Excess Long-Term Mortality following Non-Variceal Upper Gastrointestinal Bleeding: A Population-Based Cohort Study

Background

It is unclear whether an upper gastrointestinal bleed is an isolated gastrointestinal event or an indicator of a deterioration in a patient''s overall health status. Therefore, we investigated the excess causes of death in individuals after a non-variceal bleed compared with deaths in a matched sample of the general population.

Methods and Findings

Linked longitudinal data from the English Hospital Episodes Statistics (HES) data, General Practice Research Database (GPRD), and Office of National Statistics death register were used to define a cohort of non-variceal bleeds between 1997 and 2010. Controls were matched at the start of the study by age, sex, practice, and year. The excess risk of each cause of death in the 5 years subsequent to a bleed was then calculated whilst adjusting for competing risks using cumulative incidence functions.16,355 patients with a non-variceal upper gastrointestinal bleed were matched to 81,523 controls. The total 5-year risk of death due to gastrointestinal causes (malignant or non-malignant) ranged from 3.6% (≤50 years, 95% CI 3.0%–4.3%) to 15.2% (≥80 years, 14.2%–16.3%), representing an excess over controls of between 3.6% (3.0%–4.2%) and 13.4% (12.4%–14.5%), respectively. In contrast the total 5-year risk of death due to non-gastrointestinal causes ranged from 4.1% (≤50 years, 3.4%–4.8%) to 46.6% (≥80 years, 45.2%–48.1%), representing an excess over controls of between 3.8% (3.1%–4.5%) and 19.0% (17.5%–20.6%), respectively. The main limitation of this study was potential misclassification of the exposure and outcome; however, we sought to minimise this by using information derived across multiple linked datasets.

Conclusions

Deaths from all causes were increased following an upper gastrointestinal bleed compared to matched controls, and over half the excess risk of death was due to seemingly unrelated co-morbidity. A non-variceal bleed may therefore warrant a careful assessment of co-morbid illness seemingly unrelated to the bleed. Please see later in the article for the Editors'' Summary     

Gastric Cooling for Massive Upper Gastrointestinal Bleeding

The treatment of massive upper gastrointestinal hemorrhage by gastric hypothermia was studied clinically in 23 patients: five with peptic ulcer, six with multiple gastric erosions, nine with portal hypertension and varices, and three with coagulation defects. Hemorrhage was controlled in 13 of the patients. The high mortality (14 out of 23 patients) was attributed to the severity of the bleeding and to the underlying disease, particularly in patients with liver failure. This form of treatment is a useful method of treating selected patients with upper gastrointestinal hemorrhage.     

阿司匹林引发上消化道出血的相关危险因素研究

目的:比较由阿司匹林引发上消化道出血的相关危险因素OR值,探讨其引起消化道大出血的相关机制。方法:收集哈医大四院消化内科及心内科2009年5月份至2013年6月份仅口服阿司匹林一种非甾体抗炎药的100例患者,用药过程中引发上消化道出血的49例患者作为研究组,其余未发生消化道出血的51例患者作为对照组,采集现病史、既往史、吸烟史、行凝血常规、Hp检测及胃镜检查,经单因素统计分析筛选出阿司匹林引发上消化道出血的危险因素;通过多元Logistic回归分析得出阿司匹林引发上消化道出血的独立危险因素。结果:年龄60岁、Hp感染、既往溃疡病史、糖尿病、吸烟的患者在研究组所占比例明显高于对照组,差异具有统计学意义;经多元Logistic回归后表明年龄60岁、Hp感染、既往溃疡病史、糖尿病患者和阿司匹林引发上消化道出血的OR值具有统计学差异。结论:年龄60岁、Hp感染、溃疡病史、糖尿病患者是阿司匹林引发上消化道出血的4个独立危险因素。     

