REVIEW ISSN 78-, https://doi.org/0.7704/kjhugr.0..4.7 The Korean Journal of Helicobacter and Upper Gastrointestinal Research, 0;(4):7-77 비정맥류성상부위장관출혈환자의위험도평가방법 김준성, 김병욱 가톨릭대학교의과대학인천성모병원소화기내과 Risk Strategy in Non-Variceal Upper Gastrointestinal Bleeding Joon Sung Kim, Byung-Wook Kim Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea Nonvariceal upper gastrointestinal bleeding (NVUGIB) is one of the most common medical emergencies treated by gastroenterologists. Despite recent development of endoscopic techniques and acid-suppressive therapies, NVUGIB is still associated with high mortality rates. Risk assessment in NVUGIB is important for building therapeutic plans and discriminating patients with low risks. Previously developed scoring systems were rarely used by clinicians due to their complexity. Recently, new scoring systems have been introduced to overcome these disadvantages. Herein, we review the articles describing the various scoring systems. Recent data regarding the comparison of each scoring system are also discussed. (Korean J Helicobacter Up Gastrointest Res 0;:7-77) Key Words: Gastrointestinal hemorrhage; Endoscopy; Risk assessment 서 론 상부위장관출혈 (nonvariceal upper gastrointestinal bleeding, NVUGIB) 은대부분응급처치를요하며높은사망률과이환율을보이는질환이다. 상부위장관출혈의가장흔한요인으로소화성궤양이약 % 에서 7% 로알려진다. 이외에도말로리-바이스증후군 (Mallory-Weiss syndrome), Dieulafoy 병변, 혈관이형성증과종양등이포함된다. 최근내시경기기및약물의발달에도불구하고상부위장관출혈의유병률은.5% 에서 7.4% 로높게보고된다. -5 따라서출혈이있는환자에서경과및예후를예측하기위한노력이필요하다. 현재상부위장관출혈환자에서위험도평가를위한여러점수체계가보고되나임상에서많이사용되지않는다. 그이유는대부분의점수체계들이임상에서적용하기복잡하기때문이다. 통상적으로상부위장관출혈환자에서 4시간이내에내시경검사를시행하도록권고하고있으나고위험군에서는조기에위내시경및집중적인치료가필요하다. 따라서점수체계를기반으로 Received: October 5, 0 Accepted: November 7, 0 Corresponding author: Byung-Wook Kim Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary s Hospital, College of Medicine, The Catholic University of Korea, 5 Dongsu-ro, Bupyeong-gu, Incheon 4, Korea Tel: +8--80-505, Fax: +8--80-5987, E-mail: gastro@catholic.ac.kr 신속하고정확한진료를시행하는것이도움이될수있다. 본종설에서는상부위장관출혈로내원한환자에서위험도를평가하는여러점수체계들에대해서살펴보았으며특히 05년도이후에발표된연구들을중심으로논하였다. 본론. 초기평가및수액치료상부위장관출혈환자가내원시치료는개별화되어야하며출혈을일으킨원인질환에따라다르다. 그러나모든환자에서내원시활력징후를측정해서혈역학상태를파악한후적절한수액요법을시행하는것이중요하다. 내원당시중추신경계증상이있거나저혈압, 빈맥등이발생하거나시간당요량이감소한경우는중증출혈로인한쇼크상태이니이런환자들에서는초기부터적극적인모니터링과수액처치및수혈이필요하다. 또한출혈이있더라도생리적보상작용에의해내원초기에는혈압이유지되고혈색소수치가정상으로나오는경우가있으니대량출혈이의심되는경우에는주의깊은관찰이필요하다.. 