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目的分析异基因造血干细胞移植(alloHSCT)后重症胃肠道(GI)出血的临床特征、原因、治疗和转归。方法观察并分析15例白血病患者在alloHSCT后发生的急性(导致失血性休克)或亚急性(需要连续2d以上每日输注≥1U红细胞)胃肠道失血。结果15例患者共发生17次重症GI出血事件,发生时间分为早期(1周内)、中期(1～2个月)、晚期(4～7个月)。早期出血均有呕血和便血,中、晚期出血以便血为多见。出血发生时,绝大多数患者血小板<50×109/L。出血原因:预处理不良反应2例次;移植物抗宿主病(GVHD)或伴有(或疑诊)肠道巨细胞病毒(CMV)和真菌感染因素11例12例次;CMV肠炎1例次;消化性溃疡出血2例次;不明原因1例次。经过输注血小板、红细胞和新鲜血浆以及H2受体阻滞剂和奥美拉唑等支持治疗,由GVHD或伴有(或疑诊)CMV肠炎所致的出血同时予以免疫抑制剂和(或)抗病毒药等针对出血病因的治疗,最终8例9例次出血得以控制,8例患者持续出血直至死亡,主要死因为难治的急性GVHD和(或)相关合并症。结论alloHSCT后重症GI出血的主要原因为预处理不良反应和GVHD或伴有(或疑诊)CMV肠炎,前者多为自限性,预后良好,后者治疗难度较大,具有高度的病死率。
Objective To analyze the clinical features, causes, treatment and prognosis of severe gastrointestinal (GI) bleeding after alloHSCT. Methods Acute (hemorrhagic shock) or subacute (more than 1 U red blood cells requiring more than 2 days daily infusion) gastrointestinal bleeding occurred in 15 patients with leukemia after alloHSCT were observed and analyzed. Results A total of 17 severe GI bleeding events occurred in 15 patients. The onset time was divided into early stage (within 1 week), middle stage (1 to 2 months) and late stage (4 to 7 months). Hemorrhagic hematemesis and hematochezia are both early bleeding, middle and late bleeding in order to blood is more common. Bleeding occurs, the vast majority of patients with platelets <50 × 109 / L. Causes of hemorrhage: 2 cases of pretreatment adverse reactions; graft-versus-host disease (GVHD) or associated (or suspected) enteric cytomegalovirus (CMV) and fungal infection in 11 cases in 12 cases; CMV enteritis in 1 case ; Peptic ulcer bleeding 2 times; unexplained 1 case times. After infusion of platelets, red blood cells and fresh plasma and H2 receptor blockers and omeprazole and other supportive treatment, GVHD or bleeding associated with (or suspected) CMV enteritis while immunosuppressive agents and / Antiviral drugs for the treatment of bleeding etiology, the final 8 cases of 9 cases of bleeding control, 8 patients continued bleeding until death, the main cause of death was refractory acute GVHD and / or related complications. Conclusions The main causes of severe GI bleeding after alloHSCT are pretreatment adverse reactions and GVHD or CMV enteritis associated with (or suspected), the former mostly self-limiting and the prognosis is good. The latter is difficult to treat and has a high mortality.