服用阿司匹林和氯吡格雷易致胃肠道出血，该如何应对？

2021-11-21 航海消化航海消化

两条咸鱼

陕西省西安市中心医院医生/ 医师

一学就会！

大部分血栓患者都需要用药物来进行治疗，药物的种类很多，而且很多都是必备药物，其中阿司匹林和氯吡格雷就是抗血栓的常见药物。本文分享服用阿司匹林和氯吡格雷预防胃肠道出血方面的相关内容，供大家参考。

阿司匹林和氯吡格雷

对哪类血栓有效？

阿司匹林和氯吡格雷是抗血小板药物，主要用于动脉血栓栓塞性疾病的预防和治疗。对于静脉血栓栓塞性疾病和心腔内血栓形成抑制作用较弱，其抗栓疗效明显弱于抗凝药物，不作为首选。

哪些患者需要口服

阿司匹林和氯吡格雷？

阿司匹林曾经广泛应用于动脉粥样硬化性心血管病(ASCVD)的一级预防。但阿司匹林用于ASCVD 一级预防时可显增加非致死性大出血事件（胃肠道出血和颅内出血）。因此，只有在获益明显超过风险时，使用阿司匹林进行一级预防才有意义。

目前阿司匹林主要用于心血管疾病的二级预防，包括：

①慢性稳定型心绞痛。

②急性冠状动脉综合征。

③冠状动脉介入治疗术后（通常12个月，取决于是否植人支架及种类）。

④冠状动脉旁路移植术（CABG）)后。

⑤外周动脉疾病。

⑥缺血性卒中。

⑦短暂性脑缺血发作（TIA）等。

在诊断急性冠脉综合征（ASC）和经皮冠脉介入治疗（PCI）、植入药物洗脱支架（DES）术后的冠心病人，除阿司匹林外还要联用氯吡格雷来预防血栓再形成，俗称为“双抗”（DAPT）治疗。

“双抗”治疗1000例至少可减少心血管事件20例。然而，“双抗”治疗是个双刃剑，也可造成胃肠糜烂、溃疡和出血，甚至是大出血。

为何服用阿司匹林和氯吡格雷

易发生胃肠出血？

阿司匹林是可脂溶性有机酸，可直接渗透胃黏膜造成损伤或间接通过抑制前列腺素的产生。氯吡格雷可阻碍释放血小板血管内皮生长因子，两者致胃肠黏膜失去保护和修复作用。因此，两者合用抗血小板凝聚作用亦最强，同时造成胃肠出血的可能性亦增大。

胃肠黏膜损伤后出现糜烂、溃疡，侵袭黏膜下血管导致出血，侵袭到毛细血管导致小量出血，侵袭小静脉时中等量出血，侵袭小动脉时可导致大量出血，并可能危及生命。

“双抗”药物剂量越大，出血可能越大，多数发生在服药后3个月内，但出血的可能性有时难以预见，个体间存在很大差异，可能与个体基因改变相关。

服药后胃肠道损伤

和出血的表现有哪些？

①当出现腹部不适、腹痛、反酸、嘈杂、大便习惯改变时，说明有了胃肠损伤症状；

②当感到乏力、头昏时，查出有贫血、大便隐血试验阳性时，说明已有小量胃肠道出血；

③当大便呈柏油样时，说明已经有小到中等量胃出血；

④当解柏油样便同时呕血伴有头昏、心悸时，说明已是中等至大量出血；

⑤当呕血同时解暗红色便，伴有冷汗、少尿、黑蒙时，说明胃内大出血。

哪些患者“双抗”时易发生出血？

①年龄大于65岁慎用，大于80岁不用；

②原有或现有胃十二肠溃烂史或有家族史者；

③现有糜烂性胃炎、溃疡性结肠炎等活动性炎症者；

④现有幽门螺杆菌感染者未予以根治者；

⑤曾有服阿司匹林或其它止痛药有出血史者；

⑥同时服用止痛药、强的松等；

⑦伴有有严重肝病、肾病和血液病史；

⑧伴有上消化道梗阻和胃排空不畅病史者；

⑨生活无规律、压力大、喜刺激饮食者；

⑩有特异体质、阿司匹林药物过敏史者。

必要时根除幽门螺杆菌

①有上述危险因素或出现上腹不适疼痛时，选用质子泵抑制剂、H2-受体拮抗剂、黏膜保护剂等进行保护性治疗。一般联合使用6个月左右，6个月后改为按需用药，即有症状时口服，好转时停用。

②有溃疡病史者应行胃镜快速尿素酶试验或13碳尿素呼气试验检测幽门螺杆菌，如阳性者给予根除治疗，通常选用一种铋剂+质子泵抑制剂+二种抗菌素治疗10-14天，治疗后20天左右复查是否达到根治。

如何做到正确用药？

①低小剂量：小剂量阿司匹林为<100mg/日、小剂量氯吡格为75mg/日；“双抗”治疗开始时剂量可增加，须在心脏专科医生指导下使用。

②规范疗程：单纯阿司匹林口服无上述危险因素时可长期服用，80岁以上人群不再推荐继续用药，上述冠心病病员的“双抗”治疗一般6-18个月，是否延长根据个体化指导。

③正确服用：尽量选用肠溶片；肠溶片也应在餐前口服；不能压碎服或从胃管内注入；有胃肠排空差梗阻者谨防药物在胃食管内滞留溶解损伤黏膜。

一旦消化道出血后如何自救？

①呕血后应冷静不要慌张，立即平趟卧床，不能突然站立，防止站立时头昏眼前发黑跌倒。

②呕血时头要偏向一侧及时吐出防止窒息，不能大幅度硬呕防止更大出血，含漱冷开水或矿泉水将口中血液清除减轻恶心反射。

③出血原因不明时暂不要进食，以便能行急诊胃镜诊断和治疗。

④立即呼叫120救护，在家人朋友安排下尽快到医院就诊，尽快静脉补液、生命体征监护、吸氧、抽血检查等。

出血后相关性的

治疗措施有哪些？

①静脉或口服质子泵抑制剂抑制胃酸胃蛋白酶，口服胃黏膜保护剂促进胃黏膜修复。

②在积极静脉补液抗休克的同时，有条件医院可进行急诊胃镜止血。严格输血指征，血压正常，血球压积＞25%或血红蛋白＞80g/L可暂不输血。

③出血稳定6小时以上，可进少量粥米汤之类流汁，1-2天后可见半流汁饮食。出血后2~4天内注意卧床休息，不能突然站立以防体位性低血压跌倒。

胃肠出血后

如何进行抗血小板治疗？

①发生胃肠道出血并发症后是否用药需由医生评估血栓和出血的发生风险。

②一般糜烂性胃炎出血3-7天后可恢复阿司匹林口服，胃十二指肠溃疡治疗8周愈合后恢复抗血小板治疗。

③阿司匹林致溃疡出血有复发可能，建议阿司匹林和质子泵抑制剂联合应用。

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2021-11-25 1e19ea9dm99(暂无匿称)

还可以吧

108 0
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2021-11-22 ms8000000222119546

学习了

100 0
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2021-11-23 liao1619

#胃肠道#

63 0
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2021-11-23 124987a0m66(暂无昵称)

#胃肠道出血#

104 0
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2021-11-22 50277

第一：把握好适应症；2.注意禁忌症；3.适当保护胃粘膜。

84 0
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2021-11-22 zhizhuoliu

受益匪浅

95 0
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2021-11-22 moyanju2796

好文。

106 0

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服用阿司匹林和氯吡格雷易致胃肠道出血，该如何应对？

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