【作者】 杨波；

【导师】 毛高平；

【作者基本信息】 大连医科大学 ， 内科学， 2015， 硕士

【摘要】 目的:90%以上的消化道出血可通过常规消化内镜(胃镜和结肠镜)检查明确诊断,但是仍有5%-10%的消化道出血经上述检查不能明确病因,临床上称之为不明原因消化道出血或隐匿性消化道出血(obscure gastrointestinal blooding,OGIB),其中约75%发生于常规胃肠镜检查无法到达的小肠部分。双气囊小肠镜(double-balloon endoscope,DBE)是近年来临床上用于小肠疾病诊治的一项重要的新技术,DBE的应用对于OGIB的定位及定性诊断具有重要意义。本研究旨在从多个角度探讨DBE在诊断OGIB的临床应用价值。材料和方法:本研究回顾性分析了从2007年1月至2013年12月诊断为OGIB的131例患者的临床资料。入选病例:有消化道出血临床表现(黑便或便血),在我院或其他三甲医院至少做过一次胃镜或结肠镜检查不能明确病因的诊断为OGIB者,对无明显出血症状的患者,有反复便潜血试验阳性和(或)血色素下降临床怀疑为小肠出血者。根据患者的临床症状及其检查结果将其分为三组:活动性出血组68例(A组)、既往显性出血组52例(B组)和隐性出血组11例(C组)。统计DBE在A组、B组和C组的不同诊断率,并且比较DBE与全消化道钡餐、腹部CT及胶囊内镜(capsule endoscopy,CE)对OGIB的诊断价值。观察DBE检查的耐受性和并发症,并评价其安全性。结果:131例患者共行160例次DBE检查,经口检查83例次,经肛检查77例次,检查成功率分别为98.8%(82/83)和96.1%(74/77)。DBE对OGIB的诊断率为82.4%(108/131)。病变最常见的类型分别为溃疡病变、肿瘤病变、憩室病变、血管病变。病变部位以回肠多见。DBE在活动性出血组、既往显性出血组和隐性出血组中诊断率分别为91.2%(62/68)、75.0%(39/52)、63.6%(7/11),三组间的诊断率有统计学意义(X2=8.261,P<0.05)。DBE在活动性出血组中诊断率与既往显性出血组和隐性出血组相比有统计学意义,而活动性出血组的诊断率明显较高(X2AB=5.786,P<0.05;X2AC=6.495,P<0.05),DBE诊断率在既往显性出血组和隐性出血组无明显差别(X2BC=0.595,P>0.05)。13例行全消化道钡餐和DBE检查的患者,其钡餐诊断率为30.8%(4/13),DBE诊断率为76.9%(10/13),明显高于全消化道钡餐,两者之间有统计学意义(X2=4.167,P<0.05)。25例先后经腹部CT和DBE检查的OGIB病人中,腹部CT诊断率为20.0%(5/25),DBE诊断率为84.0%(21/25),DBE检查诊断率明显高于腹部CT,两者之间有统计学意义(X2=14.063,P<0.05)。23例先后经CE和DBE检查的OGIB病人中,CE断率为47.8%(11/23),DBE诊断率为69.6%(16/23),无明显差别,两者之间无统计学意义(X2=1.455,P>0.05)。根据Pennazio等[1]在CE对OGIB患者的诊断价值分析的模型,我们用真阳性率、真阴性率、假阳性率、假阴性率来评价DBE对OGIB病因的诊断价值。分为以下四个方面:1、真阳性率99.1%,2、真阴性率50.0%,3、假阳性率98.1%,4、假阴性率66.7%。少部分患者行DBE检查后出现恶心、腹痛等症状,接受DBE检查的全部病例无严重并发症(如急性胰腺炎、消化道穿孔及出血等)发生。68例患者接受随访,随访患者接受手术、药物及对症治疗,其中17例患者发生再次出血,再出血率为25.0%。结论:1.DBE检查对OGIB是一种重要检查手段,诊断率和病因诊断率高。2.DBE检查与全消化道钡餐造影及腹部CT比较具有较高的诊断价值,与CE比较诊断率无明显差异。3.DBE对部分出血病变可进行镜下活检及治疗。4.DBE检查过程安全,耐受性好,严重并发症发生率低。更多还原

