Koenig A M, Gawad K, Yekebas E, Seewald S, Izbicki J
UKE, Allgemein-, Viszeral- und Thoraxchirurgie, Hamburg, Germany.
Zentralbl Chir. 2010 Feb;135(1):65-9. doi: 10.1055/s-0028-1098920. Epub 2010 Feb 16.
Upper gastrointestinal bleeding is a frequently occurring clinical scenario with a potentially serious prognosis. In spite of excellent endoscopic results, the mortality rate after an insufficient endoscopic treatment is exception-ally high (12.5-36 %). It is crucial to recognise factors in which endoscopy reaches its limitations. Until now, no uniform guidelines and concepts concerning diagnosis and treatment as well as timing of surgical interventions, in particular, have been defined. The main goal of this study is to lower the morbidity and mortality rates after upper gastrointestinal bleeding, with potential risk stratification according to the literature and our own data. PATIENTS / MATERIAL AND METHODS: In a retrospectively designed study 220 patients were evaluated with upper gastrointestinal haemorrhage, who were hospitalised as emergencies from 1999 to 2002. Only those patients were accepted in the study who were examined within 48 hours endoscopically by oesophagogastroduodenoscopy. In order to exclude bleeding complications of a preceding endoscopic therapy, those patients were excluded who had been investigated by endoscopy in the past than 8 days.
After endoscopic evaluation of the bleed-ing activity of 33 Forrest I a / I b bleedings 5 patients and of 52 Forrest II a / II b / II c bleedings 6 patients had to undergo surgery. The haemoglobin content of conventionally treated patients was on average 10.3 mg / dL as compared to 8.4 mg / dL for the operated patients. The conventionally treated patients received an average of 3 red cell concentrates whereas the operated patients had 11 blood transfusions. The source of haemorrhage in the operated patients was located in bulbus duodeni (n = 7), cardia and fundus (n = 2) and the corpus (n = 2).
The evaluation of our own patient data including the experiences of other authors shows that a risk stratification is possible and meaningful. The indication for surgery thereby -depends on different factors: the comorbidity of the patient, the haemodynamic in- / stability, the number of necessary blood transfusions and the localisation of the bleeding source.
上消化道出血是一种常见的临床情况，预后可能很严重。尽管内镜检查效果良好，但内镜治疗不充分后的死亡率异常高（12.5% - 36%）。认识到内镜检查的局限性因素至关重要。到目前为止，尚未定义关于诊断、治疗以及手术干预时机的统一指南和概念，尤其是手术干预的时机。本研究的主要目标是降低上消化道出血后的发病率和死亡率，并根据文献和我们自己的数据进行潜在的风险分层。
患者/材料与方法：在一项回顾性设计的研究中，对1999年至2002年因上消化道出血作为急诊入院的220例患者进行了评估。仅纳入那些在48小时内接受食管胃十二指肠镜内镜检查的患者。为了排除先前内镜治疗的出血并发症，排除那些在过去8天内接受过内镜检查的患者。
在内镜评估33例福雷斯特Ⅰa/Ⅰb级出血中的5例以及52例福雷斯特Ⅱa/Ⅱb/Ⅱc级出血中的6例后，这些患者不得不接受手术。常规治疗患者的血红蛋白含量平均为10.3mg/dL，而手术患者为8.4mg/dL。常规治疗患者平均接受3单位红细胞浓缩液，而手术患者接受11次输血。手术患者的出血源位于十二指肠球部（n = 7）、贲门和胃底（n = 2）以及胃体（n = 2）。
对我们自己的患者数据以及其他作者经验的评估表明，进行风险分层是可行且有意义的。手术指征取决于不同因素：患者的合并症、血流动力学不稳定情况、必要输血次数以及出血源的位置。
