消化道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￣４８ｈ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型（１２．７％），ＦⅡａ２８例（１２．７％），ＦⅡｂ１２０例（５４．５％）和ＦⅢ４０例（１８．２％）。结果显示，球部溃疡出血明显多于胃溃疡（６１．８％比２９．１％，Ｐ〈０．００５）；出血发生率与     

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。     

1277例消化性溃疡内镜检查分析

１２７７例消化性溃疡内镜检查分析李吉华，张南征一、临床资料：我院１９７５年５月至１９８９年５月共作胃镜８９３３例，检出消化件溃疡１２７７例，占１４．３％，年龄１２～８３岁，平均４７．５岁，其中十二指肠球部溃疡７８２例（８．７５％），胃溃疡４９５例（５...     

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。     

渔民消化性溃疡984例内镜分析

本文回顾我院 10年来经内镜检出的渔民消化性溃疡 (PU)进行分析,旨在探讨该病在沿海地区发病因素及其特点。 　　1.对象和方法： 　　(1)对象：全部病例均为 1989年 1月～ 1998年 12月我院门诊和住院患者,共 984例,其中男 850例,女 134例。 　　(2)方法：采用 Olympus－ XQ30等型号内镜检查,受检者均有不同程度的消化不良,上腹痛、腹胀、泛酸、嗳气、黑便及呕血等,内镜诊断标准：十二指肠 (DU)以见到溃疡面或霜斑样溃疡,重度幽门狭窄及球腔变形,未见活动性溃疡者不列入本组,部分胃溃疡 (GU)和溃疡恶变为病理证实,复合性溃疡 …     

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。     

老年消化性溃疡167例内镜表现及临床分析

目的探讨老年消化性溃疡（peptic ulcer in the aged，PUA）的内镜及临床特点。方法总结我院近3年来经胃镜检查确诊的167例PUA患者与494例中青年PU患者临床资料，并加以对照分析。结果PUA具有临床表现不典型、高位溃疡、溃疡深大和并发症相对较多的特点。结论在PUA中进行良恶性溃疡鉴别非常重要，不论其溃疡深浅、大小均应进行病理学检查。     

消化性溃疡显性出血150例临床分析

我院1989～1993年收治的150例消化性溃疡显性出血(PUEB),皆有黑便和/或粪隐血≥++.均排除了食物、药物等其它因素引起的假阳性病例.本组患者中,男136%例,女14例,男女之比为9:1.年龄18～67岁,平均39.5岁.本组有71例(47.3%)有PU家族史,28例家族中有黑便和/或呕血史.粪隐血试验、血型:首次粪隐血++者29例(19.3%),卅42例(28.0%),卌79例(52.7%);检验血型75例,O型33例(44.0 %),A型18例(24.0%)B型15例(20.0%),AB型9例(12.0%).支持“O”型血人高发PU及出血的观察.症状、体征:106例(70.6%)出血发生于10月～翌年3月.110例(70.3%)有PU病史.本次出血前1周内有嗳气、反酸、上腹疼痛分别为30例(20.0%)、48例(32.0%)、78 例(52.0%).轻度失血69例     

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。     

Weekend and nighttime effect on the prognosis of peptic ulcer bleeding

AIM: To evaluate whether weekend or nighttime admission affects prognosis of peptic ulcer bleeding despite early endoscopy.METHODS: Retrospective data collection from four referral centers, all of which had a formal out-of-hours emergency endoscopy service, even at weekends. A total of 388 patients with bleeding peptic ulcers who were admitted via the emergency room between January 2007 and December 2009 were enrolled. Analyzed parameters included time from patients’ arrival until endoscopy, mortality, rebleeding, need for surgery and length of hospital stay.RESULTS: The weekday and weekend admission groups comprised 326 and 62 patients, respectively. There were no significant differences in baseline characteristics between the two groups, except for younger age in the weekend group. Most patients (97%) had undergone early endoscopy, which resulted in a low mortality rate regardless of point of presentation (1.8% overall vs 1.6% on the weekend). The only outcome that was worse in the weekend group was a higher rate of rebleeding (12% vs 21%, P = 0.030). However, multivariate analysis revealed nighttime admission and a high Rockall score (≥ 6) as significant independent risk factors for rebleeding, rather than weekend admission.CONCLUSION: Early endoscopy for peptic ulcer bleeding can prevent the weekend effect, and nighttime admission was identified as a novel risk factor for rebleeding, namely the nighttime effect.     

