肝硬化食管静脉曲张的食管动力初探

为进一步研究曲张静脉及硬化/套扎治疗对食管功能的影响,对19例肝硬化食管静脉曲张患者行食管测压研究。结果示:1.食管静脉曲张组LES静息压为2.87±0.83kPa,对照组为2.49±0.63kPa,两组无差异(P>0.05)。轻度与中重度曲张组、未治疗组与硬化/套扎治疗组的LES压力无差异。2.食管体部的蠕动:(1)静脉曲张组与正常组比较,前者食管下段蠕动波幅(PA)减低,蠕动时间(PD)延长,蠕动传导速度(PV)减慢(P<0.05)。(2)中重度曲张组与轻度曲张组比较,其PA减低,PD延长(P>0.05)。(3)6例硬化/套扎治疗组与非治疗组比较无显著差异,可能与例数少有关。肝硬化食管静脉曲张的食管动力改变主要表现为食管下段的蠕动波幅减低,蠕动传导时间延长,传导速度降低,且与曲张程度有一定关系。其原因可能系曲张静脉本身直接的机械作用听致,硬化治疗可引起食管下段功能障碍,故有必要对EVS患者使用促动力药。     

Effect of Endoscopic Injection Sclerotherapy on Acute Bleeding from Esophageal Varices in Cirrhotic Patients with Advanced Hepatocellular Carcinoma

Abstract: The effect of endoscopic injection sclerotherapy (EIS) on acute bleeding from esophageal varices in sixteen cirrhotic patients with advanced hepatocellular carcinoma (HCC) was analysed using the Cox proportional hazard model. Only EIS was found to have independently and significantly affected the survival rate (P = 0.0385), while clinical variables such as the extent of HCC, the presence of ascites and portal thrombosis, laboratory data and therapeutic modalities other than EIS showed no significant effect. EIS should be considered one of the treatments of choice when a cirrhotic patient with advanced HCC has acute bleeding from his/her esophageal varices.     

内镜下结扎食管静脉曲张的疗效评估:216例临床分析

作者采用内镜结扎术治疗216例食管静脉曲张病人,其中69例有急性出血,经此方法治疗后,即时止血率达92.8％。经3～5次结扎后,其中80％的食管静脉曲张消失或缩小至Ⅰ°以下。未发生与结扎术有关的严重并发症。随访4～40个月(平均16月),出血复发率为17.1％,有25例死亡。结果表明:内镜结扎术疗效好,操作方便,并发症少,可适用于肝功能差、不能耐受手术以及手术后或硬化剂治疗后食管静脉曲张复发出血的病人。     

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.     

Cyanoacrylate Injection Versus Band Ligation in the Endoscopic Management of Acute Gastric Variceal Bleeding: Meta-Analysis of Randomized,Controlled Studies Based on the PRISMA Statement

The evidence for optimal endoscopic management of bleeding gastric varices is lacking. The clinical outcome is controversial in trials comparing cyanoacrylate injection and band ligation. To help guide endoscopic decisions regarding acute gastric variceal bleeding, a meta-analysis was conducted.Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and ScienceDirect were searched for all randomized controlled trials (RCTs) containing the 2 interventions. The main outcomes evaluated in the meta-analysis were active bleeding control, blood transfusion, rebleeding, recurrence of varices, complications, and survival.Three RCTs were identified, which included 194 patients with active gastric variceal bleeding from Taiwan and Romania. Active bleeding control was achieved in 46 of 49 (93.9%) patients in the cyanoacrylate injection group, compared with 35 of 44 (79.5%) in the band ligation group (P = 0.032), for a pooled odds ratio of 4.44 (95% confidence interval, 1.14–17.30). Rebleeding rate was comparable in type 2 gastroesophageal varices (GOV2) between the 2 interventions (35.7% vs 34.8%, P = 0.895), but cyanoacrylate injection seemed superior for reducing rebleeding rate in type 1 gastroesophageal varices (GOV1, 26.1% vs 47.7%, P = 0.035) and type 1 isolated gastric varices (IGV1, 17.6% vs 85.7%, P = 0.015). Cyanoacrylate injection was also superior in controlling recurrence of gastric varices to band ligation (36.0% vs 66.0%, P = 0.002). There was no difference in complications or mortality between the 2 interventions. The major limitation of this meta-analysis is the small number of studies/patients included.Compared with band ligation, injection cyanocrylate have an advantage in the control of acute gastric variceal bleeding, also with lower recurrence rate and rebleeding (except GOV2). The limited amount of studies included attenuates the strength of this meta-analysis; therefore, more high-quality RCTs are needed.     

