急诊胃镜诊治急性上消化道非曲张静脉破裂出血42例

摘要

目的: 观察注射肾上腺素及热探头凝固疗法对上消化道非曲张静脉破裂出血的治疗作用.

方法: 对42例上消化道活动性出血患者(13例胃溃疡, 25例十二指肠球部溃疡, 4例Dieulafoy's病)进行局部注射肾上腺素及热探头凝固治疗.

结果: 42例患者经首次治疗后, 有38例(90.5%)出血停止(消化性溃疡35/38, Dieulafoy's病3/4), 再出血率为23.7%(9/38). 手术率为19.0%(8/42), 无死亡发生.

结论: 局部注射肾上腺素及热探头凝固法是治疗上消化道非静脉曲张破裂出血的有效手段.

关键词: 急诊胃镜; 肾上腺素; 热凝固法; 急性上消化道出血

Emergent gastroscopy in the treatment of acute nonvariceal upper gastrointestinal bleeding: an analysis of 42 cases

Hui Liu, Jian-Ying Bai, Lei Wang, Peng-Bin Zhang

Hui Liu, Department of Gastroenterology, Three Gorge Central Hospital, Wanzhou District, Chongqing 404000, China

Jian-Ying Bai, Lei Wang, Peng-Bin Zhang, Department of Gastroenterology, Xinqiao Hospital Affiliated to the Third Military Medical University, Chongqing 400037, China

Supported by: the Key Medical Laboratory Construction Program of Chongqing Municipality, No. [2007] 14.

Correspondence to: Hui Liu, Department of Gastroenterology, Three Gorge Central Hospital, Wanzhou District, Chongqing 404000, China. liuhui62512@sina.com

Received: January 23, 2007
Revised: February 1, 2007
Accepted: February 13, 2007
Published online: April 18, 2007

Abstract

AIM: To evaluate the efficiency of gastroscopic epinephrine injection with heat probe coagulation in the treatment of acute nonvariceal upper gastrointestinal bleeding (ANVUGIB).

METHODS: Forty-two cases of ANVUGIB (including 13 cases of gastric ulcer, 25 cases of duodenal ulcer, and 4 cases of Dieulafoy' disease) were treated with gastroscopic epinephrine injection plus heat probe coagulation.

RESULTS: Bleeding was controlled in 38 (90.5%) of 42 cases. The rebleeding rate was 23.7% (9/38), and the surgery rate was 19.0% (8/42). No death occurred.

CONCLUSION: Epinephrine injection plus heat probe coagulation is an effective method for the treatment of acute upper gastrointestinal nonvariceal bleeding.

Key Words: Emergent gastroscopy; Epinephrine; Heat probe coagulation; Acute upper digestive tract active bleeding

0 引言

上消化道出血是消化系统常见的急症. 常用治疗方法为内科保守疗法及外科手术治疗. 近年来, 经内镜对上消化道出血进行诊治得到了广泛应用. 我们对42例上消化道活动性非静脉曲张破裂出血患者进行了注射肾上腺素及热探头凝固治疗, 取得了较好的效果, 结果如下.

1 材料和方法

1.1 材料

42例患者中, 男34例, 女8例, 年龄18-54(平均26.5)岁. 其中胃溃疡13例, 十二指肠球部溃疡25例, Dieulafoy's病4例. 上述疾病患者均因呕血和/或黑便而就诊, 在行内镜检查时, 病变处有鲜血渗出或呈喷射样, 即判断为活动性上消化道出血并行内镜下治疗. 所有胃溃疡出血患者均进行了组织活检, 以排除恶性溃疡.

1.2 方法

用注射针(NM-1K, Olympus)将1:10000肾上腺液在出血灶周围及出血灶处进行多点注射, 每点注射0.5-1 mL, 直至出血停止(图1). 每例患者注射总量约6-15 mL, 平均9 mL. 注射止血后, 用热探头(CD-202, Olympus)在出血点处进行热凝固治疗, 电流25-30 W, 治疗2-3次. 经上述治疗止血成功后, 每日给予患者洛赛克40 mg静滴, 持续3 d, 后改为洛赛克20 mg口服. 经内镜治疗止血治疗后, 若患者在住院观察治疗期间再次出现呕血和(或)黑便, 内镜下发现原病灶再出血, 则行第二次内镜下治疗. 若经上述处理后不能止血, 或经第二次治疗后再次出血者, 即行手术治疗.

