稳定型急性静脉曲张出血时的紧急与非紧急内镜检查
Urgent vs. non-urgent endoscopy in stable acute variceal bleeding.
作者信息
Cheung Justin, Soo Isaac, Bastiampillai Ravin, Zhu Qiaohao, Ma Mang
机构信息
Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
出版信息
Am J Gastroenterol. 2009 May;104(5):1125-9. doi: 10.1038/ajg.2009.78. Epub 2009 Mar 31.
OBJECTIVES
The optimal timing of endoscopy with acute variceal bleeding (AVB) is unknown. The aim of this study was to evaluate the association between the timing of endoscopy and outcomes of stable AVB patients.
METHODS
Patients admitted at two tertiary-care centers with hemodynamically stable AVB from 1997 to 2006 were evaluated retrospectively. The primary outcome was mortality. Other recorded outcomes included stigmata at endoscopy, hemostasis, blood transfusions, rebleeding, renal function, hospitalization length, infection, transjugular intrahepatic portosystemic shunt use, and balloon tamponade use. Logistic regression analysis was used to assess the association of time to endoscopy with mortality. Outcome comparisons were also performed for three different urgency times (< or = vs. > 4 h, < or = vs. > 8 h, and < or = vs. > 12 h).
RESULTS
There were 210 patients with stable AVB, accounting for 52% of the total number of AVB patients. The mean (+/- s.d.) age was 55 (+/- 12) years. The mean presenting systolic blood pressure and heart rate were 121 (+/- 16) mm Hg and 98 (+/- 20) bpm, respectively. Esophageal varices accounted for 91% (n = 191) of variceal bleeding. The mean time to endoscopy was 12 (+/- 12) h. The overall hemostasis rate after endoscopy was 97% (n = 203). The mortality rate was 9.5% (n = 20). There was no significant association of time to endoscopy with mortality (odds ratio, OR, 1.0; 95% confidence interval, CI, 0.92-1.08; P = 0.91). Significant independent predictors for mortality were lower albumin (OR, 0.82; 95% CI, 0.73-0.93; P = 0.001), infection during admission (OR, 8.9; 95% CI, 2.5-31.6; P < 0.001), and higher model end-stage liver disease (MELD) (OR, 1.17; 95% CI, 1.06-1.29; P = 0.002). There was no difference in outcomes with different urgency times.
CONCLUSIONS
For patients who present with hemodynamically stable variceal bleeding, hemostasis after endoscopy is high, and the time to endoscopy does not appear to be associated with mortality.
目的
急性静脉曲张出血（AVB）时内镜检查的最佳时机尚不清楚。本研究旨在评估内镜检查时机与血流动力学稳定的AVB患者预后之间的关联。
方法
回顾性评估1997年至2006年在两家三级医疗中心收治的血流动力学稳定的AVB患者。主要结局为死亡率。其他记录的结局包括内镜检查时的病变特征、止血情况、输血、再出血、肾功能、住院时间、感染、经颈静脉肝内门体分流术的使用以及气囊压迫止血的使用。采用逻辑回归分析评估内镜检查时间与死亡率之间的关联。还对三个不同紧急程度的时间（≤4小时与＞4小时、≤8小时与＞8小时、≤12小时与＞12小时）进行了结局比较。
结果
有210例血流动力学稳定的AVB患者，占AVB患者总数的52%。平均（±标准差）年龄为55（±12）岁。入院时平均收缩压和心率分别为121（±16）mmHg和98（±20）次/分钟。食管静脉曲张占静脉曲张出血的91%（n = 191）。内镜检查的平均时间为12（±12）小时。内镜检查后的总体止血率为97%（n = 203）。死亡率为9.5%（n = 20）。内镜检查时间与死亡率之间无显著关联（比值比，OR，1.0；95%置信区间，CI，0.92 - 1.08；P = 0.91）。死亡率的显著独立预测因素为白蛋白水平较低（OR，0.82；95%CI，0.73 - 0.93；P = 0.001）、入院期间感染（OR，8.9；95%CI，2.5 - 31.6；P ＜ 0.001）以及较高的终末期肝病模型（MELD）评分（OR，1.17；95%CI，1.06 - 1.29；P = 0.002）。不同紧急程度时间的结局无差异。
结论
对于血流动力学稳定的静脉曲张出血患者，内镜检查后的止血率较高，且内镜检查时间似乎与死亡率无关。
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