Italian survey on non-steroidal anti-inflammatory drugs and gastrointestinal bleeding in children

AIM: To investigate gastrointestinal complications associated with non-steroidal anti-inflammatory drug(NSAIDs) use in children.METHODS: A retrospective, multicenter study was conducted between January 2005 and January 2013, with the participation of 8 Italian pediatric gastroenterology centers. We collected all the cases of patients who refer to emergency room for suspected gastrointestinal bleeding following NSAIDs consumption, and underwent endoscopic evaluation. Previous medical history, associated risk factors, symptoms and signs at presentation, diagnostic procedures, severity of bleeding and management of gastrointestinal bleeding were collected. In addition, data regarding type of drug used, indication, dose, duration of treatment and prescriber(physician or selfmedication) were examined. RESULTS: Fifty-one patients, including 34 males, were enrolled(median age: 7.8 years). Ibuprofen was the most used NSAID [35/51 patients(68.6%)]. Pain was the most frequent indication for NSAIDs use [29/51 patients(56.9%)]. Seven patients had positive family history of Helicobacter pylori(H. pylori) infection or peptic ulcer, and 12 had associated comorbidities. Twenty-four(47%) out of 51 patients used medication inappropriately. Hematemesis was the most frequent symptom(33.3%). Upper gastrointestinal endoscopy revealed gastric lesions in 32/51(62%) patients, duodenal lesions in 17(33%) and esophageal lesions in 8(15%). In 10/51(19.6%) patients, a diagnosis of H. pylori gastritis was made. Forty-eight(94%) patients underwent medical therapy, with spontaneous bleeding resolution, while in 3/51(6%) patients, an endoscopic hemostasis was needed.CONCLUSION: The data collected in this study confirms that adverse events with the involvement of the gastrointestinal tract secondary to NSAID use are also common in children     

经皮经肝曲张静脉栓塞治疗断流术后食管胃底静脉破裂出血的疗效

目的 研究以组织胶为主要栓塞材料,采用经皮经肝曲张静脉栓塞术(PTVE)治疗和预防门奇静脉断流术后食管胃底静脉曲张破裂出血的临床疗效.方法 2006年11月至2008年9月,对22例曾行断流术再发食管胃底静脉曲张破裂出血的患者行PTVE组织胶栓塞(n=10)或内镜下硬化剂(EIS,n=12)治疗,随访两组患者治疗后再出血率、死亡率、治疗前后静脉曲张和肝功能以及PTVE治疗组患者在曲张侧支静脉栓塞前后门静脉压力的变化.结果 ①在平均12.5个月的随访期内,PTVE治疗组患者再出血率和死亡率分别为1/10和0;EIS治疗组随访13.4个月,患者再出血率和死亡率分别为7/12和3/12,两组问差异有统计学意义(P<0.05).②PTVE和EIS治疗均可显著减轻食管和胃底静脉曲张程度.③对有门静脉血栓患者,PTVE联合门静脉球囊成形术,可以改善肝脏门静脉血供.④PTVE和EIS治疗均未加重肝功能损伤.结论 对门奇静脉断流术后食管胃底静脉破裂出血的患者,采用以组织胶为主要栓塞材料的PTVE治疗的疗效优于EIS治疗.     

内镜下套扎术预防肝硬化食管静脉曲张破裂出血的远期随访观察

目的 观察肝硬化食管静脉曲张患者分别行食管静脉曲张套扎术(endoscopic variceal ligation,EVL)和口服普萘洛尔后的再出血发生率、死亡率、治疗前后静脉曲张程度以及肝功能分级变化.方法 共纳入患者118例,其中66例采用EVL治疗,52例采用药物预防治疗.EVL 治疗组给予多次套扎,直到曲张静脉消失;药物治疗组给予普萘洛尔,起始剂量10 mg,每日2次,逐渐增至最大耐受剂量.对所有患者随访20个月,观察比较两组出血发生率和死亡率、治疗前后静脉曲张程度以及肝功能分级变化.结果 EVL治疗组有效随访58例,其问发生出血7例(12.1%),死亡2例(3.4%);药物治疗组有效随访46例,期间发生出血14例(30.4%),死亡6例(13.0%),两组间差异有统计学意义(P<0.05).EVL治疗组总静脉消失率为41.3%(24/58),药物治疗组46例曲张静脉均未消失;比较两组治疗前后肝功能未见明显变化(P>0.05).结论 与服用普萘洛尔相比,EVL能显著降低出血率、死亡率和静脉曲张程度,且对肝功能无明显损害作用.     

