underwent urgent bedside UGI endoscopy. We compared two groups of these patients, one receiving and the other not receiving endoscopic hemostasis. Ulcers with profusely bleeding stigmata occurred in 31 patients (29.5%), ulcers with clean bases or firmly adherent blood clots in 27 (25.7%), stress-related mucosal diseases in 23 (21.9%), esophageal varices in 5 (4.8%), malignancy in 4 (3.8%), and no detectable bleeding site in 15 (14.3%). Endoscopic hemostasis was attempted in 34 patients (32.4%). Primary hemostasis for them was achieved in 67.6% and the rebleeding rate was 30.4%. In-hospital mortality rate was 77.1% and death related to hemorrhage 6.2%. Length of ICU stay before endoscopic diagnosis was significantly shorter in those who underwent endoscopic hemostasis than those who did not (28.2±26.3 vs. 41.2±57.5 days).Conclusions Endoscopic hemostasis may be more beneficial when the period between ICU admission and development of hemorrhage is shorter. Bleeders can be more readily identified and controlled endoscopically in such patients. A significant proportion of bleeding sites cannot be identified by UGI endoscopy. It may indicate higher risk of small bowel hemorrhage in these critically ill patients.     

内镜下注射治疗消化性溃疡出血的临床研究

目的分析比较内镜下注射1％乙氧硬化醇和内镜下注射1：100000肾上腺素治疗消化性溃疡出血的疗效及安全性。方法选自2009年7月至2010年7月因呕血和（或）黑便人院,经急诊内镜检查确诊为消化性溃疡出血患者120例,随机分成治疗组和对照组各60例。治疗组采用注射1％乙氧硬化醇止血治疗,对照组采用注射1：100000肾上腺素止血治疗,两组患者均由同一位医师操作完成。结果治疗组止血成功率96．67％（58／60）,对照组止血成功率为92．98％（53／57）,两组比较差异无统计学意义（P〉0．05）;治疗组与对照组止血成功后3h内再出血率分别为1．72％（1／58）,3．77％（2／53）,差异无统计学意义（P〉0．05）,两组3～24h内再出血率分别为3．45％（2／58）,16．98％（9／53）,两组比较差异有统计学意义（P〈0．05）。两组患者随访2个月再出血率分别为1．72％（1／58）,1．89％（1／53）,差异无统计学意义（P〉0．05）;随访6个月均未发现再出血。均未发现与治疗相关的并发症。两组患者的外科手术率、住院天数和死亡率差别没有统计学意义。结论内镜下注射硬化剂与肾上腺素均是治疗消化性溃疡出血的安全有效方法,并且内镜下注射乙氧硬化醇治疗。