心脏外科术后30天内急性非静脉曲张性上消化道大出血特征和治疗策略

Feathers and treatment strategy of acute nonvariceal massive upper gastrointestinal bleeding within 30 days after cardiac surgery

目的:回顾性分析心脏外科术后30d内急性非静脉曲张性上消化道大出血的特征,以优化临床治疗策略。方法 :选择2016年1月至2021年7月,北京安贞医院心脏外科术后30d内,经胃镜诊断急性非静脉曲张性上消化道大出血的30例患者为心脏外科术后组,匹配30例急性非静脉曲张性上消化道大出血的患者为对照组。比较两组临床和内镜特征、治疗方法和止血效果。结果 :心脏外科术后组消化道出血严重程度Blatchford评分高于对照组[(15.5±3.2)vs.(11.8±3.2)分, P<0.001],应激性溃疡(36.7%vs.3.3%, P=0.002)和胃或十二指肠畸形动脉出血(30.0%vs.6.7%, P=0.042)多于对照组,且有更多患者存在食管贲门病变(43.3%vs.16.7%;P=0.024)。心脏外科术后组更多患者接受了输血治疗(93.3%vs.33.3%, P<0.001)和质子泵抑制剂泵入(96.6%vs.33.3%, P=0.026)。两组内镜高出血风险(Forrest Ia, Ib, IIa和IIb)接受内镜下治疗为(90.0%vs.80.0%, P=0.470),内镜治疗失败的追加介入栓塞治疗(20.0%vs.6.7%,P=0.255),所有患者均止血成功。结论:心脏外科术后30d内的患者出血更加危重,出血原因除应激性溃疡外,应考虑胃或十二指肠动脉畸形和食管贲门病变出血。积极的质子泵抑制剂泵入、针对病因的内镜下止血治疗和介入栓塞治疗,止血效果较好。

Objective: The aim of this retrospective study was to optimize the clinical diagnosis strategy by delineating the features of acute nonvariceal massive upper gastrointestinal bleeding in patients undergoing heart surgery within 30 days. Methods: 30 patients with acute nonvariceal upper gastrointestinal bleeding diagnosed by digestive tract endoscopy in Beijing Anzhen Hospital from January 2016 to July 2021 were included as the cardiac surgery group, and 30 patients with acute nonvariceal upper gastrointestinal bleeding were matched as the control group. Clinical and endoscopic data of them were retrospectively analyzed and compared. Results: The Blatchford score in the cardiac surgery group was higher than control group [(15.5 ±3.2) vs.(11.8 ± 3.2), P < 0.001]. Compared with control group, there were more stress ulcers(36.7% vs. 3.3%,P = 0.002), more abnormal arterial bleeding(30.0% vs. 6.7%, P = 0.042), and more esophageal or cardiac lesions(43.3% vs. 16.7%, P = 0.024) in cardiac surgery group. More patients in the cardiac surgery group, received blood transfusion(93.3% vs. 33.3%, P < 0.001) and proton pump inhibitor pumping(96.6% vs. 33.3%, P = 0.026) than the control group. Patients with endoscopic high-risk(Forrest Ia, Ib, IIa and IIb) received endoscopic intervention(90.0% vs. 80.0%, P =0.470),who failed endoscopic hemostasis accepted interventional embolization(20.0%vs. 6.7%, P =0.255), and all of the patients succeeded in hemostasis. Conclusions: Patients in this cohort were critically ill. Stress ulcers, artery malformation,and esophageal or cardiac lesions should be considered as causes of bleeding in cardiac surgery group. Active proton pump inhibitor pumping, endoscopic hemostasis and interventional embolization were benefit for life-threatening bleeding.