内镜下钛夹联合医用胶与单用钛夹治疗双联抗血小板所致消化性溃疡出血的比较

目的评价内镜下钛夹联合医用胶对阿司匹林和氯吡格雷双联抗血小板所致消化性溃疡出血的治疗效果。方法选取我院2013年12月~2014年10月因急性冠脉综合征或冠状动脉介入手术使用双联抗血小板治疗所致消化性溃疡出血61例,按随机数字奇、偶数分为单独钛夹治疗组和钛夹联合医用胶治疗组进行内镜下止血治疗,2组在性别、年龄、出血量、溃疡大小、部位及Forrest分级方面无明显差异,在质子泵抑制剂使用种类、剂量、疗程等方面均无差异。监测术后72 h内有无再出血。结果治疗后72 h内,单独钛夹治疗组再出血率是钛夹联合医用胶治疗组的5.4倍[17.2%(5/29)vs.3.2%(1/31),χ2=1.898,P=0.168]。结论内镜下钛夹联合医用胶治疗双联抗血小板所致消化性溃疡出血与单纯应用钛夹止血相比,再出血率有降低趋势,疗效确切。     

内镜下局部注射不同药物治疗消化性溃疡并出血疗效对比

1995～2004年,我院将119例消化性溃疡并出血病人随机分为4组,比较内镜下止血与保守治疗的效果,同时比较内镜下注射不同止血药物的止血效果。将内镜明确诊断消化性溃疡并出血的病例随机分为4组。前3组均在急诊内镜下分别注射立止血(立止血组,32例)、1∶10000肾上腺素(肾上腺素组     

急诊内镜金属夹治疗食管贲门黏膜撕裂出血(附38例报告)

目的观察急诊内镜下金属夹治疗食管贲门黏膜撕裂症(M allory-W e iss syndrom e,MW S)所致的上消化道出血的止血效果和安全性。方法急诊内镜检查确诊MW S出血38例,活动性出血病灶(ForrestⅠ)14例和近期出血性病灶(ForrestⅡ)24例,在内镜下应用金属夹治疗24 h、5 d及1~2个月后复查内镜。结果金属夹治疗全部止血成功。手术时间12~40(24±3.6)m in。金属夹治疗后无并发症,无再出血,也无死亡病例。内镜随访显示金属夹对组织无损伤,不影响MW S的愈合。1~2个月后复查内镜,30例金属夹已经脱落;8例未脱落,但病灶愈合,患者饮食正常。结论急诊内镜下金属夹治疗MW S引起的上消化道出血是一种非常有效、安全的急诊治疗措施。     

内镜下治疗Dieulafoy病出血39例

目的观察内镜下治疗Dieulafoy病出血的疗效及安全性。方法 2004年6月～2009年6月我院对39例Dieulafoy病出血急诊行高张钠-肾上腺素液黏膜内注射联合射频及钛夹治疗。结果 36例经内镜止血成功,首次治疗成功34例(87.2%),2例经2次内镜止血成功(5.1%);3例外科手术治疗(7.7%)。内镜止血术后2～4周再行胃镜检查均未发现溃疡。39例随访0.5～5年,平均2年,均无再发出血。结论高张钠-肾上腺素液黏膜内注射联合射频及钛夹是治疗Dieulafoy病出血的一种较为安全有效的方法 。     

内镜下注射治疗Forrest分级在FⅡa以上的消化性溃疡出血的初步研究

目的：探讨急诊内镜注射治疗对Ｆｏｒｒｅｓｔ分级在ＦⅡａ以上的重症出血性消化性溃疡的止血效果。方法：对１９９５年１月～１９９８年１２月内镜下确认的４３例重症出血性消化性溃疡（按Ｆｏｒｒｅｓｔ分级均在ＦⅡａ以上）分成两组：２０例行急诊内镜下注射止血（注射组），同期内镜及临床表现相似者２３例予常规抑酸止血治疗（对照组）。结果：注射组和对照组止血率分别为９５％（１９／２０）和４３．４８％（１０／２３）（λ     

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.     

