无痛内镜下注射止血联合大剂量洛赛克治疗消化性溃疡出血的临床研究

[目的]观察无痛内镜下注射止血联合大剂量洛赛克治疗消化性溃疡出血的临床效果。[方法]选择诊断为消化性溃疡出血患者90例,随机分为大剂量洛赛克治疗组(A组)、无痛内镜止血联合常规剂量洛赛克治疗组(B组)、无痛内镜止血联合大剂量洛赛克治疗组(C组),每组30例。A组患者用洛赛克40mg静脉推注,每日3次,连续5d;B组患者于内镜检查前先用洛赛克40mg静脉推注,于异丙酚镇静下行内镜检查出血点,注射1/10 000肾上腺素止血,内镜止血后继续用洛赛克40mg静脉推注,每日2次,连续5d;C组患者除内镜止血后静脉推注洛赛克40mg,每日2次改为每日3次外,其余同B组。[结果]与A组比较,B、C组的止血时间缩短、再出血率下降、手术率及住院时间降低,差异有统计学意义(P0.05);与B组比较,C组的止血时间缩短、再出血率下降、手术率及住院时间降低,差异有统计学意义(P0.05)。[结论]无痛内镜下注射止血联合大剂量洛赛克治疗消化性溃疡出血安全有效,符合基层医院的条件,也符合患者舒适化医疗的需求,值得在基层医院推广。     

急诊内镜联合选择性动脉造影诊治上消化道大出血：7例临床分析

背景：上消化道大出血属急危重症,联合多种诊治手段有助于提高救治效果。目的：探讨急诊内镜联合选择性动脉造影在上消化道大出血诊治中的应用价值。方法：选取2009年1月～2010年12月北京军区总医院经急诊内镜止血失败或止血成功后再次大出血的7例患者并给予选择性动脉造影和栓塞治疗。观察急诊内镜联合选择性动脉造影对明确病因诊断和止血效果的价值。结果：7例患者行急诊内镜检查确诊为上消化道大出血．并经镜下止血治疗后仍有严重活动性出血．行选择性动脉造影和栓塞治疗。7例患者就诊后行急诊内镜的平均时间为4．4h．选择性动脉造影平均时间为8．4h。4例患者表现为造影剂外溢的出血直接征象．其余3例表现为异常血管分支增粗紊乱的间接征象;给予弹簧圈栓塞或明胶海绵栓塞治疗后均成功止血。结论：急诊内镜联合选择性动脉造影是一种及时、安全、有效的诊治上消化道大出血的方法。     

老年非静脉曲张性上消化道大出血的内镜紧急治疗

目的探讨急诊内镜下止血治疗老年非静脉曲张性上消化道大出血的疗效及安全性。方法对68例活动性出血患者行床边急诊内镜检查,并内镜下喷药及注射止血治疗。结果所有患者包括高龄、高危患者均安全接受急诊内镜下治疗,急诊镜下止血68例,即时止血64例,近期再止血6例,1次止血成功58例,2次止血成功3例,急诊手术7例,死亡3例。结论急诊内镜下止血治疗老年非静脉曲张性上消化道大出血安全有效,对老年人及高危患者应作为首选治疗方法。     

急诊胃镜在残胃并发上消化道大出血中的临床价值

目的探讨急诊胃镜及内镜下治疗在残胃并发上消化道大出血中的临床价值。方法回顾性分析武汉大学人民医院2008年1月-2011年1月因残胃引起的上消化道大出血患者的临床资料及处理方法。结果所有并发消化道出血患者首选药物+内镜止血,其中单纯药物止血23例,药物+内镜止血37例,治疗失败行介入治疗6例,上述处理无效转外科手术1例,所有患者均成功止血。结论残胃患者一旦出现上消化道大出血,在补充有效血容量的基础上,尽快行急诊内镜检查,根据出血量及内镜下forrest分级采取不同的止血措施。     

生长抑素、垂体后叶素、洛赛克治疗肝炎性肝硬化并上消化道大出血疗效观察

目的观察生长抑素、垂体后叶素、洛赛克静脉给药治疗肝炎性肝硬化合并上消化道大出血的疗效。方法回顾性分析应用生长抑素、垂体后叶素、洛赛克静脉给药治疗的35例肝炎性肝硬化合并上消化道大出血患者的临床资料。结果35例患者中显效29例,有效5例,无效1例。结论生长抑素、垂体后叶素、洛赛克在抢救治疗肝炎性肝硬化合并上消化道大出血患者,止血迅速、操作方便。     

十二指肠乳头切开术和球囊扩张术后迟发型大出血发生率的对比研究(附视频)

目的探讨内镜引导逆行胰胆管造影术(ERCP)后十二指肠乳头迟发型大出血的影响因素及内镜下治疗策略。方法回顾性分析2008年3月至2014年12月经郑州大学人民医院(河南省人民医院)消化科行ERCP诊疗的1571例患者的临床及内镜诊疗资料。结果十二指肠乳头切开(EST)组术后迟发型大出血率(5/1034,0.48%)略高于球囊扩张组(0/479,0),但无显著差异(0.88%vs 0,P=0.066)。5例大出血患者均在内镜下成功止血,其中1例止血钳止血,2例氩离子凝固术(APC)止血,2例肾上腺素注射止血,1例注射止血成功后再次出血,采用APC止血成功。结论 APC是ERCP术后十二指肠乳头迟发型大出血止血的有效措施,操作简单且安全,采用球囊扩张可能降低十二指肠乳头迟发型大出血的发生率,但本研究样本量较少,还需要多中心大样本研究进一步验证。     

急诊内镜下硬化治疗食管静脉曲张破裂大出血12年回顾

目的探讨急诊内镜下硬化治疗食管静脉曲张破裂大出血近期止血效果,分析其术后相关并发症及可能机制。方法收集苏州大学第三附属医院2003年1月-2014年12月急诊内镜下硬化治疗食管静脉曲张破裂大出血523例次的临床资料,回顾性分析其止血率、再出血率及并发症情况。结果急诊内镜下硬化治疗523例次,483例次止血成功,急诊止血率92.4%。硬化治疗后72 h~1周再出血105例次,再出血率20.1%。急诊内镜下硬化治疗患者中,出现中-高热48例,胸痛者45例,早期并发症发生率17.8%。结论急诊内镜下硬化治疗简便、高效,近期并发症少,对于食管静脉曲张破裂大出血患者可作为急诊止血首选方案。     

洛赛克治疗胃十二指肠溃疡合并大出血患者的止血疗效观察

我们对36例因消化性溃疡合并大出血的病人,用洛赛克注射剂治疗,观察其在止血、溃疡愈合中的疗效,获得较好的效果。现报告如下。     

床边紧急内镜下微波治疗急性上消化道大出血

床边紧急内镜下微波治疗急性上消化道大出血顾荣斌戴耀曾黄介飞我院近三年来对３６例经常规内科治疗难以控制的急性上消化道大出血患者于床边紧急行内镜下微波凝固止血，取得满意疗效，现报告如下。１．临床资料：本组病例男２１例、女１５例，年龄最大６２岁、最小１７岁...     

上消化道急性应激性粘膜病变出血的内镜诊断和治疗

目的 探讨上消化道急性应激性粘膜病变出血患者的内镜诊断和治疗。方法 对上消化道急性应激性粘膜病变出血患者在24小时内急查内镜,并进行镜下止血及其他治疗。结果 30例患者中一般性出血20例,大出血10例,其病变内镜下表现为6种类型。单纯内镜下止血7例全部有效,内镜下止血加静脉止血治疗10例亦全部成功,内镜下止血加静脉止血加经胃管止血治疗10例中8例有效、死亡2例,有3例重症患者虽经内、外科综合治疗仍死亡2例。结论 急诊内镜不仅是上消化道急性应激性粘膜病变出血准确可靠的诊断手段,而且也是快速有效的治疗方法。     

Oral Proton Pump Inhibitors Are as Effective as Endoscopic Treatment for Bleeding Peptic Ulcer: A Prospective,Randomized, Controlled Trial

In managing patients with bleeding peptic ulcers, it has been reported that pharmacologic treatment can be an alternative to endoscopic treatment. We compared the hemostasis rates of the endoscopic treatment, hemoclipping, and the phamacologic treatment, oral proton pump inhibitors (PPIs), in bleeding peptic ulcer. A randomized prospective study was performed on 129 bleeding peptic ulcer patients with hematemesis or melena. Sixty-two patients were treated by endoscopic hemoclipping and subsequently H₂ receptor antagonists were injected intravenously (hemoclipping group), and 67 patients were treated with an oral PPI without endoscopic treatment (PPI group). The 24-hr gastric pH test was performed sequentially following the treatment. The initial hemostasis rate of the hemoclipping group was 93.5% (58/62) and the rebleeding rate was 6.9% (4/58), and the hemostasis rate of the PPI group was 92.5% (62/67) and the rebleeding rate was 7.5% (5/67), which were not different. The 24-hr gastric pH was 4.54 ± 2.56 in the hemoclipping group and 5.97 ± 1.30 in the PPI group (P < 0.037). In the bleeding peptic ulcer patients, the hemostasis rate with the oral administration of PPIs was not different from that with the endoscopic hemoclipping treatment.     

