内镜下注射治疗消化性溃疡并出血的临床应用评价

目的探讨内镜下注射止血的临床意义。方法2001年7月至2002年8月因呕血和(或)黑便入院，经紧急内镜检查确诊为消化性溃疡并出血患81例．分成内科保守治疗和内镜注射止血治疗二组，内镜组在内科保守治疗的基础上，内镜下于出血灶注射HLGE液。结果内镜组42例，止血成功率95．24％，对照组39例，止血成功率79．49％，二组有显性差异。结论内镜注射止血治疗简单有效，降低手术率和再出血率。     

消化性溃疡出血的内镜治疗

内镜能有效地治疗消化性溃疡出血,降低病人的急诊手术率、再出血率和输血量,并可能降低其死亡率。内镜下止血方法较多,但以热凝疗法和注射疗法为佳。     

内镜下注射治疗消化性溃疡出血的护理

内镜下注射肾上腺素或鱼肝油酸钠已成为消化性溃疡出血的主要治疗方法。1995—06／2004—09，我们共有98例消化性溃疡出血病人应用内镜注射治疗，取得了满意的疗效。现将护理体会总结报告如下。     

消化性溃疡出血急诊内镜检查220例分析

１９９０年１月～１９９５年２月．对２２０例消化性溃疡出血病人进行了急诊内镜检查。急诊内镜检查在 ２４～４８ ｈ内完成。内镜所见的出血类型参照Ｆｏｒｒｅｓｔ所建议的分类标准，其中ＦⅠａ４例（１．８％）．ＦⅠｂ２８例（１２．７％），ＦⅡａ２８例（１２．７％）．ＦⅡｂ１２０例（５４．５％）和ＦⅢ ４０例（１８．２％）。结果显示，球部溃疡出血明显多于胃溃疡（６１８％比２９．１％， Ｐ ＜０． ００５）；出血发生率与年龄有明显关系，以中年组发生率最高，占６０％．依次为青年组（２９．１％），老年组（１０．９％）。出血征象ＦⅠａ以老年组居多．其他各型均以中年组占多数。     

内镜下注射肾上腺素治疗老年消化性溃疡出血21例

老年性消化性溃疡,临床表现不典型,尤其以上消化道出血表现为主发生率很高,出血量大,不易止血,并复发出血机会多,死亡率高。本院1996年10月—1999年2月间,共发现60岁以上溃疡病28例,其中以出血表现为主21例,在内镜下用肾上腺素注射治疗取得成功,现报告如下。     

内镜下注射结合静注法莫替丁治疗消化性溃疡活动性出血疗效观察

20 0 0年 1～ 1 2月 ,我们采用随即对照的研究方法 ,对内镜注射结合静注抑酸药法莫替丁与单用法莫替丁治疗溃疡活动性出血进行疗效对照观察。现报告如下。1　资料与方法1 . 1　一般资料　同期收治 48例消化性溃疡活动性出血患者 ,均经急症胃镜检查确诊。胃镜下可见动脉喷血、活动性渗血和血管暴露等表现 ,合并有严重并发症如心力衰竭、呼吸衰竭、脑血管意外、尿毒症及肝性脑病者除外。随机分为两组 :1 组 :2 4例。男1 8例 ,女 6例 ;年龄 2 8～ 62岁。 2 组 :2 4例。男 1 9例 ,女 5例 ,年龄 2 4～ 65岁。两组患者的病情、伴随病及内镜表现…     

内镜局部注射治疗消化性溃疡出血的临床观察

探讨一种疗效好,可靠,副作用少,操作简单的内镜下止血方法。以高渗盐水立止血内下注射治疗消化性溃疡出血患者７７例为治疗组,立即止血率９７．９％,再出血率２．５％。     

内镜下血管钳夹加止血合剂注射治疗消化性溃疡并出血的临床观察

为探索治疗溃疡病并出血的新方法,我们采用内镜人血管钳类加止血合剂注射治疗消化性物异出血,并以药物治疗为对照,加以分析。20例溃疡并出血病人采用内镜下钛夹钳夹血管加止血合剂注射治疗(内镜治疗组)。中胃溃疡3例,十二指肠球部溃疡17例。重度出血15人,占75％,中度出血5人,占25％。注射用止血合剂由3％高渗盐水、立止血、肾     

内镜下血管钳夹加止血合剂注射治疗消化性溃疡并出血的临床观察

本研究旨在探索治疗溃疡病并出血的新方法。20例溃疡并出血病人采用内镜下钛夹钳夹血管加止血合剂注射治疗(内镜治疗组)。20侧病人中胃溃疡3例。十二指肠球部溃疡17例。重度出血15人,占 75％,中度出血5人,占25％。注射用止血合剂由3％高渗盐水、立止血、肾上腺素组成。另20例溃疡并出血病人采用静脉内药物注射怍为对照(药物治疗组)。药物治疗组20例病人胃溃疡2例,十二指肠球部溃疡18例,重度出血12例,占60％,中度出血8例,占40％,质子泵抑制剂选用奥美拉唑40mg,每日二次静脉注射止血。内镜治疗组人院后12小时内止血19例(占95％),输血量600-1500ml(平均800ml),转外科手术1人(占5％),奥美拉唑治疗组人院后12小时内止血9例(占45％,输血量600-3000ml(平均1500ml),转外科手术5人(占25％)。两组有非常显著性差异。本研究表明,内镜下应用钛血管夹直接钳夹破裂或显露在溃疡面的血管,主要优点是靶向性强.对血破裂所致的喷血、涌血以及血凝块复盖下潜行性出血病灶止血效果确切。在钳夹血管后,自血管夹周围环状多点注射血合剂。可引起组织水肿、血管收缩和凝血而达到止血的目的。血管夹和止血合剂联合应用具有互补和加强疗效的作用,不仅对明显喷血、涌血或显露的血管有效,对溃疡面渗血或钳夹不可靠的病例也有较好的效果。内镜下血管钳夹加上血合剂注射治疗溃疡病并出血,其效果优于应用质子泵抑制剂静脉注射。     

消化性溃疡并出血生长抑素治疗研究

目的　观察生长抑素 (SS)对出血性十二指肠溃疡 2 4h胃内pH的影响及其对消化性溃疡出血的治疗效果。方法　①十二指肠溃疡出血 16例随机分为SS组 ( 2 5 0 μg ,i.v,后 2 5 0 μg/h静滴 )和奥美拉唑组 ( 40mg ,i.v,后 8mg/h静滴 )行 2 4h胃内pH监测 ;②消化性溃疡活动性出血 (渗血或并血管显露 )随机分为治疗组 3 7例 (SS同上 ,用药到出血停止后 48h)和对照组 46例 (奥美拉唑 40mg,i.v,q12h ,5日 )。结果　①二组pH平均数和中位数 ,以及 2 3h胃内pH >6 0和pH>7 0百分比间无显著差别。②治疗组止血率 ( 91 9% )显著高于对照组 ( 73 9% ) ,再出血率 ( 11 8% )明显低于对照组( 3 5 3 % )。手术和死亡率二组间无显著差异。结论　生长抑素有效抑制胃酸分泌 ,使出血性十二指肠溃疡达最佳止血胃内pH ;有效控制消化性溃疡的活动性出血而降低再出血。     

