内镜下胃底组织胶注射联和套扎术对肝硬化患者食管胃底静脉曲张程度的影响

目的 探讨内镜下胃底组织胶注射联和套扎术治疗肝硬化食管胃底静脉曲张（EGV）的疗效及安全性.方法 研究对象为同期收治的76例肝硬化EGV破裂出血患者,均于内镜下选好胃底靶静脉以＂三明治＂法注射组织胶,并自胃食管黏膜连接处开始向近端螺旋式结扎曲张静脉.随访8周,观察不良反应及并发症发生情况,并复查胃镜判定EGV程度.结果 无异位栓塞等严重不良反应发生,2例出现再出血、再次注射组织胶后止血;食管静脉曲张和胃底静脉曲张程度降低者分别占88.2%和75.0%.结论 内镜下胃底组织胶注射联和套扎术可明显减轻肝硬化食管EGV程度,且操作简单、安全性高.     

食管胃静脉曲张合并上消化道浅表黏膜病变的内镜下治疗

目的探讨肝硬化食管胃静脉曲张合并上消化道浅表黏膜病变的内镜下治疗策略。方法收集2017年1月至2018年2月在我院消化内科行内镜下治疗的7例肝硬化食管胃静脉曲张合并上消化道浅表黏膜病变患者的临床资料,进行回顾性分析,总结其临床特征、内镜下表现、治疗方法及并发症。结果 7例患者年龄(56. 9±4. 5)岁。7例患者中2例黏膜病变位于曲张静脉之上。7例患者中6例先行内镜下静脉曲张治疗,后对黏膜病变行内镜黏膜下剥离术(ESD)治疗,1例在静脉曲张治疗同时对胃底黏膜病变行ESD治疗,合并的贲门黏膜病变择期处理。所有患者均未出现出血、穿孔等严重并发症。结论对于肝硬化食管胃静脉曲张合并上消化道浅表黏膜病变的内镜下处理,要综合衡量患者的凝血功能、静脉曲张与黏膜病变的处理时机以及相对位置关系。     

蔓状隆起型胃底静脉曲张内镜下套扎 与组织胶注射治疗的对比分析

目的评价蔓状隆起型胃底静脉曲张内镜下套扎与组织胶注射治疗带来的风险与获益。方法2015年6月—2020年6月,因食管胃底静脉曲张在安徽医科大学第一附属医院消化内科接受内镜下静脉曲张套扎术或内镜下组织胶注射术治疗,符合胃底曲张静脉呈蔓状隆起（Hashizume标准F1型）的食管胃连通型血管（LDRf分型标准Le,gf型）病例193例纳入回顾性分析,按治疗方式分成胃底及食管套扎组（胃底和食管曲张静脉均行内镜下套扎术治疗,32例）、组织胶组（胃底曲张静脉行内镜下组织胶注射术治疗、食管曲张静脉行内镜下套扎术治疗,71例）和单纯食管套扎组（仅食管曲张静脉行内镜下套扎术治疗,90例）,对比分析3组的再出血率、治疗有效率、治疗显效率和并发症发生情况。结果（1）再出血率胃底及食管套扎组、组织胶组和单纯食管套扎组分别为18.75%（6/32）、12.68%（9/71）和3.33%（3/90）,仅在胃底及食管套扎组与单纯食管套扎组间差异有统计学意义（χ2=6.110,P＜0.016）。（2）3组治疗有效率均为100.00%。治疗显效率胃底及食管套扎组、组织胶组和单纯食管套扎组分别为37.50%（12/32）、25.35%（18/71）和14.44%（13/90）,仅在胃底及食管套扎组与单纯食管套扎组间差异有统计学意义（χ2=7.702,P＜0.016）。（3）3组均未出现肺部感染、肝性脑病、自发性细菌性腹膜炎和穿孔。胸痛或腹痛发生率胃底及食管套扎组、组织胶组和单纯食管套扎组分别为18.75%（6/32）、11.27%（8/71）和2.22%（2/90）,仅在胃底及食管套扎组与单纯食管套扎组间差异有统计学意义（χ2=10.524,P＜0.016）。发热、恶心呕吐发生率3组间差异均无统计学意义（P＞0.05）。结论胃底和食管静脉曲张同时行内镜下套扎术治疗,以及胃底静脉曲张行内镜下组织胶注射术联合食管静脉曲张行内镜下套扎术治疗,对于蔓状隆起型胃底静脉曲张病例并无更多获益,而单纯行食管静脉曲张内镜下套扎术治疗可能获益更多。     

内镜下圈套结扎治疗食管静脉曲张的体会

在我国食管胃底静脉曲张(EGV)破裂出血是肝硬化门脉高压症(PHG)患者常见的死亡原因，其病死率达30％-40％以上，20％-30％的肝硬化食管静脉曲张(EV)患者迟早会发生出血(EVB)。内镜下食管静脉套扎术(EVL)是近年来治疗食管静脉曲张的一种新方法。我院自1997-2003年对21例食管静脉曲张患者行内镜下圈套结扎治疗，现报告如下。     

食管胃底静脉曲张破裂出血紧急硬化治疗18例

目的评价5%鱼肝油酸钠内镜下静脉注射法进行紧急硬化治疗对食管胃底静脉曲张破裂出血的疗效。方法对18例食管胃底静脉曲张破裂出血住院患者,用5%鱼肝油酸钠,行镜下曲张静脉内注射,观察止血效果、副作用和并发症。结果17例成功止血,止血成功率为94.4%。全部病例均有短期可忍受的胸骨后疼痛,1例呼吸骤停(经抢救治愈)。结论5%鱼肝油酸钠内镜下静脉内注射法紧急硬化治疗是食管胃底静脉曲张破裂出血的一种有效、方便和比较安全的止血方法。     

内镜下套扎治疗食管/胃底静脉曲张的临床观察

[目的]观察经胃镜下行套扎治疗食管/胃底静脉曲张的临床疗效。[方法]对122例因食管和(或)胃底静脉曲张致上消化道出血的患者行内镜下套扎治疗。[结果]122例中,对行多次套扎治疗的86例随访观察3年,均未因静脉曲张发生上消化道出血;9例失访;27例未能坚持行多次套扎,6~12个月均发生上消化道出血。[结论]食管/胃底静脉曲张内镜下套扎治疗,疗效确切,并发症发生率低,临床上有较强应用价值。     

胃底曲张静脉内镜下组织胶注射治疗并发大面积脾梗死1例

患者男性,64岁,主因“食管胃底曲张静脉内镜下治疗后复诊”于2018年9月28日入院。患者于8年前发现有HBV感染,就诊于当地医院,曾给予口服阿德福韦酯片6年,后口服恩替卡韦片抗病毒治疗至今。曾于2017年9月25日因呕血来我科住院治疗,行内镜下胃底曲张静脉组织胶注射治疗后止血成功,恢复可。     

食管胃底静脉曲张镜下治疗后早期再出血临床观察

目的 总结食管胃底静脉曲张镜下治疗前出血量、治疗后早期再出血量及再出血后死亡的发生率.方法 收集友谊医院近5年来396例次肝硬化食管胃底静脉曲张出血患者的临床资料,分析食管胃底静脉曲张结扎术和(或)内镜下组织胶注射早期再出血的特点、原因及转归.结果 镜下治疗术后早期再出血的发病率为6.6％ (26/396).早期再出血后死亡率为7.7％(2/26).镜下治疗术后早期再出血的出血量为(177.0±88.8)ml,与治疗前食管胃底静脉曲张出血量[(528.0±298.0)ml]比较,差异有统计学意义(P＜0.05).结论 镜下食管胃底静脉曲张结扎术和(或)内镜下组织胶注射治疗食管胃底静脉曲张出血,操作简便、安全,术中风险小,术后出血量少.     

内镜下组织胶注射联合套扎术治疗食道胃底静脉曲张出血的疗效观察

目的 探讨食道静脉曲张套扎术联合胃底静脉曲张组织治疗术治疗肝硬化食道胃底静脉曲张急性出血的的临床意义.方法 56例确诊肝硬化门脉高压食道或胃底静脉曲张急性出血的患者,于出血24 h内行食道静脉曲张套扎术联合胃底静脉曲张组织胶注射治疗,术后1、3、6个月行内镜随访,观察再出血率、食道胃底静脉曲张好转情况.结果 56例病人全部止血成功,1个月内再发出血5例,3例为排胶期轻度渗血,2例出血量较大,5例病人重新进镜行内镜下喷洒正肾液后血止;6个月内复查无再出血发生.食道静脉曲张治疗有效率为96%,胃底静脉曲张治疗有效率为95%.结论 肝硬化食道胃底静脉曲张急性出血应用内镜组织胶注射联合曲张静脉套扎术是一种安全、疗效肯定的的治疗方法.     

