Kim H J, Kim M H, Kim D I, Lee H J, Myung S J, Yoo K S, Park E T, Lim B C, Seo D W, Lee S K, Min Y I
Dept. of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
Endoscopy. 1999 Aug;31(6):431-6. doi: 10.1055/s-1999-42.
Hemorrhage is induced in approximately 0.5-12% of endoscopic biliary sphincterotomy (ES) procedures. We prospectively investigated the risk factors for ES-induced hemorrhage and evaluated the safety as well as the effectiveness of endoscopic hemostasis.
The study included 1304 patients who underwent ES between July 1996 and June 1998. Epinephrine spray was used initially for hemostatic treatment. If bleeding persisted, an epinephrine injection was given consecutively. In patients with exposed vessels, epinephrine injection followed by alcohol injection was given.
ES-induced hemorrhage occurred in 136 (10.4%) patients. The type of sphincterotome used (needle-knife sphincterotome, P=0.025) and the cutting speed (the so-called "zipper" cut, P = 0.049) were revealed as significant variables with regard to the occurrence of bleeding. Mild, moderate, and severe bleeding were noted in 108 (79.4%), 22 (16.2%), and six (4.4%) patients, respectively. Once bleeding occurred, patients with an associated ampullary lesion (impacted stone or cancer) or with coagulopathy were more likely to bleed profusely. Initial hemostasis was achieved in all patients. However, rebleeding occurred in eight patients who were initially classified as having moderate or severe bleeding. Finally, ES-induced hemorrhage was successfully controlled in all patients after 1-3 treatment sessions (mean 1.1 sessions). The difference in the incidence of complications between the groups treated or not treated by endoscopic hemostasis was not statistically significant.
ES-induced hemorrhage occurred in 10% of the patients studied. The use of needle-knife sphincterotomy and the cutting speed were independent risk factors for the occurrence of bleeding. Once bleeding occurred, its severity was affected by an associated ampullary lesion (impacted stone or cancer) or coagulopathy. Endoscopic hemostasis with epinephrine and/or alcohol was effective and safe in ES-induced hemorrhage.
内镜下胆管括约肌切开术（ES）过程中约0.5%-12%的患者会发生出血。我们前瞻性地研究了ES所致出血的危险因素，并评估了内镜止血的安全性和有效性。
本研究纳入了1996年7月至1998年6月期间接受ES的1304例患者。最初采用肾上腺素喷雾进行止血治疗。若出血持续，则连续给予肾上腺素注射。对于血管暴露的患者，先给予肾上腺素注射，随后进行酒精注射。
136例（10.4%）患者发生了ES所致出血。所用括约肌切开刀的类型（针刀括约肌切开刀，P=0.025）和切割速度（所谓的“拉链式”切割，P=0.049）被揭示为与出血发生相关的显著变量。分别有108例（79.4%）、22例（16.2%）和6例（4.4%）患者出现轻度、中度和重度出血。一旦发生出血，伴有壶腹病变（嵌顿结石或癌症）或凝血功能障碍的患者更易发生大出血。所有患者均实现了初始止血。然而，最初被归类为中度或重度出血的8例患者发生了再出血。最终，经过1-3次治疗（平均1.1次）后，所有患者的ES所致出血均得到成功控制。内镜止血治疗组与未治疗组之间并发症发生率的差异无统计学意义。
在所研究的患者中，10%发生了ES所致出血。针刀括约肌切开术的使用和切割速度是出血发生的独立危险因素。一旦发生出血，其严重程度受伴有壶腹病变（嵌顿结石或癌症）或凝血功能障碍的影响。肾上腺素和/或酒精内镜止血在ES所致出血中有效且安全。