Pharmacologic treatment of peptic ulcer bleeding

Opinion statement Over the last 3 decades, there has been extensive clinical research on the pharmacologic treatment of peptic ulcer bleeding. A critical review of randomized controlled trials and meta-analyses reveals insufficient evidence to recommend histamine-2 receptor antagonists (H₂RAs), somatostatin, octreotide, or tranexamic acid in the routine management of patients with peptic ulcer bleeding. In contrast, there is good-quality evidence for recommending proton-pump inhibitor (PPI) treatment for patients with peptic ulcer bleeding. PPI treatment, compared with an H₂RA or placebo, reduces rebleeding and the need for surgical intervention and, in patients with high-risk endoscopic stigmata, also reduces all-cause mortality. Patients with ulcers that demonstrate only low-risk endoscopic stigmata (clean base or flat pigmented spot) can be treated with an oral PPI at double the standard clinical dose. Patients with ulcers that demonstrate high-risk endoscopic stigmata (spurting, oozing, or nonbleeding visible vessel) should receive high-dose intravenous PPI treatment following appropriate endoscopic hemostatic treatment. The currently recommended dose is an initial intravenous bolus equivalent to 80 mg of omeprazole followed by an intravenous infusion equivalent to 8.0 mg/h of omeprazole for up to 72 hours. A switch to high-dose oral PPI treatment may be appropriate before completion of a 72-hour treatment period in some patients whose clinical status stabilizes early. Once the initial bleeding episode has been dealt with, patients will require standard pharmacologic treatment to heal the ulcer and prevent recurrence.     

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.     

Endoscopic hemoclip treatment for bleeding peptic ulcer

AIM To evaluate the efficacy of endoscopic hemoclip in the treatment of bleeding peptic ulcer.METHODS Totally, 40 patients with F1a and F1b hemorrhagic activity of peptic ulcers were enrolled in this uncontrolled prospective study for endoscopic hemoclip treatment. We used a newly developed rotatable clip-device for the application of hemoclip (MD850) to stop bleeding. Endoscopy was repeated if there was any sign or suspicion of rebleeding, and reclipping was performed if necessary and feasible.RESULTS Initial hemostatic rate by clipping was 95%, and rebleeding rate was only 8%.Ultimate hemostatic rates were 87%, 96%, and 93% in the F1a and F1b subgroups, and total cases, respectively. In patients with shock on admission, hemoclipping achieved ultimate hemostasis of 71% and 83% in F1a and F1b subgroups, respectively. Hemostasis reached 100% in patients without shock regardless of hemorrhagic activity being F1a or F1b. The average number of clips used per case was 3.0 (range 2- 5). Spurting bleeders required more clips on average than did oozing bleeders (3.4 versus 2.8 ). We observed no obvious complications, no tissue injury, or impairment of ulcer healing related to hemoclipping.CONCLUSION Endoscopic hemoclip placement is an effective and safe method. With the improvement of the clip and application device,the procedure has become easier and much more efficient. Endoscopic hemoclipping deserves further study in the treatment of bleeding peptic ulcers.     

Clinical practice and evidence in endoscopic treatment of bleeding peptic gastroduodenal ulcer

OBJECTIVE: To investigate treatment practice in non-variceal upper gastrointestinal bleeding (NVUGIB) caused by gastroduodenal ulcer and how it adheres to the best evidence as documented in randomized studies and meta-analyses. MATERIAL AND METHODS: The literature was surveyed to identify appropriate practices, and a structured multiple choice questionnaire developed and mailed to all departments in Denmark treating UGIB. RESULTS: All 42 departments responded. All had therapeutic gastroscopes and equipment necessary for endoscopic haemostasis; 90% of departments had written guidelines. Adjuvant pharmacologic treatment included tranexamic acid in 38%. Proton-pump inhibitors (PPIs) were used by all departments, with 29% starting prior to endoscopic treatment. Eight departments (19%) used continuous PPI infusion, three of them starting with a bolus dose. In 50% of departments an anaesthesiologist was always present regardless of whether endotracheal intubation (routinely used by 10%) was used or not. Ten percent did not treat Forrest IIa and IIb ulcers, while IIc ulcers were treated by 36%. In 10% of departments clots were never removed, while in 2/3 attempts were made to remove resistant clots by mechanic means. Seven departments (17%) used monotherapy with epinephrine, while 59% always used dual therapy; 19% injected less than 10 ml. In rebleeding, 92% attempted endoscopic treatment before surgery, and used epinephrine in 79% of cases, while the remainder used epinephrine or polidocanol at the discretion of the endoscopist. Two out of three departments used high-dependency or intensive-care units for surveillance. Seventeen percent applied scheduled second-look gastroscopy. CONCLUSIONS: Practice is variable, even in areas with established evidence based on randomized controlled studies, such as dosage and way of administration and duration of PPI treatment, injection treatment used as monotherapy and the volume used, including ulcers with clots for treatment, and the use of scheduled second-look endoscopy. Since the rebleeding rate has remained unchanged for decades, and rebleeding implies increased surgery and mortality rates, appropriate practices must be promoted in order to improve results. Development and implementation of national guidelines may facilitate the process.     

