Fibreoptic endoscopy and the use of the Sengstaken tube in acute gastrointestinal haemorrhage in patients with portal hypertension and varices.

The value of emergency upper gastrointestinal fibre-endoscopy, followed where required by the use of a modified Sengstaken tube, was studied during 84 episodes of acute bleeding in 75 patients who had evidence of portal hypertension with varices. The portal hypertension was due to alcoholic cirrhosis in 80% and to cryptogenic cirrhosis in 9% of the patients. By definition, varices were present in all patients, but in only 66% of episodes were the varices the cause of the bleed. The correct diagnosis of the source of bleeding was made at endoscopy in 89%. A Boyce modification of the Sengstaken-Blakemore tube was passed in 73% of the episodes of variceal bleeding. It effectively stopped the bleeding primarily in 85% of patients but was successful as a final definitive measure only in 46%. Furthermore, only 40% of the patients in whom the tube was passed, survived. Mortality rate could be related to the severity of the bleed and to hepatocellular dysfunction. Survival increased from 23% in those patients with jaundice, ascites, and encephalopathy on admission to 92% in those without these manifestations. The in-hospital survival rate was 52% in patients bleeding from varices and 64% in those bleeding from other causes, with an overall survival rate of 56%, indicating the poor prognosis in cirrhotic patients with gastrointestinal bleeding, irrespective of the cause.     

老年急性非静脉曲张性上消化道出血临床特点分析

目的总结分析急性非静脉曲张性上消化道出血≥75岁老年患者的临床特点,以便进一步了解该类患者的特殊性,为更好的临床诊治提供参考。方法回顾性分析165例于2006～2007年收住消化内科的非静脉曲张性上消化道出血患者的临床病历资料,其中老年组（≥75岁）96例,非老年组（〈60岁）59例,详细记录其临床表现、实验室检查、内镜下表现及伴随的其他系统疾病,并进行对比和分类分析。结果老年组与非老年组急性非静脉曲张性上消化道出血的首要原因均为溃疡病,老年组胃溃疡发病率（20.8%）高于非老年组（8.5%）（P〈0.05）,而非老年组十二指肠球部溃疡（57.6%）及复合性溃疡（15.3%）发病率高于老年组（39.6%及5.2%）（P〈0.05）,老年组急性糜烂出血性胃炎发病率（13.5%）明显高于非老年组（3.4%）（P〈0.05）,老年组有上腹痛和（或）上腹部压痛者（49%）低于非老年组（66.1%）（P〈0.05）。与非老年组比较,老年组伴随的其他系统疾病明显增高（P〈0.01）;应用阿司匹林/非甾体类抗炎药（NSAIDs）明显增多（P〈0.01）;血尿素氮数值明显增高（P〈0.01）;住院时间明显延长（P〈0.05）。2组幽门螺杆菌感染情况比较无显著性差异（P〉0.05）。结论≥75岁老年患者非静脉曲张性上消化道出血病情较非老年组重,住院时间长,治疗也较为复杂。对于老年组急诊内镜下诊治可以明确诊断,并可同时进行镜下止血治疗。     

13例AIDS合并非霍奇金淋巴瘤的临床分析

目的分析13例艾滋病相关非霍奇金淋巴瘤(ARL)病人的临床资料,探讨其治疗时机和治疗方案。方法采用回顾性分析的方法,对龙潭医院2008年10月至2013年6月收治的艾滋病(AIDS)合并ARL住院病人的临床特点、免疫水平、并发症、病理检查及治疗情况、转归等进行分析。结果 13例ARL病人中,男性11例,女性2例,年龄24~71岁。10例在淋巴瘤诊治中首次发现艾滋病病毒(HIV)感染,2例分别在抗病毒治疗(ART)1个月和4个月后发现ARL,1例在诊断HIV感染后4个月发现ARL(未行ART)。发病时CD+4T淋巴细胞计数为21~340个/μL。10例为B细胞淋巴瘤,其中1例为Burkitt淋巴瘤,1例为黏膜相关性淋巴样组织淋巴瘤(MALT),6例为弥漫大B细胞性淋巴瘤,2例未能进一步分型;2例未分型,1例为T细胞淋巴瘤。以颈部肿物、腹股沟肿物、腋下包块、盆腔肿块及锁骨上肿物等为首发症状的7例,上消化道出血、便血、腹胀及腹痛、吞咽时胸骨后灼热痛、发热伴咽痛、发热伴头痛等起病6例。8例进行了ART,4例进行了化疗。4例未随访,7例死亡。结论HIV感染者若出现不明原因的淋巴结肿大、发热、消化道出血等,应考虑并发淋巴瘤的可能,必要时行淋巴结活检以明确诊断。积极的ART联合规范性化疗,以及适当的治疗时机仍需要补充更多的临床实践资料进行讨论。     

