不明原因消化道出血患者行双气囊内镜检查的长期观察结果

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不明原因消化道出血患者行双气囊内镜检查的长期观察结果
Long-term outcome of patients with obscure gastrointestinal bleeding investigated by double-balloon endoscopy.
出处：Clin Gastroenterol Hepatol   2010  Feb  8(2) :151-8
作者：Shinozaki S;Yamamoto H;Yano T;Sunada K;Miyata T;Hayashi Y;Arashiro M;Sugano K
PMID：19879968

背景与目的：确定不明原因消化道出血（OGIB）的原因通常很困难。我们通过双气囊内镜（DBE）来分析其诊断率和评估OGIB患者的长期观察结果。

方法：在这个大型回顾性队列研究中，连续为200例OGIB患者进行DBE检查。有151位患者有平均29.7个月（6-78个月不等）的随访数据可以进行临床疗效的评估。

结果：DBE检查出了200例中的155 例(77.5%)患者的出血原因。出血最常见的来源是小肠溃疡/糜烂（64例）。
在最后一次显性出血后一个月内行DBE检查的患者有更高的阳性结果检出率（84%, 107/128 比 57%, 24/42; P = 0.002）。整体的OGIB控制率约为64％（97/151）。
与其他小肠病变相比，小肠血管病变的患者OGIB控制率明显低（40％，12/3074％比52/70，P = 0.001）。行DBE前需要大量输血（P = 0.012）、多病灶（P = 0.010）和可疑的（并不确切）的病变（P = 0.038），这些情况都能显着增加小肠血管病变患者再出血的可能。
结论：DBE对于OGIB患者的诊断很有意义，应在出现显性OGIB后尽快施行。有小肠血管病变的患者应该特别注意随访。

BACKGROUND & AIMS: It is often difficult to determine the cause of obscure gastrointestinal bleeding (OGIB). We evaluated the diagnostic yield and long-term outcome of patients with OGIB by using double-balloon endoscopy (DBE). METHODS: In this large, retrospective cohort study, DBE was performed in 200 consecutive patients with OGIB. Follow-up data were available from 151 patients for 29.7 months (range, 6-78 months), and clinical outcome was assessed. RESULTS: DBE detected bleeding sources in 155 of 200 patients (77.5%). The most frequent source detected was small intestine ulcers/erosions (64 patients). Patients who underwent DBE within 1 month after the last episode of overt bleeding had a better yield of positive findings than those who did not (84%, 107/128 patients vs 57%, 24/42; P = .002). The overall rate of control of OGIB was 64% (97/151 patients). Patients with vascular lesions of the small intestine had a significantly lower rate of control of OGIB than those with other small intestine lesions (40%, 12/30 patients vs 74%, 52/70; P = .001). A requirement for a large transfusion before DBE (P = .012), multiple lesions (P = .010), and suspicious (not definite) lesions (P = .038) each significantly increased the likelihood of overt rebleeding in patients with vascular lesions of the small intestine. CONCLUSIONS: DBE is useful for the diagnosis of patients with OGIB and should be performed as soon as possible after overt OGIB. Patients with vascular lesions of the small intestine should be followed with particular care.

专家评价：
Ann Chen
Stanford University School of Medicine, United States of America
Gastroenterology & Hepatology
This study included the largest number of patients to date who were followed long-term after undergoing double-balloon enteroscopy (DBE) or obscure gastrointestinal (GI) bleeding. DBE is a labor-intensive and time-consuming procedure and its utility in obscure GI bleeding is dependent on the timing of the procedure and the sources of bleeding. This study showed that, even in the best of hands, the overall diagnostic yield is around 65% and the long-term control of bleeding is approximately 60%.In this retrospective cohort study of 200 patients, the authors showed that DBE revealed definite (62%) and suspicious (16%) findings as causes of obscure GI bleeding. The yield of definite findings was significantly higher among ongoing overt bleeders than those with previous overt or occult bleeding (83% vs. 58% and 60%, respectively). The highest yield was seen among patients who underwent DBE within 1 month after an episode of overt bleeding. Interestingly, of the 155 patients with positive findings on DBE, 29 patients (19%) had non-small-bowel sources of bleeding that were detectable with conventional esophagogastroduodenoscopy (EGD) or colonoscopy. Long-term (range 6-78 months) follow-up was available for 100 patients found to have small-bowel sources of bleeding. Overall, control of bleeding was achieved in only 61% of patients. The control of bleeding was more successful in patients with tumors or polyps than in those with vascular lesions or ulcerations/erosions (84% vs. 40% and 65%, respectively). Of the 32 patients with negative DBE, 12 (37%) had uncontrolled bleeding during follow-up, and repeat DBE in four of these patients did not reveal a bleeding source.