门静脉高压症联合手术前后血流动力学变化的临床意义

目的探讨门静脉高压症患者在联合手术前后血流动力学变化的临床意义。方法回顾性分析45例脾切除、贲门周围血管离断加脾肾静脉分流(简称联合手术)患者术前、术中、术后血流动力学的变化及其对临床疗效的影响。结果本组无手术死亡。术后门静脉自由压从(37±8)cmH_2O降至(30±4)cmH_2O,两者相比差异有统计学意义(P<0.05);门静脉入肝血流量从(1098±338)ml/min减至(995±293)ml/min,两者相比差异有统计学意义(P>0.05);肠系膜上静脉血流量从(605±288)ml/min增至(735±293)ml/min,两者相比差异有统计学意义(P<0.05)。42例(93%)患者得到随访,平均随访时间2年6个月,再出血发生率为4%,其中1例死亡。门静脉高压性胃病得到明显缓解,肝性脑病发生率为4%,未发现脾静脉血栓形成,肝功能得到一定程度的改善。结论联合手术是治疗门静脉高压症较为理想的有效术式。     

Ambulatory 24-hour esophageal pH monitoring

If 24-hour esophageal pH monitoring is to be a useful diagnostic tool, it must reliably discriminate gastroesophageal reflux patients despite daily variations in distal esophageal acid exposure. To address this issue, we studied 53 subjects (14 healthy normals, 14 esophagitis patients, and 25 patients with atypical symptoms) with two ambulatory pH tests performed within 10 days of each other. Intrasubject reproducibility of 12 pH parameters to discriminate the presence of abnormal acid reflux was determined. As a group, the parameters of percent time with pH<4 (total, upright, recumbent) were most reproducible (80%). Therefore, a subject was defined as having gastroesophageal reflux disease if at least one of these three values were abnormal. Intrasubject reproducibility for the diagnosis of reflux disease was 89% for the entire sample. Among subsets, the reproducibility was 93% for the normals and esophagitis patients and 84% for the atypical symptom patients. Total percent time with pH<4 was the single most discriminate pH parameter (85%) and nearly equaled that of the three combined parameters (89%). The intrasubject variability of this parameter was determined by the mean ±2sd of the relative differences between the two test results for all 53 subjects. Total percent time with pH<4 may vary between tests by a factor of 3.2-fold or less (218% higher to 69% lower). We conclude: (1) ambulatory 24-hr esophageal monitoring is a reproducible test for the diagnosis of gastroesophageal reflux disease; and (2) the large intrastudy variability in 24-hr total acid exposure may limit this test's usefulness as a measurement of therapeutic improvement.Supported, in part, by Public Health Services Grant AM 34200-01A1 from NIADDIK.     

Pharmacologic management and treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is one of the most common diagnoses in daily practice. Diagnosis can be made on symptom evaluation, on pH-monitoring or on endoscopic findings. In contrast to commonly held opinion there is no strong evidence that lifestyle factors are a dominant factor in the pathophysiology of GERD. The various agents currently used for treatment of GERD include mucoprotective substances, antacids, H(2)-blockers and proton pump inhibitors. This article gives an overview of the pharmacological management of GERD and focuses on the differential therapy of endoscopy-negative GERD, GERD with esophagitis and maintenance therapy.     

An experimental model for the study of transient lower oesophageal sphincter relaxation and motor function of the proximal stomach in humans

A simple and reliable experimental model would be useful in human research on new drugs which target transient lower oesophageal sphincter (LOS) relaxation. The aim was to investigate the effect of repeated distensions on the rate of transient LOS relaxation, LOS pressure and motor function of the proximal stomach. Twelve healthy subjects were studied with a multilumen manometric assembly incorporating a sleeve sensor for the LOS and a bag positioned in the proximal stomach and connected to a barostat. Intrabag volume was set at 75% of the threshold for gastric discomfort and maintained for two 30-min distension periods separated by a 45-min washout with the bag deflated. The studies lasted 145 +/- 2 min. The rate of transient LOS relaxations was similar during the two distensions, 3.5;2-4 vs 3;2.5-4 (median;interquartile range) and so was LOS pressure. Baseline intrabag pressure, as a measure of gastric tone, and the number of pressure waves, as a measure of phasic contractions, were also similar, 11.3;9.3-12.3 mmHg vs 10.8;9.3-12.5 mmHg and 16;13-28 mmHg vs 19;15-29 mmHg, respectively. Our model allows to perform 1-day studies which can assess two experimental conditions on transient LOS relaxations and motor function of the proximal stomach within an acceptable time span.     

经内镜注射硬化剂治疗食管静脉曲张(附15例报告)

经内镜注射5％鱼肝油酸钠治疗食管静脉曲张15例,共注射45次。其肝功能按Child分级,A级1例,B级8例,C级6例。曾经作过脾切除,分流或断流术者7例。8例急症出血患者经用硬化疗法获得了止血成功。1例急症患者死亡。6例作了择期预防出血的注射,治疗后均得到改善。治疗出血方面,硬化疗法在15例患者中14例有效,随访6～12月无再出血。     

Technique and early clinical results of endoscopic variceal ligation (EVL)

Summary Endoscopic variceal ligation (EVL) is a new technique designed to be used instead of sclerotherapy. Small elastic O rings ligate varices resulting in their strangulation and eradication. During a 12-month period, EVL was employed in 53 consecutive patients, of whom 36 (68%) had alcoholic cirrhosis 17 were Child-Pugh class A, 22 class B, and 14 class C. Varices were graded from I to IV and repeat treatments were given at 1–2 week intervals until the varices were eliminated. At follow-up ranging from 6–18 months (mean 11.5), 217 EVL treatment sessions had been performed. Of the 13 patients (24%) who died during the study, 11 died during the index hospitalization. Active bleeding was controlled in 19 of 21 patients (90%). Of 40 survivors 13 patients (33%) had 1–2 (mean 1.4) recurrent variceal bleeds while 34 patients had repeat EVL treatment. Elimination of distal varices was achieved in 26 and 7 had reduction of varices from grade III–IV to grade I–II or less. Eradication required a mean of 4.4 EVL sessions in Child's A and B patients and 7.0 sessions in Child's C patients (P<0.025). No significant treatment-related complications were observed. EVL appears to control active bleeding, is associated with a low incidence of non-bleeding complications, and may be used as an alternative to sclerotherapy.     

