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標題: | 高風險出血性潰瘍經內視鏡治療後再出血之危險因子分析 Risk Factor Analysis for Recurrent Bleeding in High-risk Bleeding Peptic Ulcers after Endoscopic Therapy |
作者: | Chieh-Chang Chen 陳介章 |
指導教授: | 吳明賢(Ming-Shiang Wu) |
共同指導教授: | 王秀伯(Hsiu-Po Wang) |
關鍵字: | 消化性潰瘍出血,幽門螺旋桿菌,氫離子幫浦抑制劑,內視鏡止血術,再出血, Peptic ulcer bleeding,Helicobacter pylori,proton pump inhibitor,endoscopic hemostasis,recurrent bleeding, |
出版年 : | 2011 |
學位: | 碩士 |
摘要: | 背景
急性上消化道出血成因大多是急性消化性潰瘍出血。針對高危險性出血潰瘍病兆,內視鏡止血術,已被證實可預防潰瘍再出血、減低需緊急開刀手術的風險、降低住院日數。經內視鏡止血療法後,高劑量輔助性氫離子幫浦抑制劑治療已被證實可降低再出血率,然而氫離子幫浦抑制劑的劑量是否影響再出血率仍有爭議。此外氫離子幫浦抑制劑及內視鏡止血術廣泛的應用下,潰瘍再出血危險因子尚缺乏相關資料。 目的 評估內視鏡止血治療後,氫離子幫浦抑制劑的劑量是否會影響再出血率、手術比率、輸血量、住院日數、三十天死亡率,以及患者的臨床表現、內視鏡表現及既有疾病、非類固醇消炎止痛劑,幽門螺旋桿菌狀況、CYP2C19基因型是否和再出血相關。 方法 針對201位高風險出血性潰瘍患者,以內視鏡進行腎上腺素注射及熱探子熱凝止血治療後,依氫離子幫浦抑制劑劑量不同,隨機分派成高劑量組(pantoprazole八十毫克快速靜脈注射後,以每小時八毫克速率靜脈注射)或標準劑量組(每日pantoprazole靜脈注射四十毫克)共七十二小時。七十二小時後給予口服pantoprazole每天四十毫克,共二十七天。試驗期間給予必要之輸血及其他治療,並監測是否再出血。 結果 100位病患進入高劑量組,101位病患進入標準劑量。高劑量組組有6位(6.2%, 95% C.I: 1.3% ~ 11.1%),而標準劑量有5位(5.2%, 95% C.I: 0.6% ~ 11.1%) 在內視鏡治療後三十天內再出血 (p=0.77)。高劑量組平均輸血量為2.9 ± 6.2單位,標準劑量組平均輸血量為1.6 ± 2.1單位(P = 0.046)。住院天數在五天內的病患,高劑量組的病患有55位(56.7%),標準劑量組有57位(59.3%),p=0.70。高劑量組中有一位病患接受血管栓塞術止血 (0 vs. 1, p=0.32)。高劑量組中有3位(3.1%)在三十天內死亡,而標準劑量組有1位(1%)在三十天內死亡(p=0.32)。利用逐步Cox迴歸分析顯示透析、吐血、慢性阻塞性肺病為再出血的獨立危險因子(危險比:37.15、10.07、9.12,95% 信賴區間:6.76∼204.14、2.07∼49.01、1.66∼50.00)。幽門螺旋桿菌感染者較不容易發生再出血(危險比:0.20,95% 信賴區間:0.04∼0.94)。 結論 出血性潰瘍經合併兩種內視鏡止血術後,標準劑量pantoprazole靜脈輸注預防再出血的效果和高劑量pantoprazole靜脈輸注相當。透析、慢性阻塞性肺病、吐血以及幽門螺旋桿菌陰性的潰瘍為內視鏡治療後再出血之獨立危險因子。 Background Acute peptic ulcer bleeding remains the most common cause of acute upper gastrointestinal bleeding. Endoscopic hemostasis has been documented to be effective in decreasing rebleeding, need for surgery, and decreasing hospitalization days. Studies showed a high dose intravenous proton pump inhibitor infusion after endoscopic hemostasis reduced recurrent ulcer bleeding. It was controversial whether an adjuvantive use of standard-dose proton pump inhibitor therapy after endoscopic therapy had similar benefit. In addition, few literatures discussed risk factors of recurrent bleeding in the era of endoscopic therapy and proton pump inhibitors Methods Patients with actively bleeding ulcers or ulcers with non-bleeding visible vessel were treated with epinephrine injection and thermal coagulation, and randomized to receive intravenous PPIs according to a high-dose regimen (pantoprazole 80 mg bolus followed by 8 mg/h as continuous infusion for 72 h) or a standard-dose regimen (pantolprazole 40 mg bolus daily for 72 h). After 72 hours, all patients were given 40 mg pantoprazole daily orally for 27 days. The primary end point was recurrent bleeding within 30days after endoscopy. Results We enrolled 201 patients, 100 patients in the high-dose group and 101 patients in standard-dose group. Bleeding recurred within 30 days in 6 patients (6.2%, 95% CI 1.3% – 11.1%) in the high-dose group, as compared with 5 patients (5.2%, 95% CI 0.6% – 9.7%) in the standard-dose group (P=0.77). Mean units of blood transfused were 2.9 ± 6.2 in the high-dose and 1.6 ± 2.2 in the standard-dose group (P = 0.05). The duration of hospital stay was ≦ 5 days for 55 (56.7%) and 57 patients (59.3%) in the high- and standard-dose groups (P = 0.70). There were fewer surgical interventions or transcatheter arterial embolization in the standard- versus high-dose group (0 vs 1, P = 0.32). Three (3.1%) patients in the high-dose group and 1 (1%) patients died within 30 days after endoscopy (P = 0.32). The stepwise Cox regression analysis showed dialysis, hematemesis, chronic obstructive pulmonary disease (hazard ratio: 37.15, 10.07, 9.12, 95% confidence interval (CI): 6.76 - 204.14, 2.07 – 49.01, 1.66 – 50.00, respectively) were independent risk factors for recurrent bleeding and Helicobacter pylori (H. pylori) infection was associated with lower risk of recurrent bleeding (hazard ratio: 0.20, 95% CI: 0.04 – 0.94). Conclusions Following combined endoscopic hemostasis of bleeding ulcers, standard-dose pantoprazole infusion is as effective as a high-dose regimen in reducing the risk of recurrent bleeding. Dialysis, hematemesis, chronic obstructive pulmonary disease, and H. pylori negative ulcer, but no proton pump inhibitor dosage, are independent factors for recurrent bleeding. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/8747 |
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顯示於系所單位: | 臨床醫學研究所 |
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