重症病患併發急性下消化道出血之致病因探討及臨床表現之研究分析-強調緊急大腸鏡之角色

The etiology and clinical features of acute lower gastrointestinal bleeding in critically ill patients with severe comorbid diseases-Emphasize the role of urgent colonoscopy

林俊哲(Chun-Che Lin)

指導教授 ： 林肇堂 ； 李輝

中山醫學大學/醫學院/醫學研究所/博士(2005年)

https://doi.org/10.6834/CSMU.2005.00078

摘要

一般病患發生下消化道出血時常利用大腸鏡檢查迅速診斷出血病灶，並可以有效率地治療出血處。然而少有報告論及於重症病患或加護醫療之極重症病患若發生下消化道出血時，出血原因的分析，影響純存活的因素及大腸鏡檢查之必要性。本研究期待獲知於一所大學附設醫院暨醫學中心之內科因有合併症住院及加護病房內之極重症病患，急性下消化道出血之發生率、導致出血之主要病灶、以及出血後之臨床表現及影響，尤其強調大腸鏡檢查之角色。
本研究所使用的方法及研究對象為自2000年6月至2003年12月止，此期間於中山醫學大學附設醫院內科共計有3016名成年病患因下消化道出血而須接受大腸鏡檢查。首先，第一部分的研究乃針對住院病患之研究：於2001年元月至2003年12月間，中山醫學大學附設醫院內科共計有18,255名成年病患因病住院治療。而其中，總計有107名病患因發生顯著下消化道出血而須接受緊急大腸鏡檢查。此107名依照病患是否合併其他嚴重系統性疾病(comorbid diseases)區分為兩組(with comorbid diseases：61名；without comorbid diseases：46名)，分析比較兩組病人之致病(出血)原因及臨床表徵。
第二部分的研究為針對加護治療之極重症病患之研究。於2000年7月起至2003年6月間，計有5860名病患因病況危急而住進內科加護病房。其中有55名(0.92%)病患發生下消化道出血而須緊急進行床邊大腸鏡檢查。分別紀錄並分析病患之基本臨床生理數值、大腸鏡檢查之效率及診斷病灶、及病患之預後分析。
本研究所得到的結果是，第一部分的研究發現：全體病患之出血病灶檢出率為百分之78.5(84/107)，住院中死亡率為百分之 18.7(20/107)，患有合併症的病患顯著地需住院較久，失血及貧血之程度較嚴重，且所需要之輸血量亦較多，整體預後較差，死亡率亦較高(29.5%)。此組病患的出血原因較常導因於結腸炎及直腸潰瘍，而憩室及惡性腫瘤出血則顯著較少。因直腸潰瘍或腫瘤而出血之病患，需要較長的住院時間。且大部份罹患直腸潰瘍或結腸炎而引起下消化道出血之病患為加護病房內之極重症病患。
而在第二部分針對加護治療之極重症病患之研究中發現共有37名(67.3%)病患利用大腸鏡檢查發現出血病灶。病灶主要發生在左側大腸(78.4%)。常見之出血病灶依序為炎性病灶(缺血性、感染性、及放射性)、直腸潰瘍、腫瘤、及憩室性疾病。操作大腸鏡時並無發生相關嚴重併發症。整體住院中死亡率為52.7%(29/55)，而僅有兩名病患之死亡與出血有關。經多因子變項分析後發現雖經大腸鏡檢查後診斷出血病灶可降低死亡的風險，但於統計上並無顯著意義。僅有疾病的嚴重度亦即APACHE II　分數超過18者，為唯一顯著的致死危險因子。
本研究所獲得的結論為，首先，因其他合併症而住院之病患，若是住院後再發生急性下消化道出血，其出血的原因及出血後的臨床表徵，與單純只因嚴重下消化道出血而住院的病人相比，顯著有所不同。具合併症而住院之病患，常見的下消化道出血的原因為結腸炎、出血性直腸潰瘍、及血管異常增生；而較少發生憩室或腫瘤出血。其次對於極重症病患需加護醫療的病患，若發生急性下消化道出血，緊急大腸鏡檢查仍為一種安全且有效率之工具。病患原有之疾病嚴重度為影響其存活之唯一主要因素。然而，加護醫療重症病患常表現較低的自然止血率，常有較高的風險再出血，並具極高的死亡率。重症病患接受大腸鏡檢查，即使利用內視鏡治療止血，並無法顯著的因此增加病患的存活機會。真正影響病患存活的因素仍在於病患患病的嚴重性(APACHE II score)。因此，積極治療原有嚴重的疾病(underlying diseases)，改善病患的生理機能，並有效處理併發症，才真正有助於病患生命的延續。
明瞭本研究的結果，可以協助從事重症醫療的臨床醫師於治療重症病患，尤其是加護醫療之重症病患時，了解緊急大腸鏡檢查之潛在優點及極限，並且利用這些知識，期待能提供給病患傷害少卻最有利的治療方法，以增進病患之安全性。

