Effect of timing of endoscopy on clinical outcomes in patients with acute nonvaricose upper gastrointestinal bleeding
-
摘要: 目的 评估不同出血严重程度的非静脉曲张性上消化道出血(ANVUGIB)患者行紧急内镜检查与非紧急内镜检查的临床结局。方法 回顾性分析2017年1月-2022年4月在宿迁市第一人民医院经内镜检查确诊为ANVUGIB的382例患者的病例资料。从患者的病历和内镜检查记录中采集患者的人口社会学、临床和实验室检查数据。格拉斯哥-布拉奇福德出血评分(GBS) < 12分的患者视为低风险(n=240), GBS≥12分为高风险(n=121)。紧急内镜检查定义为自入院到内镜检查的时间 < 12 h, 非紧急内镜检查为自入院到内镜检查时间≥12 h。综合结局包括发生以下1项或以上的事件: 住院期间全因死亡、住院期间再出血、输血、以止血为目的的手术、介入放射学干预或内镜再干预。采用多因素logistic回归分析考察不同的内镜检查时间对综合结局的影响。结果 97例(25.4%)患者接受了紧急内镜检查, 285例(74.6%)接受了非紧急内镜检查。紧急内镜检查组患者发生再出血、以止血为目的的手术、介入放射学干预、内镜再干预、需要输血的比例高于非紧急内镜检查组。在多因素分析中, 紧急内镜检查患者发生综合结局的风险是非紧急内镜检查患者的5倍以上(OR=5.60, 95%CI: 2.80~11.40, P < 0.001)。分层分析结果发现, 在低风险患者中, 紧急内镜检查患者发生综合结局的风险是非紧急内镜检查患者的7倍以上(OR=7.20, 95%CI: 3.40~13.40, P < 0.001)。而在高风险患者中, 紧急内镜检查不是患者发生综合结局的危险因素(OR=2.88, 95%CI: 0.78~11.33, P=0.138)。结论 入院12 h内实施镜检可使高风险ANVUGIB患者获益, 低风险ANVUGIB患者不宜在入院12 h内实施镜检。
-
关键词:
- 急性非静脉曲张性上消化道出血 /
- 内镜检查 /
- 临床结局
Abstract: Objective To evaluate the clinical outcomes of acute nonvaricose upper gastrointestinal bleeding (ANVUGIB) patients with different bleeding severity undergoing urgent endoscopy and non-urgent endoscopy.Methods The medical records of 382 patients diagnosed with ANVUGIB by endoscopy in our hospital from January 2017 to April 2022 were retrospectively analyzed.Demographic, sociological, clinical and laboratory data were collected from the patient's medical and endoscopic records.Patients with GBS < 12 were considered as low risk (n=240), and patients with GBS ≥12 were considered high risk (n=121).Urgent endoscopy was defined as the time from admission to endoscopy < 12 h, and non-urgent endoscopy was defined as the time from admission to endoscopy ≥12 h.The composite outcome included the occurrence of one or more of the following events: in-hospital death from any cause, in-hospital rebleeding, blood transfusion, surgery for hemostasis, interventional radiological intervention, or endoscopic reintervention.Multivariate logistic regression analysis was used to investigate the effect of different endoscopy time on the comprehensive outcome.Results Ninety-seven patients (25.4%) underwent urgent endoscopy and 285 patients (74.6%) underwent non-urgent endoscopy.The proportion of rebleeding, surgery for hemostasis, interventional radiology intervention or endoscopic reintervention, and blood transfusion in the urgent endoscopy group were higher than those in the non-urgent endoscopy group.In multivariate analysis, patients with urgent endoscopy had