肝硬化食管静脉曲张破裂出血患者预后Cox回归分析

目的 探讨影响肝硬化食管静脉曲张破裂出血患者预后的危险因素.方法 对2000年1月-2006年12月因食管静脉曲张破裂出血首次住院且随访资料完整的肝硬化患者进行回顾性分析.预后以死亡为终点,随访时间截至2009年8月31日.记录患者入院时生命体征、实验室检查等结果,计算Child-Pugh评分和分级、终末期肝病模型(M...     

食管曲张静脉压力是预测肝硬化曲张静脉破裂出血的主要危险因素

目的:前瞻性研究影响肝硬化食管曲张静脉破裂出血的主要危险因素.方法:随访未发生过食管曲张静脉出血的57例肝硬化患者1年.采用内镜下无创性食管曲张静脉气囊测压仪检测曲张静脉压,研究终点为出现食管曲张静脉出血.研究食管曲张静脉内镜下表现、食管曲张静脉压力、肝功能分级、肝硬化病因及腹水指标与食管曲张静脉破裂出血的关系.结果:1年内34例(59.6%)患者发生首次食管曲张静脉破裂出血.单因素分析显示,食管曲张静脉压力(P=0.001)、曲张静脉直径(P=0.006)、内镜下红色征(P=0.012)与出血风险有关.进一步的多因素Logistic回归分析显示,食管曲张静脉压力是预测首次出血最主要的危险因子(OR=2.817,P=0.003),其受试者工作曲线(ROC)下面积为0.98.预测出血的食管曲张静脉压力截值为25.3 mm Hg(1 mm Hg=0.133 kPa),其敏感性与特异性均为91%.结论:食管曲张静脉压力是预测食管曲张静脉破裂出血的主要危险因素.     

Determinants of mortality in patients with cirrhosis and uncontrolled variceal bleeding

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经皮经肝食管胃底静脉栓塞断流术对肝功能的影响

目的探讨食管胃底静脉栓塞术（percutaneous transsplenic variceal embolization PTVE）治疗肝硬化门静脉高压性上消化道出血,对患者肝功能的影响。方法通过经肝经门静脉食管胃底静脉栓塞断流术治疗有食管胃底静脉曲张出血的肝硬化患者36例,对照组30例采用内科保守治疗,随访6个月的肝功能指标、Child-Pugh分级变化和出血复发率,进行对比。结果观察组的肝功能指标：ALB、TBil、PTA和NH3,与对照组对比P值分别为〈0.05、〈0.01、〈0.01和〈0.001;Chind-Pugh分级与对照组对比,P〈0.01,有显著性差异;观察组出血再发率也明显低于对照组,8.33%对26.7%,P〈0.05,两组对比显著性差异。结论食管胃底静脉栓塞断流术不仅能减少门静脉高压性上消化道出血复发率降低,同时能改善肝硬化患者的肝功能状况。     

Timing of upper gastrointestinal endoscopy does not influence short-term outcomes in patients with acute variceal bleeding