Will Helicobacter pylori affect short-term rebleeding rate in peptic ulcer bleeding patients after successful endoscopic therapy?

OBJECTIVE: Helicobacter pylori (H. pylori) can augment the pH-increasing effect of omeprazole in patients with peptic ulcer. A high intragastric pH may be helpful in preventing recurrent hemorrhage by stabilizing the blood clot at the ulcer base of bleeding peptic ulcer patients. Therefore, we hypothesized that omeprazole may reduce short-term rebleeding rate in these patients with H. pylori infection after initial hemostasis had been obtained. METHODS: Between July 1996 and December 1998, 65 bleeding peptic ulcer patients (24 gastric ulcer, 41 duodenal ulcer) who had obtained initial hemostasis with endoscopic therapy were enrolled in this trial. Thirty (46.2%) of them were found to have H. pylori infection by a rapid urease test and pathological examination. For all studied patients, omeprazole was given 40 mg intravenously every 6 h for 3 days. Thereafter, omeprazole was given 20 mg per os (p.o.) once daily for 2 months. A pH meter was inserted in the fundus of each patient under fluoroscopic guidance after intravenous omeprazole had been administered. The occurrence of rebleeding episode was observed for 14 days. RESULTS: In patients with H. pylori infection, intragastric pH (median, 95% confidence interval [CI]: 6.54, 5.90-6.68) was higher than in those without H. pylori infection (6.05, 5.59-6.50, p < 0.001). However, the patients with rebleeding (2 vs 3), volume of blood transfusion (median, range: 1000 ml, 0-2250 vs 750, 0-2000), number of operations (0 vs 1), mortality caused by bleeding (0 vs 0), and hospital stay (median, range: 6 days, 3-14 vs 7, 5-16) were not statistically different from those without H. pylori infection. CONCLUSIONS: Omeprazole does increase intragastric pH in bleeding peptic ulcer patients with H. pylori infection. However, the presence of H. pylori infection does not affect the short-term rebleeding rate in these patients.     

Endoscopic hemostasis: Safe treatment for peptic ulcer patients aged 80 years or older?

BACKGROUND AND AIM: Recently, the number of peptic ulcer patients aged 80 years or older has been increasing. However, little information is available concerning therapeutic endoscopy for these patients. The objective of this study was to evaluate the efficacy of endoscopic hemostasis for peptic ulcer bleeding in patients aged 80 years or older. METHODS: In this 7-year study, bleeding peptic ulcer patients were divided into group A (>/=80 years old) and group B (<80 years), for which prospective data, endoscopic findings and outcomes of endoscopic treatment were compared. RESULTS: Of the 459 patients who underwent endoscopic hemostasis for peptic ulcer bleeding, the 42 patients (average age 84 +/- 3 years) in group A had a significantly higher incidence of concomitant disease, lower hemoglobin, transfusional requirement over 800 mL and lower serum albumin than the 417 patients (average age 55 +/- 13 years) in group B. Significantly more patients in group A had large gastric ulcers. More patients in group A had ulcers located at the proximal third of the stomach, which is technically difficult to treat endoscopically. Nevertheless, all patients in groups A and B underwent initial hemostasis successfully. The rebleeding rate was not significantly different between group A and B. Neither group had hospital deaths nor complications related to endoscopic procedures. CONCLUSIONS: Endoscopic hemostasis for peptic ulcer bleeding in patients aged 80 years or older is effective and safe. Increasing age may no longer be a risk factor for rebleeding and hospital death after endoscopic hemostasis for peptic ulcer bleeding.     

