消化性溃疡出血处理

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,confidential for internal use only,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,confidential for internal use only,Click to edit Master title style,| Title of presentation | 00 Month Year (Go Header & Footer to edit this text),*,Click to edit Master title style,*,| Title of presentation | 00 Month Year (Go Header & Footer to edit this text),Click to edit Master title style,*,| Title of presentation | 00 Month Year (Go Header & Footer to edit this text),Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,confidential for internal use only,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,消化性溃疡出血处理新进展,广元市中心医院 谢吉良,内 容,概 要,内镜前处理,内镜处理,内镜后药物治疗,预 防,结 论,1.Lau JY, et al. Gastroenterology 2008;134(4 Suppl 1):A32;,2,.,Marc Bardou,et al.,Nat Rev Gastroenterol Hepatol. 2012 Jan 10;9(2):97-104,3.Amnon Sonnenberg,et al.,J Gastroenterol 1997;92:61420,消化性溃疡出血仍是一项重要医学课题,内镜前处理,复 苏（初始评估）,风险评估,内镜前药物治疗,Marc Bardou,et al.,Nat Rev Gastroenterol Hepatol. 2012 Jan 10;9(2):97-104,复苏（初始评估）,复苏是出血患者在初步评估时进行的首要处理,输血时机,若患者无冠状动脉疾病，组织低灌注或急性出血，当,Hb,70g/L,时应该进行输血，使患者,Hb,达到,70-90g/L,。,复 苏,Marc Bardou,et al.,Nat Rev Gastroenterol Hepatol. 2012 Jan 10;9(2):97-104,风险评估,风险评估,内镜检查前的预后评分系统,(Rockall,和,Blatchford),为综合性,评分系统， 包含临床表现和实验室参数；以往主要用于再,出血、死亡率等的预后评估。,评分量表不仅能评估再出血风险和死亡率，而且还能判断,哪些患者需要接受内镜干预。,内镜前,Blatchford,评分可用于预测患者是否需要行内镜治疗,1.,中华内科杂志编委会，中华内科杂志，,2009. 48(10): 891-4.,7,表,3,急性上消化道出血患者的,Blatchford,评分,项目,检测结果,评分,收缩压,(mmHg),100109,9099,90,1,2,3,血尿素氮,(mmol/L),6.57.9,8.09.9,10.024.9,25.0,2,3,4,6,血红蛋白,(g/L),男性,女性,120129,100119,100,100119,100mmHg,， 心率,100mmHg,， 心率,100,次,/,分；,：收缩压,100,次,/,分,中华内科杂志编委会,.,急性非静脉曲张性上消化道出血诊治指南（草案）,.,中华内科杂志,2005,；,44(1): 73-76,上消化道恶性疾病,无病变，,Mallory-Weiss,综合征,内镜诊断,心力衰竭、缺血性心脏病和其它重要伴发病,无,伴发病,低血压,心动过速,无休克,*,休克,80,60,79,4 18h,以上/天,1,根除幽门螺杆菌,pH5 18h,以上/天,1,上消化道出血,pH6 20h,以上/天,1,预防应激性黏膜病变,pH4 21h,以上,/,天,2,1.,李瑜元,.,中华消化杂志,. 2001; 21(11): 645-646,2.,中华医学杂志编辑委员会,.,中华医学杂志,. 2002; 82(14): 1000-1001,内镜后药物治疗,镜后用药,治疗消化性溃疡出血的目标,胃内,pH6,1.,Berstad A. Scand J Gastroentero. 1970; 5: 343348. 2.Venables CW. Gut. 1986; 27(3): 233-238,3.Green.FWJr et al. Gastroenterology. 1978; 74(1): 38-43.4.,李兆申,.,中华内科杂志,. 