内镜止血在急性非静脉曲张性上消化道出血治疗中的临床应用

目的:探讨内镜下金属钛夹止血在急性非静脉曲张性上消化道出血治疗中的应用价值。方法:按照随机数字表法将2014年1月-2014年12月我院收治的40例急性非静脉曲张性上消化道出血患者分为观察组(n=20)及对照组(n=20),观察组行内镜下金属钛夹止血治疗,对照组予以内镜下药物注射,比较两组治疗后的止血效果、临床疗效及并发症情况。结果:观察组患者治疗后的有效止血率、即时止血率为95.00%、100.00%,分别高于对照组的65.00%、75.00%,差异有统计学意义(P0.05)。治疗后观察组临床疗效优于对照组,差异有统计学意义(P0.05)。治疗后两组患者均未出现严重并发症。结论:内镜下金属钛夹止血用于急性非静脉曲张性上消化道出血具有止血效果好、并发症少等特点,临床有重要的参考价值。     

左侧门脉高压症并上消化道出血的诊断与治疗（附14 例临床分析）

目的:探讨左侧门脉高压症合并上消化道出血的诊断和治疗方法。方法:回顾分析我院近10年来收治的14例左侧门脉高压症合并上消化道出血患者的诊治措施和随访结果。结果:14例患者均有呕血或(和)黑便史,无肝硬化、腹水及肝功能异常等表现。14例患者中胰体尾占位6例,胰腺假性囊肿4例,慢性胰腺炎4例。14例患者均采用手术治疗。9例患者获得随访,定期内镜复查,曲张静脉明显改善或消失,随访5月～8年均无再出血。结论:胰腺疾病病史、无肝硬化和肝功能正常、孤立性胃底静脉曲张和脾肿大及脾亢是诊断左侧门脉高压症的基本要点。该疾病可通过脾切除术或联合胃底周围血管离断术结合原发胰腺疾病的治疗来获得治愈。     

上消化道出血在ICU的诊治近况

近年来,ICU在急重症上消化道出血救治中的作用越来越受到重视。上消化道出血是重症监护病房(ICU)内常见的危重病症 之一,与多器官功能不全密切相关,是多种危重病引起的常见并发症,病情严重者甚至危及生命。引起上消化道出血的病因很多, 其中非特异性粘膜异常、非甾体类抗炎药和抗血小板药物的不合理使用逐渐引起临床的重视。本文对国内外临床诊断和治疗上 消化道出血的近况进行了回顾分析,进一步阐述上消化道出血与多器官功能不全之间的联系,为多学科联合诊断提供参考。     

消化道出血病因的临床分析

目的:回顾性分析消化道出血的病因构成、相关因素及治疗情况。方法:收集2008年7月至2013年9月因消化道出血在沈阳军区总医院消化内科住院的患者资料,包括患者的一般资料、入院日期、病因、出血部位、生命体征、疾病史。依据消化道出血程度分为轻度组(86例)、中度组(90例)、重度组(132例),分析消化道出血的病因特征。结果:与轻度组比较,重度组上消化道出血患者比例较高,中、重度组Blatchford评分、心率、尿素、血肌酐、凝血酶原时间、INR、血糖明显升高(P0.05);收缩压、舒张压、红细胞、血红蛋白、总蛋白、白蛋白、总胆固醇明显减低(P0.05)。重度组患有食管胃底静脉曲张的比例较高,行内镜下治疗的比例高(P0.05)。结论:根据患者出血程度可初步判断患者消化道出血的部位及病因,为临床诊治提供有价值的参考依据。     

Recurrent Haemorrhage after Acute Gastrointestinal Bleeding

A retrospective survey of 472 consecutive hospital admissions for acute upper gastrointestinal bleeding showed that patients with a large initial bleed are more likely to bleed again than those with a small initial bleed. The incidence of recurrent haemorrhage is also related to the interval since the last bleeding episode, so that patients showing no clinical evidence of haemorrhage for 48 hours are unlikely to bleed again in the near future. Patients admitted after a haematemesis have a higher incidence of recurrent haemorrhage than those admitted after melaena only. Aetiology has been confirmed as an additional important factor, the incidence being highest in those with oesophageal varices or a chronic gastric ulcer. Contrary to widespread belief, age does not appear to affect the incidence of recurrent haemorrhage, nor do other constitutional factors such as sex or the ABO blood group.     