Cutaneous Vascular Spiders in Cirrhotic Patients: Correlation with Hemorrhage from Esophageal Varices

Ninety-two consecutive male cirrhotic patients had esophagoscopy to determine the presence and size of varices, and a concomitant skin examination for assessment of cutaneous vascular spiders. Thirty-one subjects bled from varices within 10 days of the spider evaluation, and this group was compared to 61 individuals who never bled. Our results show that incidence of spiders (90%) and varices (91%) is nearly identical, that frequency of variceal bleeding is higher among subjects with spiders compared with those who lack these lesions (36% vs 11%, p less than 0.05), and that the spider profile may be useful to identify individuals who are at increased risk for variceal hemorrhage. Frequency of bleeding was 50% (p less than 0.01) when greater than 20 spiders were present and 63% (p less than 0.01) when multiple atypically located lesions were detected. Large spiders (greater than 15 mm) correlate best with large varices and have the strongest association with bleeding (80%, p = 0.0002). If evidence of benefit from prophylactic treatment of esophageal varices can be established, then elements of the spider profile may serve as a discriminating marker to assist in selection of appropriate patients for therapy.     

A Modified Percutaneous Transhepatic Variceal Embolization with 2-Octyl Cyanoacrylate Versus Endoscopic Ligation in Esophageal Variceal Bleeding Management: Randomized Controlled Trial

BACKGROUND: Conventional percutaneous transhepatic varices embolization (PTVE) has rarely been used in recent years due to high rates of variceal recurrence and rebleeding. Herein we report a modified PTVE with 2-octyl cyanoacrylate (2-OCA) in which the whole lower esophageal and peri or para-esophageal varices, the submucosal varices, and the advertitial plexus of the cardia and fundus were sufficiently obliterated. We compared this PTVE with endoscopic band ligation (EVL) in the treatment of esophageal variceal bleeding. METHODS: In this prospective randomized controlled trial, cirrhotic patients with acute or recent esophageal variceal bleeding were assigned randomly to PTVE (52 patients) or EVL (50 patients) groups. Upper gastrointestinal (UGI) rebleeding, esophageal variceal rebleeding, and survival were followed-up. Computerized tomography (CT) scanning and portal venography were used to observe 2-OCA distribution. RESULTS: During the follow-up period (median 24 and 25 months in the PTVE and EVL groups, respectively) UGI rebleeding developed in eight patients in the PTVE group and 21 patients in EVL group (P = 0.004). Recurrent bleeding from esophageal varices occurred in three patients in the PTVE group and twelve in the EVL group (P = 0.012, relative risk 0.24, 95% confidence interval 0.05-0.74). Multivariate Cox analysis indicated that the treatment was the only factor predictive of rebleeding. A Kaplan-Meier curve showed there was no significant difference between survival in the two groups (P = 0.054). CONCLUSIONS: With the whole lower esophageal and peri or para-esophageal varices, the submucosal varices, and the adventitial plexus of the cardia and fundus sufficiently obliterated by 2-OCA, this modified PTVE was more effective than EVL in the management of esophageal varices recurrence and rebleeding. Survival in these two groups was not significantly different, however.     

Combination Endoscopic Band Ligation and Sclerotherapy Compared with Endoscopic Band Ligation Alone for the Secondary Prophylaxis of Esophageal Variceal Hemorrhage: A Meta-Analysis

Endoscopic band ligation (EBL) is the community-accepted standard therapy for the secondary prophylaxis of esophageal variceal hemorrhage. Recent data indicate that combination EBL and sclerotherapy may be a more effective therapy than EBL alone. Yet existing data are conflicting. We therefore performed a meta-analysis to compare the efficacy and safety of EBL and sclerotherapy versus EBL alone for the secondary prophylaxis of esophageal variceal hemorrhage. We performed a systematic review of two computerized databases (MEDLINE and EMBASE) along with manual-searching of published abstracts to identify relevant citations without language restrictions from 1990 to 2002. Eight studies met explicit inclusion criteria. We performed meta-analysis of these studies to pool the relative risk for the following outcomes: esophageal variceal rebleeding, death, number of endoscopic sessions to achieve variceal obliteration, and therapeutic complications. There were no significant differences between EBL and sclerotherapy versus EBL alone in the risk of esophageal variceal rebleeding (RR = 1.05; 95% CI = 0.67–1.64; P = 0.83), death (RR = 0.99; 95% CI = 0.68–1.44; P = 0.96), or number of endoscopic sessions to variceal obliteration (RR = 0.23; 95% CI = 0.055–0.51; P = 0.11). However, the incidence of esophageal stricture formation was significantly higher in the EBL group than in the sclerotherapy group. There is no evidence that the addition of sclerotherapy to endoscopic band ligation changes clinically relevant outcomes (variceal rebleeding, death, time to variceal obliteration) in the secondary prophylaxis of esophageal variceal hemorrhage. Moreover, combination EBL and sclerotherapy had more esophageal stricture formation than EBL alone.     

