门静脉高压症脾切除联合贲门周围血管离断术后消化道再出血的危险因素分析

目的探讨门静脉高压症行脾切除联合贲门周围血管离断术后消化道再出血的危险因素。方法回顾性分析2008年1月至2011年6月西安交通大学医学院第一附属医院收治的117例门静脉高压症行脾切除联合贲门周围血管离断术患者的临床资料,其中22例术后再次发生上消化道出血。患者术后半年内每3个月随访1次,半年后每6个月随访1次,随访时间截至2013年3月。单因素分析采用,检验,多因素分析采用Logistic回归模型。结果患者术后随访时间为20．6～61．7个月,术后上消化道再出血发生率为18．80％（22／117）。单因素分析结果显示：乙型病毒性肝炎病史、术前AST、术前食管胃底静脉曲张、术后l周PLT、术后门静脉血栓是术后消化道再出血的危险因素（X2=7．326,5．290,10．112,4．020,9．239,P〈0．05）。多因素分析结果显示：乙型病毒性肝炎病史≥10年、术前食管胃底静脉3度曲张、术后门静脉血栓是术后消化道再出血的独立危险因素（OR=4．758,5．560,3．616,P〈0．05）。结论乙型病毒性肝炎病史≥10年、食管胃底静脉3度曲张及术后门静脉血栓是乙型病毒性肝炎肝硬化脾切除断流术后的独立危险因素。     

美罗培南治疗肝硬化并发上消化道出血患者对感染预防和再出血的影响*

目的 探讨应用美罗培南（MEM）治疗肝硬化（LC）并发上消化道出血（UGB）患者对感染预防和再出血的影响。方法 2016年11月~2018年10月期间我院重症医学科收治的92例LC并发UGB患者被随机分为对照组46例和观察组46例,在内科止血等综合治疗的基础上,分别在确定感染时再给予头孢曲松或在入院时即给予预防性应用MEM治疗。结果 在治疗10 d,观察组死亡1例,对照组死亡2例;观察组WBC计数为（5.6±1.9）×109/L,血清降钙素原（PCT）水平为（0.25±0.03） ng/mL,显著低于对照组的（9.8±1.2）×109/L和（0.42±0.06） ng/mL,而血小板计数为（106.2±15.7）×109/L,显著高于对照组的（93.6±20.1）×109/L（P<0.05）;观察组患者再出血率和感染发生率分别为8.9%和11.1%,均显著低于对照组的25.0%和43.2%,差异有统计学意义（P<0.05）;观察组共检出8株菌株,对照组检出24株。两组感染患者均以大肠埃希菌感染为主,其次为肺炎克雷伯菌。结论 预防性使用抗生素MEM治疗LC伴UGB患者能显著降低感染发生率,并对防止再出血有帮助,值得临床进一步验证。     

肝硬化食管静脉曲张结扎术后早期再出血危险因素分析

目的探讨内镜下食管静脉曲张结扎术(EVL)后早期再出血的临床危险因素。方法总结2005年1月—2012年12月肝硬化食管静脉曲张单纯EVL治疗患者320例的资料,统计其性别、年龄、肝硬化原因、合并症、是否患肝癌、相关手术史、实验室检查、影像学结果、胃镜结果等因素对术后早期再出血发生率和患者预后的影响,寻找独立危险因素。结果多元逐步Logistic回归分析显示:中量至大量腹水(OR=60.21,95%CI 10.10～415.35,P<0.01)、结扎点数(OR=16.28,95%CI 5.05～76.28,P<0.01)、静脉曲张程度(OR=14.96,95%CI 3.84～77.49,P<0.05)和凝血酶原时间(PT)>18 s(OR=12.26,95%CI 1.85～67.65,P<0.05)是肝硬化食管静脉曲张结扎术后早期再出血的独立危险因素。结论对肝硬化食管静脉曲张结扎术后早期再出血的独立危险因素术前应予积极的治疗及预防。     

Risk factors for re-bleeding of aneurysmal subarachnoid hemorrhage: Meta-analysis of observational studies