内镜止血治疗在消化道出血中的临床应用

随着内镜下止血技术的普及,内镜治疗目前已成为消化道出血的首选止血方法［1］。通过内镜下寻找出血点,并利用多种止血技术进行及时止血,多可避免外科手术。目前临床常用内镜止血技术包括注射硬化剂止血术、金属钛夹止血、术氩离子凝固术和冰去甲肾上腺素止血术等,各种止血治疗均有不同优势,内镜止血也常需要联合应用几种不同的止血技术。复旦大学附属中山医院内镜中心自2012年1-12月间对32例不同原因引起的消化道出血患者进行内镜下止血治疗,取得满意效果,现总结报道如下。     

观察内镜下金属钛夹治疗非静脉曲张性上消化道出血的疗效

目的观察内镜下金属钛夹治疗非静脉曲张性上消化道出血的疗效。方法对54例非静脉曲张性消化道出血患者在内镜下实施金属钛夹治疗,回顾性分析患者的临床资料。结果 30例患者均即时止血成功,止血率达100%,术中平均使用钛夹2.4枚。术后均恢复良好,随访1~3个月,均无再出血及穿孔等病例发生。结论内镜下金属钛夹治疗非静脉曲张性消化道出血。疗效确切,创伤小,术后恢复快,并发症少,值得临床应用。     

血凝酶与肾上腺素在内镜下黏膜切除、息肉电切术中预防出血作用的随机对照研究

目的比较血凝酶与1∶10000肾上腺素用于消化内镜下黏膜切除术（endoscopic mucosal resection,EMR）、扁平息肉摘除术的预防出血作用和安全性。方法选择2007年4～11月在我院内镜中心因食管、胃、结肠局部病变行内镜下EMR者60例,随机分为血凝酶组和肾上腺素组,每组30例。于病变基底部注射血凝酶或肾上腺素液体垫至病变抬起,行EMR或分次内镜下黏膜切除术（endoscopic piecemeal mucosal resection,EPMR）。切除后观察切缘残端有无出血。操作中监测患者血压、心率,记录不良反应（心悸、头晕、疼痛、恶心等）。结果即刻出血血凝酶组1例（1/30,3%）,肾上腺素组6例（6/30,20%）,2组差异无显著性（χ2=2.588,P=0.108）,24小时2组均无出血病例。血凝酶组和肾上腺素组液体垫注射剂量分别为（11.0±6.0）ml（5～30ml）和（11.9±7.0）ml（5～28ml）,差异无显著性（t=-0.535,P=0.595）。肾上腺素组注射液体垫后平均动脉压和心率均较注射前明显升高[平均动脉压：注射前（96.9±7.9）mmHg,注射后（99.9±8.1）mmHg,t=-3.005,P=0.005;心率：注射前（79.8±7.9）次/min,注射后（84.3±8.1）次/min,t=-3.585,P=0.001],血凝酶组无显著性变化。注射后肾上腺素组5例出现一过性头晕伴心悸,2例食管病变患者出现注射部位明显疼痛,血凝酶组患者无明显不适。结论血凝酶作为内镜下黏膜切除术、扁平息肉摘除的液体垫成分,预防出血效果与肾上腺素相同而无明显不良反应。     

全覆膜金属支架治疗内镜乳头括约肌切开术后出血的疗效

EST是ERCP检查中常用的诊断与治疗操作,EST术后乳头切缘出血发生率为2％～9％[1-2].内镜下止血是其首选治疗方案.如内镜下治疗不能控制出血,则需行动脉栓塞和外科开腹手术治疗,增加了患者创伤和经济负担.目前临床上常用的内镜下控制EST术后出血的方法是金属夹夹闭出血灶和黏膜下注射肾上腺素[3-4].但这两种治疗方法均难以控制EST术后活动性出血,因此,临床上需要更简便有效的内镜下止血措施.近年来,笔者应用全覆膜自膨式金属支架（full covered self-expandable metal stents,FCSEMS）控制EST术后出血,取得了一定的效果.本研究回顾性分析2012年1月至2013年2月成都军区总医院应用FCSEMS治疗4例EST术后出血患者的临床资料,探讨EST术后出血治疗的新方法.     

上消化道出血外科治疗67例回顾

目的 探讨上消化道出血的外科治疗策略.方法 回顾性分析2007年7月至2010年6月67例上消化道出血病例的病因、治疗及效果.结果 本组病例中良性溃疡50例(74.6%),恶性溃疡17例(25.4%);平均住院(16.4±12.5)d,平均输血量(558.9±263.2)ml.无术后再次出血病例,有2例出现吻合口瘘,5...     

How evidence-based are current guidelines for managing patients with peptic ulcer bleeding?

Current guidelines for managing ulcer bleeding state that patients with major stigmata should be managed by dual endoscopic therapy (injection with epinephrine plus a thermal or mechanical modality) followed by a high dose intravenous infusion of proton pump inhibitors (PPIs). This paper aims to review and critically evaluate evidence supporting the purported superiority of a continuous infusion over less intensive regimens of PPIs administration and the need for adding a second hemostatic endoscopic procedure to epinephrine injection. Systematic searches of PubMed, EMBASE and the Cochrane library were performed. There is strong evidence for an incremental benefit of PPIs over H2-receptor antagonists or placebo for the outcome of patients with peptic ulcer bleeding following endoscopic hemostasis. However, the benefit of PPIs is unrelated to either the dosage (intensive vs standard regimen) or the route of administration (intravenous vs oral). There is significant heterogeneity among the 15 studies that compared epinephrine with epinephrine plus a second modality, which might preclude the validity of reported summary estimates. Studies without second look endoscopy plus re-treatment of re-bleeding lesions showed a significant benefit of adding a second endoscopic modality for hemostasis, while studies with second-look and re-treatment showed equal efficacy between endoscopic mono and dual therapy. Inconclusive experimental evidence supports the current recommendation of the use of dual endoscopic hemostatic means and infusion of high-dose PPIs as standard therapy for patients with bleeding peptic ulcers. Presently, the combination of epinephrine monotherapy with standard doses of PPIs constitutes an appropriate treatment for the majority of patients.     

Current therapy for nonvariceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding continues to plague physicians despite the discovery of Helicobacter pylori and advances in medical therapy for peptic ulcer disease. Medical therapy with new nonsteroidal anti-inflammatory medications and somatostatin/octreotide and intravenous proton pump inhibitors provides hope for reducing the incidence of and treating bleeding peptic ulcer disease. Endoscopic therapy remains the mainstay for diagnosis and treatment of upper gastrointestinal bleeding. Many methods of endoscopic hemostasis have proven useful in upper gastrointestinal hemorrhage. Currently, combination therapy with epinephrine injection and bicap or heater probe therapy is most commonly employed in the United States. Angiography and embolization play a role primarily when endoscopic therapy is unsuccessful.     

Peptic ulcer hemorrhage: Local injection of fibrin sealant—Experimental and clinical data

This study was undertaken to assess the role of fibrin sealant in achieving early hemostasis and wound healing following endoscopic injection in peptic ulcer hemorrhage. In an experimental study in Wistar-rats we looked at the healing rate and histological changes of laser-induced acute gastric ulcers and acetic acid-induced chronic gastric ulcers following injection of standard sclerosants as well as fibrin sealant. A statistically favourable result was observed in the fibrin treated group. We also treated 127 patients suffering from bleeding peptic ulcers with local injection of fibrin sealant (33 Forrest stage la, 40 Forrest lb, 54 Forrest Ila) in a prospective clinical trial during the period of 1. February 1988 to 31. January 1991. A primary recurrence was noticed in 19 (14.9%) patients. With a 2. injection the hemostasis was definite in 116 of 127 patients (91.3%). Only 11 patients (8.6%) needed surgery for hemostasis. The mortality was 6.3% (8 patients).     

