消化道出血动脉DSA诊断及栓塞治疗的临床研究
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摘要
第一部分:消化道出血的动脉DSA诊断
目的:分析消化道出血的动脉DSA表现并评价其诊断价值,探讨提高DSA检出率的方法。
资料和方法:1.回顾性分析135例临床消化道出血病例的DSA动脉造影表现。2.通过对比32例阳性患者的病理与DSA诊断结果,评价DSA定位及定性诊断的准确性。3.分析29例行超选择插管的造影病例,探讨超选择插管造影对提高阳性率的作用。
结果:1.DSA检查阳性率为58.5%(79/135),其中表现为造影剂外溢或肠腔内造影剂集聚46例(58.2%),发现异常血管33例(41.8%)。2.与手术病理对照,定位诊断符合率为84.4%(27/32),定性诊断符合率为78.1%(25/32)。3.通过增加超选择插管造影,新发现消化道出血征象7例,另5例可疑出血病例通过超选择造影确切显示了出血征象,其检查阳性率41.4%(12/29)。结论:1.DSA检查是诊断消化道出血的可靠方法。2.超选择插管造影能够提高消化道出血的DSA检出率。
第二部分:消化道出血的动脉介入栓塞治疗
目的:评价经导管栓塞治疗消化道出血的临床价值并分析影响疗效的因素;探讨对DSA阴性结果病例的介入治疗措施。资料和方法:1.对第一部分DSA检查为阳性的79例患者中有栓塞适应症的39例进行介入栓塞治疗,随访其即刻止血率、再出血率及术后并发症,评价介入栓塞治疗上、下消化道出血的效果及安全性。2. 56例DSA阴性病例中16例上消化道出血病例,对可疑出血血管进行试验性栓塞,5例下消化道出血病例的靶血管进行加压素灌注治疗(n=5)。
结果:1.39例介入栓塞术后即刻止血34例,即刻止血率为87.2%,其中上消化道出血组为90.3%,下消化道出血组为75.0%。复发出血3例,全部为胰腺炎病人,复发出血率为8.8%(3/34)。2.试验性栓塞组即刻止血率68.8%(11/16),复发出血率18.2%(2/11);加压素灌注组即刻止血3例(3/5),随访全部发生再出血。
结论:1.介入栓塞是一种治疗动脉性上、下消化道出血安全、有效的措施;2.对于DSA检查结果阴性的病例,试验性栓塞可控制部分上消化道出血;加压素灌注亦可暂时控制下消化道出血,但易复发。
PARTⅠ: Arterial DSA Diagnosis of Gastrointestinal Hemorrhage Objective: To evaluate the diagnostic value of digital subtraction angiography(DSA) findings in gastrointestinal hemorrhage, and investigate how to improve the detection rate of DSA.
Materials and Methods : 1.DSA findings of 135 patients with gastrointestinal hemorrhage were analyzed retrospectively.2. 32 positive patients of those underwent operation,comparative studies with pathology were done to evaluate the accuracy of DSA detection.3.29 negative cases were performed superselective catheterization,to investigate the effect of raising the DSA detection of gastrointestinal hemorrhage. and the positive rate of DSA was calculated.
Results:1.Positive rate of DSA was 58.5%(79/135),the findings were contrast material efflux or intra-intestinal collection (n=46),abnormal vascular (n=33).2.Compared to pathology ,accuracy rate of DSA location detection was 84.4﹪, qualitation diagnostic rate was 78.1%.3. 7 cases with negative DSA findings and 5 cases with doubtful hemorrhagic findings were detected definitely by superselective angiography,the detection rate was 41.4%. Conclusion:1. DSA is a dependable method to detect gastrointestinal hemorrhage.2. Superselective catheterization is able to improve the DSA detection of gastrointestinal hemorrhage.
PARTⅡ: Arterial Interventional Embolotherapy of Gastrointestinal Hemorrhage
Objective: To evaluate the value of Interventional embolotherapy of gastrointestinal hemorrhage, and the correlated influential factors as well; to investigate the interventional management in DSA negative cases.