Endoscopic examination of the upper gastrointestinal tract in infancy

Forty endoscopic examinations of the upper gastrointestinal tract were performed in 38 infants with an age range from 2 days to 12 months. The main indications were upper gastrointestinal bleeding, chronic intractable vomiting, and small intestinal biopsy. Duodenal ulcer, hemorrhagic gastritis, and gastric erosions were the most common causes of upper gastrointestinal bleeding in infancy. An acute viral infection with fever, aspirin ingestion, and diarrhea frequently preceded gastrointestinal bleeding from duodenal ulcer and gastric erosion. Four of the 27 bleeding patients demonstrated no abnormality endoscopically.     

肠溶阿司匹林致冠心病患者上消化道出血调查分析

目的探讨肠溶阿司匹林导致冠心病患者出现上消化道出血的具体原因。 方法回顾性分析2016年1月至2017年12月青岛市城阳区人民医院收治的的68例冠心病患者的临床资料,分析肠溶阿司匹林导致冠心病患者出现上消化道出血的具体原因。 结果68例冠心病患者中38例发生上消化道出血,上消化道出现发生率为55.88%。出血患者用药剂量为300 mg/d、用药时间>3个月、存在消化道病史、未使用胃黏膜保护剂比例高于未出血患者,差异有统计学意义(均P<0.05)。 结论冠心病患者肠溶阿司匹林致上消化道出血的原因较多,包括用药剂量大,用药时间长,存在消化道病史,未服用胃黏膜保护剂等。     

Differentiation between patients with acute upper gastrointestinal bleeding who need early urgent upper gastrointestinal endoscopy and those who do not. A prospective study

OBJECTIVE: To differentiate, among patients presented at the emergency department with acute upper gastrointestinal bleeding, those who need early urgent upper gastrointestinal endoscopy from those who do not. METHODS: Seventeen variables for each patient presenting with upper gastrointestinal bleeding were prospectively recorded and considered in a multivariate analysis. We used the presence of active bleeding during early urgent upper gastrointestinal endoscopy within 12 h from admission as the end point. The derived score was validated with data from the next consecutive patients presenting with upper gastrointestinal bleeding. RESULTS: Among 190 consecutive patients (mean age 63.7 +/- 16 years; 64.7% men), active bleeding was observed in 51 patients (26.8%). Four variables were identified as independent predictors (P < 0.05) of active bleeding in early urgent upper gastrointestinal endoscopy and were used for the derivation of the following integer-based scoring system: number of points = 6 (fresh blood in nasogastric tube) + 4 (haemodynamic instability) + 4 (haemoglobin < 8 g/dl) + 3 (white blood cell count > 12 000/microl). The validation study consisted of 110 patients (71 men; mean age 66.1 +/- 14 years; 28 patients [25.5%] with active bleeding). In this study, a cut off of < 7 points indicated absence of active bleeding and >/= 11 points indicated presence of active bleeding; this gave a sensitivity of 96%, specificity of 98%, positive predictive value of 96% and negative predictive value of 98%. CONCLUSIONS: Simple clinical and laboratory variables available at presentation can be used to differentiate patients with upper gastrointestinal bleeding who do not need an early urgent upper gastrointestinal endoscopy from those who do.     

