상부소화관 출혈에 대한 조기내시경 검사의 진단적 가치에 관한 연구

Abstract

[한글]

최근에 내시경기계 및 검사기술의 발달로 상부소화관 출혈의 조기내시경검사법이 널리

이용됨에 따라 그 성과가 높이 평가되어지고 있다. 우리나라에서는 상부소화관 출혈의 임

상적 보고는 적지 않으나 아직도 조기내시경검사의 진단율이나 그 진단적 가치에 대한 보

고가 없다. 이에 본 연구는 1974년 2월부터 1977년 1월까지 상부고화관 출혈환자 180예에

대해서 조기내시경검사를 시행하여 그 성적을 분석하고, 아울러 내시경검사를 하지 않고

임상증상이나 상부위장관 X-선 소견만으로 진단된 대조군의 성적과 비교검토하였다.

조기내시경검사의 진단율은 조기내시경검사를 시행하였던 상부소화관 출혈환자 180예중

내시경검사에 의해서 병변을 진단할 수 있었던 것이 168예(93.3%)였으며 나머지, 12예중

3예(1.7%)에서는 출혈은 있으나 위내에 혈액이 충만되어 병변을 관찰할 수 없었으며, 9

예(5.0%)에서는 검사 당시 출혈흔적이나 병변이 없었다. 내시경검사에 의하여 병변을 진

단할 수 있었던 168예중 102예는 김사시 출혈이 되고 있었으며, 37예는 병변에 최근 출혈

의 흔적이 있었고 나머지 29예는 병변은 있으나 출혈은 없었다.

출혈이 시작된 후 내시경검사를 시행하였을 때까지의 경과된 시간에 따른 출혈병 변의

진단율은 검사시 출혈이 되고 있거나 최근출혈의 흔적이 있어 조기내시경검사로 출현병변

을 확인할 수 있었던 것이 6시간이내 군에서는 90.7%, 6∼24시간군 86.4%, 24∼48시간군

84.0%, 48∼72시간군 53.8%, 72∼96시간군 45.4%, 96시간 이후 군에서는 33.3%였다. 즉

내시경검사를 출혈후 빨리 시행할수록 더욱 정확한 진단을 할 수 있었으며, 출혈 48시간

이후에는 출혈원인 질환의 확인율이 현저히 감소함을 나타냈다(P<0.01). 따자서 상부소화

관 출혈의 내시경검사 시기는 48시간이내에 시행하여야만 정확한 진단을 할 수 있다고 사

료된다.

출혈원인질환으로는 소화성궤양이 61.1%로 가장 많았으며, 그 다음이 출혈성위염, (15.

6%) 위암(9.5%) 및 식도정맥류(3.9%)의 순이었다. 최근에는 출혈성위염 및 Mallory-Weiss

증후군의 빈도가 내시경검사를 시행함으로서 과거보다 현저히 증가하는 경향이 있어 상부

소화관출혈의 원인으로서 출혈성위염의 중요성이 강조되어야 할 것이며, 정확한 진단 및

치료방침의 결정은 조기내시경검사에 의해서만 가능하다 하겠다. 출혈병변이외에 출혈과

관계없는 다른 질환을 수반한 것은 15%였다. 내시경검사시 식도정맥류나 어떤 한 질환이

발견되었다고 반드시 그것을 출혈원인으로 단정하는 것은 오진을 범하기 쉬우므로 다른

부위의 검사를 소홀히 해서는 안된다.

내시경검사군과 상부위장관 X-선 진단을 비교하면 X-선 진단이 내시경진단과 일치하였

던 것이 56.3%에 불과하였으며, 특히 출힐설위염이나 Mallory-Weiss증후군등 표재성병변

은 X-선 검사만으로는 거의 진단이 불가능하였다. 내 시경검사군은 대조군에 비하여 평균

입원기간이 짧았고(P<0.05), 사망률은 낮았으며(P<0.05) 그리고 보다높은 진단의 정확성

(P<0.05)을 나타냈다. 그러나 수혈량에 있어서는 양군간에 차이가 없었다.

조기내시경 검사로 인한 합병증은 없었으며 또한 출혈을 악화시키거나 환자를 위태롭게

한 예는 없었다.

이상의 결과로 보아 상부소화관 출혈에 있어서 조기내시경검사는 정확한 진단을 내리는

데 필수적이며 지금까지의 임상증상이나 상부위장관 X-선소견으로 진단된 대부분의 우리

나라 상부소화관출혈의 원인질환에 관한 통계는 앞으로 많은 수정이 있어야 할 것으로 사

료되며 나아가서 조기내시경검사를 시행함으로서 출혈의 원인질환을 정확하게 진단하여

적절한 처치를 조속하게 할 수 있고, 사망률 및 입원기간등을 감소시킬 수 있을 것으로

생각된다.

[영문]

The modern fiberoptic endoscopes greatly facilitate accurate and early diagnosis

of bleeding source in patients with upper gastrointestinal bleeding. Utilizing an

early and vigorous diagnostic approach with x-ray and endoscopy, Palmer(1969)

reported that accurate diagnosis of the bleeding lesion was established quickly in

93% of the cases.

It is universally accepted that early endoscopy is the most efficient method of

diagnosis in upper gastrointestinal bleeding(Sugawa et al., 1973; Hoare, 1975;

Josen et al., 1976). With improved fiberoptic instruments, the endoscopic

diagnostic accuracy has approached 92% (Katon and Smith, 1973). Panendoscopy proved

capable of quickly and safely diagnosing the site and source of an active bleeding

lesion.