Materials and Methods:1.39 cases with indication underwent interventional embolotherapy in 79 positive patients, immediate hemostasis rate and re-hemorrhage rate were checked up after embolization ,and complications were observed,then evaluated the therapeutic effect and safety.2.In 56 negative patients , 16 cases treated with trial embolotherapy in upper gastrointestinal and 5 cases treated with vasopressin infusion in lower gastrointestinal.
Results: 1. Immediate hemostasis rate was 87.2%(34/39) in embolotherapy of gastrointestinal hemorrhage, all of the 3 re-hemorrhage patients were severe acute pancreatitis ,re-hemorrhage rate was 8.8%(3/34).2. Immediate hemostasis rate was 68.8% and re- hemorrhage rate was 18.2% in group trial embolotherapy ; 3 in 5 patients treated with vasopression infusion were effective , and all of the 3 patients recurrent.
Conclusion:1. Interventional embolotherapy is a safe and effective method to manage gastrointestinal hemorrhage.2. Trial embolotherapy can control the upper gastrointestinal hemorrhage and vasopressin infusion can control the lower gastrointestinal hemorrhage in some DSA negative cases ,but re-hemorrhage rate is higher in the latter.
目的:分析消化道出血的动脉DSA表现并评价其诊断价值,探讨提高DSA检出率的方法。
资料和方法:1.回顾性分析135例临床消化道出血病例的DSA动脉造影表现。2.通过对比32例阳性患者的病理与DSA诊断结果,评价DSA定位及定性诊断的准确性。3.分析29例行超选择插管的造影病例,探讨超选择插管造影对提高阳性率的作用。
结果:1.DSA检查阳性率为58.5%(79/135),其中表现为造影剂外溢或肠腔内造影剂集聚46例(58.2%),发现异常血管33例(41.8%)。2.与手术病理对照,定位诊断符合率为84.4%(27/32),定性诊断符合率为78.1%(25/32)。3.通过增加超选择插管造影,新发现消化道出血征象7例,另5例可疑出血病例通过超选择造影确切显示了出血征象,其检查阳性率41.4%(12/29)。结论:1.DSA检查是诊断消化道出血的可靠方法。2.超选择插管造影能够提高消化道出血的DSA检出率。
第二部分:消化道出血的动脉介入栓塞治疗
目的:评价经导管栓塞治疗消化道出血的临床价值并分析影响疗效的因素;探讨对DSA阴性结果病例的介入治疗措施。资料和方法:1.对第一部分DSA检查为阳性的79例患者中有栓塞适应症的39例进行介入栓塞治疗,随访其即刻止血率、再出血率及术后并发症,评价介入栓塞治疗上、下消化道出血的效果及安全性。2. 56例DSA阴性病例中16例上消化道出血病例,对可疑出血血管进行试验性栓塞,5例下消化道出血病例的靶血管进行加压素灌注治疗(n=5)。
结果:1.39例介入栓塞术后即刻止血34例,即刻止血率为87.2%,其中上消化道出血组为90.3%,下消化道出血组为75.0%。复发出血3例,全部为胰腺炎病人,复发出血率为8.8%(3/34)。2.试验性栓塞组即刻止血率68.8%(11/16),复发出血率18.2%(2/11);加压素灌注组即刻止血3例(3/5),随访全部发生再出血。
结论:1.介入栓塞是一种治疗动脉性上、下消化道出血安全、有效的措施;2.对于DSA检查结果阴性的病例,试验性栓塞可控制部分上消化道出血;加压素灌注亦可暂时控制下消化道出血,但易复发。
PARTⅠ: Arterial DSA Diagnosis of Gastrointestinal Hemorrhage Objective: To evaluate the diagnostic value of digital subtraction angiography(DSA) findings in gastrointestinal hemorrhage, and investigate how to improve the detection rate of DSA.