The recurrent bleeding risk of a Forrest IIc lesion at the second-look endoscopy can be indicated by high Rockall scores ≥ 6

Surgical Endoscopy - The Forrest classification is widely applied to guide endoscopic hemostasis for peptic ulcer bleeding. Accordingly, practice guidelines suggest medical treatment only for ulcer...     

Acute hemorrhage secondary to gastric ulcer. Results of emergency endoscopic treatment in 775 cases

The aim of this study was to investigate the effects of endoscopic injection therapy on the clinical outcome of patients with gastric ulcer bleeding. Seven hundred and seventy-five patients with gastric ulcer bleeding were observed over a 10-year period (January 1990 to May 2000) in the First Division of General Surgery of the University of Verona. The prognostic and therapeutic implications of endoscopic treatment of acute severe gastrointestinal bleeding were analyzed on the basis of medical history and clinical and endoscopic findings. The ulcers were classified according to Forrest's classification of bleeding activity. Endoscopic therapy was performed in 500 patients with active bleeding. Haemostasis was initially obtained in all patients except one. Rebleeding occurred in 13%. All these patients were treated endoscopically at the first attempt. Multivariate analysis revealed that recent surgery, ulcer site and Forrest classification independently influenced the recurrence rate. The mortality of the entire cohort studied was 8.1%. Only 31 patients (4%) underwent surgical treatment with a higher mortality compared to unoperated patients (19.3% vs 7.7%). Endoscopic treatment is a safe procedure with a low mortality and cost, and, if successful, substantially reduces the need for emergency surgery.     

Endoscopic versus operative treatment in high-risk ulcer bleeding patients – results of a randomised study

BACKGROUND AND AIMS: The treatment of peptic ulcer bleeding is still a matter of controversy in high-risk patients with arterial bleeding or a visible vessel. Patients with recurrent bleeding during hospital stay carry an increased risk of death. Therapeutic concepts using early elective operation compete with solitary endoscopic treatment. Numerous prospective studies have contrasted comparable improvements for the different therapeutic regimens but there is still a lack of a randomised comparison. PATIENTS AND METHODS: We initiated a multicentre randomised clinical trial comparing endoscopic fibrin glue injection with early elective operation in peptic ulcer patients with arterial bleeding or a visible vessel > or =2 mm. After initial endoscopic control of bleeding, patients were randomised to repeated fibrin glue injection or early elective operation. Outcome criteria were recurrent bleeding and death. The study was terminated after a planned interim analysis. RESULTS: Due to strict inclusion and exclusion criteria 61 patients were randomised and 55 patients could be included in the per-protocol analysis, 23 in the early elective operation group and 32 in the patient group with endoscopic therapy. The type of surgery in the early elective operation group was usually gastric resection (79%). Recurrent bleeding occurred in 50% of the endoscopically treated patient group, and in the operative group in one patient (relative risk: 11.5; 95% CI: 1.6 to 80.7). There were no statistically significant differences between the two treatment groups with respect to mortality (relative risk: 0.7, 95% CI: 0.1 to 4.8). CONCLUSION: Early elective surgery is an effective procedure in bleeding peptic ulcer patients at high risk for re-bleeding. Fibrin glue injection carries a risk for re-bleeding, however, the majority of these re-bleeding episodes can be controlled by re-endoscopic treatment, but a subgroup will need an emergency operation with a fatal outcome in individual patients.     

