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。     

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。     

急诊上消化道出血186例临床分析

目的:探讨急诊科上消化道出血的病因构成及特点.方法:回顾性分析我科2010年1月至2012年1月诊治的186例上消化道出血患者的临床资料.结果:(1)上消化道出血主要病因为消化性溃疡46.9％、急性胃黏膜病变12.7％、肝硬化9.0％、胃癌7.2％,贲门撕裂症6.0％.(2)急诊内镜诊断明确的阳性率(95.6％)显著高于非急诊内镜(81.3％),P＜0.01.(3)服用非甾体消炎药(NSAIDs)患者急性胃黏膜病变发生率(39.5％)明显高于未服用者(4.1％),P＜ 0.01;服用NSAIDs患者消化性溃疡发生率(52.6％)虽高于未服用者(39.2％),但差异无统计学意义,P＞ 0.05.结论:服用NSAIDs是上消化道出血的重要原因,急性胃黏膜病变发生率较前有所增加,急诊内镜检查有助于上消化道出血的诊断.     

High-risk ED patients with nonvariceal upper gastrointestinal hemorrhage undergoing emergency or urgent endoscopy: a retrospective analysis

OBJECTIVES: The optimal timing of interventional endoscopy within the initial 24 hours remains controversial. We designed a retrospective study to compare the outcomes between emergency endoscopy (EE) and urgent endoscopy (UE) for high-risk patients with nonvariceal upper gastrointestinal hemorrhage presenting to the emergency department (ED). METHODS: The medical records of 189 patients with nonvariceal upper gastrointestinal hemorrhage who underwent endoscopy within 24 hours of admission to the ED were reviewed. Patients were divided into 2 groups: EE group (<8 hours) or UE group (8-24 hours). We compared the endoscopic findings, hemostatic procedures, rate of hemostasis, rebleeding, need for transfusion, length of hospitalization, and mortality between the 2 groups. RESULTS: There were 88 patients (47%) in the EE group and 101 patients (53%) in the UE group. Ulcers with active bleeding or exposed vessel were found more frequently in the EE group than in the UE group (19% vs 8%, P = .03; 34% vs 12%, P < .001). Fifty patients had blood retention in the stomach, especially in the EE group (40% vs 15%, P < .001). Forty-four (50%) patients in the EE group and 21 (21%) patients in the UE group received endoscopic interventions. Combination modalities of endoscopic hemostasis were more commonly used in the EE group than in the UE group (40% vs 15%, P < .001). Primary hemostasis was achieved at a rate of 95% in both groups. There was no statistical difference regarding the rate of recurrent bleeding, total amount of transfusion, length of hospital stay, and mortality rate in both groups. CONCLUSIONS: Although more active lesions were detected and more therapeutic attempts were performed in the EE group, the outcome showed no difference in both groups. Emergency endoscopy performed less than 8 hours after arrival to the ED showed no definite benefit in comparison with UE performed within 8 to 24 hours.     

内镜下钛夹治疗上消化道非静脉曲张出血60例的护理配合

摘要：目的通过对60例上消化道非静脉曲张出血患者采用金属钛夹在内镜下直接止血,总结护理配合技巧和要点。方法用金属钛夹推送器安装钛夹,对准出血部位释放金属钛夹达到止血目的。结果60例非静脉曲张上消化道出血,根据Forrest分级标准,Ⅰa6例,Ⅰb38例,Ⅱa9例,Ⅱb7例。共用金属钛夹125枚,所有病例内镜下首次止血成功率100％,术后无不良反应及并发症。结论掌握内镜性能,正确使用金属钛夹推送器,可确保内镜下金属钛夹治疗消化道出血的成功。     

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。     

Causes and clinical outcome of acute upper gastrointestinal bleeding: a prospective analysis of 1534 cases

