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常规二次内镜检查是否对急性消化性溃疡出血患者行内镜下止血有效?一项荟萃分析

发布日期:2014-1-29 12:40:47 文章来源:GIE 作者次数:1371
    201221收到,201245批准,2012614网上发布。

    背景

    常规二次内镜检查术(Second-look Endoscopy)用于现代消化性溃疡出血(PUB)仍是有争议的。

    目的

    评估常规二次内镜检查术对标准医疗与内镜疗法治疗后表现出高风险皮肤红斑的消化性溃疡出血患者的疗效。

    设计

    进行综合文献检索(1990-2011),寻求比较常规和所需的第二次内镜检查的随机试验。

    主要测量指标

    主要测量指标是再出血。次要指标为手术和死亡率。次分析评估了质量考察、再出血限定、内镜下止血方式和质子泵抑制剂(PPI)疗法的作用。采用Revman 5.1进行分析。以比值比(OR)和95%置信区间(Cl)表示各结果。

    结果

    仅包括4篇发表的完整报道此类研究的文章和4篇摘要(577篇引文),其中共包括938例患者。采用常规二次内镜检查术后,再出血发生率显著降低(OR0.5595%置信区间为0.37-0.81),需手术治疗的也显著降低(OR 0.4395%置信区间为0.19-0.96),但是死亡率未显著降低(OR 0.4395%置信区间为0.19-0.96)。采用不同的再出血限定所得结果仍显著,但采用不同的内镜下止血方式和PPI疗法所得结果不显著;而唯一使用高剂量PPI的试验未表现出二次内镜检查的优势。当去掉这两项包括处于再出血高风险的患者的试验时,也未发现二次内镜检查有着显著益处(OR0.65,95%置信区间为0.42-1.00)。

    局限性

    这些研究中试验和患者数量小。

    结论

    当缺乏高剂量的PPI时,常规二次内镜检查对这些选定的PUB患者似乎有效,尤其对处于高风险(例如:活动性出血)的患者更有效。然而,对处于高剂量PPI时代和其它未选定的高风险皮肤红斑患者来说,这些结果是否适用仍不清楚。

    缩写词:Cl,置信区间;HRS,高风险皮肤红斑;IV,静脉注射;OR,比值比;PPI,质子泵抑制剂;PUB,消化性溃疡出血;WDM,加权均数差。

     


    Is routine second-look endoscopy effective after endoscopic hemostasis in acute peptic ulcer bleeding? A meta-analysis

    Received 1 February 2012; accepted 5 April 2012. published online 14 June 2012.

    Background

    Routine second-look endoscopy in modern-era peptic ulcer bleeding (PUB) remains controversial.

    Objective

    To assess the effectiveness of routine second-look endoscopy in patients with PUB exhibiting high-risk stigmata after standard medical care and endoscopic therapy.

    Design

    Comprehensive literature searches (1990-2011) were performed, seeking randomized trials comparing a routine with an as-needed second endoscopy.

    Main Outcome Measurements

    The main outcome was rebleeding. Secondary outcomes were surgery and mortality. Subanalyses assessed the influence of study quality, rebleeding definitions, endoscopic hemostasis modality, and proton pump inhibitor (PPI) therapies. Analyses were performed with Revman 5.1. Results are shown as odds ratios (ORs) and 95% confidence intervals (CIs).

    Results

    Only 4 published articles completely reporting studies and 4 abstracts (of 577 citations) were included (938 patients). Rebleeding was significantly decreased by a routine second-look endoscopy (OR 0.55; 95% CI, 0.37-0.81), as was surgery (OR 0.43; 95% CI, 0.19-0.96), but not mortality (OR 0.65; 95% CI, 0.26-1.62). Results remained robust with varying definitions of rebleeding, but not with varying endoscopic hemostasis modalities and PPI therapies; the only trial in which high-dose PPI was used did not show a benefit of a second-look endoscopy. When removing the 2 trials that included patients at highest risk of rebleeding, no significant benefit attributable to a second-look endoscopy was noted (OR 0.65; 95% CI, 0.42-1.00).

    Limitations

    The small number of trials and patients in each of these studies.

    Conclusions

    In the absence of high-dose PPI, especially in patients at very high risk (eg, active bleeding), routine second-look endoscopy appears effective in these selected patients with PUB. However, the generalizability of these results to the era of high-dose PPI and otherwise unselected patients with high-risk stigmata is unclear.

    Abbreviations:  CI, confidence interval, HRS, high-risk stigmata, IV, intravenous, OR, odds ratio, PPI, proton pump inhibitor, PUB, peptic ulcer bleeding, WMD, weighted mean difference

     

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