關鍵字

重症病患，下消化道出血，合併症，大腸鏡

並列摘要

Background: Colonoscopy is usually first considered in massive lower astrointestinal (GI) bleeding because it is accessible in detecting the cause and is effective in treating the bleeding. Few studies have investigated the value of colonoscopy for patients with comorbid diseases, especially critically ill patients, acquired significant lower GI bleeding after admission to ward or intensive care units.
Aims: To get a clinical picture of the frequency, the etiology and the clinical impact of lower GI bleeding acquired by critically ill adults during their stay in the ward or intensive care units of an university-affiliated hospital in Taiwan.
Methods: (1). In the first study, we collect the data of hospitalized patients with acute lower gastrointestinal bleeding during their hospital stay. From January 2001 to December 2003, 107 hospitalized patients with acute lower gastrointestinal bleeding were evaluated by urgent colonoscopy. Our analyses compared the etiology and clinical characteristics of bleeding in patients with (Group A) and without (Group B) one or more comorbid illnesses.
(2). In the second study, we study the critically ill patients in intensive care units and try to emphasize the role of urgent colonoscopy in these patients. From July 1, 2000 to June 30, 2003, 55 (0.94%) out of 5860 patients admitted to ICU acquired during their stay in the ICU a lower GI bleeding that required a colonoscopy done on an emergency basis. The baseline characteristics, data on the maneuver (colonoscopy), diagnosis of bleeding lesion, and outcomes of patients were collected and analyzed.

Results: (1). In the first study, Group A patients (patients with comorbid diseases) tended to have longer hospital stays, more severe anemic conditions, and more transfusion requirements. The overall mortality rate was 29.5% in group A and 4.3% in group B (patients without comorbid disease) (p<0.05). Bleeding-related mortality was not significantly different between these two groups. Colitis, rectal ulcer, and angiodysplasia were the leading causes of lower gastrointestinal bleeding in group A. Rectal ulcer was a more common cause of bleeding in group A (16.4%) than in group B (2.1%) (p <0.05), and it resulted in longer hospital stays and more severe anemia and leukocytosis compared to patients with other causes of lower gastrointestinal bleeding.
(2). In the second study, the colonoscopy was successful in determining the source of bleeding in most patients (67.3%); its source was located in the left colon in most instances (78.4%). Colitis (ischemic, infectious or non-specific), rectal ulcers, tumors and diverticular diseases were the most frequent causes of bleeding. No serious adverse events happened during the colonoscopy. Overall in-hospital mortality was 52.7%, however, the bleeding was the immediate cause of death in only two patients. By employing multivariate regression analysis, we identified that an APACHE II score higher than 18 was the only independent predictor of mortality in our patients with lower GI bleeding after ICU admission. Neither endoscopic diagnosis nor therapeutic procedure by colonoscopy affected the final outcome.
Conclusions: Patients with acute LGI bleeding that starts after hospitalization of patients for other comorbid illnesses have distinctive etiologies and clinical characteristics compared with patients admitted to the hospital only for acute LGI bleeding. Colitis, hemorrhagic rectal ulcer, and angiodysplasia are the leading causes of LGI bleeding in patients with comorbid illnesses, while diverticular disease and carcinoma were significantly rare in these patients. Hemorrhagic rectal ulcer is an important but obscure cause of acute LGI bleeding in elderly patients with significant comorbid diseases. Bedsides, this study describes that the sources of lower GI bleeding in patients staying in ICUs are different from those in outpatients. Urgent colonoscopy in these patients is safe and has similar diagnostic accuracy and therapeutic capability. However, a lower rate of spontaneous cessation of bleeding, a higher rate of rebleeding, and an extremely high mortality rate in this population reflect the severe general condition of the underlying diseases. The APACHE II score, rather than whether a patient received a urgent colonoscopy, may better predict outcomes in this high-risk population. Knowledge of these data may help critical care clinicians estimate the potential benefits or hazards of urgent colonoscopy in critically ill patients and make the most advantageous clinical decision.

並列關鍵字

critically ill, lower gastrointestinal bleeding, comorbid disease, colonoscopy

參考文獻

Beejay U, Wolfe MM. Acute gastrointestinal bleeding in the intensive care unit: The gastroenterologist’s perspective. Gastroenterol. Clin. North. Am. 2000; 29: 309-336.

Boley SJ, DiBiase A, Brandt LJ, Sammartano RJ. Lower intestinal bleeding in the elderly. Am J Surg 1979; 137: 57 64.

Bramley PN, Masson JW, McKnight G, et al. The role of an open-access bleeding unit in the management of colonic haemorrhage. A 2-year prospective study. Scand J Gastroenterol 1996; 31: 764 769.

Branicki FJ, Coleman SY, Lam TCF, et al: Hypotension and endoscopic stigmata of recent haemorrhage in bleeding peptic ulcer: Risk models for rebleeding and mortality. J Gastroenterol Hepatol 1992; 7: 184-190.

Brown RB, Klar J, Teres D, et al: Prospective study of clinical bleeding in intensive care unit patients. Crit Care Med 1988; 16: 1171-1176.