内镜下干预对预防Forrest Ⅱb级溃疡再出血的临床价值

Clinical value of endoscopic intervention in preventing rebleeding of Forrest Ⅱb ulcers

摘要:

目的 探讨内镜下干预对预防Forrest Ⅱb级溃疡再出血的临床价值。方法 回顾性分析2015年1月－2023年4月该院因消化道出血经胃镜明确为Forrest Ⅱb级溃疡的114例患者的临床资料。86例（75.4%，86/114）行内镜下治疗的为内镜治疗组，28例行药物治疗的为药物治疗组。观察内镜治疗效果，以及不同内镜止血方法预防Forrest Ⅱb级溃疡再出血的临床效果。结果 内镜治疗与仅进行药物治疗的患者，在年龄、性别、临床症状、收缩压、血红蛋白浓度、溃疡部位方面比较，差异均无统计学意义（P > 0.05）；在溃疡大小方面，内镜治疗组溃疡直径小于药物治疗组［（9.5±5.3）和（12.8±7.7）mm］，差异有统计学意义（P = 0.013）。药物治疗组再出血率为21.4%（6/28）；内镜治疗组中，85例患者（98.8%，85/86）成功进行了内镜下治疗，再出血率为11.8%（10/85），低于药物治疗组，但两组患者比较，差异无统计学意义（P = 0.337）。成功行内镜治疗的患者中，单用注射稀释肾上腺素62例，钛夹闭合法6例，电凝或电凝联合其他止血方法17例，再出血率分别为12.9%（8/62）、16.7%（1/6）和5.9%（1/17），低于药物治疗组，但差异无统计学意义（P = 0.474）。因内镜治疗需要，15例患者采用圈套器或热止血钳去除溃疡表面血痂。其中，3例基底见喷射性出血（2例电凝成功止血；1例出血量较大，内镜止血失败，介入栓塞成功止血）。16例再出血患者，药物保守治疗3例，均成功止血；再次行内镜治疗6例，4例内镜成功止血，另2例内镜止血失败，转外科手术后成功止血；介入栓塞1例，成功止血；直接外科手术6例，均成功止血。直接外科手术中的1例患者，术后并发多器官功能衰竭，非出血死亡。结论 内镜下干预可在一定程度上降低Forrest Ⅱb级溃疡再出血发生率，电凝止血法预防再出血效果优于注射稀释肾上腺素法，但在去除溃疡表面血凝块时，有发生医源性再出血的风险，应在有条件的情况下慎重选择。

Abstract:

Objective To explore the clinical value of endoscopic intervention in preventing rebleeding of Forrest Ⅱb grade ulcers.Method A retrospective analysis was conducted on the clinical data of 114 patients from January 2015 to April 2023 due to gastrointestinal bleeding, who were confirmed by gastroscopy as Forrest Ⅱb grade ulcers. 86 (75.4%, 86/114) patients received endoscopic treatment as endoscopic treatment group, while 28 patients only received medication treatment as medication treatment group. Compare the effectiveness of endoscopic treatment and different endoscopic hemostatic methods for preventing rebleeding.Results There were no statistically significant differences in age, gender, clinical symptom, systolic pressure, hemoglobin concentration, and ulcer site between endoscopic and medication treatment patients (P > 0.05). In terms of ulcer size, the length of ulcer in the endoscopic treatment group was smaller than that in the medication treatment group [(9.5 ± 5.3) mm vs (12.8 ± 7.7) mm], the difference was statistically significant (P = 0.013). The rebleeding rate of medication treatment group was 21.4% (6/28); Among the endoscopic treatment group, 85 patients (98.8%, 85/86) successfully underwent endoscopic treatment, with a rebleeding rate of 11.8% (10/85), which was lower than that of medication treatment group, but the difference was not statistically significant (P = 0.337). Among the patients who successfully underwent endoscopic treatment, 62 cases were treated with injection of diluted adrenaline alone, 6 cases with titanium clips, and 17 cases were treated with electrocoagulation or electrocoagulation combined with other hemostatic methods. The rebleeding rate were 12.9% (8/62), 16.7% (1/6), and 5.9% (1/17), respectively, which were lower than that of medication treatment patients, but the difference was not statistically significant (P = 0.474). Due to the need for endoscopic treatment, 15 patients were treated with a snare or thermal hemostatic forceps to remove the surface blood clot of the ulcer. Among them, 3 cases had jet bleeding at the base (2 cases were successfully stopped by electrocoagulation; 1 case had a large amount of bleeding, but endoscopic hemostasis failed, and intervention embolization successfully stopped the bleeding). Among of 16 patients with rebleeding, 3 patients were treated with conservative management, and all of them were successfully stopped bleeding; 6 cases underwent endoscopic treatment again, of which 4 cases were successfully hemostasis by endoscopy, and 2 cases were successfully hemostasis by surgery after endoscopic hemostasis failure; interventional embolization in 1 case, and successfully hemostasis; 6 patients underwent direct surgical procedures, all of which successfully stopped bleeding, but one patient developed multiple organ failure during hospitalization and died without bleeding.Conclusion Endoscopic intervention can to some extent reduce the incidence of rebleeding in Forrest Ⅱb grade ulcers. The effect of electrocoagulation hemostasis on preventing rebleeding is better than that of injection dilution adrenaline method. However, there is a risk of iatrogenic rebleeding when removing blood clots on the surface of ulcers, and careful selection should be made when conditions permit.