经内镜逆行胰胆管造影术后乳头部延迟性出血的临床分析

Clinical analysis of delayed papillary hemorrhage after endoscopic retrogradecholangiopancreatography

目的分析经内镜逆行胰胆管造影术（ERCP）后乳头部延迟性出血的特征及可能出血原因，探索有效的止血方法及其策略。方法回顾性分析2000年8月至2016年8月在第二军医大学附属东方肝胆外科医院内镜科因ERCP后出血行内镜诊疗的76例患者的临床资料、止血方法及其疗效。结果ERCP后延迟性出血多发生于ERCP后48h内（67．2％，45／67），主要表现为呕血、血便及鼻胆管内血性引流物等。单纯内镜下十二指肠乳头球囊扩张术（EPBD）的出血率最低（0．1％），其次是乳头预切开（0．6％）和内镜下乳头括约肌切开术（EST，0．9％），EST＋EPBD的出血率最高（2．4％），出血部位多位于乳头切缘左侧（67．1％，51／76）。所有患者均行急诊内镜止血，序贯给予冰肾上腺素盐水注射、电凝、止血夹封闭、金属支架压迫等内镜止血治疗。71例患者内镜止血成功（93．4％），其中1次成功66例，2次成功4例，3次成功1例。止血夹封闭止血成功率76．9％（50／65）。结论针刀预切开术是安全、有效的，且其并发症发生率与EST相似。对于实施乳头部中小切开和／或扩张的患者，仍应做好出血并发症的预防与处理。临床上一旦怀疑出血应及时内镜干预，绝大多数病例可在内镜下成功止血，止血夹封闭是较为可靠的止血方法。

Objective To evaluate the clinical feature and potential reasons of delayed papillary bleeding after endoscopic retrograde cholangiopancreatography （ERCP）, and search for effective hemostasis and strategies. Methods A total of 76 patients with post-ERCP bleeding underwent endoscopic treatment in the Eastern Hepatobiliary Hospital from August 2000 to August 2016. Clinical data, haemostatie methods, and treatment outcomes of patients were retrospectively analyzed. Results Delayed papillary hemorrhage mostly occurred within 48 hours after ERCP （ 67.2%, 45/67 ） , with main manifestations of hematemesis, bloody stool, and bile. The lowest incidence of delayed bleeding was detected after endoscopic papillary balloon dilation （EPBD, 0. 1%）, which was followed by papillary precut （0.6%） and endoscopic sphincterotomy （EST, 0. 9%）. And EST＋EPBD had the highest incidence of delayed post-ERCP papillary hemorrhage （2.4%）. The most bleeding site was the left side of the incision （67. 1%, 51/76）. Emergent endoscopic interventions were applied in all patients with success of hemostasis in 71 out of 76 （93.4%） , and injection with diluted epinephrine, electric coagulation, hemoclipping, and metal stenting were used sequentially for hemostasis. Among the 71 successful cases of hemostasis, 66 patients were performed endoscopic hemostasis for once, 4 patients took twice, and 1 case took thrice. Endoscopic hemoclipping wasthe most commonly used method with successful rate of 76. 9% （50/65） for hemostasis. Conclusion Precut papillotomy is safe and effective, and its complication occurrence rate is similar to that of EST. Hemorrhage should be prevented and timely dealt with in small/median EST and/or EPBD. Once hemorrhage is suspected clinically, endoscopic inventions should be applied timely, and hemoclipping is a safe and effective method.