Materials and Methods : 1.DSA findings of 135 patients with gastrointestinal hemorrhage were analyzed retrospectively.2. 32 positive patients of those underwent operation,comparative studies with pathology were done to evaluate the accuracy of DSA detection.3.29 negative cases were performed superselective catheterization,to investigate the effect of raising the DSA detection of gastrointestinal hemorrhage. and the positive rate of DSA was calculated.
Results:1.Positive rate of DSA was 58.5%(79/135),the findings were contrast material efflux or intra-intestinal collection (n=46),abnormal vascular (n=33).2.Compared to pathology ,accuracy rate of DSA location detection was 84.4﹪, qualitation diagnostic rate was 78.1%.3. 7 cases with negative DSA findings and 5 cases with doubtful hemorrhagic findings were detected definitely by superselective angiography,the detection rate was 41.4%. Conclusion:1. DSA is a dependable method to detect gastrointestinal hemorrhage.2. Superselective catheterization is able to improve the DSA detection of gastrointestinal hemorrhage.
PARTⅡ: Arterial Interventional Embolotherapy of Gastrointestinal Hemorrhage
Objective: To evaluate the value of Interventional embolotherapy of gastrointestinal hemorrhage, and the correlated influential factors as well; to investigate the interventional management in DSA negative cases.
Materials and Methods:1.39 cases with indication underwent interventional embolotherapy in 79 positive patients, immediate hemostasis rate and re-hemorrhage rate were checked up after embolization ,and complications were observed,then evaluated the therapeutic effect and safety.2.In 56 negative patients , 16 cases treated with trial embolotherapy in upper gastrointestinal and 5 cases treated with vasopressin infusion in lower gastrointestinal.
Results: 1. Immediate hemostasis rate was 87.2%(34/39) in embolotherapy of gastrointestinal hemorrhage, all of the 3 re-hemorrhage patients were severe acute pancreatitis ,re-hemorrhage rate was 8.8%(3/34).2. Immediate hemostasis rate was 68.8% and re- hemorrhage rate was 18.2% in group trial embolotherapy ; 3 in 5 patients treated with vasopression infusion were effective , and all of the 3 patients recurrent.
Conclusion:1. Interventional embolotherapy is a safe and effective method to manage gastrointestinal hemorrhage.2. Trial embolotherapy can control the upper gastrointestinal hemorrhage and vasopressin infusion can control the lower gastrointestinal hemorrhage in some DSA negative cases ,but re-hemorrhage rate is higher in the latter.
引文
1 Nussbaum M,Baum S. Radiographic demonstration of unknowm sites of gastrointestinal bleeding. Surgery , 1963 , 14 :347.
2 杨建勇,陈伟,主编.介入放射学理论与实践.北京:科学出版社,2005,287.
3 何仕诚,滕皋军,郭金和,等. 消化道出血的选择性动脉造影诊断与介入治疗. 临床放射学杂志,2002 ,21 :976.
4 Thompson JN,Heningway AP,Mcpherson GA,et al. Obscure gastrointestinal hemorrhage of small bowel orgin. Br Med J , 1984 ,288 :1663.
5 Scheppach W, Wiffenberg G, Hahn D , et al. Massive hemorrhagefrom jejunel varices . Z Gostroenterol , 1997 ,35 :195.
6 Briley CA , Jackson DC , Johnsrude LS , et al. Acute gastrointestinal hemorrhage of smallbowel. Origin Radiolgy ,1980 ,136 :317.
7 Lewis HJ E , Gledhill T , Gilmour HM , et al. Arteriovenous malformations of the intestine. Surg Gynecol Obstet ,1972 ,147 :712.
8 Tamadn A ,M ak imo to K,O kanaM , et al. Olfactory neuroblastoma presentation of a case and review of the Japanese litcraure,L aryngo scope, 1984, 94: 252.
9 陈星荣,樊军,陈克敏,等.“原因不明”慢性肠出血的X 线诊断[J ] . 中华放射学杂志,1990 ,24(5) :259 - 262.