a more than 5-fold higher risk of composite outcome than patients with non-urgent endoscopy (OR=5.60, 95%CI: 2.80-11.40, P < 0.001).Stratified analysis showed that among low-risk patients, the risk of composite outcome was more than 7 times higher in patients with urgent endoscopy than in patients with non-urgent endoscopy (OR=7.20, 95%CI: 3.40-13.40, P < 0.001).In high-risk patients, urgent endoscopy was not a risk factor for overall outcome (OR=2.88, 95%CI: 0.78-11.33, P=0.138).Conclusion Endoscopic examination within 12 hours after admission can benefit patients with high-risk ANVUGIB, while patients with low-risk ANVUGIB should not undergo endoscopic examination within 12 hours after admission. -
-
表 1 2组患者的一般资料比较
X±S，M(P25，P75)，例(%) 特征 紧急内镜检查组(n=97) 非紧急内镜检查组(n=285) χ2/Z/t P 年龄/岁 63.3±16.5 64.7±15.8 0.745 0.456 性别 0.272 0.602 男 53(54.6) 147(51.6) 女 44(45.4) 138(48.4) 服用抗凝药物 0.154 0.695 是 6(6.2) 21(7.4) 否 91(93.8) 264(92.6) 服用非甾体类抗炎药 0.129 0.719 是 20(20.6) 54(18.9) 否 77(79.4) 231(81.1) CCI 2(1.0，3.0) 2(1.0，4.0) 0.895 0.153 入院收缩压/mmHga) 6.261 0.012 < 100 17(18.5) 24(8.4) ≥100 75(81.5) 261(91.6) 入院心率/(次·min-1) 82.55±19.11 79.67±21.34 血小板计数/(×109·L-1) 2.295 0.130 < 100 12(12.4) 21(7.4) ≥100 85(87.6) 264(92.6) 血红蛋白/(g·L-1) 0.206 0.650 ≤100 10(10.3) 25(8.8) >100 87(89.7) 260(91.2) INR 1.2(1.1，1.3) 1.1(1.0，1.3) 0.456 0.521 AIMS65评分 1.3±0.5 1.0±0.3 7.067 < 0.001 GBS评分 10.5±3.2 9.1±3.1 3.810 < 0.001 临床症状 2.007 0.367 呕血 16(16.5) 42(14.7) 黑便 41(42.3) 144(50.5) 呕血+黑便 40(41.2) 99(34.8) 出血原因 0.214 0.782 十二指肠溃疡 39(40.2) 121(42.5) 胃溃疡 20(20.6) 52(18.2) 急性胃黏膜病变 15(15.5) 48(16.8) 肿瘤 10(10.3) 32(11.2) 食管贲门黏膜撕裂综合征 8(8.2) 19(6.7) 其他 5(5.2) 13(4.6) 发病至就诊时间/h 6.35±2.11 7.11±2.65 2.561 0.011 内镜检查时间/h 5.5(4.2，10.9) 18.1(15.5，22.5) 45.223 < 0.001 主要综合结局 22(22.7) 15(5.3) 25.097 < 0.001 住院期间死亡 4(4.1) 4(1.4) 2.612 1.061 住院期间再出血 10(10.3) 10(3.5) 6.746 0.009 以止血为目的的手术干预 4(4.1) 1(0.4) 7.975 0.005 介入放射学干预 5(5.2) 3(1.1) 5.939 0.015 内镜再干预 9(9.3) 4(1.4) 13.652 < 0.001 注：a)1 mmHg=0.133 kPa；INR：国际标准化比值。 
下载: 导出CSV
表 2 综合结局预测因素的单因素和多因素分析
因素 单因素分析 多因素分析 OR(95%CI) P OR(95%CI) P 年龄/岁 1.08(0.78~1.21) 0.825 男性 0.90(0.46~1.78) 0.759 发病至就诊时间 1.11(0.74~4.33) 0.742 服用非甾体类抗炎药 1.66(0.33~1.36) 0.266 服用抗凝药物 0.19(0.02~1.40) 0.102 血红蛋白≤100g/L 1.80(0.60~2.14) 0.656 CCI 1.10(0.96~1.26) 0.166 收缩压 < 100mmHg 1.78(1.67~1.90) 0.001 1.82(1.70~1.95) 0.008 心率(每增加10次/min) 1.17(0.99~1.38) 0.072 血小板计数(< 100×109/L) 1.00(1.00~1.00) 0.507 INR 0.97(0.75~1.26) 0.840 AIMS65评分 1.68(1.21~2.32) 0.002 GBS评分 1.08(0.99~1.17) 0.093 紧急内镜检查 5.77(2.66~12.91) 0.002 5.60(2.80~11.40) < 0.001