Barium meal x-ray study can be performed for active bleeding (Allan et al., 1972;

McGinn et al., 1975; Keller and Logan, 1976), but has two major disadvantages.

Erosions and small ulcers cannot be seen nor can their presence be assumed if the

x-ray appearances are negative. If a lesion is shown it may not be the actual

source of bleeding.

Early, accurate diagnosis of the source of upper gastrointestinal bleeding is the

keystone of a rational approach to therapy. Thus the rate of correct diagnosis of

upper gastrointestinal bleeding depends upon the methods of study applied and the

time of study.

Therefore, endoscopy is indispensable and probably the initial procedure of

choice in evaluating a patients with hematemesis and/or melena.

This study was carried out to assess the diagnostic value of early endoscopy in

patients with upper gastrointestinal bleeding.

Subjects and Methods Endoscopic group: 180 patients admitted because of upper

gastrointestinal bleeding to Severance Hospital during the period from February

1974 to January 1977, comprises 146 males and 34 females, with an average age of

46.6 years (range 10 to 81 years), Out of this group 40 patients were later

operated on.

Control group: The control group who were seen from January 1970 to December

1972, consisted of 165 patients, 128 males and 37 females whose average age was

46.2 years (range 12 to 77 years). They were evaluated only on the basis of

clinical symptoms and barium meal X-ray study. Out of this group 39 patients were

operated on.

After ice water gastric lavage with large-bore Levin tube, endoscopy was carried

out under the premedication of Buscopan and atropine sulfate, and with local

anesthesia of the throat. Instruments used were Olympus EF-B^^2 esophagofiberscope,

GF-B^^2 gastrofiberscope, GIF-K gastrointestinal fiberscope and JF·B^^2

duodenofiberscope.

Among 180 patients of endoscopic group, 54 cases were examined within 6 hours

after onset of the upper gastrointestinal bleeding, 59 cases between 6∼24 hours,

25 cases between 24∼48 hours, 15 cases between 48∼72 hours, 11 cases 72∼96 hours

and 18 cases after 96 hours.

The lesions were classified as active bleeding, recent bleeding, no bleeding

evidence and lesion without bleeding evidence. Criteria of recent bleeding were a

black base, adherent clot or protruding artery.

Results and Summary

1. Among the 180 upper gastrointestinal bleeding patients in whom early endoscopy

was performed, the lesion was diagnosed by endoscopy in 168 patients (93.3%). The

remaining 12 patients (6.7%) includes 3 patients (1.7%) in whom the stomach was

filled with fresh blood and lesion could not be visualized and 9 patients (5%) in

whom no bleeding lesion or site could be found. In the 168 patients in whom

endoscopic diagnosis was successful, 102 patients had active bleeding lesions at

time of examination, lesions with recent bleeding could be visualized in 37, and

the remaining 29 had definite lesions, but it was impossible to determine whether

the lesions were the cause of the bleeding or not. Associated non-bleeding lesions

other than bleeding source were found in 15% .

2. The endoscopic success rate varies with the time that elapses between the

onset of bleeding and endoscopy. When the patients were examined within 6 hours,

the rate is 90.7%; 6 to 24 hours, 86,4%; 24 to 48 hours, 84%; 48 to 72 hours,

53.8%; 72 to 96 hours, 45.4% and when the patients were examined more than 96 hours

after bleeding started, the success rate was only 33.3%. As results of above

findings show that the earlier endoscopy is performed after bleeding, the more

accurate diagnosis may be accomplished, and that after 48 hours, it becomes

increasingly difficult to determine the disease which caused the bleeding.

3. A comparison between endoscopic and rodiological (barium meal study) diagnosis

indicated that the case where x-ray agreed to endoscopic diagnosis was only 56.3%.

It is nearly impossible to diagnose hemorrhagic gastritis or Mallory-Weiss syndrome

by barium meal study.

4. In comparing the group diagnosed by early endoscopy with the control group,

the average length of hospitalization (±S.D.) of the patients who survived and who

did not have an operation was 8.3±4.2 days in the endoscopic group and 11.7±7.6

days in the control group (P<0.05). The over all mortality rate was 2.8% in the

endoscopic group and 9.7% in control group (P<0.05). In the endoscopic group the

correct preoperative diagnosis was made in 95% and 69.2% in controls, however, the

total amount of transfusion was similar in both groups.

5. There were no complication or death attributed to early endoscopy.

The above results that early endoscopy is an accurate method which should be

employed whenever there is upper gastrointestinal bleeding. There were

significantly more active bleeding lesions or recent bleeding lesions seen in the

period within 48 hours, the endoscopic success rate dropped from 90.7% to 33.3%

when endoscopy was carried out after 96 hours.

Currently available Korean statistics on the causes of upper gastrointestinal

bleeding are largely based on clinical and barium meal x-ray study methods of

diagnosis and probably will be altered significantly when statistics from more

accurate early endoscopic diagnosis become available.

Furthermore, as we continue to use early endoscopic methods of diagnosis, there

should be more accurate diagnosis of the causes of upper gastrointestinal bleeding,

appropriate therapy can be instituted more quickly, and the mortality rate and

length of hospitalization can be reduced.