摘要
目的研究上消化道出血15年临床流行病学变化趋势。方法收集1997年1月1日至1998年12月31日与2012年1月1日至2013年12月31日中山大学附属第一医院内镜中心就诊的连续性上消化道出血患者的病例资料，对其性别、年龄、病因构成、溃疡分级、内镜治疗和住院期间病死率等变化趋势进行对比研究。结果1997-1998年和2012-2013年上消化道出血检出率分别为10．0％（928／9287）和4．5％（1092／24318）（X^2=360．089。P=0．000），1997-1998年和2012-2013年上消化道出血患者中男性比例分别为73．3％（680／928）和72．4％（791／1092，）（-0．179，P=0．672）；发病年龄分别为（47．3±16．4）岁和（51．4±18．2）岁（0=9．214，P=0．002）。上消化道出血病因构成：1997-1998年消化性溃疡以65．2％（605／928）居首位[十二指肠溃疡444例（47．8％），胃溃疡77例（8．3％），吻合口溃疡21例（2．3％），复合型溃疡63例（6．8％）]，其次为恶性肿瘤（7．0％，65／928），第3位为食管胃底静脉曲张（6．4％，59／928）；2012-2013年消化性溃疡以52．7％（575／1092）维持首位[十二指肠溃疡348例（31．9％），胃溃疡103例（9．4％），吻合口溃疡30例（2．7％），复合型溃疡94例（8．6％）]，但比例下降（X^2=32．467，P=0．000），其中十二指肠溃疡比例下降幅度最大（X^2=53．724，P=0．000）；食管胃底静脉曲张以15．1％（165／1092）上升至第2位（X^2=38．976，P=0．000），恶性肿瘤下降至第3位（9．2％，101／1092，X^2=3．352，P=0．067）。前3位病因的患者中，消化性溃疡出血患者出血年龄上升幅度最大[（46．2±16．7）岁比（51．9±18．9）岁，t=-5．548，P=0．000]，其中十二指肠溃疡贡献最大[（43．4±16．9）岁比（48．4±19．4）岁，t=-3．935，P=0．000]，食管胃底静脉曲张[（49．8±14．1）岁比（48．8±13．9）岁，t=0．458，P=0．648]和恶性肿瘤[（58．4±13．4）岁比（58．9±16．7）岁，t=-0．196，P=0．845]的出血年龄变化均较小。与1997-1998年相比，2012-2013年患者高危再出血消化性溃疡（Forrest分级Ⅰa、Ⅰb、Ⅱa和Ⅱb）检出率增加（X^2=39．958，P=0．000）。1997-1998年接受内镜治疗患者54例，内镜止血率为79．6％（43／54）；2012-2013年接受内镜治疗患者261例，内镜止血率为96．9％（253／261），差异有统计学意义（X^2=23．287，P=0．000）。与1997-1998年相比，2012-2013年更多的静脉曲张及非静脉曲张出血患者得到及时的内镜治疗（静脉曲张出血：39．0％比70．3％，X^251．930，P=0．000；非静脉曲张出血：3．6％比15．6％，X^2=62．292，P=0．000），其中消化性溃疡（Forrest分级Ⅰa、Ⅰb、Ⅱa和Ⅱb）的内镜治疗比例也增加[27．4％（26／95）比68．5％（111／162），X^2=40．739，P=0．000]；内镜治疗止血技术上更多应用了热凝法（0比15．2％，X^2=79．518，P=0．000）、止血法（0比55．9％，X^2=20．879，P=0．000）和联合法（4．3％比16．4％，X^2=5．154，P=0．023），减少注射法的单独应用（87．1％比6．2％，X2=10．420，P=0．001），完全摒弃了单独以喷洒法止血。2012-2013年住院患者再手术率下降[9．3％（86／928）比6．0％（65／1092），X^2=7．970，P=0．005]，住院期间病死率变化差异无统计学意义。结论1997-2013年上消化道出血发病年龄呈上升趋势：消化性溃疡出血比例下降，主要是十二指肠溃疡出血减少；高危消化性溃疡再出血检出率增加；上消化道出血的内镜治疗率更高，治疗措施更合理，即时止血效果更好；总体病死率无明显下降。
Objective To investigate the clinical epidemiology change trend of upper gastrointestinal bleeding （UGIB） over the past 15 years. Methods Consecutive patients who was diagnosed as continuous UGIB in the endoscopy center of The First Affiliated Hospital of Sun-Yat University during the period fi＇om 1 January 1997 to 31 December 1998 and the period from 1 Janual7 2012 to 31 December 2013 were enrolled in this study. Their gender, age, etiology, ulcer classification, endoscopic treatment and hospitalization mortality were compared between two periods. Results In periods from 1997 to 1998 and 2012 to 2013, the detection rate of UGIB was 9.99%（928/9 287） and 4.49% （1 092/24 318）（X^2= 360.089, P = 0.000） ; the percentage of male patients was 73.28% （680/ 928） and 72.44% （791/1 092） （X^2=0.179, P=0.672）, and the onset age was （47.3 ± 16.4） years and （51.4 ± 18.2） years （t = 9.214, P = 0.002） respectively. From 1997 to 1998, the first etiology of UGIB was peptic ulcer bleeding, accounting for 65.2% （605/928）[duodenal ulcer 47.8% （444/928）, gastric ulcer 8.3%（77/928）, stomal ulcer 2.3%（21/928）, compound ulcer 6.8%（63/928）] ,the second was cancer bleeding（7.0%,65/928）, and the third was esophageal and gastric varices bleeding （6.4%, 59/928）. From 2012 to 2013, peptic ulcer still was the first cause of UGIB, but the ratio obviously decreased to 52.7%（575/1092）（X^2= 