10 Best EB et al . Angiography in chronic/ recurrent gastrointestinal bleeding :a nine year study[J ] . Surg Clin North Am,1979 ,59(6) :811 - 816.
11 方淳,陈克敏,李明华,等. 介入诊断和治疗在消化道出血中的临床应用[J ] . 介入放射学杂志,2003 ,12 (6) :412-414.
12 章士正, 蒋定尧, 任志达, 等. 山莨菪碱药物血管造影在消化道出血诊断中的应用. 临床放射学杂志, 1994; 13: 51.
13 Richard SB,Tony PS,Andrew MS,et al.Provocative angiography in patients with gastrointestinal hemorrhage of obscure origin. AJG ,2000;95(10):2807-12.
14 Glickerman DJ , Kowdley KV , Rosch J , Urokinase in Gastrointestinal Tract Bleeding. Radiology , 1988 ,168 :375.
15 DarrylA Z, Thomas PB, Elisa HB. M assive hemo rrhage in the lower gastrointestinal tract in adults: diagnostic imaging and intervention. AJR, 1993; 161: 703.
16 刘善达,王林.选择性动脉造影诊断小肠出血[J].临床放射学志,2000,19(5):310-312.
17 Glickerman DJ , Kowdley KV ,Rosch J :Urokinase in gastrointestinal tract bleeding[J ] . Radiology ,1988 ,168 (1) :375 - 379.
18 Rees CR , Palmaz JC ,Alvarado R , et al . DSA in acute gastrointestinal hemorrhage :Clinical and in vitro studies [J ] . Radiology ,1988 ,169 (2) :449 - 455.
19 Chet RP,Julio CP, Rudo lph A , et al.DSA in acute gastrointestinal hemorrhage: clinical and in vitro studies. Radio lgoy, 1988; 169: 499.
1 Guy GE , Shetty PC , Sharma RP , et al . Acute lower gastrointestinal hemorrhage : Treatment by superselective embolization with polyvinylalcohol particles. AJR , 1992 , 159 :521.
2 Klas JV,Madoff RD,Surgical options in lower gastrointestinal bleeding.Semin Colon Rectal Srug 1997;8:172-177.
3 Zuckeman DA , Bochini TP , Birnbaun EH. Massive hemorrhage in the lower gastrointestinal tract in adult:Diagnostic imaging and intervention.AJR , 1993 , 166 : 703
4 Schenker MP,Duszak R,Soulen MC,et al.Upper Gastrointestinal Hemorrhage and Transcather Embolotherapy :Clinical and Technical Factors Impacting Success and Survival.J Vasc Interv Radiol 2001;12:1263-1271.
5 Bookstein JJ,Chlosta EM,Foley D,et al.Transcatheter hemostasis of gastrointestinal bleeding using modified autogenous clot.Radiology 1974;113:277-285.
6 Chuang VP,Wallace S, Zornoza J,et al. Transcatheter arterial occlusion in the management of rectosigmoidal bleeding.Radiology 1979;133:605-609.
7 Walsh RM,Anain P,Geisinger M ,et al.Role of angiography and embolization for massive gast roduodenal hemorrhage. J Gastrointest-Surg ,1999 :3 :61.
8 Palmaz JC ,Walter J F ,Cho KJ.Therapeutic embolization of the small bowel arteries. Radiology ,1984 ,152 (2) :377.
9 Okazaki M , Furui S , Higashihara H , et al. Emergent embolotherapy of small intestine hemorrhage. Gastrointest Radiol , 1992 ,17 :223.
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1 Abdo Francis JM. Treatment of non - variceal hemorrhage of the upper digestive tract. Indian J Gastroenterol , 1998 , 17 ( 3) : 109
2 Hunter JM, Pezim ME. Limited value of 99Tcm labelled red blood cell scintigraphy in localization of lower gastrointestinal bleeding. Am J Surg ,1990 , 159 : 504.
