全新应激性溃疡防治专家建议

2015-06-19 栢愚 李延青 任旭 李兆申等 中华内科杂志

应激性溃疡(Stress ulcer,SU)是指机体在各类严重创伤、危重疾病或严重心理疾病等应激状态下,发生的急性胃肠道黏膜糜烂、溃疡等病变,严重者可并发消化道出血、甚至穿孔,可使原有疾病的程度加重及恶化,增加病死率。因而,预防SU是救治危重症患者不可忽视的环节。SU在内镜下可表现为急性胃黏膜病变、急性糜烂性胃炎、急性出血性胃炎、消化道溃疡等。重症监护病房(ICU)中的危重症患者在发病后的24

应激性溃疡(Stress ulcer,SU)是指机体在各类严重创伤、危重疾病或严重心理疾病等应激状态下,发生的急性胃肠道黏膜糜烂、溃疡等病变,严重者可并发消化道出血、甚至穿孔,可使原有疾病的程度加重及恶化,增加病死率。因而,预防SU是救治危重症患者不可忽视的环节。SU在内镜下可表现为急性胃黏膜病变、急性糜烂性胃炎、急性出血性胃炎、消化道溃疡等。

重症监护病房(ICU)中的危重症患者在发病后的24h内即可发生应激相关的胃肠道黏膜损伤,发病后的1~3d内胃镜检查发现75%~100%的危重症患者出现胃黏膜损伤,SU并发出血的发生率为1%~17%,平均为8%,SU并发穿孔的发生率约为1%,但出血、穿孔一旦发生,病死率将明显升高,可达50%~80%,为ICU患者常见死亡原因之一。最近一项研究发现急性胃黏膜病变已经是我国上消化道出血的第二常见原因。

应激源和危险因素

1.诱发SU的基础疾病称为应激源,其中最常见的应激源如下:(1)严重颅脑、颈脊髓外伤(又称Cushing溃疡);(2)严重烧伤,烧伤面积>30%(又称Curling溃疡);(3)严重创伤、多发伤;(4)各种困难、复杂的手术;(5)脓毒症;(6)多脏器功能障碍综合征(MODS);(7)休克,心、肺、脑复苏后;(8)严重心理应激,如精神创伤、过度紧张等;(9)心脑等。

2.在上述应激源在的情况下,以下危险因素会增加SU并发出血的风险:(1)机械通气超过48h;(2)凝血机制障碍;(3)原有消化道溃疡或出血病史;(4)大剂量使用糖皮质激素或合并使用非甾体类抗炎药;(5)急性肾功能衰竭;(6)急性肝功能衰竭;(7)急性呼吸窘迫综合征(ARDS);(8)器官移植等。

SU的临床表现

(一)临床特征

1.原发病的程度越重,SU的发生率也越高,病情越加凶险,病死率越高。 

2.患者常无明显的前驱症状(如上腹痛、反酸等),主要临床表现为上消化道出血(呕血或黑粪)与失血性休克的症状。对无显性出血的患者,若出现胃液或粪便潜血试验阳性、不明原因血红蛋白浓度降低≥20g/L,应考虑有SU伴出血的可能。

3.SU发生穿孔时,可出现急腹症的症状与体征。

4.SU的发生大多集中在原发疾病发生的3~5d内,少数可发生在2周左右。

(二)内镜特征

1.病变以胃底、胃体部最多,也可见于胃窦、食管、十二指肠及空肠。

2.病变形态以多发性糜烂、溃疡为主,前者表现为多发性出血点、出血斑或斑片状血痂,溃疡深度可至黏膜下层、固有肌层,甚至达浆膜层。

SU的诊断

有应激源相关病史及相关危险因素、在原发病后2周内出现上消化道出血症状、体征及实验室检查异常,即可拟诊SU;如内镜检查发现糜烂、溃疡等病变存在,即可确诊SU。

SU的预防

SU关键在于预防,对合并有危险因素的危重症患者应作为预防的重点。

(一)药物预防SU的指征

1.具有以下一项高危情况者应使用预防药物:(1)机械通气超过48h;(2)凝血机制障碍[国际标准化比值(INR)>1.5,血小板<50×109/L或部分凝血酶原时间>正常值2倍];(3)原有消化道溃疡或出血病史;(4)严重颅脑、颈脊髓外伤;(5)严重烧伤(烧伤面积>30%);(6)严重创伤、多发伤;(7)各种困难、复杂的手术;(8)急性肾功能衰竭或急性肝功能衰竭;(9)ARDS;(10)休克或持续低血压;(11)脓毒症;(12)心脑血管意外;(13)严重心理应激,如精神创伤、过度紧张等。

2.若同时具有以下任意两项危险因素时也应考虑使用预防药物:(1)ICU住院时间>1周;(2)粪便隐血持续时间>3d;(3)大剂量使用糖皮质激素(剂量>氢化可的松250m/d);(4)合并使用非甾体类抗炎药。

(二)预防SU的策略和措施

1.积极处理基础疾病和危险因素,消除应激源:抗感染、抗休克,纠正低蛋白血症、电解质和酸碱平衡紊乱,防治颅内高压,保护心、脑、肾等重要器官功能。对原有溃疡病史者,在重大手术前可进行胃镜检查,以明确是否合并溃疡。

