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危险性急性上消化道出血(acute upper gastrointestinal bleeding,AUGIB)是指在24 h内大量上消化道出血导致血流动力学异常、器官功能衰竭,起病急、进展快、严重者可危及生命,是消化内科常见的危急重症。此类疾病占消化道出血比例约为15%~20%,病死率高[1]。临床上有多种评估AUGIB预后的评分,但在危险性AUGIB应用方面研究较少,如何更好地运用不同危险评分系统评估高危AUGIB病人预后显得尤为重要[2]。本研究回顾性分析299例危险性AUGIB病人的临床资料,探讨不同内镜前评分系统对其预后评估价值。现作报道。
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本研究最终共纳入危险性AUGIB病人299例,其中男223例(74.58%),女76例(25.42%); 年龄20~97岁。院内或30 d内死亡43例(14.38%),存活256例(85.62%)。主要症状为呕血(66.22%)、黑便(85.95%)和晕厥(8.03%)。既往史:肝硬化病史(26.76%),消化性溃疡病史(7.69%),高血压病史(26.76%),恶性肿瘤病史(10.37%),糖尿病病史(10.37%),口服阿司匹林(10.03%)、非甾体消炎药(5.69%)。
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住院期间行胃镜检查236例(78.93%)。行胃镜检查病人病因方面排名前5位的是,十二指肠球部溃疡68例(28.81%),肝硬化并食管胃底静脉曲张破裂出血60例(25.42%),胃溃疡47例(19.92%),复合性溃疡13例(5.51%),胃恶性肿瘤12例(5.08%)。未行胃镜检查病人63例,根据既往病史推测肝硬化并食管胃底静脉曲张破裂出血23例(36.51%)。236例行胃镜检查病人中,行紧急胃镜0~12 h 48例(20.34%),13~24 h行胃镜检查45例(19.07%),24 h以后行胃镜检查143例(60.59%)。行紧急胃镜0~12 h的病人病死率高于行13~24 h和>24 h胃镜检查病人,差异有统计学意义(P < 0.05)(见表 1)。
检查时间 n 死亡 存活 病死率/% χ2 P 0~12 h 48 10 38 20.83 13~24 h
> 24 h45
1432
143
1424.44*
0.70*28.11 < 0.01 合计 236 13 223 5.51 χ2分割检验:与0~12 h组比较* P < 0.05 表 1 胃镜检查时间对危险性AUGIB病人死亡的影响(n)
首次胃镜即行内镜下治疗111例(47.03%),再出血行内镜下治疗12例(5.08%),内镜下治疗方式包括局部喷洒去甲肾上腺素23例(9.75%), 金属夹止血49例(20.76%), 黏膜下注射止血16例(6.78%), 套扎及硬化剂注射52例(22.03%),再出血数字减影血管造影术治疗3例(1.27%),再出血行手术治疗11例(4.66%)。
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死亡组43例,存活组256例,院内或30 d内死亡组病人AMIS65、Pre-Rocall的评分值均高于存活组,差异均有统计学意义(P < 0.01),2组GBS评分差异无统计学意义(P>0.05)(见表 2)。
分组 n GBS AMIS65 Pre-Rocall 院内或30 d内死亡组 43 11.67±2.86 2.49±1.03 3.67±1.63 院内或30 d内存活组 256 11.64±2.66 1.18±0.91 1.70±1.58 t — 0.07 8.57 7.53 P — > 0.05 < 0.01 < 0.01 院内或30 d内再出血组 58 11.53±2.61 2.03±0.96 2.91±1.91 院内或30 d内未再出血组 241 11.67±2.70 1.21±0.96 1.76±1.60 t — 0.37 5.84 4.73 P — > 0.05 < 0.01 < 0.01 表 2 院内或30 d内不同临床结局与GBS、AMIS65、Pre-Rocall评分的关系(x ± s; 分)
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再出血组58例,未再出血组241例,院内或30 d内再出血病人AMIS65、Pre-Rocall的评分值均高于未再出血组,差异均有统计学意义(P < 0.01),2组GBS评分差异无统计学意义(P>0.05)(见表 2)。
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在预测院内或30 d内死亡率方面,AMIS65、Pre-Rocall、GBS评分系统的AUC分别为0.820、0.812、0.516,最优的是AMIS65,其次为Pre-Rocall,但二者之间差异无统计学意义(Z=0.17,P>0.05)。在预测院内或30 d内再出血方面,AMIS65、Pre-Rocall、GBS评分系统的AUC分别为0.729、0.676、0.511,最优的是AMIS65,其次为Pre-Rocall,但二者之间差异无统计学意义(Z=1.28,P>0.05)。在预测输血方面,AMIS65、Pre-Rocall、GBS评分系统的AUC分别为0.709、0.591、0.646,最优的是AMIS65,其次为GBS,但二者之间差异无统计学意义(Z=1.61,P>0.05)(见表 3、图 1)。
评分项目 AUC 95% CI 院内或30 d内死亡 AMIS65 0.820 0.771~0.861 Pre-Rocall 0.812 0.763~0.854 GBS 0.516 0.458~0.574 院内/30 d内再出血 AMIS65 0.729 0.675~0.778 Pre-Rocall 0.676 0.620~0.729 GBS 0.511 0.453~0.569 输血 AMIS65 0.709 0.654~0.759 Pre-Rocall 0.591 0.533~0.647 GBS 0.646 0.589~0.700 表 3 AIMS65评分、GBS评分、Pre-Rockall评分的AUC
三种内镜前评分系统对危险性急性上消化道出血预后评估的比较
Comparison of three pre-endoscopic scoring systems for prognosis evaluation of high risk acute upper gastrointestinal bleeding
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摘要:
目的探讨三种内镜前评分系统AIMS65、Glasgow-Blachford(GBS)及Pre-Rockall在危险性急性上消化道出血(AUGIB)病人预后中的评估价值。 方法回顾性分析299例危险性AUGIB病人的临床资料,回顾诊断及治疗结局。以院内死亡或30 d内死亡、再出血为终点指标,绘制ROC曲线,比较曲线下面积(AUC),评估三种评分系统对预后的评估价值。 结果299例危险性AUGIB病人,行紧急胃镜(0~12 h)的病人病死率高于行13~24 h和>24 h胃镜检查病人,差异存在统计学意义(P < 0.05)。在预测院内死亡/30 d内死亡率方面,AMIS65、Pre-Rocall、GBS评分系统的AUC分别为0.820、0.812、0.516,其中AMIS65最优,其次为Pre-Rocall,二种评分系统能力相当(P>0.05)。在预测院内/30 d内再出血方面,AMIS65、Pre-Rocall、GBS评分系统的AUC分别为0.729、0.676、0.511,其中AMIS65最优,其次为Pre-Rocall,二种评分系统能力相当(P>0.05)。在预测输血方面,AMIS65、Pre-Rocall、GBS评分系统的AUC分别为0.709、0.591、0.646,其中AMIS65最优,其次为GBS,二种评分系统能力相当(P>0.05)。 结论AIMS65、Pre-Rockall能准确预测病人死亡率及再出血率,适用于危险性AUGIB的内镜前风险评估。 -
关键词:
- 急性上消化道出血 /
- AIMS65评分 /
- Pre-Rockall评分 /
- Glasgow-Blachford评分
Abstract:ObjectiveTo explore the prognostic value of three pre-endoscopic scoring systems AIMS65, Glasgow-Blachford(GBS) and Pre-Rockall in patients with high risk acute upper gastrointestinal bleeding(AUGIB). MethodsClinical data of 299 patients with high risk AUGIB were retrospectively analyzed, and the diagnosis and treatment outcome were reviewed.The death in hospital or death and rebleeding within 30 days were taken as the study endpoints.The ROC curve was draw, and area under the curve(AUC) was compared.Clinical values among the three scores were evaluated by ROC and AUC. ResultsThe mortality of patients undergoing emergency gastroscopy in 0-12 h was higher than patients undergoing emergency gastroscopy in 13-24 h and >24 h(P < 0.05).In predicting in-hospital death or 30-day mortality, the AUC of AMIS65, Pre-Rocall and GBS were 0.820, 0.812 and 0.516, respectively, the AMIS65 was best, followed by Pre-Rocall, there were no significant differences between the two scored(P>0.05).In predicting in-hospital or 30-day rebleeding, the AUC of AMIS65, Pre-Rocall and GBS were 0.729, 0.676 and 0.511, respectively, the AMIS65 was best, followed by Pre-Rocall, there were no significant differences between the two scored(P>0.05).In predicting blood transfusion, the AUC of AMIS65, Pre-Rocall and GBS were 0.709, 0.591 and 0.646, respectively, the AMIS65 was best, followed by GBS, there were no significant differences between the two scored(P>0.05). ConclusionsAIMS65 and Pre-Rockall can accurately predict the mortality rate and rebleeding rate of patients, which are suitable for pre-endoscopic assessment of high risk AUGIB. -
Key words:
- acute upper gastrointestinal bleeding /
- AIMS65 /
- Pre-Rockall /
- Glasgow-Blachford
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表 1 胃镜检查时间对危险性AUGIB病人死亡的影响(n)
检查时间 n 死亡 存活 病死率/% χ2 P 0~12 h 48 10 38 20.83 13~24 h
> 24 h45
1432
143
1424.44*
0.70*28.11 < 0.01 合计 236 13 223 5.51 χ2分割检验:与0~12 h组比较* P < 0.05 表 2 院内或30 d内不同临床结局与GBS、AMIS65、Pre-Rocall评分的关系(x ± s; 分)
分组 n GBS AMIS65 Pre-Rocall 院内或30 d内死亡组 43 11.67±2.86 2.49±1.03 3.67±1.63 院内或30 d内存活组 256 11.64±2.66 1.18±0.91 1.70±1.58 t — 0.07 8.57 7.53 P — > 0.05 < 0.01 < 0.01 院内或30 d内再出血组 58 11.53±2.61 2.03±0.96 2.91±1.91 院内或30 d内未再出血组 241 11.67±2.70 1.21±0.96 1.76±1.60 t — 0.37 5.84 4.73 P — > 0.05 < 0.01 < 0.01 表 3 AIMS65评分、GBS评分、Pre-Rockall评分的AUC
评分项目 AUC 95% CI 院内或30 d内死亡 AMIS65 0.820 0.771~0.861 Pre-Rocall 0.812 0.763~0.854 GBS 0.516 0.458~0.574 院内/30 d内再出血 AMIS65 0.729 0.675~0.778 Pre-Rocall 0.676 0.620~0.729 GBS 0.511 0.453~0.569 输血 AMIS65 0.709 0.654~0.759 Pre-Rocall 0.591 0.533~0.647 GBS 0.646 0.589~0.700 -
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