3 Scheppach W, Wiffenberg G, Hahn D , et al. Massive hemorrhagefrom jejunel varices . Z Gostroenterol , 1997 ,35 :195
4 Nussbaum M, Baum S. Radiographic demonstration of unknowm sites ofgastrointestinal bleeding. Surgery , 1963 , 14 :347
5 何仕诚,滕皋军,郭金和,等. 消化道出血的选择性动脉造影诊断与介入治疗. 临床放射学杂志,2002 ,21 :976.
6 方淳,陈克敏,李明华,等. 介入诊断和治疗在消化道出血中的临床应用[J ] . 介入放射学杂志,2003 ,12 (6) :412-414.
7 DarrylA Z, Thomas PB, Elisa HB. Massive hemorrhage in the lower gastrointestinal tract in adults: diagnostic imaging and intervention. AJR, 1993,161: 703.
8 Schenker MP,Duszak R Jr,Soulen MC,et al. Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival.J Vasc Interv Radiol. 2001,12(11):1263-71.
9 Phillips DA , Wertheimer MD , Patwardhan N ,et al . Peroperative angiography and embolization of the site of intermittent acute small bowel bleeding with a radiopaque microcoil : Facilitated precise surgical excision of the source. Surgery , 1996 , 119 :714
10 Silver A,Bendick P,Wasvar H. Safety and efficacy of superselective angioembolization in control of lower gastrointestinal hemorrhage.Am J Surg.2005,189(3):361-3.
11 Kuo WT,Lee DE,Saad WE,et al. Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage.J Vasc Interv Radiol. 2003:14(12):1503-9.
12 Burgess AN,Evans PM. Lower gastrointestinal haemorrhage and superselective angiographic embolization.ANZ J Surg. 2004:74(8):635-8.
13 Funaki B. Microcatheter embolization of lower gastrointestinal hemorrhage: an old idea whose time has come.Cardiovasc Intervent Radiol. 2004:27(6):591-9.
14 Funaki B. Endovascular intervention for the treatment of acute arterial gastrointestinal hemorrhage.Gastroenterol Clin North Am.2002,31(3):701-13.
15 Horiguchi J,Naito A,Fukuda H,et al. Morphologic and histopathologic changes in the bowel after super-selective transcatheter embolization for focal lower gastrointestinal hemorrhage.Acta Radiol.2003, 44(3):334-9.
16 Ledermann HP,Schoch E,Jost R,et al. Embolization of the vasa recta in acute lower gastrointestinal hemorrhage: A report of five cases.Cardiovasc Intervent Radiol.1999,22(4):315-20.
17 甘万崇,刘晋新,王巧兮,等. 介入栓塞治疗下消化道大出血. 中华放射学杂志,1999 ,33 :327.
18 Guy GE , Shetty PC , Sharma RP ,et al . Acute lower gastrointestinal hemorrhage : Treatment by superselective embolization with polyvinyl alcohol particles. AJR , 1992 , 159 :521
19 Kusano S , Murata K, Ohuchi H ,et al . Low dose particulate polyvinyl alcohol embolization in massive small artery intestinal hemorrhage. Experimental and clinical results. Invest Radiol , 1987 , 22 :388
2 杨建勇,陈伟,主编.介入放射学理论与实践.北京:科学出版社,2005,287.
3 何仕诚,滕皋军,郭金和,等. 消化道出血的选择性动脉造影诊断与介入治疗. 临床放射学杂志,2002 ,21 :976.
4 Thompson JN,Heningway AP,Mcpherson GA,et al. Obscure gastrointestinal hemorrhage of small bowel orgin. Br Med J , 1984 ,288 :1663.
5 Scheppach W, Wiffenberg G, Hahn D , et al. Massive hemorrhagefrom jejunel varices . Z Gostroenterol , 1997 ,35 :195.
6 Briley CA , Jackson DC , Johnsrude LS , et al. Acute gastrointestinal hemorrhage of smallbowel. Origin Radiolgy ,1980 ,136 :317.