不同pH值对消化性溃疡并出血疗效的影响

目的：探讨不同ｐＨ值对消化性溃疡并出血疗效的影响，方法和结果：１临床和动物实验富血小板血浆（ＰＲＰ）中加入不同剂量的ＨＣｌ以改变其ｐＨ环境并测定其血小板聚集率。结果显示，随着ＨＣｌ量的增加，ｐＨ下降，血小板聚集率也降低，当ｐＨ＜６８时，血小板聚集率显著下降，用不同ｐＨ值的缓冲液冲洗大白鼠胃内活检伤口，测定其胃粘膜出血时间（ＧＭＢＴ），结果显示，当ｐＨ≥６０时，ＧＭＢＴ明显减少，约５７６±１８６秒。２胃内ｐＨ值监测连续４８小时监测胃内ｐＨ值，结果显示，甲氰米胍１６００ｍｇ静脉注射与奥美拉唑４０ｍｇ静脉注射，胃内ｐＨ值相仿，分别为５４±１３和５８±１３，逐步降低甲氰米胍用量，其ｐＨ值亦逐步下降，至８００ｍｇ时，胃内ｐＨ值为１５，基本无作用。３临床疗效观察回顾性分析３０３例应用雷尼替丁与３２６例应用奥美拉唑的溃疡出血病人，前者手术率与死亡率为７２８％和１９９％，后者为４９１％和１８４％。结论：ｐＨ值与血小板聚集率及ＧＭＢＴ密切相关，药物治疗溃疡出血成功的关键在于有效提高胃内ｐＨ值。     

Genotypes of Helicobacter pylori in patients with peptic ulcer bleeding

AIM: Helicobacter pylori causes chronic gastritis, peptic ulcer, gastric cancer and MALT-lymphoma. Different genotypes of Helicobacter pylori are confirmed from diverse geographic areas. Its association with bleeding peptic ulcer remains controversial. The aim of this study was to investigate the Helicobacter pylori vacA alleles, cagA and iceA in patients with bleeding peptic ulcer. METHODS: We enrolled patients with bleeding, non-bleeding peptic ulcers and chronic gastritis. Biopsy specimens were obtained from the antrum of the stomach for rapid urease test, bacterial culture and PCR assay. DNA extraction and polymerase chain reaction were used to detect the presence or absence of cagA and to assess the polymorphism of vacA and iceA. RESULTS: A total of 168 patients (60.4%) (25 patients with chronic gastritis, 26 patients with bleeding gastric ulcer, 51 patients with non-bleeding gastric ulcer, 26 patients with bleeding duodenal ulcer, and 40 patients with non-bleeding duodenal ulcer) were found to have positive PCR results between January 2001 and December 2002. Concerning genotypes, we found cagA (139/278, 50%), vacA s1a (127/278, 45.7%), and ice A1 (125/278, 45%) predominated in all studied patients. In patients with bleeding peptic ulcers, vacA s1a and m1T were fewer than those in patients with non-bleeding peptic ulcers (37/106 vs 69/135, P=0.017, and 4/106 vs 21/135, P =0.002). CONCLUSION: In patients with peptic ulcers, H pylori vacA s1a and m1T prevent bleeding complication.