내시경전점수체계상부위장관출혈환자를평가하는점수체계들은크게내시경소견이포함되는체계들과포함되지않는것들로나눌수 Copyright 0 Korean College of Helicobacter and Upper Gastrointestinal Research The Korean Journal of Helicobacter and Upper Gastrointestinal Research is an Open-Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Korean J Helicobacter Up Gastrointest Res: Vol, No 4, December 0 Table. Parameters Included in the Rockall Variable 0 Age (yr) <0 0 79 80 Shock No shock Systolic BP>00 Tachycardia Systolic BP>00 Hypotension Systolic BP<00 Pulse<00 (/min) Pulse>00 Co-morbidity No major Cardiac failure Ischemic heart disease Any major co-morbidity Diagnosis Mallory-Weiss tear All other diagnosis Malignancy of upper No lesion and no SRH GI tract Major SRH None or dark spot Blood in upper GI tract Adherent clot Visible or spurting vessel Renal failure Liver failure Disseminated malignancy BP, blood pressure; SRH, stimata of recent hemorrhage; GI, gastrointestinal. Table. Parameters Included in the Glasgow-Blatchford Variable Admission risk marker Blooed urea (mmol/l).5, <8.0 8.0, <0.0 0.0, <5.0 5 Hemoglobin for men (mg/dl).0, <.0 0.0, <.0 <0.0 Hemoglobin for women 0.0, <.0 (mg/dl) <0.0 Systolic blood pressure (mmhg) Other markers 00 09 90 99 <90 Pulse 00 Melena Syncope Hepatic disease Cardiac failure component value 4 있다. 상부위장관출혈환자에서가장흔하게사용되는점수체계는 99년에발표된 Rockall score () 이다 (Table ). 7 는나이, 쇼크, 동반질환, 출혈의원인이되는진단, 내시경적출혈증거를포함하는총 5가지변수를사용하며, 출혈로내원한환자의 0일이내사망가능성을예측하기위해고안되었다. Preendoscopic (PE) 는 의 5가지변수중내시경검사를해야만알수있는출혈의원인이되는진단명과내시경적출혈증거를제외하여계산하는체계다. Glasgow-Blatchford score (GBS) 는수혈, 내시경치료, 수술의필요성및사망률등을예측하기위해개발되었다 (Table ). 8 GBS 는혈중요소, 혈색소, 수축기혈압, 맥박수, 흑색변이나실신유무, 간질환이나 Table. Parameters Included in the AIMS5 Risk factor Albumin <.0 mg/dl INR >.5 Altered mental status Systolic blood pressure <90 (mmhg) Age >5 yr Maximum score 5 심장질환유무에따라점수를주며내시경소견항목이없고전신질환의정도를구할필요가없어서간단히계산할수있는장점이있다. 그러나 GBS 의항목중간질환이나심장질환유무를판단하는데명확한기준이없으며혈중요소와실신의유무가병원도착당시의상황을잘대변하지않는다는지적이있다. 이런이유로응급실에내원했을때바로간편하게계산이가능한 AIMS5 score 가최근개발되었다 (Table ). 9,0 AIMS5 score 는저알부민혈증, 프로트롬빈시간지연, 의식저하, 수축기혈압감소, 고령의 5가지위험인자로구성되어있으며내원시객관적으로간편하게측정이가능하다는장점이있다. 최근연구들에서 AIMS5 는 및 GBS 와비교하여사망률등을예측하는데뒤지지않는것으로나타났다. 특히 AIMS5 score가 점이상인환자들을이하인환자들과비교했을때에사망률이증가한다는연구도있다. 그러나다른연구에서는 AIMS5 점이상인환자들에서사망률이증가한다고보고하여추후적정한 AIMS5 cutoff value 에대해서는연구가필요할것으로생각된다. 최근일본에서는혈압, 의식소실, 토혈, 혈색소수치, 혈중요소수치, 사구체여과율과항혈소판제의복용여부에따른새로운점수체계를발표하였다. 4 이점수체계는, GBS, AIMS5 보다내시경적지혈술을예측하는데더우수한 74