内镜下食管静脉曲张套扎术治疗食管静脉曲张破裂出血27例近期疗效

食管静脉曲张破裂出血是临床急症 ,药物止血、三腔管压迫、注射硬化剂是传统的内科疗法。近年来开展的内镜下静脉曲张套扎术 (ｅｎｄｏｓｃｏｐｉｃｖａｒｉｃｅｓｌｉｇａｔｉｏｎ ,ＥＶＬ)是有效的止血方法之一 ,我们 2年半中共行ＥＶＬ2 7例 ,兹报道其近期疗效如下。临床资料一般资料　本组患者全部为确诊的肝炎后肝硬化门脉高压症所致食管静脉曲张破裂出血患者 ,男2 5例 ,女 2例 ,年龄 2 5～ 75岁 ,平均 5 0岁 ,肝硬化病程 4～ 2 5年 ,平均 5年。肝功能按Ｃｈｉｌｄ分级 ,Ａ级 2例 ,Ｂ级 17例 ,Ｃ级 8例。静脉曲张程度　内镜下静脉曲张…     

Squamous Cell Carcinoma after Endoscopic Injection Sclerotherapy for Esophageal Varices

We report two cases of squamous cell carcinoma of the esophagus following endoscopic injection sclerotherapy for esophageal varices. The interval between sclerotherapy and the development of carcinoma was 24 months in case 1 and 21 months in case 2. The sclerosant was 5% sodium morrhuate in case 1 (total dose, 10 ml) and 5% ethanolamine oleate in case 2 (45.5 ml). Although no recurrent variceal bleeding occurred after sclerotherapy, we could not perform any curative surgical treatment for esophageal cancer because of the advanced stage of the cancer and the severity of the accompanying liver dysfunction. It is difficult to determine the relationship between sclerotherapy and carcinoma; however, long-term surveillance is essential to avoid overlooking a neoplasm in the esophagus after endoscopic injection sclerotherapy.     

Analysis of Patients with Esophageal Varices Surviving More Than Three Years after Endoscopic Injection Sclerotherapy

Of the 205 patients treated by endoscopic injection sclerotherapy in the past 8 years and 4 months, 70 patients (34.1%) have survived more than 3 years. There were more Child's class A patients (p < 0.05) and fewer Child's C patients (p < 0.01) in this group as compared to 51 patients who died within 3 years. In addition, complications due to hepatoma were significantly lower (p < 0.01) in this group. The long-term cumulative survival rates of those who had already survived over 3 years were 82% at the 5-year and 78% at the 7-year follow-up. There was no significant difference among 3 groups classified by severity of liver damage or timing of the therapy. Rebleeding was noted in 13 patients (18.3%) and the cumulative bleeding rates were 9% at the 1-year, 14% at the 3-year, 18% at the 5-year and 21% at the 7-year follow-up. In 12 of these patients hemostasis was obtained by the second sclerotherapy. There was no significant difference in the long-term prognosis between patients who experienced repeat bleeding, and those who did not. Endoscopic findings in patients with rebleeding were characteristic in that the red color sign remained pronounced despite the fact that the varices had shrunk from F₂ or larger to F₁ in 6 patients. Bleeding occurred from the gastric varices in 4 patients. One of them died due to gastric bleeding, but 3 were operated on after sclerotherapy. For improving prognosis, it is important to carefully observe the clinical course and to perform additional aggressive treatments for complete obliteration of varices.     