Acid-base Balance in Acute Gastrointestinal Bleeding

Acid-base balance has been studied in 21 patients with acute upper gastrointestinal bleeding. A low plasma bicarbonate concentration was found in nine patients, accompanied in each case by a base deficit of more than 3 mEq/litre, indicating a metabolic acidosis. Three patients had a low blood pH. Hyperlactataemia appeared to be a major cause of the acidosis. This was not accompanied by a raised blood pyruvate concentration. The hyperlactataemia could not be accounted for on the basis of hyperventilation, intravenous infusion of dextrose, or arterial hypoxaemia. Before blood transfusion it was most pronounced in patients who were clinically shocked, suggesting that it may have resulted from poor tissue perfusion and anaerobic glycolysis. Blood transfusion resulted in a rise in lactate concentration in seven patients who were not clinically shocked, and failed to reverse a severe uncompensated acidosis in a patient who was clinically shocked. These effects of blood transfusion are probably due to the fact that red blood cells in stored bank blood, with added acid-citrate-dextrose solution, metabolize the dextrose anaerobically to lactic acid. Monitoring of acid-base balance is recommended in patients with acute gastrointestinal bleeding who are clinically shocked. A metabolic acidosis can then be corrected with intravenous sodium bicarbonate.     

Glasgow-Blatchford和Rockall评分系统对上消化道出血患者治疗的指导作用比较

目的：比较Glasgow-Blatchford和Rockall评分系统对上消化道出血患者治疗的指导作用。方法：回顾分析我院收治的上消化道出血病人共366例,详细记录每一位入组患者的临床表现、生命体征、实验室检查结果,根据Glasgow-Blatchford和Rockall评分系统的规则计算每一位患者的危险分值,并依据其分值将其分为低危组和高危组（Glasgow-Blatchford≥1分,Rockall≥1分）。结果：366例上消化道出血患者有243位（66.4%）经过补液、抑酸等保守治疗后出血停止,并按照临床实际将其定义为低危患者,Glasgow-Blatchford评分为0的低危患者有63位（17.2%）,Rockall评分为0的低危患者有99人（27.0%）,参照临床治疗中实际的高低危患者,计算得到Rockall评分系统对高危患者诊断的敏感性为87.0%,而Glasgow-Blatchford评分系统对高危患者诊断的敏感性为100%。Glasgow-Blatchford评分系统对上消化道出血高危患者诊断的敏感性明显高于临床Rockall评分系统。结论：基于实验室检查和临床表现的Glasgow-Blatchford评分,是一种简单、有效的判断上消化道出血严重程度的评分系统,有助于临床医师选择正确的治疗方案。     

Rockall危险性积分对急性上消化道出血患者临床预后的预测价值

目的:探讨Rockall危险性积分对急性上消化道出血(AUGIH)患者临床预后的预测价值。方法:选择2012年1月至2014年1月我院收治的120例AUGIH患者,依据Rockall评分标准对患者相关临床资料进行收集,并计算其Rockall危险性积分评分,记录患者再出血率及死亡率。结果:120例AUGIH患者中,低危组39例(32.5%)、中危组72例(60.0%)、高危组9例(7.5%)。高危组患者再出血率及死亡率分别为33.3%和22.2%,均明显高于中危组16.7%和15.3%,比较差异具有统计学意义(P0.05)。结论:Rockall评分系统可作为AUGIH患者预后预测的重要指标,对急诊AUGIH预后的判断具有重要临床意义。     

Glasgow-Blatchford和Rockall评分系统对上消化道出血患者治疗的指导作用比较

目的:比较Glasgow-Blatchford和Rockall评分系统对上消化道出血患者治疗的指导作用。方法:回顾分析我院收治的上消化道出血病人共366例,详细记录每一位入组患者的临床表现、生命体征、实验室检查结果,根据Glasgow-Blatchford和Rockall评分系统的规则计算每一位患者的危险分值,并依据其分值将其分为低危组和高危组(Glasgow-Blatchford≥1分,Rockall≥1分)。结果:366例上消化道出血患者有243位(66.4%)经过补液、抑酸等保守治疗后出血停止,并按照临床实际将其定义为低危患者,Glasgow-Blatchford评分为0的低危患者有63位(17.2%),Rockall评分为0的低危患者有99人(27.0%),参照临床治疗中实际的高低危患者,计算得到Rockall评分系统对高危患者诊断的敏感性为87.0%,而Glasgow-Blatchford评分系统对高危患者诊断的敏感性为100%。Glasgow-Blatchford评分系统对上消化道出血高危患者诊断的敏感性明显高于临床Rockall评分系统。结论:基于实验室检查和临床表现的Glasgow-Blatchford评分,是一种简单、有效的判断上消化道出血严重程度的评分系统,有助于临床医师选择正确的治疗方案。     

