华法林或达比加群预防房颤卒中及全身性栓塞的患者常因隐匿性恶性肿瘤而发生主要胃肠道出血。
Major Gastrointestinal Bleeding Often Is Caused by Occult Malignancy in Patients Receiving Warfarin or Dabigatran to Prevent Stroke and Systemic Embolism From Atrial Fibrillation.
机构信息
Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
出版信息
Clin Gastroenterol Hepatol. 2017 May;15(5):682-690. doi: 10.1016/j.cgh.2016.10.011. Epub 2016 Oct 17.
BACKGROUND & AIMS: Gastrointestinal (GI) bleeding in patients receiving anticoagulation agents can be caused by occult malignancies. We investigated the proportions and features of major GI bleeding (MGIB) events related to occult GI cancers in patients receiving anticoagulation therapy.
METHODS
We analyzed data from the Randomized Evaluation of Long Term Anticoagulant Therapy study (conducted between December 2005 and March 2009 in 951 clinical centers in 44 countries worldwide), which compared the abilities of dabigatran vs warfarin to prevent stroke and systemic embolism in 18,113 patients with atrial fibrillation. Two blinded gastroenterologists independently reviewed source documents of MGIB events (n = 595) that occurred during the study period. We collected data on MGIB events caused by previously unidentified GI malignancies, and compared characteristics of MGIB events in patients who received dabigatran vs warfarin (primary end point), and in patients with bleeding from cancer, vs patients bleeding from a nonmalignant or unidentified source.
RESULTS
Of 546 unique MGIB events, 44 (8.1%) were found to be from GI cancers (34 of 398 MGIB events in dabigatran users and 10 of 148 MGIB events in warfarin users; P = .60). Colorectal cancer accounted for 35 of 44 of all cancers identified. There were more colorectal cancer-associated MGIB events in the dabigatran group (30 of 34) than in the warfarin group (5 of 10) (P = .02), but more gastric cancer-associated MGIB events in the warfarin group (5 of 10) than in the dabigatran group (1 of 34) (P = .001). There were no differences in the short-term outcomes of cancer-related MGIB events in the dabigatran vs the warfarin group, but 75% of all cancer-related MGIB events required at least 1 blood transfusion and the mean hospital stay was 10.1 days. Compared with MGIB events from a nonmalignant or unidentified source, MGIB from cancer occurred sooner (343.0 vs 223.1 d; P = .003), but the bleeding was more likely to be chronic (for >7 d) (27.3% vs 63.6%; P < .001).
CONCLUSIONS
In evaluating data from a study of the effects of anticoagulation therapy, we found approximately 1 of every 12 MGIB events to be related to an occult cancer. Approximately two thirds of cancer-related MGIB presents with chronic bleeding, and morbidity, and resource utilization is high.
背景与目的
接受抗凝治疗的患者发生胃肠道（GI）出血可能是由隐匿性恶性肿瘤引起的。我们研究了在接受抗凝治疗的患者中，与隐匿性胃肠道癌症相关的主要胃肠道出血（MGIB）事件的比例和特征。
方法
我们分析了随机评价长期抗凝治疗研究（于 2005 年 12 月至 2009 年 3 月在全球 44 个国家的 951 个临床中心进行）的数据，该研究比较了达比加群与华法林预防心房颤动患者中风和全身性栓塞的能力。两名盲法胃肠病学家独立审查了研究期间发生的 595 例 MGIB 事件的原始文件。我们收集了由先前未识别的胃肠道恶性肿瘤引起的 MGIB 事件的数据，并比较了达比加群与华法林治疗的患者（主要终点）的 MGIB 事件特征，以及癌症出血的患者与非恶性或未识别来源出血的患者的特征。
结果
在 546 例独特的 MGIB 事件中，有 44 例（8.1%）被发现来自 GI 癌症（达比加群使用者中有 34 例 MGIB 事件，华法林使用者中有 10 例 MGIB 事件；P=.60）。所有确定的癌症中，结肠癌占 35 例。达比加群组的结肠癌相关 MGIB 事件多于华法林组（30 例比 10 例）（P=.02），但华法林组的胃癌相关 MGIB 事件多于达比加群组（5 例比 1 例）（P=.001）。达比加群组和华法林组癌症相关 MGIB 事件的短期结局无差异，但所有癌症相关 MGIB 事件中有 75%至少需要 1 次输血，平均住院时间为 10.1 天。与非恶性或未识别来源相关的 MGIB 事件相比，癌症相关的 MGIB 发生更早（343.0 天比 223.1 天；P=.003），但出血更可能是慢性的（>7 天）（27.3%比 63.6%；P<.001）。
结论
在评估一项抗凝治疗效果研究的数据时，我们发现每 12 例 MGIB 事件中就有 1 例与隐匿性癌症有关。大约三分之二的癌症相关 MGIB 表现为慢性出血，发病率和资源利用率较高。
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