胃底静脉曲张组织胶治疗并发脑动脉空气栓塞一例

胃底静脉曲张出血是肝硬化严重并发症,内镜下组织胶注射治疗已成为胃底静脉曲张的一线治疗,其异位栓塞等并发症也多次被报道。本篇报道了1例胃底静脉曲张急诊出血病例,行内镜下组织胶注射治疗后出现罕见的脑动脉空气栓塞。     

门静脉高压症患者食管静脉曲张多层螺旋CT与内镜分级的相关性

目的探讨门静脉高压症食管静脉曲张多层螺旋cT与内镜分级的相关性。方法选择2013年1至5月四川大学华西医院内镜诊断为食管静脉曲张的30例门静脉高压患者。对患者进行内镜分级和多层螺旋cT分级。采用Spearman等级相关分析检验食管静脉曲张多层螺旋CT分级结果与内镜分级结果的相关性。结果30例患者食管静脉曲张内镜分级结果：4例（13％）为轻度曲张,7例（23％）为中度曲张,19例（63％）为重度曲张。多层螺旋CT分级结果：5例（17％）为1级曲张,8例（27％）为2级曲张,17例（57％）为3级曲张。Spearman等级相关分析结果显示,食管静脉曲张多层螺旋CT和内镜分级结果不具有很好的相关性（r=0．339,P〉0．05）。结论食管静脉曲张多层螺旋CT与内镜分级不具有很好的相关性,使用多层螺旋CT对食管静脉曲张进行分级的相关标准有待探索。     

Control of isolated gastric varices by combination therapy using embolization and endoscopic scleroligation therapy

Balloon-occluded retrograde venous obliteration is a powerful new technique for eliminating gastric varices. However anatomic considerations may preclude its use in some instances. Two cases are reported in which combination embolization followed by endoscopic injection scleroligation therapy eradicated isolated gastric varices where balloon-occluded retrograde venous obliteration was impossible. Two men with alcoholic cirrhosis were admitted with bleeding gastric varices. Inability to access variceal venous drainage precluded balloon-occluded retrograde venous obliteration. In Case 1, transileocolic vein obliteration left gastric embolization, and partial splenic embolization only partially eradicated gastric varices. In Case 2, percutaneous transhepatic obliteration, left gastric embolization, and partial splenic embolization were only partially successful. In both cases, endoscopic injection scleroligation therapy was performed adjunctively. Endoscopic injection scleroligation therapy completely eradicated gastric varices in both patients following partially successful embolization therapy. These cases demonstrate the importance of individualizing treatment of esophageal varices, the value of combination therapy, and the effectiveness of endoscopic injection scleroligation therapy for treating varices.     

胃静脉曲张内镜下黏合剂栓塞治疗后排胶与再发出血的关联

目的研究胃静脉曲张内镜下黏合剂栓塞治疗后排胶过程与再发出血之间的关联和影响。 方法回顾性分析2010年1月至2017年7月期间,上海交通大学医学院附属瑞金医院消化科病房收治,经胃镜检查明确存在胃静脉曲张,并接受了内镜下黏合剂注射栓塞治疗术的患者,对其行内镜随访至少1年,分析其病史资料、内镜所见、治疗情况及随访结果。 结果总计55例患者接受了内镜下胃静脉曲张黏合剂注射栓塞治疗术,其中男性33例,女性22例,平均年龄(60.0±14.6)岁,其中GOV1型12例(21.8%),GOV2型11例(20.0%),IGV1型32例(58.2%)。共行黏合剂治疗58次,注射部位64点,平均每点注射1%聚桂醇(3.79±1.55)ml,组织黏合剂(3.02±1.17)ml。所有患者在1年的随访期间均生存,10例患者(7例IGV1型,3例GOV2型)再发上消化道出血共11次,其中排胶溃疡未愈8次、静脉曲张再发出血2次、胃角溃疡出血1次。排胶溃疡完全愈合的时间平均为(8.3±3.4)个月,其中36例患者(69.2%)于术后4～9个月完成整个排胶过程。对排胶过程≥12个月的患者共9例随访至2年,所有患者均完成排胶,且随访期间未发生上消化道出血。 结论内镜下黏合剂注射栓塞治疗术为胃静脉曲张破裂出血的重要二级预防手段。黏合剂注射术后排胶为正常现象,术后再发出血可能和曲张静脉栓塞不完全相关,确保曲张静脉完全栓塞或有助于降低术后再发出血风险。     

Endoscopic Injection Sclerotherapy for the Treatment of Recurrent Esophageal Varices after Esophageal Transection

Background: We examined the hemodynamic changes associated with recurrent esophageal varices after esophageal transection (ET) and evaluated the effectiveness of endoscopic injection sclerotherapy (EIS) as the treatment for these varices. Methods: Nineteen patients with recurrent esophageal varices after ET were treated by EIS. Endoscopic varicealography during injection sclerotherapy, following oral blockage of flow by a balloon, identified three patterns: (i) type 1: common type, continuous filling by the feeder vessel of the varix; (ii) type 2: retrograde‐disappearing type, confirmed hepatofugal flow; and (iii) type 3: immediate washout type, immediate washout of contrast medium. Results: Angiography revealed that the hepatofugal feeder vessel was the right gastric vein in all cases. Fourteen patients (73.7%) were classified as type 1, 4 patients (21.1%) as type 2, and 1 patient (5.3%) as type 3. Fewer treatment sessions were required in type 1 than in type 2 (P < 0.005). Recurrent varices were completely eradicated in all patients except the patient with type 3 disease. Cumulative re‐recurrence rates at 5 and 10 years were similar for types 1 and 2 (28.6 and 71.4%vs 25 and 25%, respectively). The cumulative survival rates after EIS at 5 and 10 years were also similar for types 1 and 2 (77.1 and 66.1%vs 66.7 and 66.7%). Conclusion: Endoscopic injection sclerotherapy is an effective treatment for recurrent esophageal varices after ET, except in type 3 disease. Our classification based on endoscopic varicealography during injection sclerotherapy provides knowledge of blood flow within the varices that helps to inform the treatment strategy.     

内镜治疗食管胃静脉曲张前后门体侧支循环的变化

目的 比较肝硬化胃食管静脉曲张(GEV)患者内镜治疗前后门体侧支循环的变化,评价内镜治疗前伴或不伴食管旁静脉曲张(Para-EV)及非静脉曲张门体分流与内镜治疗疗效的关系.方法 2007年1月至2009年12月期间在内镜中心行食管静脉曲张套扎(EVL)+胃静脉曲张组织胶注射(EBC)治疗的肝硬化食管胃静脉曲张患者26例.在治疗前1周及治疗后1年内进行64排螺旋CT门脉成像检查,观察门脉系统侧支血管在内镜治疗前后的变化情况.结果 胃左静脉平均直径在内镜治疗后显著减小[(6.7±1.9)mm比(5.0±1.9)mm,P＜0.05].治疗前GEV伴Para-EV与不伴ParaEV的内镜治疗有效率差异无统计学意义(80.0%比72.7%,P＞0.05).治疗前GEV伴非静脉曲张门体分流与不伴非静脉曲张门体分流的内镜治疗有效率差异无统计学意义(82.4%比66.7%,P＞0.05).结论 多排螺旋CT门脉成像可以为GEV的治疗方案选择及评价预后提供重要信息.     

