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长期的临床工作中，我们发现结肠憩室病并非是我们以往认为少见疾病，随着对疾病认识的加深和人口老龄化，憩室病会越来越多的进入我们外科医生的视线，为了全面了解这种疾病，更好地服务病人，我们将为科室同事解读国际权威机构指南。部分内容在此平台分享。不妥之处敬请指正！ 鸣谢： 翻译文稿得到广州医科大学附属肿瘤医院胃肠肿瘤科曾祥医师校对，特地表示感谢 Guidelinesfor Colonic Diverticular Bleeding and Colonic Diverticulitis:Japan Gastroenterological Association CQ8: What is the optimal initial diagnostic modality for identifying the source of bleeding in patients presenting with presumed acute LGIB or colonic diverticular bleeding? CQ8:什么是鉴别急性下消化道出血或结肠憩室出血来源的最佳诊断模式？ Statement: Colonoscopyis recommended as an initial diagnostic modality when acute LGIB or colonic diverticular bleeding is suspected. 声明：当怀疑急性下消化道出血或者结肠憩室出血时，推荐结肠镜检查为第一位的诊断模式。 Quality of evidence: C 证据级别：C Strength of recommendation: Do it Agreement rate: 100% 推荐强度：100% Explanation 解读 Colonoscopy ,CT angiography, scintigraphy，and abdominal US are commonly used for the diagnosis of acute LGIB and colonic diverticular bleeding. 结肠镜、CT、血管造影、闪烁扫描和腹部B超是急性下消化道出血和结肠憩室出血常用的诊断方法。 These modalities have been compared in observational studies but not in a randomized controlled study. 这些方法在一些观察性研究中做过对比，但是，尚未行该领域的随机对照研究。 Due to recent technological advances in medical devices, CT is becoming a popular diagnostic modality for acute LGIB. According to a meta-analysis, the diagnostic accuracy of CT angiography in acute GI bleeding was 85.2%sensitivity (95% CI 75.5–91.5) and 92.1% specificity (95%CI 76.7–97.7),showing excellent accuracy . 由于目前医疗设备技术的进步，CT正在成为一个针对急性下消化道出血的流行诊断模式。根据一篇荟萃分析，CT血管造影在急性消化道出血上的准确性为：敏感性82.5%（95%CI 75.5–91.5）特异性92.1%(95%CI 76.7–97.7),表明其具有良好的准确性。 Also, in a cross-sectional study on performing CT angiography after colonoscopy, the accuracy of diagnosing the site of bleeding, and thus the lesion, was higher with CT angiography than with colonoscopy . 同时，在一个横断面研究中结肠镜检查后再行CT血管造影，出血部位和病灶部位诊断的准确性，CT血管造影都明显优于结肠镜检查。 In colonoscopy, the accuracy of diagnosing the source of bleeding ranges from 52.9 to 91% .However, unlike CT angiography and scintigraphy, colonoscopy enables treatment directly after diagnosis . 在结肠镜检中，出血来源诊断准确性为52.9-91%。但是，与CT血管造影和闪烁扫描检查不同的是，结肠镜在确定诊断以后可以直接行镜下治疗。 Moreover, a case-control study comparing colonoscopy with angiography and scintigraphy and case series have shown high rates of diagnosis and treatment with low medical costs in the colonoscopy group. 并且，一项比较结肠镜、血管造影、闪烁扫描和病例报告的病例对照研究，表明结肠镜组具有高的诊断治疗率和较低的医疗支出。 Based on these findings,colonoscopy is recommended as an initial diagnostic modality in patient spresenting with presumed acute LGIB or colonic diverticular bleeding. 基于这些发现，在怀疑急性下消化道出血或结肠憩室出血的患者中，结肠镜检查被推荐为首选的诊断模式。 CT angiography is associated with radiation exposure and contrast nephropathy, but it can be an initial diagnostic choicewhen colonoscopy cannot readily be performed due to facility regulations or when patients with LGIB are intolerant to bowel preparation or examination itself . 虽然CT血管造影有放射线暴露和造影剂引起的肾脏炎症反应，但是，当设备使用制度原因使的肠镜检查不能实施时或者病人不能耐受肠道准备和检查本身时，CT血管造影可以作为首选。 Abdominal US has a lower diagnostic rate than that of colonoscopy, but because it does not require bowel preparation and is not associated with radiation exposure, this modality may be selected as an auxiliary diagnostic method to be used before colonoscopy 相比结肠镜检来说B超诊断准确率较肠镜低，但是，因为其不需要肠道准备，也不涉及放射线暴露，所以可以作为辅助诊断方法在实行肠镜检查前备选。 CQ9: Is contrastenhanced (CE)-CT prior to colonoscopy effective for acute LGIB and colonic diverticular bleeding? 岁末年初，感激所有帮助我们的所有朋友！ CQ9：对于急性下消化道出血或结肠憩室出血，肠镜检查前行增强CT扫描是否有效？ Statement: Due to insufficient evidence, CE-CT prior to colonoscopy is not recommended for all patients with acute LGIB or colonic diverticular bleeding. It has been proposed that CE-CT should be performed according to the current status of patients and facilities. 声明：由于证据不充分，肠镜检查前增强CT扫描不被推荐应用于所有的急性下消化道出血或结肠憩室出血病人。而是推荐根据当前设备和病人的状况选择增强CT扫描。 Quality of evidence: C 证据级别：C Strength of recommendation: Probably do it Agreement rate: 75% 推荐强度：75% Explanation解释 Three retrospective observational studies and one prospective observational study have investigated whether pre-colonoscopy CE-CT improves the rate of identifying the source of bleeding and the diverticula with SRH in patients presenting with acute LGIB or colonic diverticular bleeding, showing a low rate of positive extravasation and a low sensitivity (20–52%) on CE-CT 。 