内镜治疗对非活动性出血消化性溃疡的价值
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摘要
[目的]明确内镜治疗对非活动性出血消化性溃疡的价值。[方法]入选ForrestⅡa、Ⅱb级非活动性出血消化性溃疡患者各63例。各级患者均随机分为研究组和对照组,研究组经内镜治疗后抑酸治疗(但Ⅱb研究组预先去除底部的血凝块),对照组只予抑酸治疗。随访观察各组患者短期(0～7 d)和中远期(8～90 d)再出血率。[结果]Ⅱa级研究组与对照组短期再出血率(6.25%∶32.25%,)比较差异有统计学意义(P<0.05),Ⅱb级研究组与对照组短期再出血率(6.25%∶25.81%,)比较差异亦有统计学意义(P<0.05);而无论是Ⅱa级还是Ⅱb级其研究组与对照组中远期再出血率的比较均差异无统计学意义(P>0.05)。[结论]Ⅱa属于高危溃疡,内镜处理裸露血管残端可减少再出血;Ⅱb底部的血凝块会掩盖危险程度的真实性,预先去除血凝块,准确判断危险程度后,再行内镜治疗是合理的。
[Objective]To determine the value of endoscopic treatment on peptic ulcer with inactive bleeding.[Methods]Sixty-three enrolled ForrestⅡa/Ⅱb cases were divided into research and control group randomly.The cases in research groups were given endoscopic treatment(submucous injection combined with thermal and/or mechanic therapy)and a subsequent PPI treatment,whereas merely PPI treatment in control groups.The difference of endoscopic treatment between Ⅱa and Ⅱb research group was an additional preliminary procedure of removing the covering clot in Ⅱb.The rebleeding rate of short term(0-7 days)and medium-long term(8-90 days)were followed up.[Results]The difference of short-term rebleeding rates were of statistical significance in ForrestⅡa(6.25% vs 32.25%,P<0.05)and Ⅱb(6.25% vs 25.81%,P<0.05)respectively,however,the difference of medium-long term rebleeding rates were not of statistical significance in ForrestⅡa(0.00% vs 3.23%,P>0.05)and Ⅱb(3.18% vs 3.23%,P>0.05).[Conclusion]The endoscopic treatment on the visible vessels can reduce the rebleeding rate in ForrestⅡa,which is high-degree risk ulcer.The real risk of ForrestⅡb ulcer would be covered up by the adherent blot.And it is reasonable to apply endoscopic treatment including an additional preliminary procedure of removing the adherent clot to assess the accurate risk degree.
[Objective]To determine the value of endoscopic treatment on peptic ulcer with inactive bleeding.[Methods]Sixty-three enrolled ForrestⅡa/Ⅱb cases were divided into research and control group randomly.The cases in research groups were given endoscopic treatment(submucous injection combined with thermal and/or mechanic therapy)and a subsequent PPI treatment,whereas merely PPI treatment in control groups.The difference of endoscopic treatment between Ⅱa and Ⅱb research group was an additional preliminary procedure of removing the covering clot in Ⅱb.The rebleeding rate of short term(0-7 days)and medium-long term(8-90 days)were followed up.[Results]The difference of short-term rebleeding rates were of statistical significance in ForrestⅡa(6.25% vs 32.25%,P<0.05)and Ⅱb(6.25% vs 25.81%,P<0.05)respectively,however,the difference of medium-long term rebleeding rates were not of statistical significance in ForrestⅡa(0.00% vs 3.23%,P>0.05)and Ⅱb(3.18% vs 3.23%,P>0.05).[Conclusion]The endoscopic treatment on the visible vessels can reduce the rebleeding rate in ForrestⅡa,which is high-degree risk ulcer.The real risk of ForrestⅡb ulcer would be covered up by the adherent blot.And it is reasonable to apply endoscopic treatment including an additional preliminary procedure of removing the adherent clot to assess the accurate risk degree.
引文
[1] 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.
[2] LAU J Y,SUNG J,HILL C,et al.Systematic review of the epidemiology of complicated peptic ulcer disease:incidence,recurrence,risk factors and mortality[J].Digestion,2011,84:102-113.
[3] TARGOWNIK L E,NABALAMBA A.Trends in management and outcomes of acute nonvariceal upper gastrointestinal bleeding:1993—2003[J].Clin Gastroenterol Hepatol,2006,4:1459-1466.
[4] 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 2001-2009[J].Am J Gastroenterol,2012,107:1190-1195.
[5] FUJISHIRO M,IGUCHI M,KAKUSHIMA N,et al.Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding[J].Digestive Endoscopy,2016,28:363-378.
[6] ERIC P T,PATRICK S,Management of non-variceal upper gastrointestinal tract hemorrhage:Controversies and areas of uncertainy[J].W J Gastroenterol,2012,18:1159-1165.
[7] 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,2012,107:379-386.
[8] 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.
[9] 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,2003,139:237-243.
[10] 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,2002,56:1-6.
[11] 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,2002,123:407-413.
[12] 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.
[13] LAU J Y,BARKUN A,FAN D M,et al.Challenges in the management of acute peptic ulcer bleeding[J].Lancet,2013,381:2033-2043.
[14] JAVID G,MASOODI I,ZARGAR S A,et al.Omeprazole as adjuvant therapy to endoscopic combination injection sclerotherapy for treating bleeding peptic ulcer[J].Am J Med,2001,111:280-284.
[15] 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,2009,7:33-47.
[16] 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,2005,129:855-862.
[17] ANDRIULLI A,ANNESE V,CARUSO N,et al.Proton-pump inhibitors and outcome of endoscopic hemostasis in bleeding peptic ulcers:a series of meta-analyses[J].Am J Gastroenterol,2005,100:207-219.
[18] MARMO R,ROTONDANO G,PISCOPO R,et al.Dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers:a meta-analysis of controlled trials[J].Am J Gastroenterol,2007,102:279-289.
[19] BARKUN A N,BARDOU M,KUIPERS E J,et al.International Consensus Upper Gastrointestinal Bleeding Conference Group.International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding[J].Ann Intern Med,2010,152:101-113.
[20] SUNG J J,BARKUN A,KUIPERS E J,et al.Intravenous esomeprazole for prevention of recurrent peptic ulcer bleeding:a randomized trial[J].Ann Intern Med,2009,150:455-464.
[2] LAU J Y,SUNG J,HILL C,et al.Systematic review of the epidemiology of complicated peptic ulcer disease:incidence,recurrence,risk factors and mortality[J].Digestion,2011,84:102-113.
[3] TARGOWNIK L E,NABALAMBA A.Trends in management and outcomes of acute nonvariceal upper gastrointestinal bleeding:1993—2003[J].Clin Gastroenterol Hepatol,2006,4:1459-1466.
[4] 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 2001-2009[J].Am J Gastroenterol,2012,107:1190-1195.
[5] FUJISHIRO M,IGUCHI M,KAKUSHIMA N,et al.Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding[J].Digestive Endoscopy,2016,28:363-378.
[6] ERIC P T,PATRICK S,Management of non-variceal upper gastrointestinal tract hemorrhage:Controversies and areas of uncertainy[J].W J Gastroenterol,2012,18:1159-1165.
[7] 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,2012,107:379-386.
[8] 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.
[9] 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,2003,139:237-243.
[10] 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,2002,56:1-6.
[11] 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,2002,123:407-413.
[12] 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.
[13] LAU J Y,BARKUN A,FAN D M,et al.Challenges in the management of acute peptic ulcer bleeding[J].Lancet,2013,381:2033-2043.
[14] JAVID G,MASOODI I,ZARGAR S A,et al.Omeprazole as adjuvant therapy to endoscopic combination injection sclerotherapy for treating bleeding peptic ulcer[J].Am J Med,2001,111:280-284.
[15] 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,2009,7:33-47.
[16] 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,2005,129:855-862.
[17] ANDRIULLI A,ANNESE V,CARUSO N,et al.Proton-pump inhibitors and outcome of endoscopic hemostasis in bleeding peptic ulcers:a series of meta-analyses[J].Am J Gastroenterol,2005,100:207-219.
[18] MARMO R,ROTONDANO G,PISCOPO R,et al.Dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers:a meta-analysis of controlled trials[J].Am J Gastroenterol,2007,102:279-289.
[19] BARKUN A N,BARDOU M,KUIPERS E J,et al.International Consensus Upper Gastrointestinal Bleeding Conference Group.International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding[J].Ann Intern Med,2010,152:101-113.
[20] SUNG J J,BARKUN A,KUIPERS E J,et al.Intravenous esomeprazole for prevention of recurrent peptic ulcer bleeding:a randomized trial[J].Ann Intern Med,2009,150:455-464.