急性消化道出血的病因及其相关因素分析

Analysis of etiological and related factors responsible for acute gastrointestinal hemorrhage

目的回顾性分析急性消化道出血的病因构成，相关因素及内镜下表现。方法收集2006年2月至2010年2月因消化道出血急诊就诊患者资料，包括年龄、性别、既往史及用药史、镜下表现，分析急性消化道出血的病因特征。结果（1）4年间因急性消化道出血急诊就诊的患者共1415例，男女比例为2：1，男性平均发病年龄低于女性[（51±20）岁比（61±17）岁，P=0．000）]。4个季度的发病例数依次为399、361、242、413例。（2）1030例患者行内镜检查，其中上消化道出血897例（87．1％），下消化道出血133例（12．9％）；两组的平均年龄差异有统计学意义[（51±20）岁比（57±18）岁，P=0．000]；男／女差异有统计学意义（656／241比65／68，P=0．000）；非甾体抗炎药（NSAID）用药史者比例差异亦有统计学意义[22．1％（198例）比12．0％（16例），P〈0．01]。（3）上消化道出血最常见的疾病依次为消化性溃疡546例（60．8％），食管胃静脉曲张出血130例（14．5％），胃癌40例（4．6％）；根据行胃镜的时间窗分为〈12h，12—24h，24～48h，48—72h，≥72h5组，各组镜下活动出血阳性的比例分别为24．1％（20／83）、14．9％（24／161）、9．6％（16／166）、7．5％（8／106）、7．6％（29／381），x2=18．400，P=0．000；对消化性溃疡Forrest分级观察，随时间延长Ia～Ⅱc级的例数呈减少趋势，Ⅲ级呈增加趋势（x。=80．414，P=0．040）。（4）下消化道出血中常见疾病为缺血性结肠炎44例（33．1％）、小肠出血26例（19．5％）、结肠息肉18例（13．5％）。（5）〉65岁组（277例）胃溃疡及胃癌比例均高于≤65岁组（620例），分别为23．5％（65例）比8．9％（55例）和9．7％（27例）比2．1％（13例），均P〈0．01；而十二指肠溃疡比例低于后者，为22．4％（62例）比49．7％（308例），P〈0．01；下消化道出血中，前者小肠出血的比例高于后者（P〈0．01）。结论急性消化道出血第3季度发病例数最低；男性发病多于女性，男性发病年龄低于女性；上消化道出血多于下消化道出血，上消化道出血发病年龄低于下消化道出血；上消化道出血以消化性溃疡最多见；下消化道出血以缺血性结肠炎最多见；老年组中胃溃疡和胃癌的比例高于中青年组；建议尽早行急诊胃镜。

Objective To investigate the etiology, related factors and endoscopic characteristics of acute gastrointestinal hemorrhage. Methods The data including age, gender, medical and medication history, and endoscopic characteristics of patients receiving emergency treatment for acute gastrointestinal hemorrhage between February 2006 and February 2010 were collected to analyze the etiological profiles of this disorder. Results （ 1 ） A total of 1415 patients with a 2：1 male-to-female ratio visited our hospital for acute gastrointestinal hemorrhage in the past 4 years. There was a higher mean age of disease onset in men than in women [ （51 ±20） years old vs （61 ± 17） years old, P = 0. 000]. The numbers of patients were 399, 361, 242 and 413 for 4 respective quarters in order of sequence. （2） And 1030 patients received endoscopy. Among them, there were 897 （87.1%） with upper gastrointestinal hemorrhage and 133 （ 12. 9% ） with lower gastrointestinal hemorrhage. Significant differences existed in the mean age of two groups [（51 ±20） years old vs （57 ±18） years old, P =0.000]. The male-to-female ratio was 656：241 and 65：68 for these 2 groups respectively （P = 0. 000）. The percentage of patient with a history of NSAID（ non-steroidal anti-inflammatory drug） treatment was 22. 1% （ n = 198 ） and 12.0% （ n = 16 ） for these 2 groups respectively （ P 〈 0. 01 ）. （ 3 ） The most common causative diseases of upper gastrointestinal hemorrhage were peptic ulcer （ n =546, 60. 8% ）, esophageal ＆ gastric varices hemorrhage （ n = 130, 14. 5% ） and gastric cancer （n =40, 4. 6% ）. When the patients were divided into 5 groups of 〈 12 h, 12- 24 h, 24-48 h, 48-72 h and I〉72 h per time window of gastroscopy, their percentages with endoscopically active hemorrhage were 24. 1% （20/83）, 14. 9% （24/161）, 9. 6% （16/166）, 7. 5% （8/106） and 7.6% （29/381） for these groups respectively with statistically significant differences. When peptic ulcer was examined by the Forrest classification, the ratio of grade Ⅰ a- Ⅱc decreased gradually while the ratio of grade HI increased gradually among 5 groups （X2 =80. 414, P=0. 040）. （4） The most common causative diseases of lower gastrointestinal hemorrhage were ischemic colitis （ n = 44, 33.1% ）, small intestinal hemorrhage （ n = 26, 19. 5% ） and colonic polyps （ n = 18, 13.5% ）. （5） When the patients were divided into 〉 65 years old group （ n = 277 ） and ≤ 65 years old group （ n = 620）, the ratio of gastric ulcer and cancer in upper gastrointestinal hemorrhage was higher in the former than in the latter [ 23.5% （n =65） vs 8.9% （ n = 55） ＆ 9. 7% （ n = 27） vs 2. 1% （ n = 13）, P 〈 0. 01 ） ]. While the ratio of duodenal ulcer was lower in the former than in the latter [ 22.4% （ n = 62） vs 49.7% （ n = 308 ）, P 〈 0. 01 ]. The ratio of small intestinal hemorrhage in lower gastrointestinal hemorrhage was higher in the former than in the latter （ all P 〈 0. 01）. Conclusion At the lowest in the third quarter, the incidence rate of acute gastrointestinal hemorrhage is higher in males than that in females at a lower age of onset. More common than lower gastrointestinal hemorrhage, upper gastrointestinal hemorrhage has a lower mean age of onset. Peptic ulcer is the most common disorder in upper gastrointestinal hemorrhage. Ischemic colitis is the most common disorder in lower gastrointestinal hemorrhage. The rate of gastric ulcer and gastric cancer in the old age group is higher than that in the young group. Emergency gastroscopy is recommended.