AIM To examine the association between the timing of endoscopy and the short-term outcomes of acute variceal bleeding in cirrhotic patients.METHODS This retrospective study included 274 consecutive patients admitted with acute esophageal variceal bleeding of two tertiary hospitals in Korea. We adjusted confounding factors using the Cox proportional hazards model and the inverse probability weighting(IPW) method. The primary outcome was the mortality of patients within 6 wk.RESULTS A total of 173 patients received urgent endoscopy(i.e., ≤ 12 h after admission), and 101 patients received nonurgent endoscopy( 12 h after admission). The 6-wk mortality rate was 22.5% in the urgent endoscopy group and 29.7% in the non-urgent endoscopy group, and there was no significant difference between the two groups before(P = 0.266) and after IPW(P = 0.639). The length of hospital stay was statistically different between the urgent group and non-urgent group(P = 0.033); however, there was no significant difference in the inhospital mortality rate between the two groups(8.1% vs 7.9%, P = 0.960). In multivariate analyses, timing of endoscopy was not associated with 6-wk mortality(hazard ratio, 1.297; 95% confidence interval, 0.806-2.089; P = 0.284).CONCLUSION In cirrhotic patients with acute variceal bleeding, the timing of endoscopy may be independent of short-term mortality.     

肝硬化食管胃静脉曲张破裂出血危险因素分析

目的 初步探讨可以评估肝硬化患者食管胃静脉曲张破裂出血风险的临床指标.方法 回顾性总结286例合并食管胃静脉曲张破裂出血的肝硬化患者(观察组)及352例未发生出血的肝硬化患者(对照组)的临床资料,对2组间存在差异性的指标运用单因素和多因素Logistic回归模型进行分析.结果 2组在肝功能分级状况(P＜0.05)、白蛋白(t=5.05,P=0.000)、凝血酶原时间(t=-2.80,P=0.005)、门静脉内径(t=-2.28,P=0.006)、脾厚度(t=-2.73,P=0.006)方面差异有统计学意义.单因素非条件Logistic回归分析显示白蛋白(OR=0.944,P=0.000)、凝血酶原时间(OR=1.067,P=0.007)、门静脉内径(OR=3.423,P=0.007)、脾厚度(OR=1.276,P=0.007)与出血存在相关性,进一步多因素非条件Logistic回归分析提示白蛋白(OR=0.936,P=0.000)、门静脉内径(OR=4.098,P=0.013)、脾厚度(OR=1.275,P=0.000)是出血的独立危险因素.结论 白蛋白、门静脉内径、脾厚度是肝硬化并发食管胃静脉曲张破裂出血的独立危险因素,对预测食管胃静脉曲张破裂出血的发生有重要的临床价值,改善白蛋白可在一定程度上减少肝硬化并发食管胃静脉曲张破裂出血的风险.     

内镜套扎术急症止血治疗肝硬化食管静脉曲张破裂出血的疗效观察

目的探讨食管静脉曲张破裂出血的内镜套扎术急诊止血的疗效及安全性。方法对52例乙型肝炎肝硬化食管静脉曲张破裂出血患者实施内镜下急诊套扎止血术,观察术中、术后并发症,并于术后1月复查胃镜观察食管曲张静脉消失情况。结果51例（98％）患者急诊止血成功,1例（2％）止血失败,表现为术后6天内反复便血,转外科手术治疗;术后1月复查胃镜见21例（41．2％）静脉曲张消失或基本消失,28例（54．9％）中上段食管静脉曲张基本消失,2例（3．9％）存在显著的静脉曲张。术后常见并发症有咽下不适、胸骨后隐痛、低至中度发热,发生率为15．9％,未发生严重的并发症。结论急诊套扎术治疗食管静脉曲张破裂出血疗效可靠、安全性高。     