Can endoscopic injection of epinephrine prevent surgery in gastroduodenal ulcer bleeding? An analysis of 107 cases

BACKGROUND: Gastroduodenal ulcers are still a common cause of severe upper gastrointestinal bleeding. Endoscopy has gained popularity worldwide over conventional open surgery for the treatment of upper gastrointestinal bleeding. This study aims to assess the efficacy of endoscopic injection of epinephrine in the treatment of gastroduodenal ulcer bleeding. METHODS: This study was conducted between March 2000 and March 2003. We analyzed 107 consecutive patients admitted to our department of trauma and emergency surgery with upper gastrointestinal bleeding. Endoscopy was performed on all 107 patients and bleeding ulcers were treated with injection of diluted epinephrine. RESULTS: Recurrent bleeding was seen in 21 patients (19.6%), all of whom underwent a second endoscopy. Four patients (3.7%) required a third endoscopy session and nine patients (8.5%) needed surgery after endoscopy failed. There were two mortalities (1.9%). The nine patients who required surgery and the two patients who died were all in the Forrest Ia and Ib groups of acute UGI hemorrhage. DISCUSSION: Endoscopic injection therapy with epinephrine reduces operation rates and can be used safely in adequate hemostasis of gastroduodenal ulcers.     

腹腔镜与开腹胃十二指肠溃疡穿孔修补术的前瞻性随机对照研究

目的：探讨腹腔镜与开腹行胃十二指肠溃疡穿孔修补术的优缺点。方法2011年4月-2013年6月,将133例胃十二指肠溃疡急性穿孔患者采用抽取信封法随机分为腹腔镜组（68例）和开腹组（65例）,2组年龄、性别、穿孔大小、部位和麻醉学评分等方面无显著差异（P＞0．05）。对比2组手术时间、术中出血量、术后肠鸣音恢复时间、术后第1天及第3天疼痛评分及镇痛次数、术后并发症发生率和术后住院时间等指标。结果与开腹组相比,腹腔镜组术中出血少[（10．2±2．2）ml vs．（23．7±4．6）ml,t＝-21．742,P＝0．000],术后肠鸣音恢复早[（26．2±6．1）h vs．（39．4±8．5）h,t＝-10．324,P＝0．000],术后疼痛轻[第1天疼痛评分（4．1±1．1）vs．（7．6±1．7）,t＝-14．159,P＝0．000,第3天疼痛评分（1．7±0．9）vs．（3.6±1．2）,t＝-10．360,P＝0．000],镇痛次数少[中位数1（0-9） vs．3（0-12）,Z＝-7．208,P＝0．000],术后切口感染发生率低[0（0％） vs．6（9．2％）,P＝0．012],术后住院时间短[（6．3±1．3）d vs．（8．2±2．7）d,t＝-5．206,P＝0．000]。2组手术时间差异无显著性（ P＞0.05）。随访3-6个月,2组均无再次穿孔及死亡。结论腹腔镜手术修补胃十二指肠溃疡急性穿孔安全可靠,具有疼痛轻、切口感染少、康复快、术后住院时间短等优点,是治疗良性胃十二指肠溃疡急性穿孔的理想术式。     

Differential treatment of gastroduodenal ulcerous bleedings

Results of treatment of 827 patients with bleedings from chronic gastric and duodenal ulcers are analyzed. Potentialities of various methods of endoscopic hemostasis were studied. Diathermocoagulation was the least effective method of hemostasis (59%). Irrigation of the bleeding source provided hemostasis in 88.7% patients, combined methods - in 94.1%. Methods of irrigation are appropriate in diffuse bleeding from ulcer (Forrest 1B). Stream bleeding (Forrest 1A) is indication for combined methods of hemostasis. It is demonstrated that type of endoscopic procedure does not influence rate of bleeding recurrences. The main element of conservative treatment of gastroduodenal ulcerous bleedings is antisecretory therapy. Proton pump blockers are more effective than H2-blockers; the rate of recurrences was 5.0 and 28.9%, respectively. Prediction of bleeding recurrences and preventive operations are the main way to treatment results improvement.