Messmann H, Schaller P, Andus T, Lock G, Vogt W, Gross V, Zirngibl H, Wiedmann K H, Lingenfelser T, Bauch K, Leser H G, Schölmerich J, Holstege A
Dept. of Internal Medicine, University of Regensburg, Germany.
Endoscopy. 1998 Sep;30(7):583-9. doi: 10.1055/s-2007-1001360.
A second-look endoscopy is often performed to evaluate the efficacy of a prior injection therapy in patients with bleeding peptic gastric or duodenal ulcers. Although this strategy is widely established, it does not rely on unequivocal data from controlled studies. In a prospective, randomized, controlled multicenter trial we assessed the effect of programmed endoscopic follow-up examinations with eventual retreatment on the outcome of bleeding ulcers in these patients.
One hundred and five patients with gastric or duodenal peptic ulcers presenting with active (Forrest type I) or recent (Forrest type IIa and IIb) bleeding upon endoscopy within four hours after admission were included in the study. Emergency treatment consisted of the sequential injection of both epinephrine (1:10,000 v/v) and up to 2 ml of fibrin/thrombin around the ulcer base. Fifty-two patients were randomized to receive programmed endoscopic monitoring with eventual retreatment in cases of Forrest type I, IIa, or IIb ulcers beginning within 16-24 hours after the index bleed. Follow-up endoscopies were continued until the macroscopic appearance revealed a Forrest type IIc or III ulcer. Fifty-three patients in the control group were closely monitored, and only received a second endoscopy when there was clinical or biochemical evidence of recurrent bleeding. The groups did not differ with respect to age, sex, site and severity of bleeding.
The numbers of patients with recurrent bleeding were similar whether they were endoscopically monitored or not (21% versus 17%, P=0.80 chi-squared test). In addition, there was no statistically significant difference between the two groups with respect to the number of blood units transfused, need for surgical intervention, hospital stay or number of deaths (Mann-Whitney U-test). Improving local ulcer stigmata was not related to a better outcome.
Programmed endoscopic follow-up examinations with eventual retreatment in patients locally injected for an acute or recent hemorrhage from a gastric or duodenal ulcer did not influence their outcome when compared to patients receiving only a second endoscopic intervention upon evidence for recurrent hemorrhage. Scheduled control endoscopies cannot be recommended after an initial successful endoscopic treatment of peptic ulcer bleeding when selection of the patients for second-look endoscopy is directed by the Forrest criteria.
二次内镜检查常用于评估先前注射治疗对消化性胃溃疡或十二指肠溃疡出血患者的疗效。尽管这一策略已被广泛应用，但它并非基于对照研究的确切数据。在一项前瞻性、随机、对照多中心试验中，我们评估了计划性内镜随访检查及最终再次治疗对这些患者出血性溃疡结局的影响。
105例因胃或十二指肠消化性溃疡入院后4小时内内镜检查发现活动性出血（福里斯特I型）或近期出血（福里斯特IIa型和IIb型）的患者纳入本研究。急诊治疗包括在溃疡底部周围依次注射肾上腺素（1:10,000 v/v）和最多2ml纤维蛋白/凝血酶。52例患者被随机分配接受计划性内镜监测，若出现福里斯特I型、IIa型或IIb型溃疡，则在首次出血后16 - 24小时内进行最终再次治疗。随访内镜检查持续进行，直至宏观表现显示为福里斯特IIc型或III型溃疡。对照组的53例患者接受密切监测，仅在有临床或生化证据表明再次出血时才进行第二次内镜检查。两组在年龄、性别、出血部位和严重程度方面无差异。
无论是否接受内镜监测，再次出血的患者数量相似（21%对17%，卡方检验P = 0.80）。此外，两组在输血量、手术干预需求、住院时间或死亡人数方面无统计学显著差异（曼 - 惠特尼U检验）。局部溃疡征象的改善与更好的结局无关。
与仅在有再次出血证据时接受第二次内镜干预的患者相比，对因胃或十二指肠溃疡急性或近期出血而接受局部注射治疗的患者进行计划性内镜随访检查及最终再次治疗，并未影响其结局。当根据福里斯特标准选择患者进行二次内镜检查时，在消化性溃疡出血首次内镜治疗成功后，不建议进行计划性对照内镜检查。