Despite considerable improvement in the diagnostic and therapeutic approach to patients with acute upper gastrointestinal (GI) bleeding, several studies suggest there has been no overall change in mortality. The aim of this study was to evaluate prospectively the effect of early emergency diagnostic and therapeutic endoscopy and medico-surgical collaboration in the clinical outcome of 1534 patients with acute upper GI bleeding treated in our hospital over the past five years. Emergency endoscopy and injection haemostasis were performed within 24 hours of admission, or immediately after resuscitation, in patients with massive bleeding; patients were then treated with close co-operation between surgeons and gastroenterologists. We observed an increase in the incidence of peptic ulcer (67%) with a simultaneous decrease in the incidence of gastroduodenitis (13.5%) as a cause of bleeding compared with the previous decade. In peptic ulcer bleeding, emergency surgical haemostasis was required in 92 patients (8.9%), while none of the patients with erosive gastroduodenitis required surgical intervention. Overall mortality was 2.9%, and in peptic ulcer bleeding patients 2.1% with a postsurgical mortality of 8.7%. Peptic ulcer remains the main cause of upper GI bleeding. Improved clinical outcome and low mortality can be achieved with early diagnostic and therapeutic endoscopy and medico-surgical collaboration.     

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。     

Prevalence,management, and outcomes of patients with coagulopathy after acute nonvariceal upper gastrointestinal bleeding in the United Kingdom

BACKGROUND: Coagulopathy after major hemorrhage has been found to be an independent risk factor for mortality after traumatic bleeding. It is unclear whether similar associations are present in other causes of major hemorrhage. We describe the prevalence, use of plasma, and outcomes of patients with coagulopathy after acute nonvariceal upper gastrointestinal bleeding (NVUGIB). STUDY DESIGN AND METHODS: This study was a multicenter UK national audit. Data were collected prospectively on consecutive admissions with upper gastrointestinal bleeding over a 2‐month period to 212 UK hospitals. Coagulopathy was defined as an international normalized ratio (INR) of at least 1.5. Logistic regression was used to examine the relationship between coagulopathy and patient‐related outcome measures of mortality, rebleeding, and need for surgery and/or radiologic intervention. RESULTS: A total of 4478 patients were included in the study. Coagulopathy was present in 16.4% (444/2709) of patients in whom an INR was recorded. Patients with coagulopathy were more likely to present with hemodynamic shock (45% vs. 36%), have a higher clinical Rockall score (4 vs. 2), receive red blood cell transfusion (79% vs. 48%) and have high‐risk stigmata of hemorrhage at endoscopy (34% vs. 25%). After adjustment for confounders the presence of a coagulopathy was associated with a fivefold increased in the odds of mortality (odds ratio, 5.63; 95% confidence interval, 3.09‐10.27; p < 0.001). Only 35% of patients with coagulopathy received fresh‐frozen plasma transfusion. CONCLUSIONS: Coagulopathy was prevalent in 16% of patients after NVUGIB and independently associated with more than a fivefold increase in the odds of in‐hospital mortality. Wide variation in plasma use exists indicates clinical uncertainty regarding optimal practice.     

Endoscopic diagnosis,emergency therapy and outcome in 397 patients with acute gastrointestinal haemorrhage -a prospective study

Summary

The mortality of acute gastrointestinal haemorrhage in the literature varies significantly, depending on the study design and quality of the data. We therefore conducted a prospective study over 2.5 years of 397 patients with suspected acute Gl haemorrhage at the University Hospitals of Erlangen for internal quality control. In 99% of cases diagnostic endoscopy yielded one or more bleeding sources. Forty-six per cent of the patients bled from duodenal or gastric ulcers, 21% from oesophageal or gastric varices and 33% from other sources. Two hundred and twenty-eight of the 397 patients (57%) were initially treated endoscopically, 76 patients (19%) experienced a recurrence of a bleed. Patients older than 60 years of age with a haemoglobin below 8 g/dl had a significantly higher rate of recurrence of a bleed. The rate of complications during the hospital stay was 22% (n = 87), in-hospital mortality 17% (n=68). The rate of recurrence of the bleed (28 vs 20%), of complications (24 vs 18%) and mortality (20 vs 14%) was significantly higher for bleeding varices than for peptic ulcers. Patients with other causes of acute Gl-haemorrhage had a recurrence of the bleed in 13%, complications in 26% and a mortality of 19%. Bleeding varices as well as bleeding peptic ulcers and other causes of acute Gl haemorrhage still have a high mortality and require intensive medical surveillance besides diagnostic and therapeutic endoscopy.     