【Abstract】 Objective: More than 90% of gastrointestinal bleeding can be checked to confirm the diagnosis by conventional gastrointestinal endoscopy(gastroscopy and colonoscopy), but there are still 5%-10% of gastrointestinal bleeding after the examination is not a clear cause, known clinically obscure gastrointestinal blooding(OGIB), of which about 75%occurred in the conventional gastrointestinal endoscopy inaccessible part of the small intestine. Double-balloon endoscope(DBE) is a more and more important new technology for clinical diagnosis and treatment in recent years, DBE application OGIB diagnosis is important for the localization and characterization. This study was designed to investigate the DBE in the diagnosis of clinical value for OGIB from multiple angles.Materials and methods: This study retrospectively analyzed from 2007 January to 2013 December in diagnosis for the clinical data of 131 cases of OGIB patients. Inclusion criteria: diagnosis in our hospital or other same level at least for a gastrointestinal endoscopy cannot clear etiology for OGIB patients, without obvious bleeding symptoms, at least a fecal occult blood test positive and(or) the decline of hemoglobin. According to the clinical symptoms and examination of the patient’s results will be divided into three groups, respectively for the hemorrhagic activity group68 cases(group A), 52 cases of previous dominant hemorrhage group(group B) and 11 patients with recessive bleeding group(group C). Statistical DBE in different diagnosis of A group, B group and C group rate, and the comparison between DBE and gastrointestinal barium meal, abdominal CT and capsule endoscopy(CE) value in the diagnosis of OGIB. Observe the tolerance and complications of DBE, check and evaluate its safety.Results: Through the analysis of the clinical data, the 131 patients of OGIB were divided into three groups: 68 cases of active overt bleeding group,52 cases of previous overt bleeding group and 11 cases of occult bleeding group, a total of 131 patients were 160 times of DBE examination, oral examination 83 times, 77 times by rectal examination, check the success rate was 98.8%(82/83) and 96.1%(74/77). DBE diagnosis rate of OGIB was82.4%(108/131). The most common type of lesions were the ulcerative lesions,tumors, vascular lesions and diverticulum lesions, lesions locate in the ileum normally. The diagnosis rate of DBE in the active hemorrhage group,previously dominant hemorrhage group and occult bleeding group was 91.2%(62/68), 75%(39/52), 63.6%(7/11), the rate of diagnosis between the three groups was statistically significant(X2=8.261, P < 0.05). The diagnosis rate of DBE in the active bleeding group compared with previous dominant hemorrhage group and occult bleeding group had statistical significance,active hemorrhage group, in the diagnosis rate was significantly higher(X2AB=5.786, P < 0.05; X2AC=6.495, P < 0.05), the diagnostic rate of DBE in the previous dominant hemorrhage group and recessive hemorrhage group showed no significant difference(X2BC=0.595, P > 0.05). 13 cases of gastrointestinal barium meal and DBE examination of patients, the barium meal diagnosis rate is 30.8%(4/13), the diagnostic rate of DBE was 76.9%(10/13), significantly higher than that in the whole gastrointestinal barium meal, both have statistical significance(X2=4.167, P < 0.05). 25 cases of OGIB patients were examined by abdominal CT and DBE successively,the diagnosis of abdominal CT rate was 20%(5/25), the diagnostic rate of DBE was 84%(21/25), significantly higher than the CT of the abdomen, both have statistical significance(X2=14.063,P < 0.05). In 23 cases of OGIB patients after CE and DBE examination, CE fault rate was 47.8%(11/23),the diagnostic rate of DBE was 69.6%(16/23), no significant difference between them, no statistical significance(X2=1.455,P > 0.05). According to the Pennazio[1]the model in the diagnostic value of CE analysis OGIB patients, and we decided to use the true positive rate and the true negative rate, false positive rate and false negative rate to evaluate the diagnostic value of DBE for OGIB. Dividing into the following four aspects: 1, the true positive rate of 99.1%, 2, true negative rate 50%, false positive rate3, 98.1%, 4, false negative rate 66.7%. A minority of patients after DBE were nausea, abdominal pain and other symptoms, without serious complications(such as acute pancreatitis, gastrointestinal perforation and bleeding). 68 patients received follow-up, follow-up of patients receiving operation, drugs and symptomatic treatment, 17 of which occurred in patients with bleeding again, the rate of rebleeding was 25%.Conclusion: 1.DBE examination is an important diagnostic method of OGIB,high rate of detection, high rate of etiological diagnosis. 2.DBE examination compared with the whole gastrointestinal barium meal and abdominal CT has a higher diagnostic rate, compared with CE had no significant difference,3.DBE can perform a biopsy and treatment under endoscope. 4.DBE is a safety inspection, the patient can be tolerated,serious complication rate is low.更多还原