Obscure Gastrointestinal Bleeding in Hemodialysis Patients: The Role of Double Balloon Enteroscopy

洗腎併有隱晦性胃腸道出血的病人：雙氣囊小腸鏡術所扮演的角色

宋昌穆(Chang-Mu Sung) ； 邱正堂(Cheng-Tang Chiu) ； 蘇銘堯(Ming-Yao Su) ； 林偉彬(Wei-Pin Lin) ； 許振銘(Cheng-Ming Hsu) ； 陳邦基(Pang-Chi Chen)

《臺灣消化醫學雜誌》 25卷2期 (2008/06) Pp. 165-170

https://doi.org/10.6557/GJT.200806_25(2).0001

摘要

前言：胃腸道出血在洗腎血液透析病人上是常見的併發症。有些病人在經過上下消化道鏡的檢查後仍沒有找到出血點，懷疑是小腸出血。技術上的挑戰讓小腸疾病的診斷與治療仍是困難重重。一種新的腸鏡－雙氣囊小腸鏡術(Double Balloon Enteroscopy)，與傳統方法比較可以在較安全，快速及減少痛苦的情況下做全段小腸檢視，來回檢查重點段落及施行切片。
目的：本研究分析將雙氣囊小腸鏡術用於診斷及治療洗腎併有不明原因胃腸道出血的病人。
病人及方法：從2004年10月至2006年7月，本院共有10位洗腎病人藉由臨床症狀及光前檢查結果懷疑併有隱晦性胃腸道出血而接受雙氣囊小腸鏡檢查，其中四位選擇經由口端進入，六位經由肛門端進入。進行檢查之前，經由肛門端進入的病人，接受2公升的polyethylene glycol solution灌洗，經由口端進入則只接受八小時禁食。在檢查過程時如果沒有禁忌症則給予病人靜脈注射hyoscine-butylbromide 20 mg, midazolam 2-5 mg及meperidine20-50mg以達輕度麻醉的效果。
結果：經由肛門端進入的病人有三位在迴腸發現有血管異常增生不良病變(angiodysplasia)，經由口端進入的病人，有一位在空腸發現血管異常增生不良病變，這些病人在經過氫氣電漿凝固治療(argon Plasma coagulation-APC)後，出血停止。一位病人發現有多發性迴腸血管異常增生不良病變合併出血，在做完標記後(pure carbon tattoo)接受開刀治療。一位病人在空腸有息肉狀病變並接受息肉切除術，組織學檢查爲肉芽性組織。一位病人有多發性全壁性潰瘍，切片檢查後診斷爲小腸克隆式病。一位病人發現有空腸淋巴管擴張(lymphangiectasia)在經過氫氣電漿凝固治療後出血停止。有二位病人沒有發現明顯的出血，但是其中一位發現有出血性胃炎，另一位發現有大腸息肉。所有接受雙氣囊小腸鏡術都沒有任何併發症。檢查時間從30分至160分鐘不等。
結論：大多數洗腎併有隱晦性胃腸道出血的病人都可由雙氣囊小腸鏡術來獲得診斷與治療上的幫助，血管異常增生不良病變(angiodysplasia)可能是洗腎病患胃腸道出血的重要原因之一。總之，雙氣囊小腸鏡術是一種有用且低併發症的檢查工具。

關鍵字

尿毒症 ； 雙氣囊小腸鏡術 ； 隱晦性胃腸道出血

並列摘要

Introduction: Gastrointestinal bleeding is a common complication in hemodialysis patients. In some patients, definite bleeders are not found even after upper and lower gastrointestinal endoscopic examinations. An innovative form of enteroscopy, the double balloon enteroscopy (DBE), permits visualization of the complete small intestine, to and fro examination of an area of interest, and the endoscopic interventions are safer, faster and less painful than earlier methods. In this study, we used the DBE to evaluate and manage uremic patients with obscure gastrointestinal bleeding.
Patients and Methods: From October 2004, to July 2006, ten uremic patients with obscure gastrointestinal bleeding received double balloon enteroscopic examinations, four per oral and six per rectal routes. Before the procedure, bowel preparation with 2 liters of PEG solution was used for the rectal route DBE, but fastedemptying of the stomach for 8 hours for the oral route DBE. And intravenous hyoscine-butylbromide 20 mg, midazolan 2-5 mg and meperidine 20-50 mg were given if there were no contraindications.
Results: One patient had intestinal angiodysplasia in jejunum (per oral) and three in ileum (per rectal), another one had jejunal lymphangiectasia. All of these patients received local therapy with argon plasma coagulation, and bleeding stopped in all cases. Multiple ileal angiodysplasias were observed in one patient who was received operation for active bleeding from the ileum after pure carbon tattooing. One patient with jejunal polypoid lesion were resected by polypectomy, histologic diagnosis was granulation tissue. One patient exhibited multiple ulcers in the ileum, and Crohn's disease was diagnosed. Although two patients had no definite small intestinal lesions, hemorrhagic gastritis was noted in one patient, while colonic polyp was noted in another. All patients underwent the procedures uneventfully without complications, and the examination time varied from 30 to 160 minutes.
Conclusion: Most uremic patients with obscured GI bleeding can be diagnosed and managed by DBE. Although angiodysplasia is a potential cause, some other causes are possible. Double balloon enteroscopy permits deep insertion of an endoscope into the small intestine without excessive stretching of the intestinal tract. Observation of the complete small intestine as well as interventions is possible by using oral or anal approach.

並列關鍵字

uremia ； double balloon enteroscopy ； obscure gastrointestinal bleeding