- 期刊
Decision Making in the Management of Obscure-Overt Gastrointestinal Bleeding in Emergency Settings
緊急情況下針對明顯之不明原因消化道出血評估與臨床決斷
摘要
背景 儘管內視鏡檢查廣泛而常規的使用於消化道出血之診療，但有5－10％的病人仍無法確認出血位置，是為不明原因消化道出血。雖然這類病人比例較少，但是更需要使用大量醫療資源。本文中我們回顧本院在緊急狀況下，對合併大量出血的此類病人進行診斷及臨床決策之經驗。材料與方法 從1995年8月至2010年1月，從本院資料庫中搜尋到31位病人，合併明顯出血之病人如吐血，鼻胃管中有血，血便，或是瀝青便，經由初步之上消化道內視鏡及大腸鏡無法定位之出血。所有病人皆因休克或大量出血而接受手術。我們針對病歷回顧並分析術前檢查，治療以及結果。結果 共有14位病人可經由術前檢查準確定位出血位置。其餘病人仍需靠手術探查，甚至合併術中內視鏡檢查方能準確定位。血管病灶為最常見出血原因，其次是潰瘍與憩室。有9名病人術後再出血，並有17例發生合併症及12例死亡。結論 儘管檢查工具進步，在緊急情況下，明顯之不明原因消化道出血的診斷與處置仍是實務上一大挑戰。血管攝影和注射顯影劑之電腦斷層掃描，可以在相對穩定的病人使用。在緊急狀況下，手術探查與術中內視鏡仍不失為一有效的診斷與治療方法。
並列摘要
Purpose. Despite the popularity of endoscopy as the standard diagnostic tool for gastrointestinal bleeding, in 5-10% of cases the origin of bleeding is not obvious; this is referred to as obscure gastrointestinal bleeding. Despite affecting only a small number of patients, there is a disproportionate requirement for medical resources by these individuals and many patients require surgical management. We reviewed our experience with such patients during the diagnostic and decision making process, particularly in emergency settings.Methods. Between August 1995 and June 2010, we enrolled 31 patients presenting with hematemesis, blood per nasogastric tube, melena, or hematochezia and who had negative findings by first-line endoscopy. All patients underwent surgery due to shock or refractory bleeding. Medical records were retrospectively reviewed for preoperative investigation, treatment, and outcome. Results. Accurate preoperative localization of the source of bleeding was achieved by various diagnostic tools in 14 patients. Among the remainder, the diagnosis was made either by exploration or by endoscopy intraoperatively. Vascular lesions were the most common cause of bleeding, followed by ulcers and diverticula. Nine patients began bleeding again despite surgical intervention. There were 17 patients with morbidities and there were 12 mortalities. Conclusion. Angiography and enhanced computed tomography aid diagnosis when patients are relatively stable. Once available diagnostic approaches are exhausted, surgical exploration with the aid of intraoperative endoscopy remains an effective diagnostic and therapeutic measure.