肾移植术后并发消化道出血的诊治

doi:10.19723/j.issn.1671-167X.2024.05.023

摘要/Abstract

摘要：

目的: 对肾终末期疾病(end stage renal disease，ESRD)患者经过肾移植治疗术后并发急、慢性消化道出血的临床特征进行分析，提高对该并发症的诱因、诊断、治疗与预防措施的认识，完善肾移植术后患者并发消化道出血的管理。方法: 收集安徽医科大学第一附属医院泌尿外科肾移植术后患者在2015年8月至2020年12月期间出现消化道出血的临床、影像学和病理学资料。回顾性研究消化道出血的病因、前期临床表现、异常化验及检查、处理流程、后期防治措施及转归，并总结复习相关文献。结果: 共计17例患者中9例为慢性小量出血，血红蛋白逐渐降低，早期以黑便、粪便潜血阳性为表现，一般情况可，生命体征平稳，通过药物治疗治愈；2例胃镜示小溃疡伴活动性出血灶，通过钛夹夹闭止住血，预后良好；1例胃镜示胃窦体交界处前壁纵行溃疡钛夹夹闭效果不佳，行胃网膜右动脉细小分支动脉栓塞术，2周后康复出院；1例胃镜示胃窦处小弯侧深凹溃疡，行胃十二指肠远端分支动脉栓塞术，患者预后良好；2例胃镜示胃及十二指肠球部巨大多发溃疡灶，行胃大部及十二指肠部分切除、十二指肠残端旷置+残胃空肠吻合术，其中1例痊愈出院，另1例术后第12天再次出血最终死亡；2例憩室，均行手术切除憩室，预后良好。结论: 肾移植患者并发消化道出血起病多隐匿，病情有急有缓，对患者及移植肾均可造成不同程度的损害，给予积极预防、早期诊断、及时药物治疗，效果不佳时果断内镜下钛夹止血、经血管介入栓塞、甚至手术治疗，可使消化道出血的危害降到最低。

关键词: 肾移植, 消化道出血, 血液透析

Abstract:

Objective: To analyze the clinical characteristics of acute and chronic gastrointestinal bleeding in patients with end-stage renal disease (ESRD) after kidney transplantation, to improve the understanding of the causes, diagnosis, treatment and prevention of this complication, and to improve the management of patients with gastrointestinal bleeding after kidney transplantation. Methods: The clinical, imaging and pathological data of patients with gastrointestinal bleeding after kidney transplantation in the Department of Urology of The First Affiliated Hospital of Anhui Medical University from August, 2015 to December, 2020 were collected. The etiology, early clinical manifestations, abnormal laboratory tests and examinations, treatment procedures, late prevention and treatment measures and outcomes of gastrointestinal bleeding were retrospectively studied, and the relevant literature was summarized and reviewed. Results: A total of 17 patients were included in this study. Nine patients had chronic small amount of bleeding, hemoglobin gradually decreased, melena and fecal occult blood positive in the early stage, and the general condition was good, vital signs were stable, and were cured by drug treatment. Gastroscopy showed small ulcers with active bleeding foci in 2 cases, and the bleeding was stopped by titanium clips, and the prognosis was good. Gastroscopy showed that the anterior wall longitudinal ulcer at the junction of gastric antrum body was not effective in 1 case, and the small branch of right gastroepithelial artery was embolized, and the patient recovered and discharged after 2 weeks. Gastroscopy showed deep pit ulcer at the lesser curvature of gastric antrum in 1 patient, who underwent distal gastroduodenal artery embolization and had a good prognosis. Gastroscopy showed huge multiple ulcers in the stomach and duodenal bulb in 2 patients, who underwent subtotal gastrectomy and partial duodenectomy, duodenal stump exclusion and remnant gastrojejunostomy. One patient recovered and was discharged, and the other patient died of rebleeding on the 12th day after surgery. Two cases of diverticulum underwent surgical resection of diverticulum, and the prognosis was good. Conclusion: The onset of gastrointestinal hemorrhage in kidney transplant patients is insidious, and the condition is acute or slow, which can cause different degrees of damage to the patient and the transplanted kidney. Active prevention, early diagnosis, timely drug treatment, if the effect is not good, decisive endoscopic titanium clip hemostasis, transvascular interventional embolization, and even surgical treatment can minimize the harm of gastrointestinal bleeding.

Key words: Kidney transplantation, Gastrointestinal bleeding, Hemodialysis

中图分类号:

R692.5

丁汉东, 王琴, 廖贵益, 郝宗耀. 肾移植术后并发消化道出血的诊治[J]. 北京大学学报（医学版）, 2024, 56(5): 902-907.

Handong DING, Qin WANG, Guiyi LIAO, Zongyao HAO. Diagnosis and treatment of gastrointestinal bleeding after kidney transplantation[J]. Journal of Peking University (Health Sciences), 2024, 56(5): 902-907.

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