Multicenter prospective study of prognostic factors of gastroduodenal ulcer hemorrhages. Reevaluation of clinical and endoscopic factors in the era of endoscopic hemostasis

AIM: To evaluate in a prospective study the prognostic factors of recurrent bleeding and mortality in patients presenting with high risk peptic ulcer bleeding routinely treated by endoscopic hemostasis. PATIENTS AND METHODS: A multicenter study was carried out in 8 Western French hospitals in 144 patients with gastrointestinal bleeding peptic from ulcer type I or IIa, b as defined by Forrest classification. Thirty four and 38 parameters were studied respectively in order to predict recurrent bleeding and death. Significant predictive factors (P < 0.1) in univariate analysis were entered in a multivariate logistic regression analysis. RESULTS: Endoscopic hemostasis was performed in 108 of 144 cases (75%). Recurrent bleeding and death occurred in 39 (28%) and 22 cases (15%), respectively. By multivariate analysis, the only predictor of rebleeding was hypovolemia at admission. Predictors of death were ASA score, cardiovascular Goldman score and recurrent bleeding. In this study, prevalence of Helicobacter pylori infection was low (41%) but was not a predictive factor. CONCLUSIONS: In a selected population of peptic ulcer bleeding patients with high risk of rebleeding, prevalence of recurrent bleeding and death remains rather high, despite routine endoscopic hemostasis. In the era of endoscopic hemostasis, clinical parameters remain the best prognostic factors of peptic ulcer bleeding outcome.     

Renal Dysfunction is an Independent Risk Factor for Rebleeding After Endoscopic Hemostasis in Patients with Peptic Ulcer Bleeding

BackgroundDespite the progress in endoscopic hemostasis and pharmacological treatment, the mortality rate of peptic ulcer bleeding remains at 5–10%. Rebleeding after peptic ulcer bleeding is believed to be a risk factor for mortality. This study aimed to evaluate whether renal dysfunction is a predictor of rebleeding after endoscopic hemostasis in patients with peptic ulcer bleeding.Methods: In this retrospective study, consecutive patients with peptic ulcer bleeding who underwent endoscopic hemostasis at our Hospital from January 2010 to December 2018 were enrolled. The relationship between rebleeding within 30 days after endoscopic hemostasis and the patients’ admission and endoscopic characteristics were analyzed using univariate and multivariate regression models.ResultsOut of 274 patients with peptic ulcer bleeding, 17 (6.2%) patients experienced rebleeding. In the analysis of the patients’ admission characteristics, estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m² was an independent risk factor for rebleeding (odds ratio 4.77, 95% confidence interval 1.168-18.211, p = 0.03). Patients with eGFR < 15 mL/min/1.73 m² with or without hemodialysis had the highest rebleeding rate at 36.8%. With respect to endoscopic characteristics, the rate of rebleeding was associated with combination therapy (p < 0.0001) and active bleeding (p = 0.03).Conclusion: Renal dysfunction might be an independent risk factor for rebleeding after endoscopic hemostasis in patients with peptic ulcer bleeding.     

Effect of intragastric pH on control of peptic ulcer bleeding

BACKGROUND: We have performed series studies to investigate the effect of intragastric pH on control of peptic ulcer bleeding. In laboratory and animal studies, both platelet aggregation and gastric mucosal bleeding time were shown to be extremely sensitive to different pH levels. Platelet aggregation decreased significantly at pH > or = 6.8 and gastric mucosal bleeding time fell significantly at pH > or = 6.4. In a prospective clinical trial, primed infusions of different dosages of omeprazole (8 or 4 mg/h) after a bolus (40 mg) produced consistently high intragastric pH values in patients with bleeding duodenal ulcer. These results were not significantly different from that obtained from omeprazole 40 mg bolus treatment every 12 h (P > 0.05). However, primed injection with cimetidine (800 mg/12 h) was less effective (P < 0.05). METHODS: In a retrospective analysis, 303 patients with bleeding peptic ulcer who were treated with cimetidine and 326 patients who were treated with omeprazole were compared. RESULTS: The emergency surgery (4.91%) and mortality rates (1.84%) in the omeprazole group were not significantly different (P > 0.05) from those (7.28 and 1.99%) in the cimetidine group. However, the standardized emergency surgery rate of the omeprazole group (3.28%) was significantly lower than that (9.28%) of the cimetidine group (P < 0.05). CONCLUSION: We conclude that increased intragastric pH to at least 6.4 with omeprazole is helpful in controlling peptic ulcer bleeding. Chinese patients require a lower dose of omeprazole than their Western counterparts to control ulcer bleeding.     

Non-Bleeding Visible Vessel Treatment: Perendoscopic Injection Therapy versus Omeprazole Infusion

Background: The non-bleeding visible vessel in a peptic ulcer is the highest risk factor for a bleeding recurrence among not actively bleeding lesions. Perendoscopic injection of sclerosing compounds is usually used as prophylaxis against rebleeding.

Methods: Forty-two patients with visible vessels in a peptic ulcer at an emergency endoscopic procedure have been studied: 21 patients underwent prophylactic perendoscopic hemostasis, and 21 patients were infused with omeprazole intravenously.