2.加强胃肠道监护:可插入胃管,定期定时监测胃液pH值,必要时进行24h胃内pH监测,并定期监测血红蛋白水平及粪便隐血试验。

3.应尽早肠内营养:数项观察性临床研究发现,早期肠内营养对于危重症患者不仅具有营养支持作用,持续的食物刺激有助于维持胃肠黏膜的完整性、增强黏膜屏障功能;可能对预防SU有重要作用。

(三)预防SU的药物选择

临床常用的预防SU的药物包括:质子泵抑制剂(PPI)、组胺-2受体拮抗剂(H2RA)、抗酸药、胃黏膜保护剂等。

1.抑酸药:(1)术前预防:对拟做重大手术的患者,估计术后有并发SU可能者,可在手术前开始应用口服PPI或H2RA以提高胃内pH值。(2)对严重创伤、高危人群的预防:PPI比H2RA更能持续稳定的升高胃内pH值,降低SU相关出血风险的效果明显优于H2RA。最近一项随机对照试验(RCT)表明,对于准备脱机的机械通气患者,与不使用PPI或使用其他药物相比,预防性使用兰索拉唑可降低上消化道出血的发生率。另一项成本效益分析研究也认为,与H2RA相比,使用兰索拉唑的成本效益比最佳。因此,PPI是预防SU的首选药物,推荐在原发病发生后以标准剂量PPI静脉滴注,每12h 1次,至少连续3d,当患者病情稳定可耐受肠内营养或已进食、临床症状开始好转或转入普通病房后可改为口服用药或逐渐停药。

2.抗酸药:氢氧化铝、铝碳酸镁、5%碳酸氢钠溶液等,可从胃管内注入,使胃内pH值升高。但其降低SU相关出血风险的效果不及PPI和H2RA针剂。

3.黏膜保护剂:可增加胃黏膜的防御功能,但是不能中和胃酸和提高胃内pH值。其降低SU相关出血风险的效果也不及PPI或H2RA针剂。

(四)监测SU治疗药物的副作用

为了减少预防SU药物的副作用,对危重症患者需把握给药指征。当患者存在SU相关出血的危险因素时才给予预防性用药,一旦危重症患者病情好转,应及时停用抑酸药。

SU并发出血的治疗

一旦发现呕血或黑便等消化道出血症状及体征,提示SU已发生,此时除继续治疗原发病外,还必须立即采取各种止血措施治疗SU。

1.立即补液,维持正常的血液循环;必要时输血。

2.迅速提高胃内pH值,使之≥6,以促进血小板聚集和防止血栓溶解,创造胃内止血必要的条件。(1)可选用PPI或H2RA抑酸治疗,但首选PPI针剂;(2)胃内注入抗酸药。

3.对合并有凝血机制障碍的患者,可输注血小板悬液、凝血酶原复合物等,以及其他纠正凝血机制障碍的药物。

4.药物治疗后,仍不能控制病情者,若条件许可,应立即进行紧急内镜检查,以明确诊断,并进行内镜下止血治疗。

5.经药物、内镜治疗、放射介人等治疗措施仍不能有效止血者,在条件许可的情况下,可考虑外科手术治疗。

6.在出血停止后,应继续使用抗溃疡药物,直至溃疡愈合。推荐使用PPI,疗程为4~6周。

原始出处:

中华医学杂志,2015,95(20):1555-1557

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    2017-03-26 ylzr123

    感谢小编为我们精心准备了如此精辟的精神大餐,小编辛苦了!

