Surgery Intervention of Acute Hemorrhagic Rectal Ulcer in Critically Ill Patients: Analysis of Surgical Outcome

對於急性出血性直腸潰瘍病危病人的手術治療：手術預後分析

潘慕嵩(Mu-Song Pan) ； 鄭立勤(Li-Chin Cheng) ； 田宇峯(Yu-Feng Tian) ； 周家麟(Chia-Lin Chou)

《中華民國大腸直腸外科醫學會雜誌》 26卷3期 (2015/09) Pp. 93-101

https://doi.org/10.6312/SCRSTW.2015.26(3).10403

摘要

目的　急性出血性直腸潰瘍為單發或多發性直腸潰瘍，其特徵為無痛且合併大出血的一種症候群。患者通常合併有嚴重的原發症，本研究是以回顧性分析調查其在重症加護病房的發病率，治療方式和總死亡率。方法　研究期間自2010年11月到2014年7月，共有18971位重症加護病房住院患者。其中有96 在患者在發生急性大量血便的24－48小時內接受大腸鏡檢查。急性出血性直腸潰瘍的診斷是根據下列標準：1. 突然發作無痛，塊狀血便；2. 大腸鏡下發生潰瘍與正在進行的性出血或近期出血紅斑；3. 排除其他直腸潰瘍性疾病，例如粘膜脫垂症候，孤立性直腸潰瘍症候群，糞性潰瘍，炎症性腸病，缺血性結腸炎，感染性疾病（結核，巨細胞病毒感染等），癌症或可能的機械損傷；4. 一週內有接受非類固醇抗炎藥劑病史。回顧性分析案例的臨床過程，止血的方法，手術次數和死亡率。結果　96例中有28例急性出血性直腸潰瘍(29.1%)，在重症加護病房的發病率為1.48/1000。其中13名患者(13/28, 46.4%)，因出血合併低血容量休克。所有28例患者皆進行手術治療，16位患者於手術後未再出血，第一次手術成功止血率為57.1%(16/28)。另外12例(12/28, 42.9%) 在手術後4週內發生再次出血，11例患者接受第二次手術且成功止血，手術成功止血率為63.6% (7/11)。在28個案例中，有4例併發二次以上再出血 (4/28, 14.3%)，儘管接受再次手術或其他治療方式，這4位患者最後皆死亡。總存活率為64.3% (18/28)，其中4例死於頑固性急性出血性直腸潰瘍出血。結論 急性出血性直腸潰瘍是重症加護病房住院患者，急性下消化道出血的重要病因。臨床上需早期察知以及給予早期診斷和治療。頑固性和反覆性出血會導致高死亡率和不佳的預後。

關鍵字

急性出血性直腸潰瘍

並列摘要

Purpose. Acute hemorrhagic rectal ulcer (AHRU) is a syndrome characterizedby painless, massive hemorrhage from a solitary or multiple rectalulcers in patients with serious underlying disease. Aretrospective analysisis presented to investigate disease incidence rate in the intensive care unit(ICU), treatment modalities, and overall mortality.Methods. Between November 2010 and July 2014, 18971 patients wereadmitted to the ICU ward. Of these, 96 patients with acute massive hematocheziareceived colonoscopy within 24 to 48 hours after onset. Diagnosesof AHRU were made according to the following criteria: (1) suddenonset of painless, massive hematochezia; (2) presence of ulcerations withongoing bleeding or stigmata of recent bleeding in the rectum, as investigatedby colonoscopy; (3) exclusion of other ulcerative disorders in therectum such as mucosal-prolapse syndrome, solitary rectal ulcer syndrome,stercoral ulcer, inflammatory bowel diseases, ischemic colitis, infectiousdiseases (e.g., tuberculosis, cytomegalovirus infection), cancer, or possiblemechanical injuries; and (4) no history of nonsteroidal anti-inflammatorydrug suppositories within one week. Data on the clinical course, methodsof hemostasis, number of operations, and mortality were collected and analyzedretrospectively.Results. AHRU was diagnosed in 28 of 96 patients (29.1%), and the incidencerate for AHRU in the ICU was 1.48/1000. Thirteen patients (13/28,46.4%) developed hypovolemic shock after the onset of bleeding. Surgicalintervention was performed in all 28 patients with first-time bleedingand showed a success rate of 57.1% (16/28). Twelve patients (12/28,42.9%) developed rebleeding within four weeks, and surgery was performedin 11 patients for hemostasis, with a success rate of 63.6% (7/11).Rebleeding recurred in four patients (4/28, 14.3%), all of whom died despiterepeated surgery and other management efforts. The overall survivalrate was 64.3% (18/28), and four patients died of intractable rectal ulcerbleeding.Conclusions. Acute hemorrhagic rectal ulcer syndrome is an importantetiology of acute lower gastrointestinal tract bleeding in ICU patients.Awareness of this clinical entity requiring a high index of suspicion resultsin early detection, diagnosis, and appropriate therapy. Intractable andrepeated bleeding is associated with high mortality rate and worse outcomes.

並列關鍵字

Acute hemorrhagic rectal ulcer

參考文獻

jandra JJ, Fazio VW, Church JM, Lavery IC, Oakley JR, Milsom JW. Clinical conundrum of solitary rectal ulcer. Dis Colon Rectum 1992;35:227–34."

akeuchi K, Tsuzuki Y, Ando T, Sekihara M, Hara T, Ohno Y, et al. Clinical characteristics of acute hemorrhagic rectal ulcer. J Clin Gastroenterol 2001;33:226–8."

seng CA, Chen LT, Tsai KB, Su YC, Wu DC, Jan CM, et al. Acute hemorrhagic rectal ulcer syndrome: a new clinical entity? Report of 19 cases and review of the literature. Dis Colon Rectum 2004;47:895–903."

ung HY, Changchien CR, You JF, Chen JS, Chiang JM, Yeh CY, et al. Massive hematochezia from acute hemorrhagic rectal ulcer in patients with severe comorbid illness: rapid control of bleeding by per anal suturing of bleeder using anoretractor. Dis Colon Rectum 2006;49:238–43."

ku T, Maeda M, Ihara H, Umeda I, Kitaoka K, WagaE, et al. Clinical and endoscopic features of acute hemorrhagic rectal ulcer. J Gastroenterol 2006;41:962–70."