Rubin Timothy A, Murdoch Maureen, Nelson Douglas B
Minneapolis Veterans Affairs Medical Center, Department of Medicine, University of Minnesota, Minneapolis 44417, USA.
Gastrointest Endosc. 2003 Sep;58(3):369-73.
Acute GI bleeding is a life-threatening complication of warfarin therapy. Acute GI bleeding in patients with an international normalized ratio of 4.0 or greater (supratherapeutic) is often attributed to trivial mucosal lesions. The aim of the study was to determine the frequency of potentially significant lesions that would warrant endoscopy in this setting.
A retrospective review was conducted of patients treated with warfarin who were admitted to a single Veterans Affairs hospital from 1996 to 2000 with acute GI bleeding. Endoscopic findings, clinical management, and outcomes are reviewed for patients with a supratherapeutic international normalized ratio (>or=4.0) and compared with patients with an international normalized ratio in the therapeutic range (2.0-3.9).
Fifty-five patients with an international normalized ratio of 4.0 or greater (mean 8.4 [3.9]) and 43 patients with an international normalized ratio between 2.0 and 3.9 (mean 2.9 [0.6]) were hospitalized with acute GI bleeding. Thirty-seven patients (67%) with a supratherapeutic international normalized ratio and GI bleeding underwent upper endoscopy. Of these, 81.1% had positive findings, 18.9% had peptic ulcer disease, and 7.2% required endoscopic treatment. Thirty-eight percent of the patients with a supratherapeutic international normalized ratio underwent lower endoscopy; of these, 57.1% had abnormal findings and 9.5% required endoscopic treatment. Four patients (7.3%) in the supratherapeutic international normalized ratio group died during the index hospitalization. When patients with GI bleeding and a therapeutic international normalized ratio were compared with those with a supratherapeutic international normalized ratio, there were no significant differences between the two groups with regard to days of hospitalization, units of blood transfused, frequency of recurrent bleeding, need for surgery, or in-hospital deaths.
The high frequency of clinically significant lesions in patients taking warfarin with an international normalized ratio in the supratherapeutic range and acute GI bleeding supports a role for endoscopic evaluation.
急性胃肠道出血是华法林治疗的一种危及生命的并发症。国际标准化比值为4.0或更高（治疗剂量以上）的患者发生急性胃肠道出血通常归因于轻微的黏膜病变。本研究的目的是确定在此种情况下需要进行内镜检查的潜在重要病变的发生率。
对1996年至2000年入住一家退伍军人事务医院、因急性胃肠道出血接受华法林治疗的患者进行回顾性研究。对国际标准化比值高于治疗剂量（≥4.0）的患者的内镜检查结果、临床处理及转归进行分析，并与国际标准化比值在治疗范围内（2.0 - 3.9）的患者进行比较。
55例国际标准化比值为4.0或更高（平均8.4 [3.9]）以及43例国际标准化比值在2.0至3.9之间（平均2.9 [0.6]）的患者因急性胃肠道出血住院。37例（67%）国际标准化比值高于治疗剂量且有胃肠道出血的患者接受了上消化道内镜检查。其中，81.1%有阳性发现，18.9%有消化性溃疡病，7.2%需要内镜治疗。38%国际标准化比值高于治疗剂量的患者接受了下消化道内镜检查；其中，57.1%有异常发现，9.5%需要内镜治疗。国际标准化比值高于治疗剂量组有4例（7.3%）患者在本次住院期间死亡。将有胃肠道出血且国际标准化比值在治疗范围内的患者与国际标准化比值高于治疗剂量的患者进行比较，两组在住院天数、输血量、再出血频率、手术需求或院内死亡方面无显著差异。
国际标准化比值高于治疗剂量且发生急性胃肠道出血的华法林治疗患者中，具有临床意义的病变发生率较高，这支持了内镜评估的作用。
