Cochran T A
Baylor College of Medicine, Houston, Texas.
Gastroenterol Clin North Am. 1993 Dec;22(4):751-78.
The management of bleeding peptic ulcer disease varies with multiple clinical and endoscopic variables. For the patient with rapid hemorrhage and hemodynamic instability refractory to endoscopic control, operation clearly is indicated. For patients with a low probability of recurrent ulcer hemorrhage because of the absence of endoscopic stigmata or clinical predictors of further ulcer bleeding, nonoperative management with selective use of endoscopic hemostasis is appropriate. For the remaining patients with a moderate risk of recurrent ulcer hemorrhage, the clinician must use what is known of the clinical and endoscopic predictors of recurrent hemorrhage and arrive at a judgment regarding the selective use of endoscopic hemostasis and subsequent early operation. For elderly patients with a large duodenal or gastric ulcer who have experienced significant blood loss precipitating an episode of hypovolemic shock and who have endoscopic stigmata of ulcer hemorrhage, early elective operation after endoscopic hemostasis is the most judicious course. Surgery also is the wise choice for those patients in whom an initially successful attempt at endoscopic hemostasis fails and who rebleed while hospitalized. Recommendations for the surgical management of bleeding peptic ulcer disease include Immediate operation for (1) patients with rapidly exsanguinating ulcer hemorrhage and (2) patients with active bleeding and failure of endoscopic hemostasis to control the bleeding. Early elective operation after initial endoscopic hemostasis for (1) elderly patients with comorbid disease and/or hemodynamic instability who have active arterial ulcer hemorrhage (Forrest Ia) controlled with endoscopic hemostasis; (2) elderly patients with comorbid disease and/or hemodynamic instability who have a visible vessel in an ulcer crater (Forrest IIa) treated with endoscopic hemostasis: surgery is particularly advised in this circumstance for those with a positive arterial Doppler signal in the ulcer crater or a large posterior duodenal ulcer or a large lesser-curvature gastric ulcer; and (3) elderly patients with comorbid disease and/or hemodynamic instability who develop recurrent ulcer bleeding while hospitalized or with a total blood transfusion requirement exceeding 5 U.
出血性消化性溃疡疾病的治疗因多种临床和内镜变量而异。对于出血迅速且血流动力学不稳定、内镜治疗无效的患者，显然需要进行手术。对于因无内镜下出血迹象或进一步溃疡出血的临床预测因素而溃疡再出血可能性低的患者，采用选择性内镜止血的非手术治疗是合适的。对于其余有中度溃疡再出血风险的患者，临床医生必须利用已知的再出血临床和内镜预测因素，对选择性内镜止血及随后的早期手术做出判断。对于患有十二指肠或胃溃疡且失血严重导致低血容量休克发作且有溃疡出血内镜下迹象的老年患者，内镜止血后早期选择性手术是最明智的做法。对于那些内镜止血最初成功但住院期间再次出血的患者，手术也是明智的选择。出血性消化性溃疡疾病的手术治疗建议包括：立即手术治疗（1）溃疡出血迅速导致失血性休克的患者和（2）有活动性出血且内镜止血无法控制出血的患者。初始内镜止血后早期选择性手术治疗（1）患有合并症和/或血流动力学不稳定且内镜止血控制了活动性动脉溃疡出血（Forrest Ia）的老年患者；（2）患有合并症和/或血流动力学不稳定且溃疡 crater 中有可见血管（Forrest IIa）并接受内镜止血治疗的老年患者：对于溃疡 crater 中动脉多普勒信号阳性、十二指肠后壁大溃疡或胃小弯大溃疡的患者，在这种情况下特别建议手术；（3）患有合并症和/或血流动力学不稳定且住院期间发生溃疡再出血或总输血量超过5U的老年患者。
