Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan.
Department of Medicine, University of Washington, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington.
Clin Gastroenterol Hepatol. 2017 Sep;15(9):1373-1381.e7. doi: 10.1016/j.cgh.2017.02.018. Epub 2017 Feb 27.
BACKGROUND & AIMS: Gastroenterologists should strive to improve the outcomes associated with acute variceal hemorrhage (AVH) by optimizing care delivery and clinician preparedness through training. Unfortunately, data regarding contemporary outcomes and management of AVH are limited.
We performed a systematic review of cohort studies examining outcomes and management of AVH from January 1990 to September 2016. We pooled data on mortality and utilization of medical therapy, endoscopic interventions, balloon tamponade (BT), and salvage procedures (portal decompressive surgery or transjugular portosystemic shunt).
The pooled 6-week mortality rate after AVH was 17.7% (95% confidence interval [CI], 14.4%-21.7%). Sclerotherapy was used in 18.7% of cases (95% CI, 9.2%-34.3%), and no endoscopic intervention was provided in 14.3% of patients (95% CI, 9.7%-20.6%). The overall rate of BT use was 10.8% (95% CI, 8.2%-14.1%). Salvage procedures were used in 5.7% (95% CI, 3.7%-8.6%), falling to 1.7% (95% CI, 0.7%-3.8%) among patients treated after 2000. Although pooled rates of timely endoscopy and vasoactive medication use were high (85.8% and 83.0%, respectively), only half of patients received prophylactic antibiotics (52.8%; 95% CI, 40.0%-66.2%). In studies that enrolled patients exclusively after 2000, 13.8% of patients (95% CI, 7.0%-25.4%) received sclerotherapy, salvage transjugular portosystemic shunt fell to 1.7% (95% CI, 0.7%-3.8%), BT use fell slightly to 8.7% (95% CI, 6.4%-11.6%), and vasoactive medication and prophylactic antibiotic use rose to 91.4% (95% CI, 86.0%-94.9%) and 62.7% (95% CI, 48.9%-74.9%), respectively.
AVH is associated with high mortality rates and suboptimal implementation of evidence-based therapies including prophylactic antibiotics and endoscopic interventions, suggesting a need for quality improvement. In addition, the frequent need for BT and sclerotherapy suggests that specific attention to these procedures in gastroenterology training curricula may be warranted.
通过培训来优化医疗服务的提供和临床医生的准备，胃肠病学家应努力改善与急性静脉曲张出血（AVH）相关的预后。遗憾的是，有关 AVH 的当代结局和管理的数据十分有限。
我们对 1990 年 1 月至 2016 年 9 月间研究 AVH 结局和管理的队列研究进行了系统回顾。我们汇总了死亡率和药物治疗、内镜介入、气囊填塞（BT）和挽救性手术（门静脉减压手术或经颈静脉肝内门体分流术）应用的数据。
AVH 后 6 周的死亡率为 17.7%（95%置信区间 [CI]，14.4%-21.7%）。硬化疗法的使用率为 18.7%（95%CI，9.2%-34.3%），14.3%的患者未行内镜干预（95%CI，9.7%-20.6%）。BT 的总体使用率为 10.8%（95%CI，8.2%-14.1%）。挽救性手术的使用率为 5.7%（95%CI，3.7%-8.6%），2000 年后治疗的患者中该比例降至 1.7%（95%CI，0.7%-3.8%）。虽然及时行内镜检查和应用血管活性药物的汇总率较高（分别为 85.8%和 83.0%），但仅有一半的患者接受了预防性抗生素治疗（52.8%；95%CI，40.0%-66.2%）。在纳入仅在 2000 年后患者的研究中，13.8%的患者（95%CI，7.0%-25.4%）接受了硬化疗法，挽救性经颈静脉肝内门体分流术降至 1.7%（95%CI，0.7%-3.8%），BT 的应用略有下降至 8.7%（95%CI，6.4%-11.6%），血管活性药物和预防性抗生素的使用率分别上升至 91.4%（95%CI，86.0%-94.9%）和 62.7%（95%CI，48.9%-74.9%）。
AVH 死亡率较高，且证据为基础的治疗措施的实施并不理想，包括预防性抗生素和内镜干预，提示需要进行质量改进。此外，频繁需要 BT 和硬化疗法，这表明在胃肠病学培训课程中可能需要特别关注这些操作。