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=182808, encodeId=648518280830, content=感谢小编为我们精心准备了如此精辟的精神大餐,小编辛苦了!, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo7s7ZCKOmmbBTD6nE7gcd5OZpvyGEzkxBP3S275k5ZJVrsPkotZhBglRHM9rKvcj1OgkssqhcnoPw8zIaMZTF8c/0, createdBy=4c441942088, createdName=ylzr123, createdTime=Sun Mar 26 09:48:40 CST 2017, time=2017-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=172342, encodeId=049e1e23422b, content=很好的指南意见, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5ede2012638, createdName=1e1f3761m34(暂无匿称), createdTime=Tue Jan 24 11:31:16 CST 2017, time=2017-01-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=103017, encodeId=126b10301ee4, content=继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzfPkmqRTH5rHib5mcib8Wb3QdXjhfOK1UubQL2lictjJFdFJ6Lc3cnnCOSWqxXZ4Kk6y5GdzDoy764R/0, createdBy=156e1644785, createdName=doctorJiangchao, createdTime=Wed Aug 24 13:28:00 CST 2016, time=2016-08-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=103016, encodeId=00691030162e, content=继续学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzfPkmqRTH5rHib5mcib8Wb3QdXjhfOK1UubQL2lictjJFdFJ6Lc3cnnCOSWqxXZ4Kk6y5GdzDoy764R/0, createdBy=156e1644785, createdName=doctorJiangchao, createdTime=Wed Aug 24 13:28:00 CST 2016, time=2016-08-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=94603, encodeId=bfc894603ee, content=不错,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=9b111710540, createdName=1dea0e03m63(暂无匿称), createdTime=Mon Jul 25 15:05:00 CST 2016, time=2016-07-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=34565, encodeId=cee034565a2, content=全面介绍了应激性溃疡的防治,值得借鉴!, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=332823945, createdName=hlycom3356, createdTime=Wed Aug 05 16:43:00 CST 2015, time=2015-08-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=34564, encodeId=dc0f3456424, content=应激性溃疡在当前我国是普遍现象, beContent=null, objectType=article, channel=null, level=null, likeNumber=81, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=332823945, createdName=hlycom3356, createdTime=Wed Aug 05 16:43:00 CST 2015, time=2015-08-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=34563, encodeId=a7be34563b1, content=这些专家建议很宝贵, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=332823945, createdName=hlycom3356, createdTime=Wed Aug 05 16:42:00 CST 2015, time=2015-08-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=34018, encodeId=6667340184f, content=了解, beContent=null, objectType=article, channel=null, level=null, likeNumber=126, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ed101627734, createdName=Messichen1992, createdTime=Sat Aug 01 20:05:00 CST 2015, time=2015-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=29713, encodeId=13e129e139c, content=。。。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bdd81616126, createdName=BiochemY, createdTime=Sat Jun 27 22:55:00 CST 2015, time=2015-06-27, status=1, ipAttribution=)]
    2017-01-24 1e1f3761m34(暂无匿称)

    很好的指南意见

    0

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    2016-08-24 doctorJiangchao

    继续关注

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=182808, encodeId=648518280830, content=感谢小编为我们精心准备了如此精辟的精神大餐,小编辛苦了!, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo7s7ZCKOmmbBTD6nE7gcd5OZpvyGEzkxBP3S275k5ZJVrsPkotZhBglRHM9rKvcj1OgkssqhcnoPw8zIaMZTF8c/0, createdBy=4c441942088, createdName=ylzr123, createdTime=Sun Mar 26 09:48:40 CST 2017, time=2017-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=172342, encodeId=049e1e23422b, content=很好的指南意见, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5ede2012638, createdName=1e1f3761m34(暂无匿称), createdTime=Tue Jan 24 11:31:16 CST 2017, time=2017-01-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=103017, encodeId=126b10301ee4, content=继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzfPkmqRTH5rHib5mcib8Wb3QdXjhfOK1UubQL2lictjJFdFJ6Lc3cnnCOSWqxXZ4Kk6y5GdzDoy764R/0, createdBy=156e1644785, createdName=doctorJiangchao, createdTime=Wed Aug 24 13:28:00 CST 2016, time=2016-08-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=103016, encodeId=00691030162e, content=继续学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzfPkmqRTH5rHib5mcib8Wb3QdXjhfOK1UubQL2lictjJFdFJ6Lc3cnnCOSWqxXZ4Kk6y5GdzDoy764R/0, createdBy=156e1644785, createdName=doctorJiangchao, createdTime=Wed Aug 24 13:28:00 CST 2016, time=2016-08-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=94603, encodeId=bfc894603ee, content=不错,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=9b111710540, createdName=1dea0e03m63(暂无匿称), createdTime=Mon Jul 25 15:05:00 CST 2016, time=2016-07-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=34565, encodeId=cee034565a2, content=全面介绍了应激性溃疡的防治,值得借鉴!, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=332823945, createdName=hlycom3356, createdTime=Wed Aug 05 16:43:00 CST 2015, time=2015-08-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=34564, encodeId=dc0f3456424, content=应激性溃疡在当前我国是普遍现象, beContent=null, objectType=article, channel=null, level=null, likeNumber=81, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=332823945, createdName=hlycom3356, createdTime=Wed Aug 05 16:43:00 CST 2015, time=2015-08-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=34563, encodeId=a7be34563b1, content=这些专家建议很宝贵, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=332823945, createdName=hlycom3356, createdTime=Wed Aug 05 16:42:00 CST 2015, time=2015-08-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=34018, encodeId=6667340184f, content=了解, beContent=null, objectType=article, channel=null, level=null, likeNumber=126, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ed101627734, createdName=Messichen1992, createdTime=Sat Aug 01 20:05:00 CST 2015, time=2015-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=29713, encodeId=13e129e139c, content=。。。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bdd81616126, createdName=BiochemY, createdTime=Sat Jun 27 22:55:00 CST 2015, time=2015-06-27, status=1, ipAttribution=)]
    2016-08-24 doctorJiangchao

    继续学习

    0

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    2016-07-25 1dea0e03m63(暂无匿称)

    不错,学习了

    0

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    2015-08-05 hlycom3356

    全面介绍了应激性溃疡的防治,值得借鉴!

    0

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    2015-08-05 hlycom3356

    应激性溃疡在当前我国是普遍现象

    0

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    2015-08-05 hlycom3356

    这些专家建议很宝贵

    0

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    2015-08-01 Messichen1992

    了解

    0

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    2015-06-27 BiochemY

    。。。。

    0

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