图1 十二指肠球部溃疡并出血治疗前后变化. A: 十二指肠球部溃疡喷射状出血; B: 十二指肠球部溃疡并出血注射治疗中; C: 十二指肠球部溃疡并出血注射治疗后, 出血停止, 局部可见少许血凝块.

2 结果

42例患者经首次治疗后, 有38例(90.5%)出血停止(消化性溃疡35/38, Dieulafoy's病3/4), 再出血率为23.7%(9/38). 手术率为19%(8/42), 无死亡发生(表1).

表1 内镜治疗上消化道非静脉曲张破裂出血效果.

出血原因	n	首次治疗止血率	再出血率	手术率
胃溃疡	13	84.6%(11/13)	27.3%(3/11)	23.1%(3/13)
十二指肠球部溃疡	25	96.0%(24/25)	20.8%(5/24)	12.0%(3/25)
Dieulafoy's病	4	75.0%(3/4)	33.3%(1/3)	50.0%(2/4)

3 讨论

目前, 对于非曲张静脉破裂性上消化道出血, 主要治疗手段包括内科保守治疗及手术治疗. 这类消化道出血, 经内科保守治疗后, 仍有1/3患者需要急诊手术治疗[1-2]. 而通过内镜进行局部止血治疗, 可明显减少患者出血量及输血量, 减少住院时间, 降低死亡率[3-7]. 内镜下治疗非静脉曲张破裂出血措施有多种, 主要包括热凝固疗法、注射疗法及血管夹法[8]. 热凝固疗法主要应用热探头及氩等离子电凝产生高温, 使局部血液凝固而达到治疗效果[9-10]. 注射疗法主要注射肾上腺素或凝血酶等通过压迫和收缩血管而达到止血效果[11]. 在这些治疗方法中, 每个方法均具有明显的治疗效果, 但是结合应用效果比单个疗法效果好[12]. 目前最常用而且最经济的方法是内镜下注射肾上腺上素及热凝固疗法[13]. 肾上腺素常用浓度为1:10000, 于出血灶周围及病灶处进行注射, 通过注射产生压迫作用及肾上腺素的血管收缩作用而止血. 为提高止血效果, 降低再出血率, 常在注射止血后采取进一步措施使局部血管形成血栓, 热凝固疗法是其中手段之一. Chung et al[14]发现注射肾上腺素止血后, 加用热凝固治疗可使再出血率降低, 减少了输血量及住院时间, 降低了手术率. 在本组治疗中, 再出血率为23.7%, 与相关文献报道相当.

Dieulafoy's病占上消化道非静脉曲张破裂出血的1%-5.8%[15], 目前常用的内镜下治疗手段包括注射肾上腺素及热凝固法、血管夹法及套扎法. 在应用注射肾上腺素及热凝固疗法治疗的4例患者中, 效果较差, 手术率达50%. 与常规治疗上消化道出血相仿, 在内镜治疗活动出血病灶后, 应静脉应用质子泵抑制剂, 抑制胃酸分泌, 提高胃腔内pH值, 减少纤溶作用, 促进血小板聚集, 从而降低再出血率, 减少输血量及手术率[5,16-17].

内镜下注射肾上腺素及热凝固法治疗上消化道活动性非静脉曲张破裂出血有较好效果, 加用质子泵抑制剂能进一步降低再出血率, 提高治疗效果.

评论

背景资料

非静脉曲张破裂出血是上消化道出血的主要原因之一, 主要治疗手段包括内科保守治疗及手术治疗. 这类消化道出血, 经内科保守治疗后, 仍有1/3患者需要急诊手术治疗. 而通过内镜进行局部止血治疗, 可明显减少患者出血量及输血量, 减少住院时间, 降低死亡率.

同行评价

本研究运用局部注射肾上腺素及热探头凝固治疗, 取得了较好的疗效, 与国外的相关报道相一致. 该方法具有操作方便、价格低廉等特点, 是治疗上消化道非静脉曲张破裂出血行之有效的方法.

备注

编辑:张焕兰 电编:张敏

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