Stollman N H, Putcha R V, Neustater B R, Tagle M, Raskin J B, Rogers A I
University of Miami School of Medicine/Jackson Memorial Medical Center, Division of Gastroenterology, Florida 33101, USA.
Gastrointest Endosc. 1997 Oct;46(4):324-7. doi: 10.1016/s0016-5107(97)70119-6.
The implications and outcomes of patients with an uncleared fundal pool of blood found at emergent upper endoscopy are not well described.
We reviewed the records of 484 consecutive patients who presented over a 12-month period to our medical center with acute upper gastrointestinal hemorrhage. All patients underwent upper endoscopy within 24 hours of their initial presentation. Patients with an uncleared fundal pool of blood at initial endoscopy were included in this study, and their findings and outcomes were compared with a randomly selected subgroup of these same patients who did not have residual gastric blood.
Sixty-one patients (13%) had uncleared fundal pools despite gastric lavage and patient positioning. Findings on initial endoscopy included esophageal varices in 29 (47%), gastric ulcer in 12 (20%), portal hypertensive gastropathy in 5 (8%), Mallory-Weiss tear in 5 (8%), duodenal ulcer in 5 (8%), gastric varices in 4 (7%), Dieulafoy's lesion in 2 (3%), and other in 7 (11%). Twelve of these 61 patients had multiple findings and 4 (7%) had no lesion identified. Thirty-two of the 61 patients (52%) had at least one follow-up endoscopy, with new fundal lesions identified in 13 (41%): portal hypertensive gastropathy in 8, gastric ulcer in 2, gastric varices in 2, and leiomyoma in 1. Of these 13 new findings, 5 (38%) were judged significant either by the presence of active bleeding or stigmata of recent hemorrhage. Of the 4 patients with no identifiable lesion on initial endoscopy, 3 had a follow-up endoscopy and 2 were found to have a significant new finding in the fundus. The control group had a statistically significant lower percentage of endoscopic findings related to portal hypertension. Recurrent bleeding during the index hospitalization occurred in 54% of the patients with uncleared fundal pools versus 11% of the control group (0 < 0.01). Length of stay, number of units of blood transfused, need for emergent surgery for bleeding, as well as overall and bleeding-related mortality were all significantly greater in the patients with the uncleared fundal pool than in the control patients.
The inability to clear a fundal pool of blood at emergent upper endoscopy is associated with significant morbidity and mortality. Further, new fundal lesions can be identified in 41% of patients on follow-up examination, with many being clinically significant. These data support the importance of clearing a fundal pool in patients undergoing endoscopy for upper gastrointestinal bleeding.
急诊上消化道内镜检查时发现胃底有未清除的血液池，其影响和结果尚未得到充分描述。
我们回顾了在12个月期间连续到我们医疗中心就诊的484例急性上消化道出血患者的记录。所有患者在首次就诊后24小时内接受了上消化道内镜检查。本研究纳入了初次内镜检查时胃底血液池未清除的患者，并将他们的检查结果和结局与随机选择的这些患者中没有残留胃内血液的亚组进行比较。
尽管进行了洗胃和调整患者体位，仍有61例患者（13%）胃底血液池未清除。初次内镜检查结果包括食管静脉曲张29例（47%）、胃溃疡12例（20%）、门静脉高压性胃病5例（8%）、马洛里-魏斯撕裂伤5例（8%）、十二指肠溃疡5例（8%）、胃静脉曲张4例（7%）、迪厄拉富瓦病损2例（3%）、其他7例（11%）。这61例患者中有12例有多种检查结果，4例（7%）未发现病变。61例患者中有32例（52%）至少接受了一次随访内镜检查，其中13例（41%）发现了新的胃底病变：门静脉高压性胃病8例、胃溃疡2例、胃静脉曲张2例、平滑肌瘤1例。在这13例新发现中，5例（38%）因存在活动性出血或近期出血征象而被判定为具有临床意义。初次内镜检查未发现可识别病变的4例患者中，3例接受了随访内镜检查，2例被发现胃底有具有临床意义的新发现。对照组与门静脉高压相关的内镜检查发现率在统计学上显著较低。初次住院期间，胃底血液池未清除的患者中54%发生了再出血，而对照组为11%（P<0.01）。胃底血液池未清除的患者的住院时间、输血量、因出血需急诊手术的情况以及总体死亡率和与出血相关的死亡率均显著高于对照组患者。
急诊上消化道内镜检查时无法清除胃底血液池与显著的发病率和死亡率相关。此外，在随访检查中，41%的患者可发现新的胃底病变，其中许多具有临床意义。这些数据支持了对上消化道出血患者进行内镜检查时清除胃底血液池的重要性。