Gastrointestinal bleeding in the elderly.

Among patients with acute gastrointestinal bleeding, older age is associated with an increased rate of comorbidity, greater medication use, and atypical clinical presentations. The aging of the population makes the evaluation and management of gastrointestinal bleeding in the elderly a special and increasingly common clinical challenge. The unique features and common causes of upper and lower gastrointestinal bleeding in the elderly are reviewed. Important management issues considered include hemodynamic resuscitation; anticoagulation; and medical, surgical, and endoscopic therapy.     

Prevalence of esophagogastric varices in patients with non-alcoholic steatohepatitis.

Aim: In non-alcoholic steatohepatitis (NASH), fibrosis begins around the central veins, as also happens with alcoholic liver disease, so the symptoms of portal hypertension may be due to central vein occlusion. The aim of this study was to define the prevalence of esophagogastric varices and the clinical outcome after endoscopic treatment in NASH patients with severe fibrosis. Methods: The subjects were 72 patients with clinicopathologically confirmed NASH who had bridging fibrosis (F3) or cirrhosis (F4) determined by the examination of liver biopsy specimens, and who underwent upper gastrointestinal endoscopy. The prevalence and pattern of endoscopically detected varices at the time of liver biopsy were evaluated. The results of NASH patients (n = 11) with endoscopically treated esophageal varices were compared to those with alcoholic (n = 67) and hepatitis C virus-associated cirrhosis (n = 152). Results: Esophagogastric varices were detected in 34 out of the 72 (47.2%) patients; esophageal varices in 25 (34.7%) and gastric varices in nine (12.5%), while six of these patients had variceal bleeding. In NASH patients, the cumulative recurrence-free probability at 24 months after endoscopic treatment was 63.6%, the bleeding-free probability was 90.9%, and the 5-year survival was 100%. Only one out 11 patients died of liver failure at 70 months after treatment. Conclusion: About half of NASH patients with severe fibrosis had esophagogastric varices. The clinical status and course of the varices do not necessarily improve after endoscopic treatment. NASH patients with esophagogastric varices need to be followed up carefully, like patients with other chronic liver diseases.     

Description of prescribing practices in patients with upper gastrointestinal bleeding receiving intravenous proton pump inhibitors: a multicentre evaluation.

BACKGROUND: Intravenous forms of proton pump inhibitors (IV PPI) are routinely used for patients with acute upper gastrointestinal bleeding, but a significant concern for their inappropriate use has been suggested. patients and METHODS: All consecutive patients who received IV PPI (pantoprazole) over 20 months in six Canadian hospitals were reviewed. Prescribing practices, endoscopic findings and outcomes were recorded. RESULTS: A total of 854 patients received IV PPI. Over 90% of patients were given IV PPI for treatment of known or suspected active upper gastrointestinal bleeding. Most patients (69%) underwent upper endoscopy, and 58% of these patients had peptic ulcer disease (PUD). The majority of patients who had endoscopy (57%) had IV PPI administered in advance of the procedure. Of the 334 patients who had IV PPI given in advance, 46 (13.8%) were found to have high risk bleeding PUD stigmata at endoscopy. The remaining 288 patients (86.2%) with advance IV PPI had low-risk PUD lesions or non-PUD lesions; IV PPI was continued after endoscopy in 164 (56.9%) of these patients. CONCLUSIONs: IV PPI is often used before endoscopy in suspected upper gastrointestinal bleed and maintained, regardless of endoscopic findings, after the endoscopy in many Canadian centres. Further study is required to support these clinical practices.     

Evaluation and treatment of gastrointestinal tract hemorrhage in patients with AIDS

Hemodynamically significant gastrointestinal tract hemorrhage is infrequently seen among patients with AIDS. During a 35-month period, we evaluated 37 AIDS patients with substantial gastrointestinal tract bleeding: 13 patients had upper gastrointestinal disease; 24 patients had colorectal disease. AIDS-associated lesions were identified as the etiology of the hemorrhage in 8 of 13 patients with upper and 9 of 24 patients with lower gastrointestinal tract bleeding.     

Epidemiology of AIDS in females with hemophilia and other chronic bleeding disorders in the United States: comparisons with males with chronic bleeding disorders and AIDS and with nonhemophilic female blood-transfusion recipients with AIDS.

From January 1, 1981 through June 30, 1990, 32 females with chronic bleeding disorders were diagnosed with acquired immunodeficiency syndrome (AIDS) in the United States. Most (81.3%) were white and greater than or equal to 30 years of age, with a median age of 37.5 years. Eighteen (56.3%) had von Willebrand's disease. Pneumocystis carinii pneumonia was reported for 16 (50%). None had Kaposi sarcoma. The median survival time was 10.8 months, with a cumulative probability of survival at 1 year of 47.3% and at 2 years of 27.6%. We compared the demographic data and survival times of these females with those of males with a chronic bleeding disorder and AIDS, and with those of nonhemophilic females with AIDS whose exposure to the human immunodeficiency virus (HIV) was through receipt of blood transfusions, blood components, or tissue. The principal demographic difference was age distribution. The females with chronic bleeding disorders tended to be younger than the transfused, nonhemophilic females, but older than the males. The survival time from AIDS diagnosis to death for the females with chronic bleeding disorders did not differ statistically from that of the other two groups, although older nonhemophilic females whose exposure was transfusion may progress more rapidly to AIDS.     

Endoscopic injection sclerotherapy for 1,000 patients with esophageal varices: a nine-year prospective study.

We report here the results of endoscopic injection sclerotherapy performed in 1,000 consecutively treated Japanese patients with esophageal varices. This prospective study covered the period from 1982 to 1990. Variceal bleeding was controlled in 215 (97.7%) of 220 patients. Esophageal varices were completely eradicated in 778 patients (77.8%); the mean number of sessions was 4.2. In only 3 of the 778 patients did esophageal varices of the same size recur. Small, dilated, venous vessels that required additional sclerotherapy in follow-up endoscopy at 3-mo intervals appeared in 171 (22.2%) of 778 patients. The cumulative nonbleeding rate at 5 yr was 94.5% in patients in whom the varices had been eradicated. Deaths caused by upper gastrointestinal bleeding accounted for 2.6% of cases, whereas the rates of liver failure and hepatoma were 4.6% and 47.3%, respectively. The 5-yr cumulative survival rate was 54.1% in patients without concomitant hepatoma; it was 12.0% in patients with hepatomas. Multivariate analysis showed that hepatoma, Child classification, indication (acute, elective or prophylactic) and eradication were independent factors that significantly influenced survival time. This study clearly shows that close follow-up with endoscopy and complete eradication lead to significant reduction in bleeding from esophageal varices and reduction of mortality related to this bleeding.     

Acute upper gastrointestinal hemorrhage in patients with chronic renal disease

In order to reassess the role of duodenal ulcers as a cause of acute upper gastrointestinal hemorrhage in patients with chronic renal failure, 20 consecutive patients with moderate to severe chronic renal failure and a comparison group of patients without renal disease who were seen for acute upper gastrointestinal hemorrhage were reviewed. Gastric bleeding sites (gastric ulcer in 35 percent and gastritis in 20 percent) rather than duodenal ulcers were the most common sources of bleeding and were significantly associated with the use of ulcerogenic drugs. Patients with renal disease in whom acute upper gastrointestinal hemorrhage developed had significantly more morbidity and a trend toward higher mortality than the comparison group of patients without renal disease. It is concluded that gastric mucosal lesions, at least in part due to the use of ulcerogenic drugs, are the most common cause of significant acute upper gastrointestinal hemorrhage in patients with chronic renal failure.     

Value of a centralised approach in the management of haematemesis and melaena: experience in a district general hospital.

All patients presenting with acute upper gastrointestinal bleeding between November 1986 and April 1988 were admitted to a centralised joint medical/surgical unit, with a policy of early clinical and endoscopic assessment and rapid surgical intervention in those at high risk. Of the 430 patients admitted 69.5% were over the age of 60 and 30% had significant additional medical conditions. 50.4% were bleeding from peptic ulcers and one third had been taking non-steroidal anti-inflammatory agents. Fifty five patients underwent surgery, which in two thirds was carried out within 24 hours of admission, usually for continued bleeding. In patients with peptic ulcer the operation rate was 21.6%. Overall mortality was 3.7%, and in those with bleeding gastric or duodenal ulcers 5.5%; surgical mortality in the later group was 15.2%. All patients who died had serious concomitant pathology and 87% were over 70 years of age. Adoption of a centralised approach to management of haematemasis and melaena is feasible in a District General Hospital and associated with an improved survival.     

老年人上消化道出血的病因构成及相关因素研究

[目的]探讨老年人上消化道出血的病因构成及其相关因素。[方法]选取2011年2月~2013年6月间因上消化道出血到我院就诊的250例老年上消化道出血患者,对其发病原因进行统计分析,并研究病因与诱因的相关性。[结果]250例老年急性上消化道出血患者的主病因依次为：出血性胃炎（32％）、胃（24％）及十二指肠溃疡（28％）、胃肿瘤（10％）等,男性患者发病的比例明显高于女性患者（P〈O．05）;不同病因间的诱因构成不同,出血性胃炎主由酗酒（33％）引起;而胃溃疡的主诱因为饮食不当（38．1％）和长期服用药物（22％）;此外,老年上消化道出血患者中服用非甾体类抗炎药物的患者比例高达40．4％。[结论]老年患者急性上消化道出血病因主包括出血性胃炎、胃及十二指肠溃疡等,常见诱因的相关因素包括酗酒、饮食不当、药物影响等,在诊疗过程中应尽早明确病因,并针对不同病因制订不同治疗方案,才能取得患者较好的疗效及预后。     

急性非静脉曲张性上消化道出血临床分析

目的分析非静脉曲张性上消化道出血的临床特征。方法回顾分析我院消化内科2009年1月-2011年12月期间收治的经胃镜证实的301例非静脉曲张性上消化道出血病例,分析总结非静脉曲张性上消化道出血的常见病因及临床诊治情况。结果非静脉曲张性上消化道出血的常见病因依次为消化性溃疡、消化道肿瘤、急性胃黏膜病变,内科保守治疗的有效率为96.35%(290/301),内镜下止血成功率93.55%(58/62)。结论消化性溃疡是非静脉曲张性上消化道出血最常见的病因。在消化道出血的救治中,急诊内镜、选择性血管造影以及内外科的紧密配合与协作发挥着重要作用。     

上消化道出血322例分析

目的探讨上消化道出血的原因和相关因素。方法回顾性分析我科2年来322例上消化道出血的临床资料。结果322例中通过检查有明确病因者293例,主要病因依次为消化性溃疡、急性胃粘膜病变、食管胃底静脉曲张、胃癌;男性明显高于女性;消化性溃疡占各年龄组上消化道出血的首位,中、青年组以十二指肠溃疡多见,老年组以胃溃疡多见;胃癌位于老年组上消化道出血的第二位,显著高于中、青年组(P<0.01)。结论上消化道出血的病人以消化性溃疡、胃癌、食道胃底静脉曲张、急性胃粘膜病变为最常见的病因,性别、年龄等均为上消化道出血的相关因素。     

Predictors of morbidity and mortality after the first episode of upper gastrointestinal bleeding in liver cirrhosis

BACKGROUND/AIMS: Upper gastrointestinal (GI) bleeding is one of the most frequent causes of morbidity and mortality in the course of liver cirrhosis. The aim of this study was to determine the independent predictors of morbidity, mortality, and survival after the first episode of GI bleeding in patients with liver cirrhosis. METHODS: In a retrospective study of 403 cirrhotic patients who were admitted in the period January 1982 to December 1994 because of a first episode of GI hemorrhage, epidemiological factors, bleeding-related variables and cirrhosis-related variables that may be associated with hepatic and extrahepatic complications, mortality at 48 h and 6 weeks, and survival up to 30 June 1996 were assessed. RESULTS: Forty-five percent of patients developed hepatic and/or extrahepatic complications, with a mortality rate of 7.4% at 48 h and 24% at 6 weeks. Renal failure, rebleeding, hepatocellular carcinoma, and hepatic encephalopathy were independent predictors of mortality. The Kaplan-Meier method showed a median survival of 30.9+/-4.5 months (95% confidence interval 22 to 39.7 months). The cumulative percentage of survivors was 60.2% at 1 year, 33.6% at 5 years, and 14% at 10 years. In a Cox's multiple regression analysis, age, hepatic encephalopathy, hepatocellular carcinoma, Child-Pugh grade, and renal failure were independently associated with long-term survival. CONCLUSIONS: The first episode of GI bleeding in patients with liver cirrhosis is associated with high morbidity and mortality. Renal failure, rebleeding, hepatocellular carcinoma, and hepatic encephalopathy were independent risk factors for early death.     

Long-term monitoring of patients with clinical symptoms of upper gastrointestinal tract bleeding with a negative endoscopy result

The authors present the results of a long-term monitoring of patients who presented with clinical signs of bleeding from the upper gastrointestinal tract (GIT) but totally negative endoscopy results on admission. Retrospective-prospective analysis of acute endoscopies in patients with clinical signs of bleeding from the upper gastrointestinal tract performed in the Endoscopy Centre of the OstravaTeaching Hospital from 2002 to 2005, long term monitoring of the sample with negative results on admission. A total of 133 patients, i.e. 16.3 % of all acute procedures, with no source of bleeding detected in the first endoscopy. 26.4% of wrong indications. In the rest of the sample, a source of bleeding was detected by endoscopy in 17 patients (15 in an early examination and 2 within one month from the event), i.e. 17.3%. The rate of bleeding recurrence was 15%. The risk of recurrence was higher in patients with haematemesis and a decrease in the blood count (BC) at the time of the first event. In 19 patients, i.e. 14.3%, the source was not detected. In the remaining 33 patients, the findings were as follows: 1) in 4 patients, the source of bleeding was detected in the small intestine (push enteroscopy or enteroclysis); 2) in 3 patients, the source of bleeding was detected in the colon; 3) in 6 patients, IBD was detected; 4) in 5 patients, cirrhosis of the liver was diagnosed within months or years from the event.     

Long-term follow-up study of adult patients with non-cirrhotic obstruction of the portal system: comparison with cirrhotic patients.

Thirty-two patients with non-cirrhotic portal system obstruction and oesophageal varices of non-malignant etiology were recruited over 13 years. Diagnosis was based on the presence of oesophageal varices at endoscopy, minor alterations in liver function tests and liver histology, a low hepatic venous pressure gradient, and pertinent angiographic patterns. Twenty-three had portal vein thrombosis, nine had splenic vein thrombosis. Twenty-one had idiopathic portal vein obstruction, 11 had secondary obstruction. The outcome was compared with a group of 32 patients with cirrhosis and portal hypertension, matched for age, Child-Pugh class, previous history of gastrointestinal bleeding, and size of oesophageal varices. Patients with non-cirrhotic obstruction of the portal system were followed for up to 171 months (mean 94 months). During follow-up ten patients had gastrointestinal bleeding, and eight died (five of gastrointestinal bleeding). After 6 years of follow-up, the cumulative risk of gastrointestinal bleeding was 24%, the cumulative risk of death was 17%, and the cumulative risk of death from gastrointestinal bleeding was 14%. Cumulative probability of death by any cause and the probability of gastrointestinal bleeding were significantly lower in patients with non-cirrhotic obstruction of the portal system than in patients with cirrhosis comparable for liver function and portal hypertension (p = 0.04 for both). The cumulative probability of death by gastrointestinal bleeding was not significantly different. In conclusion, the prognosis for non-cirrhotic obstruction of the portal system is significantly better than for patients with cirrhosis with comparable levels of liver function impairment and severity of portal hypertension.