Characteristics of hepatocellular carcinoma presenting with variceal bleeding

Patients with hepatocellular carcinoma may present with variceal bleeding as the initial symptoms. The aims of this study is to investigate the characteristics of such patients. A total of 1046 hepatocellular carcinoma cases were retrospectively retrieved from our computer records between 1980 and 1993. The medical records and image studies were reviewed. The status of each patient was assessed at the time of presentation. A total of 14 (about 1 %) patients with hepatocellular carcinoma presented with variceal bleeding. Five (36%) did not have past history of liver disease. The tumour size ranged from 2.5 to 11.3 cm. Compared with hepatocellular carcinoma patients not presenting with variceal bleeding, these patients had a higher percentage of portal vein thrombosis (57.1 vs 19.4%). In two patients, the hepatic tumours were missed in the initial abdominal sonography. The average survival time was 71 days. Seven patients died within 2 months mainly due to variceal bleeding (41.6%).Variceal bleeding might be a clue to the presence of hepatocellular carcinoma with portal vein thrombosis even in patients without a previous history of liver disease. The tumours in such patients might be the infiltrative type, and thus the portal vein should be carefully worked-up. Overall, these patients have an extremely poor prognosis. In the management of patients with variceal bleeding, the possibility of hepatocellular carcinoma with portal vein thrombosis should not be overlooked, especially in areas where this cancer is prevalent.     

肝硬化食管胃静脉曲张破裂出血的相关危险因素分析

目的探讨可以评估肝硬化患者食管胃静脉曲张破裂出血风险的临床指标。方法回顾性分析572例合并食管胃静脉曲张破裂出血的肝硬化患者(观察组)及704例未发生出血的肝硬化患者(对照组)的临床资料,对两组间存在差异性的指标运用单因素和多因素Logistic回归模型进行分析。结果两组在肝功能分级状况(P0.05)、血清白蛋白(t=5.05,P=0.000)、凝血酶原时间(t=-2.80,P=0.005)、门静脉内径(t=-2.28,P=0.006)、脾脏厚度(t=-2.73,P=0.006)方面比较,差异有统计学意义。单因素非条件Logistic回归分析显示白蛋白(OR=0.944,P=0.000)、凝血酶原时间(OR=1.067,P=0.007)、门静脉内径(OR=3.423,P=0.007)、脾脏厚度(OR=1.276,P=0.007)与出血存在相关性,进一步多因素非条件Logistic回归分析提示白蛋白(OR=0.936,P=0.000)、门静脉内径(OR=4.098,P=0.013)、脾脏厚度(OR=1.275,P=0.007)是出血的独立危险因素。结论白蛋白、门静脉内径、脾脏厚度是肝硬化并发食管胃静脉曲张破裂出血的独立危险因素,对预测食管胃静脉曲张破裂出血的发生有重要的临床价值,改善白蛋白可在一定程度上减少肝硬化并发食管胃静脉曲张破裂出血的风险。     

经皮经肝医用胶栓塞治疗肝硬化瘤样胃底静脉曲张临床观察

目的 评价以医用胶为栓塞剂的经皮经肝胃底曲张静脉栓塞术(PTVE)治疗和预防肝硬化患者瘤样胃底静脉曲张破裂出血的临床疗效.方法 回顾性分析24例采用医用TH胶完成PTVE治疗的肝硬化胃底静脉曲张破裂出血患者的病例资料,比较治疗前后胃底静脉曲张程度的变化情况,统计术后再出血率及死亡率.结果 治疗前24例患者胃底曲张静脉团直径均在20 mm以上,治疗后胃底静脉曲张程度显著减轻,其中20例(83.3％)曲张静脉团直径减至5 mm以下或消失,4例(16.7％)曲张静脉团直径减至5 ～10 mm.在术后1～36个月,平均16.6个月的随访期内,再出血率和病死率分别为12.5％和12.5％,其中l例死于肝癌,另外2例死于慢性肝功能衰竭.结论 对于肝硬化瘤样胃底静脉曲张破裂出血的患者,行医用胶为栓塞剂的PTVE治疗具有良好的临床效果.     

Gallbladder-duodenal fistula presenting with liver abscess and upper gastrointestinal bleeding

Background. Bilio-enteric communications leading to liver abscess formation are encountered rarely and are therefore not easily suspected by the attending physician. Case outline. A bilio-enteric communication involving the gallbladder and the duodenum presented as a septic event with upper gastrointestinal bleeding in a 71-year-old man who was wrongly thought to have undergone a previous cholecystectomy. A pyogenic bacterial liver abscess developed from the fistula in the absence of biliary obstruction. The patient was treated surgically with disconnection of the fistula and drainage of the abscess. Discussion. The liver abscess presumably arose as a consequence of contamination of the bile via the cholecysto-duodenal fistula. The previous operation is likely to have been a simple cholecystostomy.     