基于诺模图模型预测内镜下治疗肝硬化胃静脉曲张的疗效

目的通过诺模图(Nomogram)模型预测内镜下组织黏合剂治疗肝硬化患者胃静脉曲张的疗效。方法选择2014年8月至2017年9月因肝硬化食管胃底静脉曲张破裂出血至复旦大学附属中山医院就诊且接受内镜下组织黏合剂治疗的158例患者。随访12个月,主要结局指标为再出血。分析肝硬化胃静脉曲张内镜下治疗后再出血的影响因素。构建诺模图模型,比较其与Child分级、计算机体层摄影血管造影(CTA)和肝静脉压力梯度(HVPG)预测肝硬化胃静脉曲张内镜下治疗后再出血的准确性。统计学分析采用单因素和多因素Cox回归分析,以及Kaplan-Meier曲线和log-rank检验。结果随访中,在内镜下治疗后2、6和12个月分别出现再出血18例(11.4%)、37例(23.4%)和49例(31.0%)。单因素Cox回归分析结果显示,性别、酒精性肝硬化、糖尿病、Child-Pugh分级(A级与B或C级)、CTA腔外血管(有与无)、HVPG(<16 mmHg与≥16 mmHg,1 mmHg=0.133 kPa)、门脉系统广泛栓塞、食管静脉曲张、食管胃静脉曲张2型、组织黏合剂注射点(≤3点与>3点)和组织黏合剂注射量(≤3 mL与>3 mL)均为胃静脉曲张内镜下治疗后再出血的影响因素(HR=0.575、2.018、1.562、3.433、2.945、1.859、2.743、0.324、1.840、1.477、1.716,95%CI 0.305~1.084、0.902~4.514、0.814~2.792、1.753~6.724、1.663~5.217、1.012~3.415、0.852~8.830、0.079~1.335、1.012~3.317、0.839~2.602、0.935~3.152,P均<0.2)。多因素Cox回归分析结果显示,Child-Pugh分级、CTA腔外血管和HVPG均为胃静脉曲张内镜下治疗后再出血的独立危险因素(HR=2.665、2.886、2.095,95%CI 1.339~5.300、1.580~5.271、1.099~3.995,P均<0.05)。Kaplan-Meier曲线显示,Child-Pugh分级(A级与B或C级)、CTA腔外血管(有与无)和HVPG(<16 mmHg与≥16 mmHg)均能有效预测胃静脉曲张内镜下治疗后1年累积未再出血率,差异均有统计学意义(P均<0.05)。ROC曲线分析显示,联合Child-Pugh分级、CTA腔外血管和HVPG(<16 mmHg与≥16 mmHg)的模型可能比Child-Pugh分级和HVPG有更好的预测价值(AUC=0.746、0.673和0.585,95%CI 0.662~0.829、0.583~0.762和0.486~0.683,P<0.01、P=0.001、P=0.089)。根据诺模图评分的下四分位数和上四分位数将患者分为低、中、高危组,结果显示诺模图可以有效区分胃静脉曲张内镜下治疗后再出血的高危人群,差异有统计学意义(P<0.01)。结论CTA腔外血管、HVPG和Child-Pugh分级是肝硬化胃静脉曲张内镜下治疗疗效的独立预测指标,基于此3项指标建立的诺模图模型的预测准确性可能优于Child-Pugh分级和HVPG。     

Current status of ectopic varices in Japan: Results of a survey by the Japan Society for Portal Hypertension

Aim: The Clinical Research Committee of the Japan Society for Portal Hypertension has conducted a nationwide questionnaire survey to clarify the current status of ectopic varices in Japan. Methods: A total of 173 cases of ectopic varices were collected. Results: Duodenal varices were found in 57 cases, and most of them were located in the descending to transverse parts. There were 11 cases of small intestinal varices and 6 cases of colonic varices, whereas 77 patients had rectal varices, accounting for the greatest proportion (44.5%). Other sites of varices were the biliary tract, anastomotic sites, the stoma, and the diaphragm. Liver cirrhosis was the most frequent diseases (80.3%) underlying ectopic varices. It was noted that patients with rectal varices frequently had a history of esophageal varices (94.8%) and received endoscopic treatment (87.0%). The treatments for ectopic varices were as an emergency in 46.5%, elective in 35.4% and prophylactic in 18.2%. In emergency cases, endoscopic therapy was most frequent (67.4%), followed by interventional radiology (IVR; 15.2%), and endoscopy‐IVR combination (6.5%). Elective treatment was performed by endoscopy in 34.3%, IVR in 28.6%, combined endoscopy‐IVR in 5.7%, and surgical operation in 25.7%. The prophylactic treatment was endoscopic in 50.0%, IVR in 33.3%, combined treatments in 11.1%, and prophylactic surgery in none. The change of ectopic varices after treatment was disappearance in 54.9%, remnant in 35.4% and recurrence in 9.7%. The rate of disappearance was significantly lower in rectal varices (40.8%) than in duodenal varices (73.4%). The patient outcome did not differ among the various sites of the lesion. Conslusions: Current status of ectopic varices in Japan has been clarified by a nationwide questionnaire survey. The authors expect that the pathophysiology of ectopic varices will be further elucidated, and that improved diagnostic modalities and treatment methods are established in the future.     