ObjectiveThe mortality of re-bleeding following aneurysmal subarachnoid hemorrhage is high, and surviving patients often have poor clinical condition and worse outcome than patients with a single bleed. In this study, we performed an updated systematic review and meta-analysis to determine the most common risk factors for re-bleeding in this patient population, with the goal of providing neurologists, neurosurgeons, neuro-interventionalists with a simple and fast method to evaluate the re-bleeding risk for aneurysmal subarachnoid hemorrhage.MethodWe conducted a thorough meta-analysis of the risk factors associated with re-bleeding or re-rupture of intracranial aneurysms in cases published between 2000 and 2013. Pooled mean difference was calculated for the continuous variables (age), and pooled odds ratio (OR) was calculated for categorical factors. If heterogeneity was significant (p < 0.05), a random effect model was applied; otherwise, a fixed model was used. Testing for pooled effects and statistical significance for each potential risk factor were analyzed using Review Manager software.ResultsOur literature search identified 174 articles. Of these, only seven retrospective studies met the inclusion criteria. These seven studies consisted of 2470 patients, 283 of which had aneurysmal re-bleeding, resulting in a weighted average rate of re-bleeding of 11.3% with 95% confidence interval [CI]: 10.1–12.6. In this population, sex (OR 1.46; 95% CI: 1.11–1.92), high systolic blood pressure [SBP] (OR 2.52; 95% CI: 1.40–4.53), aneurysm size (OR 3.00; 95% CI: 2.06–4.37), clinical condition (Hunt & Hess) (OR 4.94; 95% CI: 2.29,10.68), and Fisher grade (OR 2.29; 95% CI: 1.45, 3.61) were statistically significant risk factors for re-bleeding.ConclusionSex, high SBP, high Fisher grade, aneurysm size larger than 10 mm, and poor clinical condition were independent risk factors for aneurysmal re-bleeding. The importance of early aneurysm intervention and careful consideration of patient risk factors should be emphasized to eliminate the risk of re-bleeding and poor outcome.     

Comparison of infusion or low-dose proton pump inhibitor treatments in upper gastrointestinal system bleeding

Background

The most effective schedule of proton pump inhibitor (PPI) administration following endoscopic hemostasis of bleeding ulcers remains uncertain.

Aim

To compare the treatment effects of continuous infusion and low-dose esomeprazole therapies in patients with non-variceal upper gastrointestinal (GI) bleeding.

Methods

This prospective clinical study compared continuous infusion of esomeprazole (80 mg bolus followed by 8 mg∕h continuous infusion for 72 h) and low-dose esomeprazole (40 mg twice daily IV) treatments in GI bleeding patients with peptic ulcer presenting a high risk of re-bleeding, who were administered a successful endoscopic homeostasis. The primary end point was the occurrence of re-bleeding during hospitalization and within one month of discharge. Secondary outcomes were defined as duration of hospitalization, need of transfusion, surgical treatment, and mortality rate. After 72 h, both groups were switched to oral esomeprazole therapy for one-month.

Results

A hundred thirty-two subjects were enrolled. Re-bleeding occurred in 11 (16.7%) patients in the infusion therapy group and in 12 (18.2%) patients in the low-dose group (P = 0.819) within the first 72 h. No patient experienced re-bleeding in the first month following discharge. There was no statistical significant difference between the two groups in terms of transfusion need, durations of hospitalization, need for surgery and mortality rate.

Conclusion

PPI infusion therapy following endoscopic hemostasis treatment was not found superior to low-dose PPI therapy in the terms of re-bleeding, need of surgery and mortality.     

超早期血压控制对降低高血压脑出血患者再出血风险的效果观察

目的：探讨超早期血压控制对降低高血压脑出血患者再出血风险的效果影响。方法：回顾性分析我院超早期血压控制的61例高血压脑出血患者（观察组）,未给予超早期血压控制的60例高血压脑出血患者（对照组）,比较两组患者再出血发生率及其对神经功能的影响。结果：与对照组比较,观察组血压达标率明显增高（76.67％VS93.44％）,再出血发生率明显降低（31.67％VS4.92）,两组比较差异具有统计学意义（P＜0.05）;观察组治疗前后平均血肿体积比较差异无显著性（P＞0.05）,而对照组治疗后明显高于观察组和治疗前,比较差异具有显著性（P＜0.05）,再出血患者神经功能缺损评分也明显高于无再出血患者（ P＜0.05）。结论：超早期血压控制通过显著降低高血压脑出血患者再出血发生率和防止血肿体积扩大以改善患者神经功能。     