下载: 导出CSV
表 3 低风险患者综合结局预测因素的单因素和多因素分析
因素 单因素分析 多因素分析 OR(95%CI) P OR(95%CI) P 年龄 0.92(0.71~1.20) 0.541 男性 1.11(0.47~2.64) 0.812 发病至就诊时间 1.09(0.67~4.32) 0.672 服用非甾体类抗炎药 1.37(0.45~2.83) 0.336 服用抗凝药物 1.78(0.56~5.67) 0.333 血红蛋白≤100 g/L 1.66(0.54~3.14) 0.674 CCI 1.17(0.99~1.39) 0.071 收缩压 < 100 mmHg 1.77(1.64~2.93) 0.006 1.84(1.69~3.96) 0.004 心率(每增加10次/min) 1.14(0.92~1.41) 0.221 血小板计数(< 100×109/L) 1.00(0.99~1.00 0.369 INR 1.20(0.91~1.58) 0.188 AIMS65 2.68(1.31~4.52) 0.005 3.14(1.70~5.80) < 0.001 紧急内镜检查 6.64(2.49~14.83) 0.001 7.20(3.40~13.40) < 0.001
下载: 导出CSV
表 4 高风险患者综合结局预测因素的单因素和多因素分析
因素 单因素分析 多因素分析 OR(95%CI) P OR(95%CI) P 年龄 1.09(0.72~1.67) 0.673 男性 0.63(0.21~1.95) 0.427 发病至就诊时间 1.13(0.87~3.67) 0.542 服用非甾体类抗炎药 1.06(0.76~4.54) 0.336 服用抗凝药物 0.20(0.02~1.58) 0.126 血红蛋白≤100 g/L 1.87(0.33~4.34) 0.690 CCI 0.98(0.78~1.24) 0.893 收缩压 < 100 mmHg 1.73(1.34~4.98) 0.035 1.72(1.32~3.99) 0.043 心率(每增加10次/min) 1.21(0.91~1.60) 0.194 血小板计数(< 100×109/L) 1.00(1.00~1.00) 0.865 INR 0.47(0.17~1.32) 0.153 AIMS65 2.68(1.31~4.52) 0.005 3.14(1.70~5.80) < 0.001 紧急内镜检查 3.94(0.88~10.13) 0.312 2.88(0.78~11.33) 0.138
下载: 导出CSV
-
[1] 中国医师协会内镜医师分会消化内镜专业委员会. 急性非静脉曲张性上消化道出血诊治指南(2018年, 杭州)[J]. 中华医学杂志, 2019, 99(8): 571-578. doi: 10.3760/cma.j.issn.0376-2491.2019.08.003
[2] Sung JJ, Chiu PW, Chan FKL, et al. Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018[J]. Gut, 2018, 67(10): 1757-1768. doi: 10.1136/gutjnl-2018-316276
[3] Gralnek IM, Stanley AJ, Morris AJ, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage(NVUGIH): European Society of Gastrointestinal Endoscopy(ESGE)Guideline-Update 2021[J]. Endoscopy, 2021, 53(3): 300-332. doi: 10.1055/a-1369-5274
[4] Fujishiro M, Iguchi M, Kakushima N, et al. Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding[J]. Dig Endosc, 2016, 28(4): 363-378. doi: 10.1111/den.12639
[5] Barkun AN, Almadi M, Kuipers EJ, et al. Management of nonvariceal upper gastrointestinal bleeding: guideline recommendations from the international consensus group[J]. Ann Intern Med, 2019, 171(11): 805-822. doi: 10.7326/M19-1795
[6] 孙寅力, 张振玉. 急性非静脉曲张性上消化道出血指南对比解读[J]. 胃肠病学, 2020, 25(7): 417-423. doi: 10.3969/j.issn.1008-7125.2020.07.008
[7] 中国医师协会急诊医师分会, 中华医学会急诊医学分会, 全军急救医学专业委员会, 等. 急性上消化道出血急诊诊治流程专家共识(2020版)[J]. 中华急诊医学杂志, 2021, 30(1): 15-24. https://www.cnki.com.cn/Article/CJFDTOTAL-ZJJY202101001.htm
[8] 奚黎婷, 朱锦舟, 杨奕, 等. 急性非静脉曲张性上消化道出血评分系统的研究进展[J]. 中国中西医结合消化杂志, 2020, 28(9): 726-730. doi: 10.3969/j.issn.1671-038X.2020.09.19