Low Fibrinogen Levels Are Associated with Bleeding After Varices Ligation in Thrombocytopenic Cirrhotic Patients

Introduction and Aim. EVBL is a procedure frequently performed in cirrhotic patients for primary prophylaxis of bleeding. Patients with cirrhosis display various degrees of alteration of common coagulation parameters, and it is not known whether these alterations may predict post-EVBL bleeding. To evaluate factors predictive of post-endoscopic variceal band ligation (EVBL) bleeding in cirrhotic patients with thrombocytopenia.Material and methods. We included 109 patients with cirrhosis undergoing EVBL for primary prophylaxis of variceal bleeding. Common coagulation parameters (INR, fibrinogen levels) and complete haemogram were obtained in all patients and evaluated subdividing patients in bleeders and non bleeders following EVBL.Results. The incidence of post-EVBL bleeding was 5.5% (6 patients). INR and platelet counts, considered as continuous or dichotomous variables according to common cut-offs (i.e., INR > 1.5, platelet count < 50 × 10⁹/L) were not predictors of post-EVBL bleeding. Patients who bled had significantly lower fibrinogen levels [146 mg/dL (98 - 262) vs. 230 mg/dL (104 - 638), P = 0.009], and no other biochemical or clinical predictors of bleeding were identified. A fibrinogen cut-off of 179 mg/dL had 98.6% negative predictive value for bleeding.Conclusion. Low fibrinogen levels are associated with an increased risk of bleeding following prophylactic EVBL in cirrhotic patients, and might be used to stratify patients’ risk. However, due to their preliminary nature, these findings need to be confirmed in larger populations.     

Endoscopic Clipping of Esophageal Varices

Abstract: A new method of endoscopic therapy for esophageal varices using a clipping apparatus was devised and applied prophylactically in nine patients with esophageal varices which were not bleeding. Eighty two ligations were placed in 21 separate treatment sessions in this study. All the esophageal varices were eradicated or reduced in size and length within 2 months following treatment. No major complications such as massive bleeding, the development of deep esophageal ulcers, esophageal perforation, esophageal stenosis and pleural effusion developed. The follow-up period ranged from 6 months to 18 months. Three patients (33%) were re-treated by the same method because of the regrowth of esophageal varices during this period, but no bleeding occured in these patients. It seems that this newly developed method is a safe, simple and effective technique for the treatment of esophageal varices.     

Combined Non-Surgical Treatment with Transileocolic Obliteration and Endoscopic Injection Sclerotherapy for Esophageal and Gastric Varices

Abstract: Clinical results associated with the combined treatment of endoscopic injection sclerotherapy (EIS) followed by transileocolic obliteration (TIO) for esophageal of gastric varices were evaluated in 31 patients. Twenty patients underwent emergency treatment, and 11 underwent non-ememgency treatment. No fatal complications developed after this combined treatment.     

Endoscopic Ligation of Esophageal Varices Using a Detachable Snare and Transparent Cap with Rim

Abstract: The authors developed a new method of endoscopic varix ligation (EVL) using a detachable snare and a transparent cap with rim (EVLsc). The advantages of EVLsc are as follows; 1) no need for an overtube, 2) multiple varix ligation can be achieved in a relatively short time after an easy preparation, and 3) the procedure is associated with less discomfort for the patient. Between August 1995 and December 1996, 31 patients with esophageal varices were treated in Sakura National Hospital by EVL, and were randomized into two groups; 16 with EVLsc and 15 with conventional EVL. Each patient was treated only by the randomly chosen method for the purpose of achieving complete hemostasis and/ or eradicating esophageal varices at risk for bleeding. The only major complication was pharyngeal injury due to overtube insertion in the EVL group. There were no complications in the EVLsc group. Eradication was achieved in 14 of 16 cases (87.5%) in the EVLsc group, and 13 of 15 (86.7%) in the EVL group, there being no statistically significant difference between the two groups. The EVLsc was not associated with discomfort, required no complex techniques, and satisfactory results were obtained.     

Successful Endoscopic Band Ligation for Treatment of Postpolypectomy Hemorrhage

We describe a case of large pedunculated tubulovillous adenoma of the stomach associated with postpolypectomy hemorrhage, which was successfully treated by endoscopic band ligation. The case study involved a 60‐year‐old Japanese woman with a pedunculated polyp with a slightly lobular surface, measuring 25 mm in diameter. It was detected on the posterior wall of the middle body of the gastric remnant. The lesion was diagnosed as a tubulovillous adenoma by a biopsy specimen and treated by endoscopic polypectomy using the detachable snare to prevent postpolypectomy hemorrhage. There was no episode of immediate postpolypectomy hemorrhage, but hematemesis occured 18 h after the excision. Endoscopic examination of the stomach showed the mark left by bleeding on the cutting surface and the absence of the detachable snare. Endoscopic intervention by rubber band ligation was performed to prevent the recurrent bleeding. Complete hemostasis was obtained and no serious complications occured.