Comparison between endoscopic sclerotherapy and band ligation for hemostasis of acute variceal bleeding

AIM:To compare band ligation(BL) with endoscopic sclerotherapy(SCL) in patients admitted to an emergency unit for esophageal variceal rupture. METHODS:A prospective,randomized,single-center study without crossover was conducted.After endoscopic diagnosis of esophageal variceal rupture,patients were randomized into groups for SCL or BL treatment.Sclerotherapy was performed by ethanolamine oleate intravascular injection both above and below the rupture point,with a maximum volume of 20 mL.For BL patients,banding at the rupture point was attempted,followed by ligation of all variceal tissue of the distal esophagus.Primary outcomes for both groups were initial failure of bleeding control(5 d) ,early re-bleeding(5 d to 6 wk),and complications,including mortality.From May 2005 to May 2007,100 patients with variceal bleeding were enrolled in thestudy:50 SCL and 50 BL patients.No differences between groups were observed across gender,age,ChildPugh status,presence of shock at admission,mean hemoglobin levels,and variceal size. RESULTS:No differences were found between groups for bleeding control,early re-bleeding rates,complications,or mortality.After 6 wk,36(80%) SCL and 33(77 %) EBL patients were alive and free of bleeding.A statistically significant association between Child-Pugh status and mortality was found,with 16%mortality in Child A and B patients and 84%mortality in Child C patients(P<0.001) . CONCLUSION:Despite the limited number of patients included,our results suggest that SCL and BL are equally efficient for the control of acute variceal bleeding.     

肝硬化食管胃静脉曲张破裂出血的防治

食管胃静脉曲张破裂出血是肝硬化患者的严重并发症,病死率高,是最常见的消化系统急症之一。近年来,随着研究的深入,食管胃静脉曲张破裂出血的预防和治疗方法都有了一些新的进展,本文对此进行综述。     

经内镜栓塞术联合套扎术治疗食管胃底静脉曲张出血的疗效观察

目的探讨胃底静脉曲张栓塞术联合内镜下食管静脉曲张套扎术（EVL）治疗肝硬化上消化道出血的疗效。方法经急诊胃镜检查发现活动性胃底静脉曲张出血合并Ⅱ°以上食管静脉曲张且排除其他病因的上消化道出血患者共156例,分为治疗组和对照组,治疗组胃底静脉曲张组织粘合剂栓塞同时食管静脉EVL治疗;对照组胃底静脉曲张组织粘合剂栓塞治疗2个月后行食管静脉EVL。结果两组均未发生与治疗相关的并发症。止血成功率治疗组为96．3％（77／80）,对照组为97．4％（74／76）,（P〉0．05）;近期再出血率治疗组为6．4％（5／78）,对照组为21．3％（16／75）,两组差异有统计学意义（P〈0．05）;两组患者随访6个月,再出血率分别为13．0％（9／69）、25．4％（17／67）,差异有统计学性意义（P〈0．05）。胃底静脉曲张改善总有效率治疗组和对照组分别为61．6％、59．1％,食管曲张静脉改善总有效率为74．0％、67．9％,差异均无统计学意义。结论胃底静脉曲张栓塞联合EVL是治疗肝硬化胃底静脉曲张出血并食管静脉曲张的安全有效方法,同时联合治疗更能降低再出血率。     

