Koperna T, Kisser M, Reiner G, Schulz F
Department of Surgery, Hospital Mistelbach Liechtensteinstrasse 67, A-2130 Mistelbach, Austria.
Hepatogastroenterology. 2001 May-Jun;48(39):702-5.
BACKGROUND/AIMS: Colonic diverticula are the most frequent cause of major lower intestinal bleeding and pose a diagnostic and therapeutic challenge to the attending physician. Emergency surgical resection is associated with a high mortality and morbidity and patients who will stop bleeding spontaneously cannot be distinguished from those who will continue to bleed. Our aim was to evaluate the efficacy of barium enema as a sole less invasive treatment option for severe diverticular bleeding.
We evaluated 102 patients admitted with colonic diverticular bleeding, from 1993 to 1997, who needed transfusion of 2 or more units of blood. We compared the clinical efficacy of surgical resection, conservative treatment, and therapeutic barium enema with regard to the cessation of bleeding, morbidity, mortality, and rebleeding rate. The therapeutic strategies used after further episodes of bleeding were also registered.
Transfusion requirements were highest in patients who underwent surgical treatment, while the least amount of blood was required by the barium enema group (6.9 +/- 3.1 vs. 3.6 +/- 1.5 units of blood). However, the quantity of transfused blood did not correlate with the initial hemoglobin level, which was highest in the conservative treatment group and lowest in the operative group (9.0 +/- 1.2 vs. 8.1 +/- 1.3 g/dL). These data support the fact that the most severe bleeding would necessitate surgical resection and that therapeutic barium enema may be considered more effective than conservative treatments. With regard to the outcome of treatment, conservative treatment led to a rebleeding rate of 43.3%, which differed significantly from a 15.9% rebleeding rate after therapeutic barium enema (P = 0.009). No rebleeding was registered in surgically treated patients. Sixty percent of patients in whom therapeutic barium enema failed were treated by colonic resection without mortality, while 77% of patients who had rebleeding after conservative treatment were successfully treated with barium enema. Overall, barium enema was the most frequently applied second-line treatment (56.5%). The mortality after surgery was significantly higher than that after other treatment modalities (33% vs. 1%; P = 0.0001).
If diverticular bleeding is clinically suspected as the cause of major lower intestinal hemorrhage, barium enema is a more promising alternative than conservative treatment because of diagnostic and therapeutic importance in the long-term. In the event of urgent secondary surgery following the failure of barium enema to stop bleeding, we recommend a sigmoidoscopy and, optionally, an angiography before surgery in order to first localize the bleeding. We conclude that therapeutic barium enema is the treatment of choice for the first bleeding episode, while surgical resection should be performed if rebleeding occurs.
背景/目的：结肠憩室是下消化道大出血最常见的原因，给主治医生带来诊断和治疗方面的挑战。急诊手术切除的死亡率和发病率很高，且无法区分哪些患者出血会自行停止，哪些患者会持续出血。我们的目的是评估钡剂灌肠作为严重憩室出血唯一的微创治疗选择的疗效。
我们评估了1993年至1997年因结肠憩室出血入院且需要输注2个或更多单位血液的102例患者。我们比较了手术切除、保守治疗和治疗性钡剂灌肠在止血、发病率、死亡率和再出血率方面的临床疗效。还记录了再次出血后采用的治疗策略。
接受手术治疗的患者输血需求量最高，而钡剂灌肠组所需的血量最少（6.9±3.1单位血液对3.6±1.5单位血液）。然而，输血量与初始血红蛋白水平无关，保守治疗组的初始血红蛋白水平最高，手术组最低（9.0±1.2对8.1±1.3 g/dL）。这些数据支持这样一个事实，即最严重的出血需要手术切除，且治疗性钡剂灌肠可能比保守治疗更有效。关于治疗结果，保守治疗的再出血率为43.3%，与治疗性钡剂灌肠后的再出血率15.9%有显著差异（P = 0.009）。手术治疗的患者未出现再出血。治疗性钡剂灌肠失败的患者中有60%接受了结肠切除，无死亡病例，而保守治疗后再出血的患者中有77%成功接受了钡剂灌肠治疗。总体而言，钡剂灌肠是最常应用的二线治疗方法（56.5%）。手术后的死亡率显著高于其他治疗方式（33%对1%；P = 0.0001）。
如果临床上怀疑憩室出血是下消化道大出血的原因，由于钡剂灌肠在长期诊断和治疗方面的重要性，它比保守治疗更具前景。如果钡剂灌肠未能止血而需要紧急二次手术，我们建议在手术前进行乙状结肠镜检查，必要时进行血管造影，以便首先定位出血部位。我们得出结论，治疗性钡剂灌肠是首次出血发作的首选治疗方法，而如果发生再出血则应进行手术切除。
