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系統識別號 U0026-2508201714552400
論文名稱(中文) Rockall scores大於或等於6分的消化性潰瘍出血患者具有較高的長期再出血風險: 3.5年世代回顧研究
論文名稱(英文) Peptic ulcer bleeding patients with Rockall scores ≥ 6 are at risk of long-term ulcer rebleeding: a 3.5-year prospective longitudinal study
校院名稱 成功大學
系所名稱(中) 臨床醫學研究所碩士在職專班
系所名稱(英) Institute of Clinical Medicine(on the job class)
學年度 105
學期 2
出版年 106
研究生(中文) 楊貳翔
研究生(英文) Er-Hsiang Yang
學號 S97041085
學位類別 碩士
語文別 中文
論文頁數 70頁
口試委員 指導教授-許博翔
指導教授-鄭修琦
召集委員-紀志賢
口試委員-劉志銘
中文關鍵字 胃腸道出血  消化性潰瘍疾病  反覆性出血 
英文關鍵字 gastrointestinal bleeding  peptic ulcer disease  rebleeding 
學科別分類
中文摘要 上消化道出血是全世界造成病人住院及死亡的重要原因。在過往幽門螺旋桿菌 (Helicobacter pylori) 感染以及非類固醇抗發炎 (nonsteroidal anti-inflammatory drugs, NSAIDs) 的使用被視為是造成消化性潰瘍最主要的二個成因,而近年來合併多重器官疾患的消化性潰瘍出血獲得愈來愈多的重視。Rockall scores包括了年齡、有無休克、共病症 (comorbidity) 以及胃鏡下的診斷及出血嚴重程度;Rockall scores被廣泛用於預測潰瘍出血病人30天內的死亡率及再出血風險。本研究想探討經由氫離子幫浦抑制劑治療達到潰瘍癒合後,Rockall scores較高的病患在三年半的觀察下是否有較高的潰瘍復發再出血率,以及哪些風險因子影響著這群病人在長期追蹤中產生潰瘍再發性出血。
本研究是前瞻性世代研究從2011年8月至2014年7月於成大醫院所收集的消化性潰瘍出血患者。在胃鏡下呈現高風險出血表徵 (major stigmata of recent hemorrhage) 共368位病患被收案進入此研究,經內視鏡止血術、氫離子幫浦抑制劑8到16週的治療、以及胃幽門桿菌除菌治療後,以Rockall scores ≥ 6分及Rockall scores < 6分將病患分為二組,二組病人數分別為257及111位病人,並追蹤至2015年7月觀察病患是否發生消化性潰瘍再出血。利用Cox 比例風險回歸來分析Rockall scores ≥ 6的病人再出血之獨立風險因子。
在3.5年的追蹤期間,在Rockall scores ≥ 6這組中共45位病人發生再出血事件,而Rockall scores < 6這組中有8位病人發生再出血。Rockall scores ≥ 6的這組病人與Rockall scores < 6相比有較高的累積再出血機率 (10.51 per 100 person-year vs. 3.63 per 100 person-year, P = 0.004, log-rank test)。在Rockall score ≥ 6分的病患中再出血的獨立因子 (independent factor) 包括活化部分凝血活酶時間 (activated partial thromboplastin time, aPTT) 延長大於1.5倍 (P = 0.045)、美國麻醉醫師公會的麻醉風險等級評估 (American Society of Anesthesiologists physical status classification, ASA) 第三等級以上 (P = 0.02),癌症病患 (P = 0.01),及胃潰瘍 (P = 0.04)。將aPTT ≥ 1.5倍,ASA ≥ 3,及胃潰瘍當作附加風險因子 (additional risk factor)。在Rockall scores ≥ 6的病人中,具有二個以上的附加風險因子比一個或沒有附加風險因子的病人有較高的長期累積再出血風險 (15.69 vs. 7.63 per 100 person-year, P = 0.012, log-rank test)
總結Rockall scores ≥ 6的病人在3.5年的追蹤期間有較高的再出血風險,而在Rockall scores ≥ 6的病人中,aPTT延長大於1.5倍、ASA grade ≥ 3、以及胃潰瘍是長期再出血的三個附加風險因子。
英文摘要 Patients with peptic ulcer bleeding have high cumulative rate of rebleeding in long-term follow-up. The Rockall scoring system can predict the short-term 30-day outcomes of peptic ulcer bleeding, but it is uncertain whether a high Rockall scores can serve as a long-term predictor of rebleeding after cessation of proton pump inhibitor treatment. The cohort study recruited patients who underwent endoscopy because of bleeding peptic ulcers with major stigmata of recent hemorrhage from August 2011 to July 2014. There were 368 patients in either a Rockall scores ≥6 group (n=257) or a Rockall scores <6 group (n=111), and they received follow-up until July of 2015. During the 3.5-year follow-up, the cumulative probability of rebleeding was higher in patients with Rockall scores ≥6 than in those with scores <6 (10.51 per 100 person-year vs. 3.63 per 100 person-year, P=0.004, log-rank test). In the Rockall scores ≥6 group, aPTT prolong ≥1.5-fold (P=0.045), American Society of Anesthesiology (ASA) physical status class ≥III (P=0.02), and gastric ulcer (P=0.04) were three additional independent factors of rebleeding. Among patients with Rockall scores ≥ 6, the cumulative rebleeding rate was higher in patients with two or more additional factors than in those with less than two additional factors (15.69 vs. 7.63 per 100 person-year, P=0.012, log-rank test). Rockall scores ≥6 can serve as a predictor of an increased risk of long-term rebleeding. The risk of long-term rebleeding is increased for patients Rockall scores ≥6 combined with a prolonged aPTT, ASA class ≥III, and gastric ulcer.
