每日一题_2024.05.16

A 79-year-old woman presented to the emergency department with a 3-day history of hematemesis, melena, and epigastric pain. Approximately 1 day before the onset of symptoms, nonbloody vomiting had developed after she had eaten unrefrigerated food. She was taking aspirin daily for coronary artery disease. Her heart rate was 102 beats per minute, and her blood pressure was 89/66 mmHg. Physical examination was notable for pallor and diaphoresis. Her hemoglobin level was 9.1 g per deciliter (reference range, 11 to 15), a decrease from a baseline level of 12 g per deciliter 6 months previously. Computed tomography of the chest was performed to evaluate for esophageal rupture and showed only a mucosal tear and soft-tissue swelling at the gastroesophageal junction. An upper endoscopy was performed. A diagnosis of Mallory-Weiss syndrome was made. Which of the following would be the LEAST appropriate next step in management for this diagnosis?

一位79岁的女性因3天的呕血、黑便和上腹痛被送至急诊科。在症状发作前大约1天，她在吃了未冷藏的食物后出现了非血性呕吐。她因冠状动脉疾病每天服用阿司匹林。她的心率为每分钟102次，血压为89/66毫米汞柱。体检时发现面色苍白和出汗。她的血红蛋白水平为每分升9.1克（参考范围，11至15克），比6个月前的基础水平12克每分升有所下降。为了评估食管破裂，进行了胸部计算机断层扫描，只显示了胃食管交界处的粘膜撕裂和软组织肿胀。随后进行了上消化道内窥镜检查。诊断为马洛里-维斯综合征。对于这一诊断，下列哪一步是管理中最不恰当的下一步？

A. Acid suppression 酸抑制剂

B. Anti-emetics 抗呕吐药

C. Endoscopic therapy for bleeding 内窥镜治疗出血

D. Fluid resuscitation 液体复苏

E. Tranexamic acid 氨甲环酸

答案解析：

在这种上消化道出血综合征中，反复干呕导致浅表黏膜撕裂伤，最常发生在胃食管交界处。通常只有一个撕裂伤，但也可能出现更多撕裂伤，就像这个病例。给予质子泵抑制剂和氟喹诺酮类药物治疗(针对之前可能发生的细菌性胃肠炎)。

马洛里-维斯综合征（Mallory-Weiss syndrome）通常是由剧烈呕吐引起的食管下端粘膜撕裂，导致上消化道出血。治疗通常包括液体复苏、酸抑制以减少胃酸分泌，以及抗呕吐药物来控制症状。如果出血严重，可能需要内窥镜治疗来止血。氨甲环酸是一种抗纤维蛋白溶解药物，通常用于治疗与纤维蛋白溶解过度有关的出血，但在马洛里-维斯综合征中，它通常不是首选治疗，因为这种综合征的出血通常是自限性的，并且酸抑制和内窥镜治疗是更常用的方法。（来自kimi解答）

正确答案：E