Joon Sung Kim and Byung-Wook Kim: Risk Strategy in NVUGIB 것으로나타났으나다른나라들에서검증이추후필요할것으로생각된다. 이탈리아에서는환자의전체적인컨디션, 맥박, 혈압, 혈색소의 4가지인자를이용한 T-score 가내시경에서고위험출혈병소 (high risk endoscopic stigmata) 와출혈과관련된사망률을예측하는데유용한것으로나타났다. 5 따라서 T-score 가조기에위내시경이필요한환자들을선별하는데에도움이될수있을것으로보인다.. 내시경후점수체계 앞서언급했듯이 는 5가지변수를사용하며, 출혈로내원한환자의 0일이내사망가능성을예측하기위해고안되었다. American Baylor score는 99년도에발표됐으며내시경지혈술을받은환자들에서재출혈을예측하기위해서고안되었다. Cedar Sinai score 는상부위장관출혈환자에서예후와입원기간을예측하기위해서발표되었다. 7 실제비교연구에서 는 American Baylor score와 Cedar Sinai score와비교하여상부위장관출혈환자들에서저위험환자들을예측하는데더우수한것으로나타났다. 8 Spanish Almela score 는외래에서치료가가능한저위험군을선별하기위해서만들어졌다. 9 최근에는 Italian Progetto Nazionale Emorragia Digestiva (PNED) score 가출혈후사망률을예측하기위해만들어졌으며 와비교시 0일사망률을예측하는데더뛰어난것으로나타났지만이탈리아이외의나라들에서검증이되지는않았 다. 0 현재내시경을포함하는점수체계중에서 가가장많이사용되며이보다더좋다고알려진점수체계는밝혀지지않았다. 그러나 는다소복잡하고내시경검사를시행한경우에만구할수있는단점이있다. 4. 해외에서여러점수체계비교최근미국에서상부위장관출혈환자에서 AIMS5 를 GBS,, PE 와비교하였다. 그결과 AIMS5 는사망률과중환자실입원의필요성을예측하는데다른점수들보다효과적인것으로나타났다. 최근유럽에서 5명의상부위장관출혈환자에서 GBS, PE, AIMS5 의유용성을조사하였다. 그결과세가지점수모두사망률및재출혈률의예측에는차이가없는것으로나타났으며, 수혈의예측에는 GBS 가가장우수한것으로나타났다. 또다른유럽연구에서상부위장관출혈로내원한 09명의환자들에서 AIMS5와 GBS 및 의유용성을조사하였다. 그결과세가지점수체계모두사망률을잘예측하였으나, 내시경적중재술은 AIMS5 와 GBS 가잘예측하는것으로나타났다. 그러나 AIMS5 는재출혈률예측에는도움이되지않는것으로나타났다. 미국에서 5세이상의상부위장관출혈환자들 5 명에서 GBS 와 AIMS5 의유용성을조사하였다. 4 그결과입원시사망률, 내시경, 방사선및수술적중재술의필요성을예측하는데 GBS 가 AIMS5 보다우수한것으로나타났다. 그러나두가지점수체계모두내시경적지혈술의 Table 4. Articles Regarding Comparison of Different Scoring Systems in Korea Authors Year Patients Scoring system Outcomes Conclusions Park et al. 0 0 5 AIMS5 GBS PE Yang et al. 8 0,584 GBS PE 0-d mortality Endoscopic intervention Transfusion Hospital intervention Therapeutic intervention Death Hypotension AIMS5,, PE >GBS: 0-d mortality GBS, pre-, >AIMS5: rebleeding GBS >AIMS5, pre-, : transfusion >AIMS5, GBS, pre-: intervention GBS, >PE: hospital based intervention, PE >GBS: death >GBS, PE: rebleeding Kim et al. 7 0 747 GBS PE GBS, PE not sufficient for predicting hypotension Park et al. 9 05 4 AIMS5 Mortality AIMS5 superior to RA in predicting mortality Jung et al. 04 5 AIMS5 Clinical outcomes AIMS5 not useful for predicting outcomes in PUB Kim et al. 008 9 Forrest Forrest, Cedars-Sinai, GBS usefull for rebleeding Death Forrest, usefull for death Baylor College Cedars-Sinai GBS Oh et al. 5 004 75 Forrest Mortality GBS, Glasgow-Blatchford score; PE, preendoscopic Rockall score;, Rockall score. Rockall usefull for predicting rebleeding and mortality 75
Korean J Helicobacter Up Gastrointest Res: Vol, No 4, December 0 예측에는도움이되지않는것으로나타났다. 5. 국내에서여러점수체계비교 국내에서는 004년에소화성궤양출혈환자에서 를 Forrest 분류와비교했을때재출혈률및사망률예측에독립적인예견인자인것으로보고하였다. 5 반면 Forrest 분류는재출혈률은예측하나사망률은예측하지못하는것으로나타났다. 이는재출혈의예견은내시경소견이중요하지만, 사망률은동반된임상질환이나연령이중요하게작용하는것을시사한다. 이후다른국내연구에서는 00년부터 0년까지상부위장관출혈로내원한 5 명의환자들에서 AIMS5 의유용성을조사하였다. 그결과 AIMS5 는소화성궤양출혈환자의예후를예측하지못하는것으로나타났다. 저자들은그이유를 AIMS5 점수에포함되어있는알부민과프로트롬빈수치가간경화환자들의예후를나타내는지표이기때문으로설명하였다. 또다른국내연구에서상부위장관출혈로내원한환자에서 GBS 와 PE 가저혈압의발생을예측할수있는지조사하였다. 7 그결과 GBS 와 PE 모두내원당시정상혈압인환자들에서 4시간이내에저혈압의발생을예측하는데부적합한것으로나타났다. 이외에도경북지역다기관연구에서,584명의상부위장관출혈환자들에서 GBS,, PE 의유용성을비교하였다. 8 그결과 GBS 와 는중재시술을예측하는데우수했으며, 는사망률과재출혈을예측하는데우수한것으로나타났다. 그러나어떤점수체계도재출혈을완벽하게예측하지는못하는것으로나타났다. 또다른국내연구에서소화성궤양출혈환자 4명에서 AIMS5를 와비교시사망률을예측하는데더유용하며특히 AIMS5 점수가높은환자들에서는긴급내시경을시행하는게좋겠다고보고하였다. 9 최근에 Park 등 0 은상부위장관출혈로내원한 5명의환자들을분석한결과 0일사망률이.4%, 재출혈률.5% 로보고하였다. Park 등 0 의분석에서 는내시경지혈의필요성을예측하는데가장유용하였으며 GBS 는수혈을예측하는데가장유용한것으로보고하였다. AIMS5 는사망률, 수혈, 내시경치료를예측하는데유용했으나 와 GBS 보다뛰어나지는않는것으로나타났다 (Table 4). 5- 결 론 최근에국내에서많은점수체계의유용성을검증하고임상상황에적용하려는연구들이발표되고있다. 그러나어느한점수체계도완벽하게여러임상결과들을완벽하게는예측하지못하는것으로나오고있으며결국은의사의경험에근거한판단이중요할것으로생각된다. 실제로의사의직감이상부위장관 출혈환자에서시술의필요성, 재출혈, 사망률을예측하는데중요하다는연구도보고되었다. 이연구에서기존의점수체계에의사의직감을같이사용했을때에재출혈과사망률을가장잘예측하는것으로나와임상의의판단이중요함을보여주고있다. 인구의고령화로인하여아스피린을포함하는항혈소판제와항응고제의복용이상부위장관출혈의중요한원인인자이다. 그러나현재알려진대부분의점수체계들은이러한약제에관한내용이포함되지않았다. 또한대부분의점수체계들이서양에서만들어져헬리코박터유병률이높고의료기관및내시경에대한접근성이좋은국내의현실에는맞지않을수있다. 따라서국내상황에맞는점수체계와지침의개발이이루어져야할것으로생각된다. REFERENCES. Kim KB, Yoon SM, Youn SJ. Endoscopy for nonvariceal upper gastrointestinal bleeding. Clin Endosc 04;47:5-9.. Holster IL, Kuipers EJ. Management of acute nonvariceal upper gastrointestinal bleeding: current policies and future perspectives. World J Gastroenterol 0;8:0-07.. Hearnshaw SA, Logan RF, Lowe D, Travis SP, Murphy MF, Palmer KR. Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 007 UK audit. Gut 0;0:7-5. 4. Leontiadis GI, Molloy-Bland M, Moayyedi P, Howden CW. Effect of comorbidity on mortality in patients with peptic ulcer bleeding: systematic review and meta-analysis. Am J Gastroenterol 0;08:-45; quiz 4. 5. Targownik LE, Nabalamba A. Trends in management and outcomes of acute nonvariceal upper gastrointestinal bleeding: 99-00. Clin Gastroenterol Hepatol 00;4:459-4.. Gralnek IM, Dumonceau JM, Kuipers EJ, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 05;47:a-a4. 7. Rockall TA, Logan RF, Devlin HB, Northfield TC. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 99;8:-. 8. Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 000;5:8-. 9. Saltzman JR, Tabak YP, Hyett BH, Sun X, Travis AC, Johannes. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointest Endosc 0;74:5-4. 0. Nakamura S, Matsumoto T, Sugimori H, Esaki M, Kitazono T, Hashizume M. Emergency endoscopy for acute gastrointestinal bleeding: prognostic value of endoscopic hemostasis and the AIMS5 score in Japanese patients. Dig Endosc 04;:9-7
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