急性上消化道出血是指屈氏韌帶以上的食管、胃、十二指腸和胰管、膽管病變引起的急性出血，胃空腸吻合術(shù)后吻合口附近的空腸上段病變所致出血也屬這一范圍。常見(jiàn)病因有消化性潰瘍、肝硬化門脈高壓癥、應(yīng)激性潰瘍、惡性腫瘤及膽道出血等，臨床以前兩者多見(jiàn)。

    急性上消化道出血的治療措施是補(bǔ)充血容量，先以補(bǔ)液為主，必要時(shí)輸血。臨床對(duì)急性上消化道出血患者的血紅蛋白降至何值時(shí)需要輸血還有爭(zhēng)議，發(fā)表在2013年1月3日《新英格蘭醫(yī)學(xué)雜志》中的一項(xiàng)研究將有限制條件的輸血方案與無(wú)限制條件的兩種輸血方案進(jìn)行了比較。

    研究納入921名急性重癥上消化道出血的患者，隨機(jī)分為兩組，其中，461名接受有限制條件的輸血方案（當(dāng)每100mL血液的血紅蛋白含量低于7g時(shí)給予輸血），460名接受無(wú)限制條件的輸血方案（每100mL血液的血紅蛋白含量低于9g時(shí)就給予輸血），并按照有無(wú)肝硬化進(jìn)行隨機(jī)化分層。

    結(jié)果顯示，1.限制性輸血組有225名（51%）患者未接受輸血，無(wú)限制輸血組有65名（15%）未接受輸血。2.可靠存活概率：有限制的輸血組高于無(wú)限制的輸血組（P=0.02）。3.再次出血：有限制的輸血組中有10%的患者發(fā)生再次出血，而無(wú)限制的輸血組中有16%的患者發(fā)生再次出血（P=0.01）。4.不良反應(yīng)：有限制的輸血組中有40%的患者出現(xiàn)不良反應(yīng)，而無(wú)限制的輸血組中有48%的患者出現(xiàn)（P=0.02）。5.在上消化道潰瘍出血的亞組中，采用有限制的輸血方案患者的幸存概率略高于無(wú)限制的輸血方案；在肝硬化Child-Pugh A級(jí)和B級(jí)患者的亞組中，采用有限制的輸血方案患者的幸存概率明顯高于無(wú)限制的輸血方案；但是在肝硬化C級(jí)患者中，前者并未高于后者。6.在治療后的第五天，無(wú)限制輸血組的門脈壓力升高梯度明顯高于有限制的輸血組。

    研究者認(rèn)為，與無(wú)限制條件的輸血方案相比，有限制條件的輸血方案能夠明顯改善急性上消化道出血患者的治療效果。

    Transfusion Strategies for Acute Upper Gastrointestinal Bleeding

    Càndid Villanueva, M.D., Alan Colomo, M.D., Alba Bosch, M.D., Mar Concepción, M.D., Virginia Hernandez-Gea, M.D., Carles Aracil, M.D., Isabel Graupera, M.D., María Poca, M.D., Cristina Alvarez-Urturi, M.D., Jordi Gordillo, M.D., Carlos Guarner-Argente, M.D., Miquel Santaló, M.D., Eduardo Muñiz, M.D., and Carlos Guarner, M.D.N Engl J Med 2013; 368:11-21January 3, 2013DOI: 10.1056/NEJMoa1211801

    Background: The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy.

    Methods: We enrolled 921 patients with severe acute upper gastrointestinal bleeding and randomly assigned 461 of them to a restrictive strategy (transfusion when the hemoglobin level fell below 7 g per deciliter) and 460 to a liberal strategy (transfusion when the hemoglobin fell below 9 g per deciliter). Randomization was stratified according to the presence or absence of liver cirrhosis.

    Results: A total of 225 patients assigned to the restrictive strategy (51%), as compared with 65 assigned to the liberal strategy (15%), did not receive transfusions (P<0.001). The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P=0.01), and adverse events occurred in 40% as compared with 48% (P=0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child–Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child–Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P=0.03) but not in those assigned to the restrictive strategy.

    Conclusions: As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding.