内镜诊治上消化道出血320例临床分析

目的探讨上消化道出血在48h内、外进行内镜直视下止血的疗效,并对其进行分析总结。方法选取2001年1月~2002年7月经内镜检查确诊的消化道出血患者320例,分为研究组和对照组。其中研究组228例在出血48h内进行内镜检查及镜下治疗;对照组92例在48h后进行内镜检查及治疗。并评价止血效果。结果研究组228例,成功止血有224例,成功止血率是98.24%;对照组92例,成功止血有78例,成功止血率是84.78%,两者相比,差异有统计意义(P<0.05)。结论上消化道出血患者,在积极改善一般情况血压稳定后,尽快行急诊内镜检查;治疗时间越早,成功止血率越高,对明确病因及成功止血十分重要。     

Endoscopic hemostasis in sphincterotomy-induced hemorrhage: its efficacy and safety.

BACKGROUND AND STUDY AIMS: Hemorrhage is induced in approximately 0.5-12% of endoscopic biliary sphincterotomy (ES) procedures. We prospectively investigated the risk factors for ES-induced hemorrhage and evaluated the safety as well as the effectiveness of endoscopic hemostasis. PATIENTS AND METHODS: The study included 1304 patients who underwent ES between July 1996 and June 1998. Epinephrine spray was used initially for hemostatic treatment. If bleeding persisted, an epinephrine injection was given consecutively. In patients with exposed vessels, epinephrine injection followed by alcohol injection was given. RESULTS: ES-induced hemorrhage occurred in 136 (10.4%) patients. The type of sphincterotome used (needle-knife sphincterotome, P=0.025) and the cutting speed (the so-called "zipper" cut, P = 0.049) were revealed as significant variables with regard to the occurrence of bleeding. Mild, moderate, and severe bleeding were noted in 108 (79.4%), 22 (16.2%), and six (4.4%) patients, respectively. Once bleeding occurred, patients with an associated ampullary lesion (impacted stone or cancer) or with coagulopathy were more likely to bleed profusely. Initial hemostasis was achieved in all patients. However, rebleeding occurred in eight patients who were initially classified as having moderate or severe bleeding. Finally, ES-induced hemorrhage was successfully controlled in all patients after 1-3 treatment sessions (mean 1.1 sessions). The difference in the incidence of complications between the groups treated or not treated by endoscopic hemostasis was not statistically significant. CONCLUSIONS: ES-induced hemorrhage occurred in 10% of the patients studied. The use of needle-knife sphincterotomy and the cutting speed were independent risk factors for the occurrence of bleeding. Once bleeding occurred, its severity was affected by an associated ampullary lesion (impacted stone or cancer) or coagulopathy. Endoscopic hemostasis with epinephrine and/or alcohol was effective and safe in ES-induced hemorrhage.     

内镜治疗非静脉曲张上消化道出血随机对照试验的Meta分析

比较不同内镜方式治疗非静脉曲张上消化道出血（NVUGB）的效果。方法 在Pubmed、Web of Science、Embase、Cochrane Library、中国生物医学文献数据库、中国知网数据库、万方数据库和维普数据库检索自建库以来至2018年11月公开发表的、有关内镜治疗NVUGB的所有中英文随机对照试验（RCT）,对纳入的研究进行质量评价,采用Revman 5.3软件进行Meta分析。结果 经过文献筛选后,共37篇RCT最终被纳入分析,共3 064例患者。Meta分析结果显示,金属钛夹与药物局部注射比较,即时止血成功率高（RR=1.12,95%CI：1.04～1.21）、再出血率低（RR=0.30,95%CI：0.22～0.42）、急诊外科手术率低（RR=0.24,95%CI：0.13～0.42）;金属钛夹与热凝止血比较,再出血率低（RR=0.32,95%CI：0.16～0.65）、即时止血成功率差异无统计学意义（RR=0.96,95%CI：0.89～1.05）、急诊外科手术率差异无统计学意义（RR=0.43,95%CI：0.15～1.25）;热凝止血与局部药物注射比较,即时止血成功率差异无统计学意义（RR=1.02,95%CI：0.98～1.05）、再出血率差异无统计学意义（RR=0.98,95%CI：0.76～1.27）、急诊外科手术率差异无统计学意义（RR=1.03,95%CI：0.75～1.41）。结论 内镜下金属钛夹治疗NVUGB的疗效优于药物局部注射和热凝止血,具有临床推广和应用价值。     

Preventing complications of endoscopic hemostasis in acute upper gastrointestinal hemorrhage

Over the last 20 years, endoscopic hemostasis has become the primary method of controlling acute, overt upper gastrointestinal hemorrhage (UGIH) and prevent rebleeding. Although uncommon, procedure-related complications may occur. This article reviews the risks attributable to endoscopic hemostasis in acute UGIH and how to help prevent these complications.     

消化道动脉灶性出血的内镜注射套扎联合治疗

目的探讨内镜注射套扎联合治疗消化道动脉灶性出血的可行性、安全性和临床应用价值。方法对消化道Dieulafoy病、息肉切除术后和消化性溃疡的动脉灶性出血的患者,进行内镜注射套扎联合治疗,首先于出血的动脉及其周围的黏膜下层注射10%高渗钠溶液3～5mL,其后应用单发或双发套扎器,套扎出血的动脉及其周围组织,从而达到止血的目的。结果胃、十二指肠和直肠Dieulafoy病出血12例(ForrestⅠa10例、Ⅱa2例),胃、大肠息肉切除术后出血6例(ForrestⅠa6例),胃、十二指肠球部溃疡出血8例(ForrestⅠa6例、Ⅱa2例),共26例动脉灶性出血的患者,经内镜注射套扎联合治疗后均止血成功,并以瘢痕愈合而治愈,无并发症发生。结论内镜注射套扎联合治疗消化道动脉灶性出血具有明确的理论基础,操作简易,疗效确切,是一种可行的、安全的和有效的治疗方法。     

Endoscopic hemostasis by local injection of epinephrine and polidocanol in bleeding ulcer. A prospective randomized trial

The present prospective randomized trial has been carried out to assess the efficacy of the endoscopic injection of epinephrine plus polidocanol, in the prompt treatment of upper gastrointestinal bleeding due to peptic lesions. Over a period of one year, 72 patients were admitted to the study. Thirty-six of these underwent endoscopic treatment (group A), while the others received medical treatment (group B). Definitive hemostasis was achieved in 29 patients in group A, and in 21 in group B (p less than 0.05). Seven patients in group A and 12 in group B underwent emergency surgery for persistent or recurrent bleeding (p = NS). Three patients from group B received endoscopic treatment owing to relative surgical contraindications. It was successful in all of them. Patients from group A needed a significantly lower number of units of packed red cells (p less than 0.05). Our results show that it is justified to employ endoscopic injection as the first therapeutic step in upper GI bleeding due to peptic gastroduodenal lesions.     

血液透析过程中并发上消化道出血的急诊内镜下诊治探讨

目的探讨血液透析过程中并发急性上消化道出血患者急诊内镜下的表现及止血措施。方法对48例血液透析过程中并发急性上消化道出血患者进行急诊内镜检查及治疗,总结消化道出血原因、内镜下表现、内镜下治疗方法及疗效。结果急诊胃镜检查发现上消化道出血病因以胃黏膜糜烂出血为主20例(41.7%),其次为十二指肠球部溃疡12例(25.0%)、胃溃疡8例(16.7%)。幽门螺旋杆菌阳性36例(75.0%)。上消化道出血内镜下改良Forrest分级:ForrestⅠa 6例,ForrestⅠb 18例,ForrestⅡa 8例,ForrestⅡb 8例,ForrestⅡc 4例,ForrestⅢ4例。对分级为ForrestⅠa至ForrestⅡb的38例患者进行内镜下止血,包括喷洒止血药止血6例,注射止血药止血4例,高频电凝止血8例,氩离子凝固术10例,钛夹止血6例,多种方法联合应用4例。48例患者中上消化道出血治愈46例,死亡2例,总体即时止血率为63.2%,有效止血率31.6%,再发出血率5.3%。结论血液透析中并发急性上消化道出血以急性胃黏膜糜烂为主,内镜下表现以ForrestⅠb及ForrestⅡb为主,急诊内镜下止血效果显著。     

开展血栓与止血实验项目的优化组合和临床应用研究

随着科学技术的发展，血栓与止血实验室检测的新技术和新方法不断涌现，该类检测项目的种类繁多，目前已逾百种。应用单一的检测项目有局限性，不能完全反映疾病的类型和状态。将这些单一的检测项目，在循证检验医学（evidence-based laboratory medicine，EBLM）指导下，结合临床实际需要，进行多项目的优化组合应用，为临床决策提供有效的实验证据，这已成为当前血栓与止血检测的发展趋势和热点之一。     

Efficacy of absolute ethanol injection for upper gastrointestinal massive bleedings with hemorrhagic shock

We applied the absolute ethanol injection method in 182 cases of massive bleeding with hemorrhagic shock before the performance of emergency endoscopy in 627 cases of upper gastrointestinal bleeding at our department and five related institutions since June 1979. Following results were obtained: Temporary hemostasis could not be obtained in only 2 (1.1%) out of 182 cases; in the remaining 180 cases bleeding was ceased. Rebleeding was seen in 15 cases (8.2%) and new bleeding in 17 cases (9.3%). In 21 (66%) of these cases hemostasis was obtained again by the absolute ethanol injection method. Eight patients (4.4%) underwent emergency operation and 4 patients (2.2%) died from bleeding. The complete hemostasis was obtained in 170 cases (93.4%).     

上消化道胃肠道间质瘤的内镜及临床分析

目的探讨上消化道胃肠道间质瘤(GIST)的内镜、病理及免疫组化特征,以提高内镜医生对该疾病的认识和诊断,减少误诊和漏诊。方法检索我院2007年1月至2010年4月所有经手术治疗的GIST,选择病变部位在食管、胃、十二指肠的病例,分析其临床表现、胃镜表现,辅助检查、手术病理及免疫组化结果。结果 30例患者中,以消化道出血为主要症状的患者11例(36.7%),腹痛的患者6例(20%),腹部不适的4例(13.3%),查体发现的3例(10%)。GIST部位:胃底12例(40%),胃体7例(23.3%)。胃镜下表现:(1)黏膜下隆起,表面光整,12例;(2)黏膜下隆起伴顶端溃疡7例;(3)溃疡型肿物4例;(4)黏膜下隆起顶端凹陷3例;(5)黏膜下隆起表面增殖糜烂1例;(6)黏膜下隆起伴糜烂2例;(7)胃镜阴性:1例。其中14例行超声内镜检查,多数病变来源于固有肌层。29例病理为梭形细胞肿瘤,免疫组化:CD117阳性29例(96.7%),CD34阳性27例(90%)。结论上消化道GIST临床表现多样,症状以消化道出血和腹痛、腹部不适为多。胃镜下表现不一,表现为黏膜隆起性病变,40%的病例黏膜表面光整,56.7%的病例呈溃疡表现或糜烂,少数病例肿物表面增殖,与胃癌不易鉴别。超声胃镜的诊断率高。     

时间护理对消化道出血患者止血的效果及健康知识的影响

目的探讨时间护理对消化道出血患者止血的效果及健康知识的影响。方法将消化道出血的患者120例随机分为对照组和观察组各60例,2组的治疗方法基本相同,对照组采用常规护理,观察组采用时间护理,比较2组的止血效果及健康知识的掌握。结果观察组的止血时间、输血量、治疗后的Hb以及总疗效与对照组无统计学意义(P0.05);观察组的疾病知识、规范服药、合理饮食、生活方式等健康知识得分高于对照组,差异有统计学意义(P0.05)。结论时间护理能够确保消化道出血患者的止血效果,增加患者的健康知识,有利于预防复发。     

不同生物止血材料研究进展及复合型止血材料的临床应用

背景:随着生物医用高分子材料如纤维素、甲壳素等天然高分子材料以及聚乙烯醇、胶原等合成高分子材料的研发,止血材料的运用和发展获得了飞跃.目的:文章综述了近年来不同种类高分子止血敷料的研究进展,评价了不同种类复合止血敷料的临床应用价值.方法:应用计算机检索万方和PubMed数据库中1996-01/2010-12关于医用高分子止血敷料研究应用的文章,在标题和摘要中以"止血材料;纤维蛋白;高分子材料;胶原蛋白;明胶海绵"或"biological;occlude the flow of blood;gelatin sponge; fibrae sanguis"为检索词进行检索.选择医用高分子止血敷料领域发表在近期文献或权威杂志上的文章.初检得到126篇文献,根据纳入标准选择28篇文章进行综述.结果与结论:近年来国内外主要应用的可吸收止血材料包括壳聚糖、纤维蛋白胶、吸收性明胶海绵、微纤维胶原等以及常用的按材质和用途分类的藻酸盐类和水胶体类,不同的止血材料其止血机制和止血效果均不相同.文章通过对多种复合止血材料的效果进行比较观察,说明了各种止血材料止血途径和止血机制还有待进一步的研究,以便于开发出更卓越、更有效的止血材料.     

The effect of endoscopic hemostasis with alcohol on the mortality rate of nonvariceal upper gastrointestinal hemorrhage. A randomized prospective study

One hundred and forty-five patients with nonvariceal upper GI hemorrhage, active or with stigmata (Forrest I and II) were divided into two groups according to the day of the week on which emergency endoscopy was performed: group A (78 patients) in which conventional treatment was applied (blood transfusions, antacids, cimetidine, pirenzepine), and group B (65 patients) in which endoscopic hemostasis with absolute alcohol (Asaki's method) was performed. The two groups were comparable as regards age, sex distribution and type of hemorrhage (after Forrest). Emergency surgery was performed in both groups if the bleeding did not stop or if it recurred. Twenty patients (11 in group A and 9 in group B) were operated on some time after the bleeding episode (5-18 days) to prevent new episodes. Absolute alcohol injection achieved hemostasis in all the cases of active hemorrhage (Forrest I) and prevented recurrence in 24 out of 25 cases with a clot or visible vessels (Forrest II), so that emergency surgery was not necessary in any of the patients of group B. Mortality rate was significantly lower in group B than in group A (10 deaths in group A, 2 in group B, p less than 0.05) being explained mainly by the reduced post-operative mortality (18% in group B), due to the small number of the operated patients (28 in groups A, 10 in B; p less than 0.02), especially of those operated on as an emergency (one in the endoscopic hemostasis group as compared with 17 in the conventional treatment group; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Development of a triage protocol for patients presenting with gastrointestinal hemorrhage: a prospective cohort study

Introduction  

Many patients presenting with acute gastrointestinal hemorrhage (GIH) are admitted to the intensive care unit (ICU) for monitoring. A simple triage protocol based upon validated risk factors could decrease ICU utilization.