奥曲肽在内镜粘合剂D-TH治疗食管和胃静脉曲张中的应用

目的 探讨奥曲肽在内镜粘合剂Ｄ－ＴＨ治疗食管和胃静脉曲线中的作用。方法 粘合剂Ｄ－ＴＨ内镜注射治疗前５ｈ起静脉维持滴注奥曲肽０．０２５ｍｇ／ｈ,术前２０＇静脉注射冲击量奥曲肽０．１ｍｇ。内镜直观下注射Ｄ－ＴＨ液治疗肝硬化食管和胃静脉曲线及其出血。结果 Ｄ－ＴＨ治疗７例食管和胃硬化剂治疗均无针孔出知。结论 应用奥曲肽有助于食管和胃静脉曲张及其出血的内镜下Ｄ－ＴＨ硬化治疗,术后维持治疗可有效降低出血率     

十二指肠静脉曲张内镜诊治方法研究

目的探讨十二指肠静脉曲张内镜下诊断及治疗方法。方法对2000年11月至2008年8月93283例内镜检查发现的26例十二指肠静脉曲张的内镜下表现,采用位置（L）、直径（D）、危险因素（跗）即LDRf分型方法进行分型,观察依照分型对十二指肠静脉曲张治疗的效果,并进行随访。结果内镜下分型：Ld1 5例（19．2％）,Ld1.2 22例（7．7％）,Ld2 19例（73．1％）;D。0例,D0.5 2例,D1 10例,D2 13例,D3 1例;Rf0 23例,Rf1 0例,Rf2 3例。其中伴食管及（或）胃底静脉曲张18例。17例住院患者中乙型肝炎肝硬化9例（52．9％）。对其中的3例Rf2患者行内镜下治疗,1例活动出血者（Ld：D,Rf2）行组织粘合剂治疗后即刻止血,1例（Ld2D2Rf2）行组织粘合剂治疗,另1例患者（Ld2D1Rf2）进行了套扎治疗,随后进行了平均14．6个月的随访,3例患者在治疗后1．0～3．5个月内静脉曲张消失,且无复发;其余患者未行内镜治疗,对其中11例进行随访,未发现静脉曲张出血,有2例患者因其他原因死亡。结论LDRf内镜下分型能基本反映十二指肠静脉曲张的内镜特点,依照该分型选择十二指肠静脉曲张内镜治疗方法是安全可行的。     

Prevalence of esophagogastric varices in patients with non-alcoholic steatohepatitis.

Aim: In non-alcoholic steatohepatitis (NASH), fibrosis begins around the central veins, as also happens with alcoholic liver disease, so the symptoms of portal hypertension may be due to central vein occlusion. The aim of this study was to define the prevalence of esophagogastric varices and the clinical outcome after endoscopic treatment in NASH patients with severe fibrosis. Methods: The subjects were 72 patients with clinicopathologically confirmed NASH who had bridging fibrosis (F3) or cirrhosis (F4) determined by the examination of liver biopsy specimens, and who underwent upper gastrointestinal endoscopy. The prevalence and pattern of endoscopically detected varices at the time of liver biopsy were evaluated. The results of NASH patients (n = 11) with endoscopically treated esophageal varices were compared to those with alcoholic (n = 67) and hepatitis C virus-associated cirrhosis (n = 152). Results: Esophagogastric varices were detected in 34 out of the 72 (47.2%) patients; esophageal varices in 25 (34.7%) and gastric varices in nine (12.5%), while six of these patients had variceal bleeding. In NASH patients, the cumulative recurrence-free probability at 24 months after endoscopic treatment was 63.6%, the bleeding-free probability was 90.9%, and the 5-year survival was 100%. Only one out 11 patients died of liver failure at 70 months after treatment. Conclusion: About half of NASH patients with severe fibrosis had esophagogastric varices. The clinical status and course of the varices do not necessarily improve after endoscopic treatment. NASH patients with esophagogastric varices need to be followed up carefully, like patients with other chronic liver diseases.