Results: Eight patients (19%), four in each group, had early rebleeding (within 48 h after the enrollment). There was no significant difference between the two types of treatment. At the endoscopic control after 48 h there were significantly more lesions with higher risk of rebleeding (Forrest IIa and IIb) in the group treated with perendoscopic hemostasis.

Conclusions: Our data suggest that omeprazole infusion is a valid alternative to injection treatment of non-bleeding visible vessels.     

Second look endoscopy in acute non-variceal upper gastrointestinal bleeding

Bleeding peptic ulcer remained an important cause of hospitalization worldwide. Primary endoscopic hemostasis achieved more than 90% of initial hemostasis for bleeding peptic ulcer. Recurrent bleeding amounted to 15% after therapeutic endoscopy, and rebleeding is an important risk factor to peptic ulcer related mortality. Routine second look endoscopy was one of the strategies targeted at prevention of rebleeding. The objective of second look endoscopy was to treat persistent stigmata of recent hemorrhage before rebleeding. Three meta-analyses showed that performance of routine second look endoscopy significantly reduced ulcer rebleeding especially when the endoscopic therapy was performed with thermal coagulation. Two cost-effectiveness analyses, however, demonstrated that selective instead of routine second look endoscopy is the most cost-effective approach to prevent ulcer rebleeding. While international consensus and guidelines did not recommend routine performance of second look endoscopy for prevention of ulcer rebleeding, further research should focus on identification of patients with high risk of rebleeding and investigate the effect of selective second look endoscopy in prevention of rebleeding among these patients.     

Predictors of hemostatic failure after adrenaline injection in patients with peptic ulcers with non-bleeding visible vessel

BACKGROUND: Non-bleeding visible vessel (NBVV) in patients with bleeding peptic ulcer is associated with a high risk of rebleeding. The aim of this study was to define factors associated with failure of endoscopic hemostasis and rebleeding in patients with NBVV. METHODS: Clinical and endoscopic parameters related to failure of endoscopic hemostasis with adrenaline in 191 bleeding peptic ulcer patients with NBVV were evaluated. RESULTS: Endoscopic hemostasis was permanently successful in 154 patients (80.6%). Emergency surgical hemostasis for rebleeding was required in 37 patients (19.4%). Univariate analysis showed that therapeutic failure was significantly related to the presence of shock on admission (P=0.003), posterior duodenal ulcers (P=0.001), peptic ulcer history (P=0.001), previous peptic ulcer bleeding (P=0.002), or lack of history of non-steroidal anti-inflammatory drugs consumption, when compared to use of such drugs (P=0.04). Patients where therapy failed had lower hemoglobin levels at admission (7.8+/-1.9 g/dL versus 10+/-2.4 g/dL, P=0.005). In a multivariate analysis low hemoglobin (P<0.001) as well as history of previous peptic ulcer bleeding (P=0.002) and posterior duodenal ulcers (P=0.001) were negative predictors. Using the mean value of hemoglobin as the cut-off point, it is noteworthy that only 2 out of 81 patients (2.5%) who had none of these predictive factors required emergency surgical hemostasis, whereas 34 out of 110 patients (30.9%) with at least one predictive factor required emergency surgery. CONCLUSION: It is possible, by employing specific characteristics, to define a subgroup of high-risk patients for rebleeding in patients with NBVV despite therapeutic endoscopy and thus candidates for a complementary endoscopic method of hemostasis or emergency surgical intervention.     

Esomeprazole for the treatment of peptic ulcer bleeding

Peptic ulcer bleeding is the most common cause of acute bleeding in the upper GI tract. The incidence of peptic ulcer bleeding has slowly decreased and endoscopic treatment options have improved; nevertheless, it remains a very common condition with a 7–15% mortality. Acidic environments have a negative effect on hemostasis. Therefore, acid inhibitors have been applied in the adjuvant treatment of peptic ulcer bleeding, both in preventing rebleeding and in treating the underlying cause. This requires profound acid suppressive therapy aiming for a rapid onset of effect and a persistent intragastric pH above 6. This can only be achieved by proton pump inhibitors (PPIs). Esomeprazole is the S-isomer of omeprazole, and the first PPI to consist of only the active isomer. A number of studies have compared esomeprazole with other PPIs, demonstrating a faster and more persistent increase in intragastric pH with the use of esomeprazole than with other agents. Continuous high-dose intravenous treatment with esomeprazole decreases rebleeding, surgery, transfusion rates and hospital days in peptic ulcer bleeding.