[9] Siau K, Ishaq S. Timing of endoscopy for acute upper gastrointestinal bleeding[J]. N Engl J Med, 2020, 383(4): e19. doi: 10.1056/NEJMc2014572
[10] 吴攀, 徐理茂, 黄长玉. 不同时机内镜诊治对急性非静脉曲张性上消化道出血主要综合结局的影响[J]. 临床和实验医学杂志, 2021, 20(17): 1841-1845. doi: 10.3969/j.issn.1671-4695.2021.17.015
[11] Alexandrino G, Domingues TD, Carvalho R, et al. Endoscopy timing in patients with acute upper gastrointestinal bleeding[J]. Clin Endosc, 2019, 52(1): 47-52. doi: 10.5946/ce.2018.093
[12] Ahmed HS, Lichtenstein DR. In high-risk patients with acute upper GI bleeding, urgent vs. early endoscopy did not differ for 30-day mortality[J]. Ann Intern Med, 2020, 173(4): JC19. doi: 10.7326/ACPJ202008180-019
[13] Tarar ZI, Zafar MU, Farooq U, et al. Does performing endoscopy sooner have an impact on outcomes in patients with acute nonvariceal upper gastrointestinal hemorrhage?A systematic review[J]. Cureus, 2021, 13(7): e16092.
[14] 孟庆志, 张月华, 王海舰, 等. 去甲肾上腺素、血凝酶联合质子泵抑制剂治疗对肝硬化合并上消化道出血患者血液流变学及外周血NO、ET的影响[J]. 中国中西医结合消化杂志, 2022, 30(2): 122-127. https://www.cnki.com.cn/Article/CJFDTOTAL-ZXPW202202009.htm
[15] 洪依萍, 韦炜, 丁进, 等. 超早期急诊胃镜在急性非静脉曲张性上消化道出血中的应用研究[J]. 胃肠病学, 2020, 25(10): 611-613. https://www.cnki.com.cn/Article/CJFDTOTAL-WIEC202010008.htm
[16] Guo CLT, Wong SH, Lau LHS, et al. Timing of endoscopy for acute upper gastrointestinal bleeding: a territory-wide cohort study[J]. Gut, 2022, 71(8): 1544-1550.
[17] Kim J, Gong EJ, Seo M, et al. Timing of endoscopy in patients with upper gastrointestinal bleeding[J]. Sci Rep, 2022, 12(1): 6833. doi: 10.1038/s41598-022-10897-3
[18] Guan JL, Han YY, Fang D, et al. Urgent endoscopy in nonvariceal upper gastrointestinal hemorrhage: a retrospective analysis[J]. Curr Med Sci, 2022, 42(4): 856-862.
[19] Merola E, Michielan A, de Pretis G. Optimal timing of endoscopy for acute upper gastrointestinal bleeding: a systematic review and meta-analysis[J]. Intern Emerg Med, 2021, 16(5): 1331-1340.
[20] Chaudhary S, Stanley AJ. Optimal timing of endoscopy in patients with acute upper gastrointestinal bleeding[J]. Best Pract Res Clin Gastroenterol, 2019, 42-43: 101618.
[21] Satılmış D, Yavuz BG, Güven O, et al. The effectiveness of Glasgow-Blatchford Score in early risk assessment of hemodialysis patients[J]. Intern Emerg Med, 2022, 17(3): 753-759.
[22] Ramaekers R, Mukarram M, Smith CAM, et al. The predictive value of preendoscopic risk scores to predict adverse outcomes in emergency department patients with upper gastrointestinal bleeding: a systematic review[J]. Acad Emerg Med, 2016, 23(11): 1218-1227.
-