Vergara M, Calvet X, Gisbert J P
Hospital de Sabadell, Unitat de Malaties Digestives, Institut Universitari Parc Tauli, Universitat Autonoma de Barcelona. Parc Tauli s/n, Sabadell, Spain, 08208.
Cochrane Database Syst Rev. 2007 Apr 18(2):CD005584. doi: 10.1002/14651858.CD005584.pub2.
Endoscopic therapy reduces rebleeding rate, need for surgery, and mortality in patients with bleeding peptic ulcers. Injection of epinephrine is the most popular therapeutic method. Guidelines disagree on the need for a second haemostatic procedure immediately after epinephrine.
The objective of this review was to determine whether the addition of a second procedure improves efficacy or patient outcomes or both after epinephrine injection in adults with high risk bleeding ulcers.
We searched the Cochrane Central Register of Controlled Trials - CENTRAL (which includes the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register) (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006) and reference lists of articles. We also contacted experts in the field.
Randomised studies comparing endoscopic treatment: epinephrine alone versus epinephrine associated with a second haemostatic method in adults with haemorrhage from peptic ulcer disease with major stigmata of bleeding as defined by the Forrest classification. Bleeding must have been confirmed by endoscopy.
Two authors independently assessed trial quality and extracted data.
Seventeen studies including 1763 people were included. Adding a second procedure reduced further bleeding rate from 18.8% to 10.4%; Peto Odds Ratio 0.51; 95% confidence interval (CI) 0.39 to 0.66, and emergency surgery from 10.8% to 7.1%; OR 0.63; 95% CI 0.45 to 0.89. Mortality fell from 5% to 2.5% OR 0.50; 95% CI 0.30 to 0.82. Subanalysis showed that the risk of further bleeding decreased regardless of which second procedure was applied. In addition, the risk was reduced in all subgroups.
AUTHORS' CONCLUSIONS: Additional endoscopic treatment after epinephrine injection reduces further bleeding, the need for surgery and mortality in patients with bleeding peptic ulcer.
内镜治疗可降低消化性溃疡出血患者的再出血率、手术需求及死亡率。肾上腺素注射是最常用的治疗方法。对于在肾上腺素注射后是否需要立即进行第二次止血操作，指南存在分歧。
本综述的目的是确定在成人高危出血性溃疡患者中，在肾上腺素注射后增加第二次操作是否能提高疗效或改善患者预后，或两者兼具。
我们检索了Cochrane对照试验中心注册库（CENTRAL）（其中包括Cochrane上消化道和胰腺疾病组试验注册库）（《Cochrane图书馆》2006年第1期）、MEDLINE（1966年至2006年2月）、EMBASE（1980年至2006年2月）以及文章的参考文献列表。我们还联系了该领域的专家。
随机研究，比较内镜治疗：在患有根据Forrest分类定义的具有大出血征象的消化性溃疡疾病出血的成人中，单纯肾上腺素治疗与肾上腺素联合第二种止血方法治疗的效果。出血必须经内镜证实。
两位作者独立评估试验质量并提取数据。
纳入了17项研究，共1763人。增加第二次操作可将再出血率从18.8%降至10.4%；Peto比值比为0.51；95%置信区间（CI）为0.39至0.66，急诊手术率从10.8%降至7.1%；比值比为0.63；95%CI为0.45至0.89。死亡率从5%降至2.5%，比值比为0.50；95%CI为0.30至0.82。亚组分析表明，无论采用哪种第二次操作，再出血风险均降低。此外，所有亚组的风险均降低。
肾上腺素注射后额外的内镜治疗可降低消化性溃疡出血患者的再出血率、手术需求及死亡率。