胃镜下重酒石酸去甲肾上腺素喷洒与注射治疗急性 非静脉曲张性上消化道出血的疗效比较

目的探讨和比较胃镜下重酒石酸去甲肾上腺素喷洒与注射治疗急性非静脉曲张性上消化道出血(ANVUGIB)的临床疗效。方法选取2015年12月-2017年11月该院收治的92例ANVUGIB患者作为临床研究对象,采用随机数字表法,将入选患者随机分为观察组47例和对照组45例。观察组患者给予胃镜下重酒石酸去甲肾上腺素注射的临床药物治疗,对照组患者则给予胃镜下重酒石酸去甲肾上腺素喷洒的临床药物治疗,并分别对两组患者的临床治疗情况、临床指标变化情况和不良反应发生情况进行比较和分析。结果与对照组患者相比,观察组患者临床治疗的显效率57.45%(27/47)和总有效率91.49%(43/47)均明显提高,而无效率8.51%(4/47)则明显降低,差异均有统计学意义(P 0.05);观察组患者止血成功率91.49%(43/47)明显提高,差异有统计学意义(P 0.05),同时再出血率6.38%(3/47)和急诊手术率2.13%(1/47)则均有所降低,但差异均无统计学意义(P0.05);观察组患者腹部不适、大便频繁、胀气和血压不稳等不良反应总发生率10.65%(5/47)明显降低,差异有统计学意义(P 0.05)。结论胃镜下重酒石酸去甲肾上腺素注射治疗ANVUGIB较喷洒给药疗效更为确切,且预后效果好,并发症少。     

Factors associated with myocardial infarction after emergency endoscopy for upper gastrointestinal bleeding in high-risk patients: a prospective observational study

BACKGROUND: Because myocardial infarction (MI) after emergency endoscopy for upper gastrointestinal bleeding carries high mortality, we investigated factors associated with procedure-related MI in high-risk patients. METHODS: Consecutive patients with coronary artery disease or age-based risk for coronary artery disease (men, age >45 years; women, >55 years) who underwent emergency endoscopy were enrolled at a single ED. Demographic, laboratory, and outcome data were recorded. Patients fit 1 of 3 groups: MI before endoscopy (pre-panendoscopy [PES] MI), MI after endoscopy (post-PES MI), or non-MI. RESULTS: We enrolled 108 high-risk patients, including 5 (4.6%) with MI diagnosed preendoscopy. Five patients (4.6%) had MIs postendoscopy. Compared with non-MI patients, significantly more post-PES MI patients had heart disease (60.0% vs 12.2%; P = .021), lower systolic pressure on arrival (86.2 +/- 16.6 vs 128.0 +/- 27.2 mm Hg; P = .002), lower diastolic pressure on arrival (50.0 +/- 6.3 vs 69.5 +/- 15.8 mm Hg; P = .003), lower hemoglobin on arrival (6.7 +/- 1.1 vs 9.1 +/- 2.4 g/dL; P = .021), and more persistent shock status preendoscopy (80.0% vs 13.3%; P = .002). There was no significant difference in factors including duration of procedure and rates of recurrent bleeding, postprocedure complication, and mortality. CONCLUSIONS: Heart disease, lower blood pressure or hemoglobin level on arrival, and persistent shock before endoscopy are associated with increased risk for procedure-related MI.     