Effectiveness of therapeutic barium enema for diverticular hemorrhage

AIM:To evaluate the effectiveness of barium impaction therapy for patients with colonic diverticular bleeding.METHODS:We reviewed the clinical charts of patients in whom therapeutic barium enema was performed for the control of diverticular bleeding between August2010 and March 2012 at Yokohama Rosai Hospital.Twenty patients were included in the review,consisting of 14 men and 6 women.The median age of the patients was 73.5 years.The duration of the followup period ranged from 1 to 19 mo(median:9.8 mo).Among the 20 patients were 11 patients who required the procedure for re-bleeding during hospitalization,6patients who required it for re-bleeding that developed after the patient left the hospital,and 3 patients who required the procedure for the prevention of rebleeding.Barium(concentration:150 w%/v%)was administered per the rectum,and the leading edge of the contrast medium was followed up to the cecum by fluoroscopy.After confirmation that the ascending colon and cecum were filled with barium,the enema tube was withdrawn,and the patient’s position was changed every 20 min for 3 h.RESULTS:Twelve patients remained free of rebleeding during the follow-up period(range:1-19mo)after the therapeutic barium enema,including 9men and 3 women with a median age of 72.0 years.Re-bleeding occurred in 8 patients including 5 men and 3 women with a median age of 68.5 years:4developed early re-bleeding,defined as re-bleeding that occurs within one week after the procedure,and the remaining 4 developed late re-bleeding.The DFI(disease-free interval)decreased 0.4 for 12 mo.Only one patient developed a complication from therapeutic barium enema(colonic perforation).CONCLUSION:Therapeutic barium enema is effective for the control of diverticular hemorrhage in cases where the active bleeding site cannot be identified by colonoscopy.     

预防门脉高压症断流术后消化道再出血的护理

目的探讨门脉高压断流术后消化道再出血的原因,降低术后再出血的护理要点及注意事项。方法对1999-2005年219例门脉高压症患者行脾切除、贲门周围血管离断术后患者的临床资料进行回顾性分析。结果术后随访6个月~3年,随访率96%(210/219),有8例患者术后消化道再次出血,再出血率3.8%(8/210),其中急性胃粘膜病变出血5例,残留食管胃底曲张静脉再次破裂大出血2例,脾切除术后间断少量黑便伴门静脉、脾静脉及肠系膜上静脉血栓形成1例。结论断流术是治疗门静脉高压症引起上消化道大出血的良好术式,良好的术后护理和出院后的健康教育是手术成功及预防术后再出血的重要保证。     

Role of proton pump inhibitors in the management of peptic ulcer bleeding

Peptic ulcer bleeding is a serious medical problem with significant morbidity and mortality. Endoscopic therapy significantly reduces further bleeding, surgery and mortality in patients with bleeding peptic ulcers and is now recommended as the first hemostatic modality for these patients. The efficacy of large-dose proton pump inhibitor (PPI) therapy in reducing re-bleeding after endoscopic therapy has been supported by evidence derived from randomized controlled trials. It may be premature to recommend small-dose intravenous injection PPI after endoscopic hemostasis in patients with bleeding ulcers. An updated systematic review shows that PPI therapy before endoscopy significantly reduces the proportion with major stigmata and requirement for endoscopic therapy at index endoscopy. Some studies show that there is no significant difference between oral and intravenous PPIs in raising intragastric pH. However, clinical data is lacking in patients with peptic ulcer bleeding to date.     

上消化道大出血术后再出血的教训和治疗体会(附56例报告)

目的探讨上消化道大出血术后再出血应吸取的教训和处理对策。方法对56例上消化道大出血术后再出血的原因进行分析。结果再次手术37例,治愈33例(89.2%),死亡4例(10.8%);经腹腔内动脉插管介入治疗2例,止血成功1例,另1例再手术治愈;非手术治疗18例,治愈10例(55.6%),死亡8例(44.4%)。12例死亡病人再次出血距首次手术时间均在48小时内。结论对该类病人采取再手术与否,关键是看再出血的部位和原因以及非手术疗法止血的效果,应掌握好再手术的时机和正确的探查方法。