消化性溃疡高危险出血内镜征像对内镜治疗的指导价值
|
摘要
目的根据Forrset分级、Rockall和Blatchford评分分层分析,探索内镜治疗的价值。方法选取2016年3月至2018年3月因上消化道出血就诊且内镜检查确诊的消化性溃疡患者为研究对象,ForrestⅠ级11例,Ⅱa级、Ⅱb级各63例,Ⅱa、Ⅱb级患者采取随机数字表法再分为观察组(32例)和对照组(31例)。ForrestⅠ级患者行急诊内镜OTSC系统止血治疗;Ⅱa和Ⅱb级观察组患者行内镜治疗(其中Ⅱb级内镜治疗前预先去除溃疡底部血凝块)后抑酸治疗,对照组患者仅采用抑酸治疗。随访90d,统计分析止血率、近期和远期再出血率及总再出血率。结果 ForrestⅠ级患者止血率为90.91%,再出血率为0;Rockall高危与中低危患者止血率(87.50%vs.100.00%)、Blatchford中高危与低危患者止血率(90.00%vs.100.00%)比较,差异均无统计学意义(P>0.05)。ForrestⅡa级观察组与对照组患者近期再出血率(6.25%vs.32.26%)、总再出血率(6.25%vs.35.48%)比较,差异均有统计学意义(P<0.05);Rockall评分中低危与高危、Blatchford评分低危与中高危患者再出血率比较,差异均无统计学意义(P>0.05)。ForrestⅡb级观察组与对照组患者近期再出血率(6.25%vs.25.81%)、总再出血率(9.38%vs.29.03%)比较,差异均有统计学意义(P<0.05);Rockall评分中低危与高危、Blatchford评分低危与中高危患者再出血率比较,差异均无统计学意义(P>0.05)。结论据Forrest分级分层后采用相应的内镜治疗可达到满意的止血率及降低再出血率,Rockall和Blatchford评分判定是否需要内镜干预的价值有限。
Objective To determine the value of endoscopic treatment in peptic ulcer based on the stratification analysis of Forrest classification,Rockall and Blatchford scores.Methods Patents initially admitted to hospital due to upper gastrointestinal bleeding and finally diagnosed with peptic ulcer by endoscopic examination from March 2016 to March 2018 were selected.There were 11 cases of ForrestⅠ,63 cases ofⅡa andⅡb.The cases of ForrestⅡa and Ⅱb were divided into the observation group(32 cases)and the control group(31 cases)by random number table method.Patients of ForrestⅠ were performed emergency endoscopic hemostasis via OTSC system.For patients of ForrestⅡa andⅡb,the endoscopic treatment(submucous injection of epinephrine solution combined with thermal and/or mechanic therapy)and a subsequent PPI treatment were given to those in the observation group(an additional preliminary procedure of removing the covering blood clot was applied to the exposed vessels or bleeding lesions in cases of ForrestⅡb),whereas those in the control group only received PPI treatment.During 90 dfollow-up,the endoscopic hemostasis rate,shortterm and long-term rebleeding rate and total rebleeding rate were analyzed statistically.Results In ForrestⅠpatients,the hemostasis rate and rebleeding rate were 90.91% and 0,respectively.No significant difference was found in hemostasis rate between the high and medium-low risk of Rockall cases(87.50%vs.100.00%,P>0.05),and between the medium-high and low risk of Blatchford cases(90.00%vs.100.00%,P>0.05).In ForrestⅡapatients,there were statistically significant differences in the short-term rebleeding rate(6.25%vs.32.26%,P<0.05)and total rebleeding rate(6.25% vs.35.48%,P<0.05)between the observation group and the control group,while no significant difference was found in the rebleeding rate between the high and medium-low risk of Rockall cases(P>0.05),and between the medium-high and low risk of Blatchford cases(P>0.05).In ForrestⅡb patients,there were statistically significant differences in the short-term rebleeding rate(6.25%vs.25.81%,P<0.05)and total rebleeding rate(9.38% vs.29.03%,P<0.05)between the observation group and the control group,while no significant difference was found in the rebleeding rate between the high and medium-low risk of Rockall cases(P>0.05),and between the medium-high and low risk of Blatchford cases(P>0.05).Conclusion According to the Forrest classification,the application of corresponding endoscopic treatment can achieve satisfying hemostasis rate and reduce rebleeding rate for peptic ulcer patients,while Rockall and Blatchford scores are of limited value in assessing the need for endoscopic intervention.
Objective To determine the value of endoscopic treatment in peptic ulcer based on the stratification analysis of Forrest classification,Rockall and Blatchford scores.Methods Patents initially admitted to hospital due to upper gastrointestinal bleeding and finally diagnosed with peptic ulcer by endoscopic examination from March 2016 to March 2018 were selected.There were 11 cases of ForrestⅠ,63 cases ofⅡa andⅡb.The cases of ForrestⅡa and Ⅱb were divided into the observation group(32 cases)and the control group(31 cases)by random number table method.Patients of ForrestⅠ were performed emergency endoscopic hemostasis via OTSC system.For patients of ForrestⅡa andⅡb,the endoscopic treatment(submucous injection of epinephrine solution combined with thermal and/or mechanic therapy)and a subsequent PPI treatment were given to those in the observation group(an additional preliminary procedure of removing the covering blood clot was applied to the exposed vessels or bleeding lesions in cases of ForrestⅡb),whereas those in the control group only received PPI treatment.During 90 dfollow-up,the endoscopic hemostasis rate,shortterm and long-term rebleeding rate and total rebleeding rate were analyzed statistically.Results In ForrestⅠpatients,the hemostasis rate and rebleeding rate were 90.91% and 0,respectively.No significant difference was found in hemostasis rate between the high and medium-low risk of Rockall cases(87.50%vs.100.00%,P>0.05),and between the medium-high and low risk of Blatchford cases(90.00%vs.100.00%,P>0.05).In ForrestⅡapatients,there were statistically significant differences in the short-term rebleeding rate(6.25%vs.32.26%,P<0.05)and total rebleeding rate(6.25% vs.35.48%,P<0.05)between the observation group and the control group,while no significant difference was found in the rebleeding rate between the high and medium-low risk of Rockall cases(P>0.05),and between the medium-high and low risk of Blatchford cases(P>0.05).In ForrestⅡb patients,there were statistically significant differences in the short-term rebleeding rate(6.25%vs.25.81%,P<0.05)and total rebleeding rate(9.38% vs.29.03%,P<0.05)between the observation group and the control group,while no significant difference was found in the rebleeding rate between the high and medium-low risk of Rockall cases(P>0.05),and between the medium-high and low risk of Blatchford cases(P>0.05).Conclusion According to the Forrest classification,the application of corresponding endoscopic treatment can achieve satisfying hemostasis rate and reduce rebleeding rate for peptic ulcer patients,while Rockall and Blatchford scores are of limited value in assessing the need for endoscopic intervention.
引文
[1]LAINE L,YANG H,CHANG S C,et al.Trends for incidence of hospitalization and death due to GI complications in the United States from 2001to 2009[J].Am J Gastroenterol,2012,107(8):1190-1195.
[2]BAI Y,DU Y Q,WANG D,et al.Peptic ulcer bleeding in China:a multicenter endoscopic survey of 1006patients[J].J Dig Dis,2014,15(1):5-11.
[3]WONG S H,SUNG J J.Management of patients with rebleeding[J].Gastrointest Endosc Clin N Am,2015,25(3):569-581.
[4]SKINNER M,GUTIERREZ J P,NEUMANN H,et al.Over-the-scope clip placement is effective rescue therapy for severe acute upper gastrointestinal bleeding[J].Endosc Int Open,2014,2(1):E37-40.
[5]史宁,李锟,胡营滨,等.OTSC金属夹治疗难治性急性非静脉曲张性上消化道出血的效果评估[J].中国内镜杂志,2017,23(4):98-101.
[6]张占洁,于红刚,沈磊,等.Forrest分级和Rockall评分对消化性溃疡大出血患者预后的判断[J],成都医学院学报,2011,6(4):344-346.
[7]LAINE L,PETERSON W L.Bleeding peptic ulcer[J].NEngl J Med,1994,331:717-727.
[8]LAINE L,KIVITZ A J,BELLO A E,el al.Double-blind randomized trials of single-tablet ibuprofen/high dose famotidine vs ibuprofen alone for reduction of gastric and duodenal ulcers[J].Am J Gastroenterol,2012,107(3):379-386.
[9]《中华内科杂志》编委会,《中华消化杂志》编委会,《中华消化内镜杂志》编委会.急性非静脉曲张性上消化道出血诊治指南(2015,南昌)[J].中华内科杂志,2016,55(2):164-168.
[10]FUJISHIRO M,IGUCHI M,KAKUSHIMA N,et al.Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding[J].Dig Endosc,2016,28(4):363-378.
[11]李俊达,何剑琴.不同Forrest分级溃疡出血患者内镜下注射治疗的疗效观察[J].中华消化内镜杂志,2004,21(4):248-250.
[12]LAINE L,MCQUAID K R.Endoscopic therapy for bleeding ulcers:an evidencebased approach based on meta-analyses of randomized controlled trials[J].Clin Gastroenterol Hepatol,2009,7(1):33-47.
