Marion Y, Lebreton G, Le Pennec V, Hourna E, Viennot S, Alves A
Service de chirurgie digestive, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France; Université de Caen, faculté de médecine, 14000 Caen, France.
Service de chirurgie digestive, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France; Université de Caen, faculté de médecine, 14000 Caen, France.
J Visc Surg. 2014 Jun;151(3):191-201. doi: 10.1016/j.jviscsurg.2014.03.008. Epub 2014 Apr 24.
Lower gastrointestinal (LGI) bleeding is generally less severe than upper gastrointestinal (UGI) bleeding with spontaneous cessation of bleeding in 80% of cases and a mortality of 2-4%. However, unlike UGI bleeding, there is no consensual agreement about management. Once the patient has been stabilized, the main objective and greatest difficulty is to identify the location of bleeding in order to provide specific appropriate treatment. While upper endoscopy and colonoscopy remain the essential first-line examinations, the development and availability of angiography have made this an important imaging modality for cases of active bleeding; they allow diagnostic localization of bleeding and guide subsequent therapy, whether therapeutic embolization, interventional colonoscopy or, if other techniques fail or are unavailable, surgery directed at the precise site of bleeding. Furthermore, newly developed endoscopic techniques, particularly video capsule enteroscopy, now allow minimally invasive exploration of the small intestine; if this is positive, it will guide subsequent assisted enteroscopy or surgery. Other small bowel imaging techniques include enteroclysis by CT or magnetic resonance imaging. At the present time, exploratory surgery is no longer a first-line approach. In view of the lesser gravity of LGI bleeding, it is most reasonable to simply stabilize the patient initially for subsequent transfer to a specialized center, if minimally invasive techniques are not available at the local hospital. In all cases, the complexity and diversity of LGI bleeding require a multidisciplinary collaboration involving the gastroenterologist, radiologist, intensivist and surgeon to optimize diagnosis and treatment of the patient.
下消化道（LGI）出血通常不如上消化道（UGI）出血严重，80%的病例出血可自行停止，死亡率为2%-4%。然而，与UGI出血不同的是，关于其治疗尚无共识。一旦患者病情稳定，主要目标和最大困难是确定出血部位，以便提供具体的适当治疗。虽然上消化道内镜检查和结肠镜检查仍然是必不可少的一线检查，但血管造影技术的发展和应用使其成为活动性出血病例的重要成像方式；血管造影可实现出血的诊断定位，并指导后续治疗，无论是治疗性栓塞、介入性结肠镜检查，还是在其他技术失败或无法应用时，针对出血精确部位进行的手术。此外，新开发的内镜技术，特别是视频胶囊内镜检查，现在能够对小肠进行微创探查；如果检查结果呈阳性，将指导后续的辅助小肠镜检查或手术。其他小肠成像技术包括CT小肠造影或磁共振成像小肠造影。目前， exploratory surgery不再是一线治疗方法。鉴于LGI出血的严重性较低，如果当地医院没有微创技术，最合理的做法是先简单地稳定患者病情，随后将其转至专业中心。在所有情况下，LGI出血的复杂性和多样性需要胃肠病学家、放射科医生、重症监护医生和外科医生进行多学科协作，以优化患者的诊断和治疗。
