Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Division of Hematology and Oncology, Mayo Clinic, Rochester, Minnesota, USA.
Gastrointest Endosc. 2018 Jul;88(1):55-61. doi: 10.1016/j.gie.2018.01.028. Epub 2018 Feb 2.
Gastrointestinal bleeding (GIB) in the setting of thrombocytopenia raises concerns about endoscopic procedure risk. We aimed to assess the safety and outcomes of endoscopy for overt GIB in the setting of severe thrombocytopenia in liver cirrhosis (LC) and non-liver cirrhosis (NLC).
This is a retrospective study on inpatients who underwent endoscopy within 24 hours of presentation for overt GIB with a platelet count (PC) of 20 to <50 × 10/mL. Outcomes included diagnostic and therapeutic yields, procedural adverse events, packed red blood cell (pRBC) and platelet transfusions, recurrent bleeding rate, and all-cause and GIB-related mortality.
One hundred forty-four patients were identified. The median PC was 41 × 10/mL and 61% had LC. The diagnostic yield was 68% (LC = 61%, NLC = 79%, P = .04). Therapeutic yield was 60% (59% vs 60%, P = 1.00). The initial hemostasis rate was 94% with one adverse event. The median number of pRBC and platelet transfusions decreased after intervention in the entire cohort. Recurrent bleeding rates were 22% at 1 month and 30% at 1 year, with no differences between groups. An increased international normalized ratio (INR) >2 was a predictor of recurrent bleeding. All-cause mortality was 19% at 1 month and 37% at 1 year, whereas GIB-associated mortality in our cohort was only 3% at 1 month and 4% at 1 year, with no significant difference between LC and NLC. Predictors of mortality were INR >2, activated partial thromboplastin time >38 seconds, hypotension, intensive care unit admission, and pulmonary comorbidities.
In this study cohort, we observed that endoscopy for overt GIB in the setting of severe thrombocytopenia in patients with LC and NLC appears safe, has moderate diagnostic and therapeutic yields with high initial hemostasis rate, and is associated with a significant decrease in pRBC and platelet transfusions. Recurrent bleeding and all-cause mortality rates remain high.
血小板减少症伴胃肠道出血（GIB）时，人们会担心内镜检查的风险。我们旨在评估肝硬化（LC）和非肝硬化（NLC）患者中严重血小板减少症伴显性 GIB 行内镜检查的安全性和结局。
这是一项回顾性研究，纳入了在显性 GIB 发作后 24 小时内行内镜检查且血小板计数（PC）为 20~<50×10/mL 的住院患者。结局包括诊断和治疗效果、操作相关不良事件、输浓缩红细胞（pRBC）和血小板、再出血率以及全因和 GIB 相关死亡率。
共纳入 144 例患者，中位 PC 为 41×10/mL，61%有 LC。诊断率为 68%（LC=61%，NLC=79%，P=0.04）。治疗率为 60%（59% vs 60%，P=1.00）。初始止血率为 94%，仅有 1 例不良事件。整个队列中，干预后 pRBC 和血小板输注量中位数均减少。1 个月和 1 年时的再出血率分别为 22%和 30%，组间无差异。国际标准化比值（INR）>2 是再出血的预测因素。1 个月和 1 年时的全因死亡率分别为 19%和 37%，而本队列中 GIB 相关死亡率分别为 1 个月时的 3%和 1 年时的 4%，LC 和 NLC 之间无显著差异。死亡率的预测因素包括 INR>2、活化部分凝血活酶时间>38 秒、低血压、入住重症监护病房和肺部合并症。
在本研究队列中，我们观察到 LC 和 NLC 患者中严重血小板减少症伴显性 GIB 行内镜检查似乎是安全的，具有中等的诊断和治疗效果，初始止血率高，且显著减少了 pRBC 和血小板的输注。再出血和全因死亡率仍然很高。
