Röher H D, Imhof M, Goretzki P E, Ohmann C
Klinik für Allgemein- und Unfallchirurgie, Heinrich-Heine-Universität Düsseldorf.
Chirurg. 1996 Jan;67(1):20-5.
Understanding of peptic ulcer disease has dramatically changed within the last years. Today ulcer disease can be considered as a chronic infection. Based on this new pathophysiological concept treatment policies for ulcer bleeding and perforation have to be revised. For ulcer bleeding the standard procedure consists of a diagnostic emergency endoscopy and endoscopic treatment based on the bleeding activity. Patients with recurrent bleeding during hospital stay carry an increased risk for death. More than 50% of these patients have to be operated, nearly 25% die during hospital stay. For that reason an early elective operation can be recommended in patients with a high risk for further bleeding. This includes patients with arterial bleeding (Forrest Ia) and with a vissible vessel (Forrest IIa) with an additional risk (e. g. posterior wall of the duodenum, lesser curvature). All other bleeding activities can primarily treated conservatively. Because of an effective medical treatment of the ulcer disease with eradication, the operation should be restricted to ulcer excision and ulcer oversewing in bleeding or perforated gastric ulcer and duodenotomy, ulcer ligation and extraluminal ligature in bleeding duodenum ulcer and excision and oversewing with pyloroplasty in perforated duodenal ulcer. More definite surgery is not reasonable and should be avoided. With treatment policies based on early elective operation in high risk groups and medical treatment in the other patients a mortality of 5% or less can be achieved.
在过去几年中，对消化性溃疡病的认识发生了巨大变化。如今，溃疡病可被视为一种慢性感染。基于这一新的病理生理概念，溃疡出血和穿孔的治疗策略必须修订。对于溃疡出血，标准程序包括诊断性急诊内镜检查以及根据出血活动情况进行内镜治疗。住院期间反复出血的患者死亡风险增加。这些患者中超过50%必须接受手术，近25%在住院期间死亡。因此，对于有进一步出血高风险的患者，可建议早期择期手术。这包括动脉出血（福里斯特Ia级）和可见血管（福里斯特IIa级）且伴有额外风险（如十二指肠后壁、小弯侧）的患者。所有其他出血情况可首先进行保守治疗。由于通过根除治疗对溃疡病有有效的药物治疗，手术应限于溃疡切除和对出血或穿孔的胃溃疡进行溃疡缝扎，对出血的十二指肠溃疡进行十二指肠切开、溃疡结扎和腔外结扎，以及对穿孔的十二指肠溃疡进行切除、缝扎并加做幽门成形术。更确定性的手术不合理且应避免。通过基于高风险组早期择期手术和其他患者药物治疗的策略，可实现5%或更低的死亡率。
