Stiegmann Greg V
Gastrointestinal, Tumor and Endocrine Surgery, University of Colorado Denver and Health Science Center, Denver, Colorado, USA.
Am Surg. 2006 Feb;72(2):111-5.
Treatment for most patients with upper gastrointestinal bleeding has shifted from the operating room to the endoscopy suite. Endoscopic treatment has resulted in substantial benefit for patients with bleeding from peptic ulcer. Ulcers associated with high-risk stigmata of recent hemorrhage (SRH) not treated endoscopically have 40 per cent to 100 per cent risk of continued or recurrent bleeding and up to a 35 per cent chance of requiring surgical control of bleeding. Endoscopic therapy has reduced the risk of recurrent bleeding to 10 per cent to 20 per cent and the need for surgery to 5 per cent to 10 per cent. These improvements translate to shorter hospital stays, fewer transfusions, lower costs, and less morbidity. Similar progress has been made for patients bleeding from esophageal varices. Mortality for a first variceal bleed is now approximately 20 per cent as compared with 40 per cent to 60 per cent in past decades. Rebleeding after initially successful endoscopic hemostasis is often best treated by a second attempt at endoscopic control. The decision regarding management of recurrent bleeding should be made at the time initial endoscopic control is achieved. Local factors such as experience of the endoscopic team, availability of interventional radiologists, and individual patient characteristics should guide these decisions. Failures of endoscopic control and patients with massive hemorrhage still require operative intervention.
大多数上消化道出血患者的治疗已从手术室转移到内镜室。内镜治疗已给消化性溃疡出血患者带来了显著益处。近期出血高危征象（SRH）相关的溃疡若未接受内镜治疗，持续或再次出血的风险为40%至100%，且高达35%的几率需要手术控制出血。内镜治疗已将再次出血的风险降低至10%至20%，手术需求降低至5%至10%。这些改善带来了住院时间缩短、输血减少、成本降低以及发病率降低。食管静脉曲张出血患者也取得了类似进展。首次静脉曲张出血的死亡率目前约为20%，而过去几十年为40%至60%。最初内镜止血成功后的再出血通常最好通过再次内镜控制来治疗。关于复发性出血管理的决策应在内镜首次控制成功时做出。诸如内镜团队经验、介入放射科医生的可及性以及个体患者特征等局部因素应指导这些决策。内镜控制失败以及大出血患者仍需要手术干预。