論文目次 中文摘要 I
Extended Abstract III
誌 謝 VII
目 錄 VIII
符號與縮寫對照表 XI
壹、緒論 1
一、消化性潰瘍出血的重要性及再出血風險 1
二、消化性潰瘍及潰瘍再出血的成因 2
三、合併多重器官疾患與消化性潰瘍出血的關係 5
四、消化性潰瘍出血的風險評估量表 6
五、消化性潰瘍及潰瘍出血的治療 7
六、消化性潰瘍再出血的長期預防策略 9
七、研究方向 12
貳、材料與方法 13
一、研究對象 13
二、研究設計及方法 14
三、再出血事件的紀錄 15
四、統計方法 16
參、研究結果 18
一、病人特徵及病人追蹤 18
二、在3.5年的追蹤期間內Rockall scores ≥ 6的病人比Rockall scores < 6的病人有較高的長期再出血風險 19
三、Rockall scores ≥ 6有較高長期再出血風險的原因並不是未治療的幽門螺旋桿菌感染所造成 20
四、Rockall scores ≥ 6對於長期潰瘍再出血的影響比抗小板藥物更顯著 22
五、NSAIDs的使用並非Rockall scores ≥ 6有較高長期再出血風險的干擾因子 23
六、Rockall scores ≥ 6再出血的附加風險因子 24
七、Rockall scores < 6再出血的成因 25
八、AIMS65 score無法預測潰瘍性出血病人長期再出血風險 25
肆、討論 27
一、Rockall scores ≥ 6為長期潰瘍再出血的預測因子 27
二、影響長期再出血相關因子的調整 27
三、幽門螺旋桿菌感染及NSAIDs於長期潰瘍再出血所扮演的角色 29
四、Rockall scores ≥ 6三個附加風險因子所代表的意義 30
五、Rockall scores ≥ 6比特發性出血潰瘍更適合作為長期再出血的預測因子 31
六、長期消化性潰瘍再出血風險評估量表的選擇 33
七、Rockall scores能作為長期潰瘍再出血預測因子的原因 34
八、Rockall scores中的共病症 37
九、AIMS65 scores無法預測長期潰瘍再出血及其原因 38
十、研究局限 40
十一、使用PPIs作為消化性潰瘍再出血的次級預防 41
十二、研究的臨床應用 43
伍、總結 44
參考文獻 45
圖一:Forrest classification 56
圖二:研究設計的流程圖 57
圖三:在3.5年的追蹤期間內Rockall scores ≥ 6的病人比Rockall scores < 6的病人有較高的長期再出血風險 58
圖四:Rockall scores ≥ 6及Rockall scores < 6二組病人幽門螺旋桿菌檢查及除菌治療的流程圖 59
圖五:排除未接受幽門螺旋桿菌檢查以及未成功除菌的病人後,Rockall scores ≥ 6仍然比Rockall scores < 6的病人有較高的累積再出血風險 60
圖六:Rockall scores ≥ 6及Rockall scores < 6二組病人抗血小板藥物使用及停用的流程圖 61
圖七:排除長期血小板藥物的使用者後,Rockall scores ≥ 6仍然比Rockall scores < 6的病人有較高的累積再出血風險 62
圖八:在Rockall score ≥ 6中,具有二個以上的附加風險因子比一個或沒有附加風險因子的人有較高的長期累積再出血風險 63
圖九:AIMS65 score無法預測潰瘍性出血病人長期再出血風險 64
表一:Rockall scores由年齡、休克、共病症、內視鏡的診斷及出血徵象所組成,隨著Rockall scores分數愈高,再出血及死亡的風險也愈高 65
表二:Blatchford scores應用於評估病人是否需要輸血、手術、或內視鏡介入性治療 66
表三:AIMS65 scores包括了血液白蛋白、凝血酶時間、意識狀態、血壓、及年齡,其可預測死亡率、住院時間及花費 67
表四:Rockall scores ≥ 6 及 Rockall scores < 6 二組病人特徵比較 68
表五:使用多變項Cox迴歸模式向前選取法分析Rockall scores ≥ 6的病人長期再出血的的獨立風險因子 69
自 述 70
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