摘要
目的 分析致命性医源性胆道出血(LIH)的影像学特征和发病机制,评价经动脉腔内治疗LIH的价值.方法 收集2009年8月—2023年7月南京医科大学第一附属医院收治的上消化道出血住院患者269例,对其中确诊为LIH并得到治疗的24例患者的临床资料进行回顾性分析,包括LIH的医源性原因、血管造影结果和动脉腔内治疗方法.23例患者使用明胶海绵颗粒和弹簧圈进行动脉栓塞(TAE),1例患者使用覆膜支架进行隔离.评估疗效的主要标准是手术技术成功率、相关并发症和长期疗效的临床随访.结果 12例LIH是由介入手术引起,12例是由肝胆胰外科手术所致.主要表现为显著的血压或持续血红蛋白下降(n=13)和上消化道出血(n=18).2例患者在手术期间即出现症状,4例患者在24 h内出现症状,18例患者在24 h后出现症状.血管造影术显示出血阳性率为100%(24/24).表现为假性动脉瘤(n=15)、肝动脉截断(n=3)、造影剂外渗(n=5)、肝动脉胆道瘘(n=3).23例患者行TAE,1例患者行支架置入术.23例患者成功止血,技术成功率为95.8%(23/24).4例TAE术后出现肝坏死和脓肿.治疗止血后无再出血复发.结论 多种肝内外医源性损伤均可引起致命性胆道出血且临床及影像学表现多样.综合影像诊断联合动脉腔内治疗是LIH最佳的有效救命措施.
Abstract
Objective To investigate the imaging features and pathogenesis of lethal iatrogenic hemobilia(LIH)and the value of transarterial intervention in the treatment of LIH.Methods A total of 269 patients with upper gastrointestinal bleeding who were admitted to The First Affiliated Hospital of Nanjing Medical University from August 2009 to July 2023 were enrolled,among whom 24 had a confirmed diagnosis of LIH and received treatment,and a retrospective analysis was performed for the clinical data of these 24 patients,including the iatrogenic causes,angiographic findings,and arterial interventions of LIH.Among the 24 patients,23 received transarterial embolization(TAE)with gelatin sponge particles and coils,and 1 received a covered stent for isolation.The main criteria for assessing treatment outcome included the technical success rate of surgery,procedure-related complications,and long-term clinical follow-up.Results Among the 24 patients with LIH,12 had LIH caused by interventional procedures,and 12 had LIH caused by hepatobiliary and pancreatic surgery.The main clinical manifestations included a significant reduction in blood pressure or a persistent reduction in hemoglobin in 13 patients and upper gastrointestinal bleeding in 18 patients.Among the 24 patients,2 developed symptoms during surgery,4 developed symptoms within 24 hours,and 18 developed symptoms after 24 hours.Angiography showed a positive bleeding rate of 100%(24/24),and imaging findings included pseudoaneurysms in 15 patients,hepatic artery truncation in 3 patients,extravasation of contrast medium in 5 patients,and hepatic arteriobiliary fistula in 3 patients.Among the 24 patients,23 received TAE and 1 received stent implantation.Successful hemostasis was achieved for 23 patients,with a technical success rate of 95.8%(23/24).Four patients developed hepatic necrosis and abscess after TAE,and there was no rebleeding or recurrence after hemostatic treatment.Conclusion Various iatrogenic injuries may result in LIH with diverse clinical and imaging findings,and integrated diagnostic imaging combined with transarterial intervention is the best effective life-saving measure for LIH.
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