急诊老年人酸相关性上消化道出血分析

目的探讨诊老年人与酸相关性上消化道出血的原因及特点。方法对239例与酸相关性老年人消化道出血进行回顾性分析。结果老年人酸相关性上消化道出血占所有上消化道出血的57.87%,其中,胃食管反流病占1.67%,消化性溃疡占63.18%,胃炎或十二指肠球炎占9.21%,功能性消化不良占0.84%,急性胃黏膜病变占25.10%。死亡27例,其中直接死于出血1例,占3.70%,死于全身慢性疾病恶化以及出血后并发症及继发的多脏器功能衰竭24例,占88.89%。病死率占总数的11.30%。结论酸相关性疾病是老年人上消化道出血的主要原因,影响预后的因素更倾向于基础疾病及全身状况的恶化。      

乐奥尼龙绳联合钛夹荷包封闭溃疡面在急性非静脉曲张性上消化道出血中的临床应用*

目的研究应用乐奥尼龙绳联合钛夹荷包缝合封闭溃疡面在急性非静脉曲张性上消化道出血(ANVUGIB)中的作用。方法回顾性分析该院2015年7月-2019年3月应用上述方法治疗的126例ANVUGIB患者,观察止血时间、术后再出血率、并发症、术后外科手术率和随访观察溃疡愈合情况等。结果126例患者均成功完成止血治疗,平均操作时间15 min(8~21 min),止血成功率100%。术后平均随访6个月,所有溃疡均愈合良好,无1例再出血。结论尼龙绳联合钛夹荷包封闭溃疡面止血是一种治疗ANVUGIB安全有效的方法。     

Emergency endoscopy for upper gastrointestinal bleeding in patients with coronary artery disease

Background

Endoscopy is useful for diagnosis and treatment of upper gastrointestinal bleeding (UGIB). However, both endoscopy and UGIB may compromise the cardiovascular function. The present study is to investigate the cardiovascular responses of emergency endoscopy for patients with UGIB and stable coronary artery disease (CAD).

Methods

Consecutive 50 patients with known CAD and 50 patients without CAD history (non-CAD group) in whom emergency endoscopy was requested for UGIB were prospectively enrolled. All patients received ambulatory electrocardiographic monitoring before, during, and after endoscopies. Cardiac indices including supraventricular and ventricular arrhythmia, ST ischemic change, and autonomic nervous function evaluated by heart rate variability were compared.

Results

All patients in both groups had successful primary hemostasis, and peptic ulcer bleeding was the main etiology (82%). Compared with the non-CAD group, patients with CAD had a significantly higher incidence (42% vs 16%, P = .004) and frequency (1.19 vs 0.12 events per minute, P = .003) of ventricular arrhythmias during endoscopy. Nine patients with CAD and 1 patient without CAD had ischemic ST changes (P = .016). Comorbidity with congestive heart failure was not only associated with a higher frequency (P = .02) but also a more severe fluctuation (P = .002) of ventricular arrhythmia. None in both groups had angina or MI before, during, or after endoscopy. Heart rate variability did not show a difference.

Conclusions

Ventricular arrhythmias and myocardial ischemia, although mostly subclinical, were common in patients with stable CAD undergoing emergent endoscopy for UGIB, especially in those with concomitant congestive heart failure.     

急诊内镜检查在上消化道出血中的应用

目的探讨急诊内镜检查在上消化道出血患者中的临床应用价值。方法回顾性分析2003年10月至2007年5月因上消化道出血于48h内行急诊内镜检查159例患者的临床资料，对比分析不同时间内镜检查的差异以及检查前冰盐水洗胃与否对检查结果的影响。结果急诊内镜检查确诊率为94．97％，不同时间内镜检查确诊率不同，发生出血后24h内行内镜检查其确诊率明显提高，与24～48h相比差异有显著性（P〈0．01）。内镜检查前洗胃与否两组对比分析无明显差异（P〉0．05），所有患者均未发生严重并发症。结论急诊内镜检查是安全有效的，尽早行内镜检查可提高诊断准确率，内镜检查前无需冰盐水洗胃。     

Efficacy and safety of nurse-administered propofol sedation during emergency upper endoscopy for gastrointestinal bleeding: a prospective study

BACKGROUND AND STUDY AIMS: Recent studies have documented the safety of propofol sedation for endoscopic procedures, but many endoscopists are reluctant to use propofol for high-risk patients because of adverse effects. The aim of this study was to demonstrate the safety and efficacy of nurse-administered propofol sedation during emergency upper endoscopy for patients with gastrointestinal bleeding. PATIENTS AND METHODS: Over a period of 18 months, 120 patients suffering from acute upper gastrointestinal bleeding received propofol sedation administered by a registered nurse. Among these, 15 patients were classified into American Society of Anesthesiologists (ASA) class IV, 84 were ASA class III, and 21 were ASA class II. Patients without gastrointestinal bleeding, who also received propofol during the same period and were matched for age, gender, and ASA class, served as controls. RESULTS: Endoscopic hemostasis was achieved in 98.3 % of patients, and 97.5 % were satisfied with the procedure. In patients with gastrointestinal bleeding, the rates of hypotension (systolic blood pressure < 90 mmHg) and hypoxemia (peripheral oxygen saturation < 90 %) were 8.3 % and 6.7 % respectively, values higher than those in the control group. However, neither mask ventilation nor endotracheal intubation was necessary. Although two patients with gastrointestinal bleeding developed pneumonia, most likely due to aspiration during the procedure, they recovered within 5 days of treatment. There were no sedation-associated severe complications or mortalities. CONCLUSION: Using a strict protocol designed to protect the patient's airway and cardiovascular function, nurse-administered propofol sedation during emergency upper gastrointestinal endoscopy is safe and appropriate in cases of acute gastrointestinal bleeding.     

Significance of emergency endoscopy in severe upper gastrointestinal hemorrhage

312 of a total of 543 emergency endoscopies were carried out in patients with severe haemorrhage of the upper gastrointestinal tract. This was defined as a haemorrhage of such severity that at least 2 of the following 3 criteria were present: a shock index greater than 1, an erythrocyte count of less than 3 million/mm3, and a transfusion requirement of three or more 500 ml bags of blood. The source of the bleeding was exactly located in 247 endoscopies, and accurate diagnoses were established in 94.4% of the cases examined. The most frequent source of bleeding was oesophageal varices, followed by duodenal ulcers. In 20.2% of these cases, further sources of potential haemorrhage were found in the upper gastrointestinal tract. Endoscopic diagnosis resulted in immediate, specific therapy in 286 cases. Treatment was given within the first 24 hours in every case. 24.7% of our patients had to undergo laparotomy immediately after endoscopy. 30.4% were given H2 receptor inhibitors, and 35.6% underwent endoscopic haemostasis. The mortality rate in these patients was 29.5%. These results indicate that emergency endoscopy is an important aid to decision-making in cases of severe haemorrhage of the upper gastrointestinal tract.     

术中内镜在急性消化道大出血急诊剖腹探查术中的应用价值

目的 探讨术中内镜在急性消化道大出血患者行急诊剖腹探查术中的应用价值及其安全性。方法对25例急性消化道大出血行急诊剖腹探查的患者进行术中内镜检查，评价其应用价值。结果25例术中内镜检查有24例明确了出血原因，检出率达96．0％。术中内镜平均用时13min，无一例术中内镜受检者发生术中内镜相关性并发症。所有患者均根据术中内镜诊断进行了相关手术治疗，术后无一例再出血。结论急性消化道大出血患者术中内镜的应用，不仅提高了病变的检出率，而且能对病灶进行准确定位与定性，可提高剖腹探查的成功率。     

Endoscopic orientation within the duodenal bulb.

Laparotomy performed for bleeding duodenal ulcer after diagnostic/therapeutic endoscopy revealed a disparity in location of the lesion on several occasions at our institution. The position of the duodenal lesion is important in assessing bleeding potential. Twenty consecutive patients underwent upper gastrointestinal endoscopy by a staff and trainee gastroenterologist to evaluate the ability to determine the true posterior position of the duodenal bulb. Documentation of the posterior bulb location was verified by pooled colored fluid with the patient in a supine position. True posterior location was chosen only 30% of the time by an experienced gastroenterologist. This observation may have clinical implications in assessing the patient's bleeding potential and in the use of coaptive coagulation for control of ulcer bleeding.