三个回顾性的研究和一个前瞻性观察性研究以肠镜前行增强CT检查是否能提高出血来源的诊断率及在急性下消化道出血或结肠憩室出血病人中是否能识别具有最近出血红斑（stigmataof recent hemorrhage）为研究目的，结果显示肠镜前行增强CT有较低的阳性溢出率(15–36%)和较低的敏感性。 Conversely, bleeding diverticula were identified on colonoscopy in 60–68% of patients with extravasation on CE-CT (positive predictive value) and 20–31% of those without extravasation, demonstrating a higher identification rate in the former . 相反，出血性憩室在60–68%的增强CT中有造影剂外溢的病人可以通过结肠镜识别，20–31%没有造影剂外溢的病变也得以识别，证明了前者有较高的识别率。 相反，肠镜检查中发现出血性憩室并行增强CT的患者中，有60-68%出现造影剂外渗和20-31%无造影剂外渗，表明肠镜前行增强CT有较高的出血识别率。 In one of the retrospective observational studies, CE-CT significantly improved the rate of identifying vascular lesions(35.7 vs. 20.6%; p = 0.01) and the rate of providing endoscopic therapy (34.9vs. 13.4%; p < 0.01), with a high rate of agreement regarding the source of bleeding between CE-CT and colonoscopy (κ value: 0.83; p < 0.01) . 在一个回顾性观察性研究中，增强CT明显改善了识别血管病变的发生率(35.7vs. 20.6%; p = 0.01)，提高内镜的治疗率(34.9 vs. 13.4%; p < 0.01),两种方法具有较高的诊断出血来源一致率(κ value:0.83; p < 0.01) 。 On the other hand, in the cross-sectional study , the positive rate of extravasation on CE-CT was not high, at 15.4% (8/52), and thus the application of CE-CT for all patients is not recommended. 另一方面，在一个横断面研究中显示不高的外溢阳性率15.4%(8/52),因此，不推荐所有病人均使用增强CT。 Although the differences not significant, the rate of extravasation is high when CE-CT is performed within 2 h of the last episode of hematochezia (p = 0.123), suggesting thatCE-CT may be indicated for acute LGIB and colonic diverticular bleeding for these patients. 虽然差异不明显，但是在末次血便两小时内造影剂的外溢率较高。提示对于急性下消化道出血和结肠憩室出血病人增强CT可以作为一个检查的指征。 CQ10: Is it effective to perform colonoscopy for acute LGIB within 24 h of a hospital visit? CQ10:对于急性下消化道出血住院24小时之内行肠镜检查是否有效？ Statement: It is proposed that colonoscopy be performed within 24 h to identify the source of bleeding and as a therapeutic intervention. 声明：指南建议在24小时之内行结肠镜检查以识别出血来源同时可以作为一个治疗干预。 Quality of evidence: B 证据级别：B Strength of recommendation: Probably do it Agreement rate: 100% 推荐强度：100% Explanation 解释 Three studies have involved a meta-analysis of patients with acute LGIB who underwent colonoscopy in the early phase and those who waited some interval before undergoing colonoscopy . 三项研究涉及对急性下消化道出血病人的荟萃分析，这些病人全部在早期接受了结肠镜检查，并且在接受结肠镜检之前有一个等待期。 Two of these 3 studies included 2 randomized controlled studies, 4 observational studies, and 1 retrospective cohort study that involved propensity score matching and the results revealed a significantly higher rate of identifying the source of bleeding in the early colonoscopy group, with no significant difference in rebleeding rate, in-hospital mortality, or rate of transition to surgery . 这三项研究中的两项包括两个随机对照研究，四个观察性研究和一个倾向评分匹配的回顾性队列研究，其结果揭示行早期结肠镜检查具有明显高的出血来源诊断率，而在再次出血率、住院死亡率或中转手术率方面没有明显的差别。 In contrast, the third study that included 2 randomized controlled studies and 10 observational studies found that the rate of performing endoscopic therapy was significantly higher in the early colonoscopy group, with no significant difference in the rate of identifying the source of bleeding, unexpected complications, rebleeding, blood transfusion, or death . 相反，第三个研究包括两个随机对照研究和十个观察性研究，发现在早期结肠镜检查的研究组中接受镜下治疗的比例明显较高，在识别出血来源、没有预测到的并发症、再出血率、输血或者死亡率方面没有明显差异。 Although insignificant,the early colonoscopy group had a shorter hospital stay and lower overall medical cost. However, 2 randomized controlled studies had a small sample size,with a possibility of a type II error . 尽管差异不明显，但是早期结肠镜研究组有较短的住院天数，较低的医疗花费。然而，两个随机对照研究样本例数较小，具有二型错误的可能性。 中国加油 曙光在前头！ One of the studies also included randomized patients treated between 1993 and 1995, when the utility of endoscopic hemostasis for acute LGIB had not been established . 这些研究中的其中之一包括1993和1995之间随机接受治疗的病人，那时急性下消化道出血的内镜治疗方式尚未建立。 Therefore, it is necessary to perform a randomized controlled study with a sample size large enough to address the question “Is it effective to perform colonoscopy within24 h of hospital visit?” Until then, it remains unclear as to whether the primary outcome can be improved, but it is proposed that colonoscopy be performed in the early phase, if possible, to also facilitate triage. 因此，有必要做一个样本量足够大的随机对照研究来解决“住院24小时内行内镜检查是否有效？”这个问题。到那时，是否最初的结果可以改善尚不可知晓，但是，建议如果可能尽早实行结肠镜检查，这样也便于治疗分类。 |
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