2005; 44(1): 34,5.Li Y et al. J Gastroenterol Hepatol. 2000; 15(2): 148-54.6.Yacyshyn BR et al. Dig Dis, 2000. 18(3): 117-28.,维持胃内,pH6,才能降低血小板解聚,4-6,pH 1-4,之间，有两个最适,pH,，可溶解纤维蛋白血栓,pH=4,时，活性明显降低,pH6,时，活性完全丧失,胃内,pH,4,时胃蛋白酶活性明显降低,1-3,0,20,40,60,80,100,最大,胃蛋白酶活性,(%),胃内,pH,值,4,3,2,1,0,镜后用药,2010,年非静脉曲张性上消化道出血国际共识,C. Pharmacologic management,药物治疗,C1,.,Histamine-2 receptor antagonists,are not recommended,for patients with acute ulcer bleeding.*,C2. Somatostatin and octreotide are not routinely recommended for patients with acute ulcer bleeding.*,C3.,An intravenous bolus followed by continuous-infusion PPI therapy,should be used to decrease rebleeding and mortality in patients,with high-risk stigmata,who have undergone successful endoscopic therapy.,C4. Patients should be discharged with a prescription for a single daily-dose oral PPI for a duration as dictated by the underlying etiology.,Alan N.Barkun,et Intern Med. 2010;152:101-113.,指南共识,注：说明书推荐：对于不能口服用药的,Forrest,分级,IIc-III,的急性胃或十二指肠溃疡出血患者，推荐静脉滴注本品,40mg,，每,12,小时一次，用药,5,天。,C,药物治疗,C1.,不推荐,H2RA,用于急性溃疡出血患者,*,C2.,不推荐,生长抑素和奥曲肽常规用于急性溃疡出血患者,*,C3. PPI,静脉推注,+,持续性滴注用于成功内镜治疗高危患者,可降低再出血和死亡率；,C4.,鉴于潜在病因，出院患者仍应持续口服,PPI,（一次,/,天）,成功内镜止血后，静脉,PPI,治疗（,80mg bolus+8mg/h infusion 72h,）应该用于高危溃疡出血患者,(,强烈推荐,),；,低危溃疡出血患者可服用标准剂量,PPI,治疗（如口服,PPI1,次,/,天）,(,强烈推荐,),-2012 ACG Practice Guidelines,注：说明书推荐：对于不能口服用药的,Forrest,分级,IIc-III,的急性胃或十二指肠溃疡出血患者，推荐静脉滴注本品,40mg,，每,12,小时一次，用药,5,天。,2012,年美国胃肠病学会溃疡出血患者处理指南,指南共识,Loren Larne,MD,et al. Am J Gastroenterol 2012; 107:345360,Hp,相关溃疡出血患者应接受,Hp,根除治疗。,Hp,根除后一般不需再抑酸维持治疗，除非患者还需要进行非甾体抗炎药或抗血小板聚集药物治疗。（强烈推荐、高）,非甾体抗炎药相关性溃疡出血患者，需对,NSAID,应用认真评估，若情况容许，可停止,NSAID,应用；若患者必须服用,NSAID,，建议选用最低有效剂量的,COX-2,选择性非甾体抗炎药，并每日联用,PPI,。（强烈推荐、高）,预 防,Am J Gastroenterol 2012; 107:345360,-2012 ACG Practice Guidelines,消化性溃疡再出血预防的推荐策略,应该对低剂量阿司匹林相关的出血性溃疡患者阿司匹林的使用情况进行评估。,若作为二线预防（如确诊心血管疾病），多数患者应在出血停止后,13,天尽快恢复阿司匹林用药、最迟,7,天，同时推荐长期使用,PPI,。,若作为一线预防（即没有确诊心血管疾病），大多数患者可能不应该继续进行抗血小板治疗。（有条件推荐、中）,特发性溃疡患者（,non-Hp,，,non-NSAID,），推荐长期抗溃疡治疗（如每天,PPI,治疗）（有条件推荐、低）,预 防,Am J Gastroenterol 2012; 107:345360,-2012 ACG Practice Guidelines,消化性溃疡再出血预防的推荐策略,结 论,复苏应先于其它任何治疗程序；,准确进行风险评估和治疗；,内镜治疗方法联合应用以更好地控制出血；,内镜前,/,后大剂量静脉,PPI,应用对溃疡出血治疗至关重要；,PPI,在众多原因导致的溃疡再出血预防中发挥重要作用。,结 论,