64层螺旋CT门静脉造影对肝硬化患者肝功能分级和食管静脉曲张破裂出血的预测价值

目的：评价64层螺旋 CT 门静脉造影在肝硬化患者肝功能分级和食管静脉曲张破裂出血（EVB）预测中的临床价值。方法使用64层螺旋 CT 对64例肝硬化患者（消化道出血组30例、非出血组34例）及36例正常对照人群门静脉主干（MPV）、脾静脉（SPV）、胃左静脉（LGV）、肝内门静脉左支（IHLPV）和肝内门静脉右支（IHRPV）进行测量;应用受试者工作特征曲线下面积（AUC）评价上述各指标预测 EVB 的价值。结果肝硬化患者 MPV、SPV、LGV、IHLPV 和 IHRPV 直径分别为（1.68±0.21）cm、（1.45±0.18）cm、（0.53±0.12）cm、（1.21±0.15）cm 和（1.26±0.22）cm,显著高于对照组[分别为（1.18±0.14）cm、（0.80±0.09）cm、（0.42±0.07）cm、（0.95±0.07）cm 和（0.96±0.11）cm,P＜0.05];Child-Pugh C 级患者 MPV、SPV、LGV、IHLPV 和 IHRPV 直径分别为（2.01±0.20）cm、（1.57±0.10）cm、（0.59±0.11）cm、（1.36±0.09）cm 和（1.45±0.12）cm,显著高于 Child-Pugh A 级患者[分别为（1.68±0.15） cm、（1.35±0.13）cm、（0.48±0.09）cm、（1.11±0.13）cm 和（1.15±0.21）cm,P＜0.05];消化道出血患者 MPV、SPV、LGV 和 IHLPV 直径分别为（1.78±0.16）cm、（1.54±0.20）cm、（0.62±0.10）cm 和（1.28±0.15）cm,显著高于非出血患者[分别为（1.60±0.21）cm、（1.36±0.13）cm、（0.45±0.06）cm 和（1.15±0.13）cm,P＜0.05];出血患者 IHRPV 直径[（1.29±0.21）cm]与非出血患者[（1.25±0.23）cm]差异无统计学意义;LGV 的 AUC 为0.906。当 LGV＞0.61 cm 时,预测 EVB 的敏感度为93.3%,特异度为58.8%。结论64层螺旋 CT 门静脉造影能够清晰显示肝硬化门静脉高压侧支循环血管情况,并对预测 EVB 具有一定的临床应用价值。     

内镜套扎术在治疗食管静脉曲张破裂出血中的临床应用价值

目的探讨内镜下食管静脉曲张套扎术（EVL）治疗和预防肝硬化患者食管静脉曲张破裂出血的临床应用价值。方法回顾性分析2008-01～2012-01该院142例肝硬化食管静脉曲张破裂出血患者,其中行EVL治疗74例（治疗组）,内科保守治疗68例（对照组）,并对其临床疗效进行随访观察。结果所有患者随访6个月以上,治疗组的早期再出血率、迟发出血率、曲张静脉好转率、复发率、手术率及病死率均低于对照组（P〈0.05或〈0.01）。结论 EVL能有效地降低肝硬化门脉高压患者食管静脉曲张的程度,降低再出血率、复发率、手术率和病死率,是一种有效的内镜治疗手段。     

食管静脉曲张出血硬化治疗十三年回顾

目的评价食管静脉曲张出血硬化治疗疗效.方法对我院1987年4月至2000年5月行食管静脉曲张硬化治疗(EVS)的1010例门脉高压食管静脉曲张出血患者,进行回顾分析.肝硬化患者850例,肝癌160例,共行EVS3203例次,急诊602例次,择期2601例次,追加治疗502例次,710例肝硬化患者首次进行EVS(3.18±1.1)次,对579例肝硬化患者进行了3～157个月的随访,平均随访时间为(42.47±32.78)个月.肝硬化患者850例,其中治疗结束时706例行胃镜检查.结果1.全组急诊止血率为970%,治疗并发症为13.4%,死亡率为1.8%.2.肝硬化患者食管静脉曲张消失和基本消失率为84.1%,远期再发出血率为23.7%,生存率按Kaplan-Meier法计算,1、3、5、10年分别为(95.8±0.8)%、(86.1±1.6)%、(745±2.4)%和(53.6±3.8)%.结论EVS对食管静脉曲张出血仍是一重要治疗方法.