Histological score for cells with irregular nuclear contours for the diagnosis of reflux esophagitis in children

Histological criteria for the diagnosis of reflux esophagitis include basal zone hyperplasia, stromal papillae elongation, and inflammatory infiltrate. However, endoscopic esophageal biopsy specimens may include little or no lamina propria. Intraepithelial T lymphocytes, seen in hematoxylin and eosin-stained sections as cells with irregular nuclear contours (CINC), may have a higher density in children with esophagitis. We evaluated the diagnostic accuracy of a numerical score built up by grading the "classical" parameters and its correlation with CINC density in grasp biopsy specimens obtained from children undergoing esophagogastroduodenoscopy with and without esophagitis. We analyzed esophageal biopsy specimens from 349 children (median age, 5 years) subdivided in 4 groups according to the previous routine histology report: group 1, 144 children with esophagitis; group 2, 65 controls; group 3, 51 children with dubious esophagitis; and group 4, 75 children with esophagitis on endoscopy but a normal histology report. A numerical value was assigned to each parameter; the sum of these values represented the histological score. We also evaluated intraepithelial CINC density (ie, number of CINC per high-power field). We separately analyzed histological sections with and without lamina propria. For both total score and for CINC density, we calculated a cutoff using a receiver operating characteristic curve. Cutoffs of 6 for score and of 4 for CINC density provided the best sensitivity and specificity. Sensitivity of the histological score was better in biopsy specimens containing lamina propria (94%) than in those without lamina propria (4%). Sensitivity of CINC density was satisfactory in both specimens with (78%) and without (75%) lamina propria. Specificity was satisfactory for both parameters. In conclusion, when lamina propria was present in sections of endoscopic esophageal biopsy specimens, histological score provided a better diagnostic accuracy for the diagnosis of esophagitis. However, when no lamina propria was present, as was the case in 67% of our children, CINC density had better sensitivity. In addition, this latter parameter showed esophageal mucosa damage in 34% of previously dubious cases or cases with esophagitis at endoscopy but a previous routine histology report of normal mucosa.     

Angioarchitectural study of esophageal varices

Summary Pathomorphological and angioarchitectural characteristics of esophageal varices, mainly of ruptured varices, were studied in autopsy cases. Contrast medium was injected into the esophageal vein in 25 among 75 cases with varices, and in 4 cases without varices as a control. Out of the 75 cases with varices, rupture was confirmed in 8 cases. Ruptured points were recognized at the oral end of the longitudinal veins (these veins were called sudare-like veins in this study) in the lamina propria at the lower end of the esophagus in all of the 8 cases. This ruptured area was called the critical area. By morphometric examination, dilatation of these sudare-like veins was the most obvious in severe varices, and these veins were observed to penetrate the muscularis mucosae to connect to the submucosal veins at the critical area. This area seemed to be of the greatest significance in the pathogenesis of spontaneous variceal rupture.     

断流术并吻合器横断食管治疗食管曲张静脉出血疗效观察

目的探讨采用断流术并吻合器横断食管治疗门静脉高压症所致食管曲张静脉破裂出血的手术方法和临床效果。方法对48例包括急性出血期急诊手术22例,有出血病史作择期手术的19例和无出血病史作预防性手术的7例,经腹采用吻合器横断食管下段同时进行食管下段及贲门周围血管的选择性离断,观察其近期和远期止血效果。结果术后近期和远期止血效果都比较满意。结论该手术为食管下段横断和对食管下段与贲门周围血管选择性离断的联合应用,术中使用一次性吻合器进行食管下段的横断与吻合,使手术方法简便快捷,可减少手术创伤。     

食管静脉曲张出血3种治疗方法的成本效果分析

目的　对比 3种疗法治疗食管静脉曲张出血 (EVB)的临床成本 /效果。方法　 98例EVB分为 3组 ,36例给予垂体后叶素 (0 .2～ 0 .4u·min-1,共 2d)联用硝苯啶 (垂体组 )、30例给予施他宁 (2 5 0 μg·h-1,共 2d) (施他宁组 ) ,32例给予硬化剂治疗 (硬化剂组 ) ,并对 3组成本和效果进行分析。结果　垂体组、施他宁组和硬化剂组 2 4h内有效止血分别为 32例 (88.89% )、2 7例 (90 .0 0 % )和 2 8例 (87.5 0 % ) ,各组间比较无显著差异 (P >0 .0 5 ) ;平均输血量垂体组与硬化剂组、施他宁组与硬化剂组间比较均差异性显著 (P <0 .0 5 ) ;3d和 7d再出血率各组间比较无明显差异 (P >0 .0 5 ) ;成本 /效果比值 (C/E)垂体组明显低于施他宁组和硬化剂组 (P <0 .0 5 )。结论　垂体后叶素联用硝苯啶不但安全有效 ,相比更经济 ,应为治疗EVB紧急止血的一线药物