7 Lewis HJ E , Gledhill T , Gilmour HM , et al. Arteriovenous malformations of the intestine. Surg Gynecol Obstet ,1972 ,147 :712.
8 Tamadn A ,M ak imo to K,O kanaM , et al. Olfactory neuroblastoma presentation of a case and review of the Japanese litcraure,L aryngo scope, 1984, 94: 252.
9 陈星荣,樊军,陈克敏,等.“原因不明”慢性肠出血的X 线诊断[J ] . 中华放射学杂志,1990 ,24(5) :259 - 262.
10 Best EB et al . Angiography in chronic/ recurrent gastrointestinal bleeding :a nine year study[J ] . Surg Clin North Am,1979 ,59(6) :811 - 816.
11 方淳,陈克敏,李明华,等. 介入诊断和治疗在消化道出血中的临床应用[J ] . 介入放射学杂志,2003 ,12 (6) :412-414.
12 章士正, 蒋定尧, 任志达, 等. 山莨菪碱药物血管造影在消化道出血诊断中的应用. 临床放射学杂志, 1994; 13: 51.
13 Richard SB,Tony PS,Andrew MS,et al.Provocative angiography in patients with gastrointestinal hemorrhage of obscure origin. AJG ,2000;95(10):2807-12.
14 Glickerman DJ , Kowdley KV , Rosch J , Urokinase in Gastrointestinal Tract Bleeding. Radiology , 1988 ,168 :375.
15 DarrylA Z, Thomas PB, Elisa HB. M assive hemo rrhage in the lower gastrointestinal tract in adults: diagnostic imaging and intervention. AJR, 1993; 161: 703.
16 刘善达,王林.选择性动脉造影诊断小肠出血[J].临床放射学志,2000,19(5):310-312.
17 Glickerman DJ , Kowdley KV ,Rosch J :Urokinase in gastrointestinal tract bleeding[J ] . Radiology ,1988 ,168 (1) :375 - 379.
18 Rees CR , Palmaz JC ,Alvarado R , et al . DSA in acute gastrointestinal hemorrhage :Clinical and in vitro studies [J ] . Radiology ,1988 ,169 (2) :449 - 455.
19 Chet RP,Julio CP, Rudo lph A , et al.DSA in acute gastrointestinal hemorrhage: clinical and in vitro studies. Radio lgoy, 1988; 169: 499.
1 Guy GE , Shetty PC , Sharma RP , et al . Acute lower gastrointestinal hemorrhage : Treatment by superselective embolization with polyvinylalcohol particles. AJR , 1992 , 159 :521.
2 Klas JV,Madoff RD,Surgical options in lower gastrointestinal bleeding.Semin Colon Rectal Srug 1997;8:172-177.
3 Zuckeman DA , Bochini TP , Birnbaun EH. Massive hemorrhage in the lower gastrointestinal tract in adult:Diagnostic imaging and intervention.AJR , 1993 , 166 : 703
4 Schenker MP,Duszak R,Soulen MC,et al.Upper Gastrointestinal Hemorrhage and Transcather Embolotherapy :Clinical and Technical Factors Impacting Success and Survival.J Vasc Interv Radiol 2001;12:1263-1271.
5 Bookstein JJ,Chlosta EM,Foley D,et al.Transcatheter hemostasis of gastrointestinal bleeding using modified autogenous clot.Radiology 1974;113:277-285.
6 Chuang VP,Wallace S, Zornoza J,et al. Transcatheter arterial occlusion in the management of rectosigmoidal bleeding.Radiology 1979;133:605-609.
7 Walsh RM,Anain P,Geisinger M ,et al.Role of angiography and embolization for massive gast roduodenal hemorrhage. J Gastrointest-Surg ,1999 :3 :61.
8 Palmaz JC ,Walter J F ,Cho KJ.Therapeutic embolization of the small bowel arteries. Radiology ,1984 ,152 (2) :377.
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