内镜治疗并发胃肠道出血的预防与处理

Prevention and treatment of gastrointestinal bleeding after therapeutic endoscopy for alimentary tract disease

目的:探讨内镜介入微创治疗消化道疾病并发出血的原因及预防和处理措施.方法:分析42例内镜治疗术并发出血的原因,比较不同治疗方法出血后的处理措施、安全性和有效性.结果:在13516例检查内镜中有1089例治疗内镜,其中氩气刀治疗术(APC)392例,并发出血3例,出血率0.8%;橡皮圈套扎术36例,并发出血4例,出血率11.1%;内镜黏膜切除术(EMR)64例,并发出血8例,出血率12.5%,高频电凝电切治疗术367例(其中预置钛夹265例无1例出血,无预置钛夹102例),并发出血17例,出血率4.6%;十二指肠乳头切开术(ERCP-EST)230例,并发出血10例,出血率4.4%.多数术中即刻出血经内镜下钛夹止血或氩等离子凝固术止血成功;4例出血内镜无法控制,中途转外科手术成功止血;1例贲门息肉套扎术后并发大出血,经内镜下无效处理,48h内行血管介入治疗后并发多脏器栓塞坏死及膈肌麻痹,患者死亡;1例胆总管结石患者ERCP-EST术后切口大出血,经保守治疗6d,输血7000mL,最终内镜下钛夹止血成功;1例结肠息肉电凝电切术后并发大出血和1例十二指肠镜检查致贲门黏膜撕裂大出血,分别在48h内经内镜下氩等离子凝固术治疗止血成功.结论:内镜下微创治疗术并发胃肠道出血,具有可预防性,可确定性和可治疗性的特点.术中即刻出血采用氩气刀或钛夹止血最有效.延迟出血在48h内采用有效治疗措施可减少失血量、输血量和用药量,提高临床成效比.预置钛夹是预防电凝电切并发出血的有效措施.

AIM： To analyze the prevention and treatment of gastrointestinal bleeding after therapeutic endoscopy for alimentary tract disease. METHODS： The clinical data for 42 patients who received endoscopic treatment for acute hemorrhage after endoscopic therapy were retrospectively analyzed. RESULTS： Of 1 089 patients undergoing therapeutic endoscopy, 392 underwent argon plasma coagulation （APC）, of them 3 （0.8%） had gastrointestinal bleeding; 36 underwent loop ligature, of them 4 （11.1%） had bleeding; 64 underwent endoscopic mucosal resection （EMR）, of them 8 （12.5%） had bleeding; 367 underwent high frequency electric coagulation, of them 17 （4.6%） had bleeding; 230 underwent ERCP-EST, of them 10 （4.4%） had bleeding. The total incidence of iatrogenic bleeding was 3.9% （42/1 089）. The majority of patients developing bleeding were managed successfully by APC or titanium clipping during endoscopic procedures, whereas 4 patients developed uncontrolled bleeding and turned to surgical intervention. One patient developed bleeding after loop ligature and died of multiple organ dysfunction syndrome and diaphragmatic paralysis after vascular interventional therapy. CONCLUSION： Gastrointestinal bleeding after minimally invasive endoscopic surgery is preventable and controllable. Effective therapeutic measures for hemorrhage within 48 hours can decrease blood loss, blood transfusion and drug consumption, and increase the rate of cost/effectiveness. Preventive usage of metal clip can significantly decrease the incidence of postoperative bleeding after therapeutic endoscopy.