幽门螺杆菌与消化性溃疡并出血的研究现状

幽门螺杆菌是消化性溃疡的确定性致病因素,其在溃疡并出血的作用尚不十分明确.目前,幽门螺杆菌在消化性溃疡并出血的感染率受检测方法、药物等影响不尽相同.幽门螺杆菌感染在一定程度上增加了消化性溃疡并出血的危险性,从长远上根除幽门螺杆菌可以降低溃疡出血风险,促进溃疡愈合.     

溃疡病非喷射性出血内镜征象与转归的关系

目的　比较溃疡病合并非喷射性出血患者不同内镜征象者临床表现、内镜治疗效果及转归的差异。方法　参考Forrest分级将143 例患者分为3 组:单纯渗血(Ⅰb)、渗血伴血管裸露(Ⅰb Ⅱa)和渗血伴血凝块(Ⅰb Ⅱb)。所有患者均接受内镜药物喷洒治疗,未止血者继续予内镜下注射治疗,反复大出血者外科手术。结果　内镜喷洒的即时止血率为Ⅰb 50.0% ,Ⅰb Ⅱa 0.0% ,Ⅰb Ⅱb 25.4% ;注射的即刻止血率均为100.0% 。3种不同征象的患者治疗后的再出血率为15.0% ～23.5% ,差异无显著性意义;注射治疗的再出血率低于喷洒治疗(13.7% 与37.5% ,P< 0.01)。4.0%～9.0% 的病例需要手术治疗,各组之间手术率差异无显著性意义。结论　Ⅰb Ⅱa、Ⅰb Ⅱb 者临床表现较重。内镜下注射治疗的即时效果优于喷洒治疗,且再出血的发生率较低。经内镜成功治疗的患者,尤其是接受注射者再出血和手术率与内镜征象无关     

Anaesthesia care for emergency endoscopy for peptic ulcer bleeding. A nationwide population-based cohort study

Objective: Currently, no standard approach exists to the level of monitoring or presence of staff with anaesthetic expertise required during emergency esophago-gastro-duodenoscopy (EGD) for peptic ulcer bleeding (PUB). We assess the association between anaesthesia care and mortality. We further describe the prevalence and inter-hospital variation of anaesthesia care in Denmark and identify clinical predictors for choosing anaesthesia care. Material and methods: This population-based cohort study included all emergency EGDs for PUB in adults during 2012–2013. About 90-day all-cause mortality after EGD was estimated by crude and adjusted logistic regression. Clinical predictors of anaesthesia care were identified in another logistic regression model. Results: Some 3.056 EGDs performed at 21 hospitals were included; 2074 (68%) received anaesthesia care and 982 (32%) were managed under supervison of the endoscopist. Some 16.7% of the patients undergoing EGD with anaesthesia care died within 90 days after the procedure, compared to 9.8% of the patients who had no anaesthesia care, adjusted OR?=?1.51 (95% CI?=?1.25–1.83). Comparing the two hospitals with the most frequent (98.6% of al EGDs) and least frequent (6.9%) use of anaesthesia care, mortality was 13.7% and 11.7%, respectively, adjusted OR?=?1.22 (95% CI?=?0.55–2.71). The prevalence of anaesthesia care varied between the hospitals, median?=?78.9% (range 6.9–98.6%). Predictors of choosing anaesthesia care were shock at admission, high ASA score, and no pre-existing comorbidity. Conclusions: Use of anaesthesia care for emergency EGD was associated with increased mortality, most likely because of confounding by indication. The use of anaesthesia care varied greatly between hospitals, but was unrelated to mortality at hospital level.     

Impact of epinephrine volume on further bleeding due to high-risk peptic ulcer disease in the combination therapy era

BACKGROUNDIn monotherapy studies for bleeding peptic ulcers, large volumes of epinephrine were associated with a reduction in rebleeding. However, the impact of epinephrine volume in patients treated with combination endoscopic therapy remains unclear. AIMTo assess whether epinephrine volume was associated with bleeding outcomes in individuals who also received endoscopic thermal therapy and/or clipping.METHODSData from 132 patients with Forrest class Ia, Ib, and IIa peptic ulcers were reviewed. The primary outcome was further bleeding at 7 d; secondary outcomes included further bleeding at 30 d, need for additional therapeutic interventions, post-endoscopy blood transfusions, and 30-day mortality. Logistic and linear regression and Cox proportional hazards analyses were performed.RESULTSThere was no association between epinephrine volume and all primary and secondary outcomes in multivariable analyses. Increased odds for further bleeding at 7 d occurred in patients with elevated creatinine values (aOR 1.96, 95%CI 1.30-3.20; P < 0.01) or hypotension requiring vasopressors (aOR 6.34, 95%CI 1.87-25.52; P < 0.01). Both factors were also associated with all secondary outcomes.CONCLUSIONEpinephrine maintains an important role in the management of bleeding ulcers, but large volumes up to a range of 10-20 mL are not associated with improved bleeding outcomes among individuals receiving combination endoscopic therapy. Further bleeding is primarily associated with patient factors that likely cannot be overcome by increased volumes of epinephrine. However, in carefully-selected cases where ulcer location or size pose therapeutic challenges or when additional modalities are unavailable, it is conceivable that increased volumes of epinephrine may still be beneficial.     

Small bowel ulcerative lesions are common in elderly NSAIDs users with peptic ulcer bleeding

AIM: To determine the frequency of small bowel ulcerative lesions in patients with peptic ulcer and define the significance of those lesions.METHODS: In our prospective study, 60 consecutive elderly patients with upper gastrointestinal bleeding from a peptic ulceration (cases) and 60 matched patients with a non-bleeding peptic ulcer (controls) underwent small bowel capsule endoscopy, after a negative colonoscopy (compulsory in our institution). Controls were evaluated for non-bleeding indications. Known or suspected chronic inflammatory conditions and medication that could harm the gut were excluded. During capsule endoscopy, small bowel ulcerative lesions were counted thoroughly and classified according to Graham classification. Other small bowel lesions were also recorded. Peptic ulcer bleeding was controlled endoscopically, when adequate, proton pump inhibitors were started in both cases and controls, and Helicobacter pylori eradicated whenever present. Both cases and controls were followed up for a year. In case of bleeding recurrence upper gastrointestinal endoscopy was repeated and whenever it remained unexplained it was followed by repeat colonoscopy and capsule endoscopy.RESULTS: Forty (67%) cases and 18 (30%) controls presented small bowel erosions (P = 0.0001), while 22 (37%) cases and 4 (8%) controls presented small bowel ulcers (P < 0.0001). Among non-steroidal anti-inflammatory drug (NSAID) consumers, 39 (95%) cases and 17 (33%) controls presented small bowel erosions (P < 0.0001), while 22 (55%) cases and 4 (10%) controls presented small bowel ulcers (P < 0.0001). Small bowel ulcerative lesions were infrequent among patients not consuming NSAIDs. Mean entry hemoglobin was 9.3 (SD = 1.4) g/dL in cases with small bowel ulcerative lesions and 10.5 (SD = 1.3) g/dL in those without (P = 0.002). Cases with small bowel ulcers necessitate more units of packed red blood cells. During their hospitalization, 6 (27%) cases with small bowel ulcers presented bleeding recurrence most possibly attributed to small bowel ulcers, nevertheless 30-d mortality was zero. Presence of chronic obstructive lung disease and diabetes was related with unexplained recurrence of hemorrhage in logistic regression analysis, while absence of small bowel ulcers was protective (relative risk 0.13, P = 0.05).CONCLUSION: Among NSAID consumers, more bleeders than non-bleeders with peptic ulcers present small bowel ulcers; lesions related to more severe bleeding and unexplained episodes of bleeding recurrence.     

抑酸药对消化性溃疡并出血的疗效

目的探讨抑酸药H2受体拮抗剂与质子泵抑制剂（PPI）对消化性溃疡并出血的疗效。方法（1）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）；（2）连续48小时监测胃内pH值；（3）回颀性分析303例应用雷尼替了与326例应用奥美拉唑的消化性溃疡并出血病人手术率与死亡率。结果（1）体外动物实验结果显示当pH≥6时，其GMBT明显减少，约57．6±18．6秒。（2）胃内pH值监测结果，西咪替丁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土1．3，逐步降低西咪替丁用量，其pH值亦逐步下降，至常规剂量800mg时，胃内pH值为1．5，基本无作用。（3）临床疗效观察，303例雷尼替丁与326例奥美拉唑组的消化性溃疡并出血者手术率与死亡率，前者分别为7．28％和1．99％，后者分别为4．91％和1．84％。结论质子泵抑制剂奥美拉唑静脉注射的抑酸效果，适用于消化性溃疡并出血病人，其疗效优于H2受体拮抗剂。     

Optimal injection volume of epinephrine for endoscopic treatment of peptic ulcer bleeding

AIM: To define the optimal injection volume of epinephrine with high efficacy for hemostasis and low complication rate in patients with actively bleeding ulcers. METHODS: This prospective, randomized, comparative trial was conducted in a medical center. A total of 228 patients with actively bleeding ulcers (spurting or oozing) were randomly assigned to three groups with 20, 30 and 40 mL endoscopic injections of an 1:10000 solution of epinephrine. The hemostatic effects and clinical outcomes were compared between the three groups. RESULTS: There were no significant differences in all background variables between the three groups. Initial hemostasis was achieved in 97.4%, 98.7% and 100% of patients respectively in the 20, 30 and 40 mL epinephrine groups. There were no significant differences in the rate of initial hemostasis between the three groups. The rate of peptic ulcer perforation was significantly higher in the 40 mL epinephrine group than in the 20 and 30 mL epinephrine groups (P < 0.05). The rate of recurrent bleeding was significantly higher in the 20 mL epinephrine group (20.3%) than in the 30 (5.3%) and 40 mL (2.8%) epinephrine groups (P < 0.01). There were no significant differences in the rates of surgical intervention, the amount of transfusion requirements, the days of hospitalization, the deaths from bleeding and 30 d mortality between the three groups. The number of patients who developed epigastric pain due to endoscopic injection, was significantly higher in the 40 mL epinephrine group (51/76) than in the 20 (2/76) and 30 mL (5/76) epinephrine groups (P < 0.001). Significant elevation of systolic blood pressure after endoscopic injection was observed in the 40 mL epinephrine group (P < 0.01). Significant decreasing and normalization of pulse rates after endoscopic injections were observed in the 20 mL and 30 mL epinephrine groups (P < 0.01). CONCLUSION: Injection of 30 mL diluted epinephrine (1:10000) can effectively prevent recurrent bleeding with a low rate of complications. The optimal injection volume of epinephrine for endoscopic treatment of an actively bleeding ulcer (spurting or oozing) is 30 mL.     

Acetylsalicylic acid use in patients with acute myocardial infarction and peptic ulcer bleeding

BACKGROUND:

Acetylsalicylic acid (ASA) is used in the treatment of acute myocardial infarction (AMI) but is also a risk factor for peptic ulcer disease (PUD) bleeding.

OBJECTIVE:

To determine the factors associated with continued ASA use in patients with AMI who develop PUD bleeding.

METHODS:

AMI patients who developed PUD bleeding during the same hospitalization at two tertiary care hospitals in Edmonton, Alberta, between January 1999 and December 2006, were evaluated retrospectively. Multivariate analysis was used to determine predictors of the primary outcome of continued ASA use during PUD bleeding.

RESULTS:

A total of 102 patients were analyzed. Thirty-eight patients (37%) were continued on ASA, while 64 (63%) had ASA discontinued during their hospitalization. On multivariate regression analysis, significant predictors of continued ASA use included low-risk ulcer stigmata on endoscopy (OR 3.7; 95% CI 1.4 to 10.2; P=0.01) and AMI requiring coronary intervention (OR 8.2; 95% CI 2.1 to 32.1; P=0.002). The mean (± SD) blood transfusion requirement was 3.9±3.6 units. The 30-day rebleeding and mortality rates were 14% and 14%, respectively.

CONCLUSIONS:

The continued use of ASA during AMI and PUD bleeding was variable. However, patients with low-risk ulcers and those who received coronary intervention were more likely to have ASA continued during PUD bleeding. Further studies evaluating the gastrointestinal risk of immediate ASA use in AMI with acute PUD bleeding are required.     

Endoclips vs large or small-volume epinephrine in peptic ulcer recurrent bleeding

AIM: To compare the recurrent bleeding after endoscopic injection of different epinephrine volumes with hemoclips in patients with bleeding peptic ulcer.METHODS: Between January 2005 and December 2009, 150 patients with gastric or duodenal bleeding ulcer with major stigmata of hemorrhage and nonbleeding visible vessel in an ulcer bed (Forrest IIa) were included in the study. Patients were randomized to receive a small-volume epinephrine group (15 to 25 mL injection group; Group 1, n = 50), a large-volume epinephrine group (30 to 40 mL injection group; Group 2, n = 50) and a hemoclip group (Group 3, n = 50). The rate of recurrent bleeding, as the primary outcome, was compared between the groups of patients included in the study. Secondary outcomes compared between the groups were primary hemostasis rate, permanent hemostasis, need for emergency surgery, 30 d mortality, bleeding-related deaths, length of hospital stay and transfusion requirements.RESULTS: Initial hemostasis was obtained in all patients. The rate of early recurrent bleeding was 30% (15/50) in the small-volume epinephrine group (Group 1) and 16% (8/50) in the large-volume epinephrine group (Group 2) (P = 0.09). The rate of recurrent bleeding was 4% (2/50) in the hemoclip group (Group 3); the difference was statistically significant with regard to patients treated with either small-volume or large-volume epinephrine solution (P = 0.0005 and P = 0.045, respectively). Duration of hospital stay was significantly shorter among patients treated with hemoclips than among patients treated with epinephrine whereas there were no differences in transfusion requirement or even 30 d mortality between the groups.CONCLUSION: Endoclip is superior to both small and large volume injection of epinephrine in the prevention of recurrent bleeding in patients with peptic ulcer.