32.467, P = 0.000）[duodenal ulcer 31.9%（348/1092）, gastric ulcer 9.4% （103/1092）, stomal ulcer 2.8% （30/1092）, compound ulcer 8.6%（94/1092） ]. The decreased ratio of duodenal ulcer bleeding was the main reason （X^2=53.724, P = 0.000）. Esophageal and gastric varices bleeding became the second cause （15.1%, 165/1 092, X^2= 38.976, P = 0.000）, and cancer was the third cause （9.2%, 101/1 092, X^2= 3.352, P = 0.067）. The largest increasing amplitude of the onset age was peptic ulcer bleeding [（46.2 ± 16.7） years vs. （51.9 ± 18.9） years, t=-5.548, P = 0.000）, and the greatest contribution to the amplitude was duodenal ulcer bleeding [（43.4 ± 15.9） years vs. （48.4 ± 19.4） years, t = -3.935, P = 0.0001, while the onset age of esophageal and gastric varices bleeding [（49.8 ± 14.1） years vs. （48.8 ± 13.9） years, t = 0.458, P = 0.6481 and cancer [（58.4 ± 13.4） years vs. （58.9 ± 16.7） years, t=-0.196, P = 0.845] did not change significantly. Compared with the period from 1997 to 1998, the detection rate of high risk peptic ulcer rebleeding （Forrest stageⅠ a, Ⅰ h, Ⅱa and lib） increased （X^2=39.958, P =0.000） in the period from 2012 to 2013. From 1997 to 1998, 54 patients underwent endoscopic treatment, and the achievement ratio of hemostasis was 79.6% （43/54）. From 2012 to 2013, 261 patients underwent endoscopic treatment and the achievement ratio of hemostasis was 96.9% （253/261）, which was significantly higher （X^2 = 23.287, P = 0.000）. Compared to the period from 1997 to 1998, more patients with variceal bleeding or non-variceal bleeding received endoscopic treatment in time （39.0% vs. 70.3%, X^2=51.930, P= 0.000; 3.6% vs. 15.6%, X^2=62.292, P = 0.000, respectively）, and higher ratio of patients staging Forrest stage Ⅰa to Ⅱ h also received endoscopic treatment in the period from 2012 to 2013 [27.4% （26/95） vs. 68.5% （111/162）, X^2= 40.739, P = 0.0001. More qualified endoscopic hemostatic techniques were used, containing thermocoagulation （0 vs. 15.2%, ±2=79.518, P = 0.000）, hcmostatic clip （0 vs. 55.9% , X^2 = 20.879, P = 0.000）, hemostatic clip combined with thermocoagulation （4.3% vs. 16.4%, X^2 = 5.154, P = 0.023）, while less single injection was used （87.1% vs. 6.2%, X^2= 10.420, P = O.001）, and single spraying for hemostasis was completely abandoned in the period from 2012 to 2013. The ratio of inpatients undergoing reoperation decreased obviously in the period from 2012 to 2013 [9.3%（86/928） vs. 6.0%（65/1092）, X^2=7.970, P = 0.0051, while no significant difference was found in mortality during hospitalization between two periods. Conclusion Compared with the period from 1997 to1998, the mean onset age of UGIB increased, and the ratio of peptic ulcer bleeding decreased due to the reduction of duodenal ulcer bleeding, the detection rate of high risk peptic ulcer rebleeding increased, the cure rate of endoscopic treatment for UGIB increased, more reasonable and immediate hemostatic methods were used, but overall mortality did not change obviously in the period from 2012 to 2013.
出处
《中华胃肠外科杂志》
CAS
CSCD
北大核心
2017年第4期425-431,共7页
Chinese Journal of Gastrointestinal Surgery
关键词
上消化道出血:病因
治疗
Upper gastrointestinal bleeding
Etiology
Treatment
