急性上消化道出血是指屈氏韧带以上的食管、胃、十二指肠和胰管、胆管病变引起的急性出血，胃空肠吻合术后吻合口附近的空肠上段病变所致出血也属这一范围。常见病因有消化性溃疡、肝硬化门脉高压症、应激性溃疡、恶性肿瘤及胆道出血等，临床以前两者多见。

    急性上消化道出血的治疗措施是补充血容量，先以补液为主，必要时输血。临床对急性上消化道出血患者的血红蛋白降至何值时需要输血还有争议，发表在2013年1月3日《新英格兰医学杂志》中的一项研究将有限制条件的输血方案与无限制条件的两种输血方案进行了比较。

    研究纳入921名急性重症上消化道出血的患者，随机分为两组，其中，461名接受有限制条件的输血方案（当每100mL血液的血红蛋白含量低于7g时给予输血），460名接受无限制条件的输血方案（每100mL血液的血红蛋白含量低于9g时就给予输血），并按照有无肝硬化进行随机化分层。

    结果显示，1.限制性输血组有225名（51%）患者未接受输血，无限制输血组有65名（15%）未接受输血。2.可靠存活概率：有限制的输血组高于无限制的输血组（P=0.02）。3.再次出血：有限制的输血组中有10%的患者发生再次出血，而无限制的输血组中有16%的患者发生再次出血（P=0.01）。4.不良反应：有限制的输血组中有40%的患者出现不良反应，而无限制的输血组中有48%的患者出现（P=0.02）。5.在上消化道溃疡出血的亚组中，采用有限制的输血方案患者的幸存概率略高于无限制的输血方案；在肝硬化Child-Pugh A级和B级患者的亚组中，采用有限制的输血方案患者的幸存概率明显高于无限制的输血方案；但是在肝硬化C级患者中，前者并未高于后者。6.在治疗后的第五天，无限制输血组的门脉压力升高梯度明显高于有限制的输血组。

    研究者认为，与无限制条件的输血方案相比，有限制条件的输血方案能够明显改善急性上消化道出血患者的治疗效果。

    Transfusion Strategies for Acute Upper Gastrointestinal Bleeding

    Càndid Villanueva, M.D., Alan Colomo, M.D., Alba Bosch, M.D., Mar Concepción, M.D., Virginia Hernandez-Gea, M.D., Carles Aracil, M.D., Isabel Graupera, M.D., María Poca, M.D., Cristina Alvarez-Urturi, M.D., Jordi Gordillo, M.D., Carlos Guarner-Argente, M.D., Miquel Santaló, M.D., Eduardo Muñiz, M.D., and Carlos Guarner, M.D.N Engl J Med 2013; 368:11-21January 3, 2013DOI: 10.1056/NEJMoa1211801

    Background: The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy.

    Methods: We enrolled 921 patients with severe acute upper gastrointestinal bleeding and randomly assigned 461 of them to a restrictive strategy (transfusion when the hemoglobin level fell below 7 g per deciliter) and 460 to a liberal strategy (transfusion when the hemoglobin fell below 9 g per deciliter). Randomization was stratified according to the presence or absence of liver cirrhosis.

    Results: A total of 225 patients assigned to the restrictive strategy (51%), as compared with 65 assigned to the liberal strategy (15%), did not receive transfusions (P<0.001). The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P=0.01), and adverse events occurred in 40% as compared with 48% (P=0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child–Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child–Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P=0.03) but not in those assigned to the restrictive strategy.

    Conclusions: As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding.