Cheung Frances K Y, Lau James Y W
Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China.
Gastroenterol Clin North Am. 2009 Jun;38(2):231-43. doi: 10.1016/j.gtc.2009.03.003.
Massive bleeding from a peptic ulcer remains a challenge. A multidisciplinary team of skilled endoscopists, intensive care specialists, experienced upper gastrointestinal surgeons, and intervention radiologists all have a role to play. Endoscopy is the first-line treatment. Even with larger ulcers, endoscopic hemostasis can be achieved in the majority of cases. Surgery is clearly indicated in patients in whom arterial bleeding cannot be controlled at endoscopy. Angiographic embolization is an alternate option, particularly in those unfit for surgery. In selected patients judged to belong to the high-risk group--ulcers 2 cm or greater in size located at the lesser curve and posterior bulbar duodenal, shock on presentation, and elderly with comorbid illnesses--a more aggressive postendoscopy management is warranted. The optimal course of action is unclear. Most would be expectant and offer medical therapy in the form of acid suppression. Surgical series suggest that early elective surgery may improve outcome. Angiography allows the bleeding artery to be characterized, and coil embolization of larger arteries may further add to endoscopic hemostasis. The role of early elective surgery or angiographic embolization in selected high-risk patients to forestall recurrent bleeding remains controversial. Prospective studies are needed to compare different management strategies in these high-risk ulcers.
消化性溃疡大出血仍然是一个挑战。由技术娴熟的内镜医师、重症监护专家、经验丰富的上消化道外科医生和介入放射科医生组成的多学科团队都能发挥作用。内镜检查是一线治疗方法。即使是较大的溃疡，大多数情况下也能通过内镜止血。对于在内镜检查时无法控制动脉出血的患者，显然需要进行手术治疗。血管造影栓塞是一种替代选择，尤其适用于那些不适合手术的患者。对于被判定属于高危组的特定患者——位于胃小弯和十二指肠球后部、直径2厘米或更大的溃疡，就诊时出现休克，以及患有合并症的老年人——内镜检查后需要采取更积极的管理措施。最佳行动方案尚不清楚。大多数人会采取观察等待的方式，并给予抑酸药物治疗。外科手术系列研究表明，早期择期手术可能会改善预后。血管造影可以确定出血动脉的特征，对较大动脉进行弹簧圈栓塞可能会进一步增强内镜止血效果。在特定高危患者中，早期择期手术或血管造影栓塞在预防复发性出血方面的作用仍存在争议。需要进行前瞻性研究来比较这些高危溃疡的不同管理策略。