[13]KAHI C J,JENSEN D M,SUNG J J,et al.Endoscopic therapy versus medical therapy for bleeding peptic ulcer with adherent clot:a meta-analysis[J].Gastroenterology,2005,129(3):855-862.
[14]SUNG J J,CHAN F K,LAU J Y,et al.The effect of endoscopic therapy in patients receiving omeprazole for bleeding ulcers with nonbleeding visible vessels or adherent clots:a randomized comparison[J].Ann Intern Med,2003,139(4):237-243.
[15]BLEAU B L,GOSTOUT C J,SHERMAN K E,et al.Recurrent bleeding from peptic ulcer associated with adherent clot:a randomized study comparing endoscopic treatment with medical therapy[J].Gastrointest Endosc,2002,56(1):1-6.
[16]JENSEN D M,KOVACS T O,JUTABHA R,et al.Randomized trial of medical or endoscopic therapy to prevent recurrent ulcer hemorrhage in patients with adherent clots[J].Gastroenterology,2002,123(2):407-413.
[17]孙晓滨,史维,赵聪,等.内镜多普勒超声测定十二指肠溃疡血流的价值[J].中华消化内镜杂志,2006,23(4):298-300.
[2]BAI Y,DU Y Q,WANG D,et al.Peptic ulcer bleeding in China:a multicenter endoscopic survey of 1006patients[J].J Dig Dis,2014,15(1):5-11.
[3]WONG S H,SUNG J J.Management of patients with rebleeding[J].Gastrointest Endosc Clin N Am,2015,25(3):569-581.
[4]SKINNER M,GUTIERREZ J P,NEUMANN H,et al.Over-the-scope clip placement is effective rescue therapy for severe acute upper gastrointestinal bleeding[J].Endosc Int Open,2014,2(1):E37-40.
[5]史宁,李锟,胡营滨,等.OTSC金属夹治疗难治性急性非静脉曲张性上消化道出血的效果评估[J].中国内镜杂志,2017,23(4):98-101.
[6]张占洁,于红刚,沈磊,等.Forrest分级和Rockall评分对消化性溃疡大出血患者预后的判断[J],成都医学院学报,2011,6(4):344-346.
[7]LAINE L,PETERSON W L.Bleeding peptic ulcer[J].NEngl J Med,1994,331:717-727.
[8]LAINE L,KIVITZ A J,BELLO A E,el al.Double-blind randomized trials of single-tablet ibuprofen/high dose famotidine vs ibuprofen alone for reduction of gastric and duodenal ulcers[J].Am J Gastroenterol,2012,107(3):379-386.
[9]《中华内科杂志》编委会,《中华消化杂志》编委会,《中华消化内镜杂志》编委会.急性非静脉曲张性上消化道出血诊治指南(2015,南昌)[J].中华内科杂志,2016,55(2):164-168.
[10]FUJISHIRO M,IGUCHI M,KAKUSHIMA N,et al.Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding[J].Dig Endosc,2016,28(4):363-378.
[11]李俊达,何剑琴.不同Forrest分级溃疡出血患者内镜下注射治疗的疗效观察[J].中华消化内镜杂志,2004,21(4):248-250.
[12]LAINE L,MCQUAID K R.Endoscopic therapy for bleeding ulcers:an evidencebased approach based on meta-analyses of randomized controlled trials[J].Clin Gastroenterol Hepatol,2009,7(1):33-47.
[13]KAHI C J,JENSEN D M,SUNG J J,et al.Endoscopic therapy versus medical therapy for bleeding peptic ulcer with adherent clot:a meta-analysis[J].Gastroenterology,2005,129(3):855-862.
[14]SUNG J J,CHAN F K,LAU J Y,et al.The effect of endoscopic therapy in patients receiving omeprazole for bleeding ulcers with nonbleeding visible vessels or adherent clots:a randomized comparison[J].Ann Intern Med,2003,139(4):237-243.
[15]BLEAU B L,GOSTOUT C J,SHERMAN K E,et al.Recurrent bleeding from peptic ulcer associated with adherent clot:a randomized study comparing endoscopic treatment with medical therapy[J].Gastrointest Endosc,2002,56(1):1-6.
[16]JENSEN D M,KOVACS T O,JUTABHA R,et al.Randomized trial of medical or endoscopic therapy to prevent recurrent ulcer hemorrhage in patients with adherent clots[J].Gastroenterology,2002,123(2):407-413.
[17]孙晓滨,史维,赵聪,等.内镜多普勒超声测定十二指肠溃疡血流的价值[J].中华消化内镜杂志,2006,23(4):298-300.