血管内介入治疗内镜下止血失败的动脉性消化道出血

Interventional embolization treatment for gastrointestinal arterial hemorrhage after failed endoscopic hemostasis

目的探讨血管内介入治疗内镜下止血失败的动脉性消化道出血的临床疗效。方法 2006年1月—2012年2月苏北人民医院介入科对23例内镜下止血失败的动脉性消化道出血的患者行血管造影及血管腔内治疗,对明确有对比剂外溢的出血直接征象的患者行栓塞治疗。对于肠道血管增多、扭曲、紊乱的间接征象的患者行留置导管泵药治疗。结果 23例患者造影阳性发现为19例,其中16例为行内镜下钛夹治疗失败的患者,造影检查发现对比剂外溢的直接出血征象,栓塞治疗后出血均得到控制,随访1个月内未出现再发消化道出血症状。3例造影发现间接出血征象的患者行留置导管泵入缩血管药物3～7 d,经导管泵入垂体后叶素或去甲肾上腺素等药物,患者出血逐渐停止,2例患者出院后1个月内再次出现出血症状。4例造影未有阳性发现的患者行经验性栓塞术后继续行内科止血治疗,止血效果欠佳。结论对于内镜下治疗失败的动脉性消化道出血患者可以行选择血管腔内治疗,尤其是对内镜下发现明确出血的患者效果更佳。术前的内镜检查对超选择性插管造影检查发现异常血管病变有着非常重要的指导意义。

Objective To investigate the clinical efficacy of interventional embolization treatment for gastrointestinal arterial hemorrhage after failed endoscopic hemostasis. Methods During the period from January 2006 to February 2012, a total of 23 patients with nonvariceal gastrointestinal bleeding, who failed to respond to endoscopic hemostasis treatment, were admitted to authors＇ hospital. Angiography and endovascular interventional treatment were carried out in all the patients. Interventional embolization was employed in 16 patients who had definite bleeding sign （contrast extravasation） on angiogram. For patients with indirect bleeding sign, i.e. hypervascularity, tortuosity and confusion of vessels, vasoconstrictor drug infusion through the retained catheter was adopted. Results Of the 23 patients, positive angiographic finding was seen in 19. Among the 19 patients, 16 had failed to endoscopic titanium folder treatment and had direct bleeding sign （contrast extravasation） on angiogram. After interventional embolization, the bleeding was controlled in all patients. During the follow- up period lasting for one month, no recurrent hemorrhage occurred. For three cases with indirect bleeding signs, the vasoconstrictor drugs such as pituitary vasopressin and norepinephrine was pumped into the bleeding vessel through the retained catheter for 3 to 7 days, and the bleeding was gradually controlled, but 2 cases had recurrence of bleeding within one month after discharge from the hospital. Four patients had no positive angiographic findings, and empirical embolization with subsequent hemostasis medication was used and the result was poor. Conclusion For patients with gastrointestinal arterial hemorrhage after failed endoscopic hemostasis, selective endovascular interventional management can be employed, This technique is especially useful for patients in whom clear bleeding sites have been demonstrated by endoscopy. The preoperative endoscopy is very important in guiding superselective angiography in order to find out the abnormal vessels.（J Intervent Radiol, 2012, 21： 783-786）