Alcohol,Aspirin, and Gastrointestinal Bleeding

In 20 healthy male subjects faecal blood loss was measured by means of a chromium-51-labelled red blood cell technique. Mean daily faecal blood loss associated with unbuffered aspirin ingestion was significantly increased by alcohol in the 13 subjects studied. In seven others alcohol alone did not cause gastrointestinal bleeding. These findings suggest that alcohol may accentuate gastrointestinal blood loss associated with unbuffered aspirin ingestion.     

枯草杆菌二联活菌预防肝硬化上消化道出血后并发症的临床疗效研究

目的:探讨枯草杆菌二联活菌预防肝硬化上消化道出血后自发性细菌性腹膜炎(SBP)和肝性脑病(HE)等并发症的疗效。方法:将60例确诊为肝硬化合并上消化道出血患者随机分为对照组和治疗组(各30例),对照组采用常规综合治疗,治疗组在常规综合治疗基础上加用枯草杆菌二联活菌制剂,连续治疗2周后观察两组疗效及肝功能指标治疗前后的变化情况。结果:治疗组和对照组预防SBP的有效率分别为83.3%和56.7%,差异有统计学意义(P0.05);预防肝性脑病的有效率分别为83.3%和80%,差异无统计学意义(P0.05)。两组治疗后ALT、AST和ALB水平均明显改善,且治疗组改善较对照组更为显著,差异有统计学意义(P0.05)。结论:在基础治疗前提下,枯草杆菌二联活菌可预防肝硬化上消化道出血后SBP的发生,且有利于肝功能的改善。     

Acute Myocardial Infarction Risk in Patients with Coronary Artery Disease Doubled after Upper Gastrointestinal Tract Bleeding: A Nationwide Nested Case-Control Study

Prior studies of upper gastrointestinal bleeding (UGIB) and acute myocardial infarction (AMI) are small, and long-term effects of UGIB on AMI have not been delineated. We investigated whether UGIB in patients diagnosed with coronary artery disease (CAD) increased their risk of subsequent AMI. This was a population-based, nested case-control study using Taiwan’s National Health Insurance Research Database. After propensity-score matching for age, gender, comorbidities, CAD date, and follow-up duration, we identified 1,677 new-onset CAD patients with AMI (AMI^[+]) between 2001 and 2006 as the case group and 10,062 new-onset CAD patients without (AMI^[−]) as the control group. Conditional logistic regression was used to examine the association between UGIB and AMI. Compared with UGIB^[−] patients, UGIB^[+] patients had twice the risk for subsequent AMI (adjusted odds ratio [AOR] = 2.08; 95% confidence interval [CI], 1.72–2.50). In the subgroup analysis for gender and age, UGIB^[+] women (AOR = 2.70; 95% CI, 2.03–3.57) and patients < 65 years old (AOR = 2.23; 95% CI, 1.56–3.18) had higher odds of an AMI. UGIB^[+] AMI^[+] patients used nonsignificantly less aspirin than did UGIB^[−] AMI^[+] patients (27.69% vs. 35.61%, respectively). UGIB increased the risk of subsequent AMI in CAD patients, especially in women and patients < 65. This suggests that physicians need to use earlier and more aggressive intervention to detect UGIB and prevent AMI in CAD patients.     

VEGF, MVD 在胃癌预后及上消化道出血风险的研究进展

胃癌是危害人类健康的常见恶性肿瘤,也是上消化道出血常见的病因之一。其发生发展是多因素、多基因改变参与的长期、协同的病理过程。血管生成(angiogenesis)是这一发展过程中的关键步骤,血管内皮生长因子(vascular endothelial growth factor,VEGF)和微血管密度(micro vessel density,MVD)作为调控血管生成的主要因子和微血管的主要评价指标,在胃癌患者预后、临床病理因素中的作用被广泛研究。上消化道出血(upper gastrointestinal hemorrhage)是胃癌患者的常见临床症状威胁和影响患者的生存质量。新近有研究者提出,VEGF及MVD与胃癌患者的上消化道出血风险正相关,本文就相关研究进展进行介绍。