胃底静脉曲张出血33例临床分析

目的 分析胃底静脉曲张出血的病因、诊断和治疗方法。方法 回顾分析该院1994年元月～2003年12月检查确诊为胃底静脉曲张出血33例，对其临床资料进行分析讨论。结果 病因：肝硬化门脉高压23例，肝癌6例，脾静脉阻塞4例。治疗结果：内镜下套扎17例；5例于1～3d内复发大出血死亡，另有9例2个月内复发出血，硬化剂治疗4例，均有复发出血；17例行手术治疗，14例术后无再出血，3例虽有复发出血，但频率及出血量明显减少。结论 胃底静脉曲张是门脉高压，特别是脾胃区门脉高压的表现。胃底静脉曲张较食管静脉曲张出血率低，但出血更严重。内镜对胃底静脉曲张的诊断价值有限。对胃底静脉曲张不宜行套扎或硬化剂治疗。能手术者应首选手术治疗，不宜手术者可考虑介入治疗，栓塞胃底静脉。     

Isolated gastric varices: Splenic vein obstruction or portal hypertension?

The presence of isolated gastric varices without esophageal varices is thought to be highly suggestive of splenic vein obstruction. A review of our radiologic files revealed 14 patients with isolated gastric varices on barium studies performed during the past 10 years. Eight of the 14 patients had adequate clinical and/or radiologic follow-up to suggest the pathophysiology of the varices. Seven had evidence of portal hypertension, and the remaining patient had evidence of splenic vein obstruction. Six patients had signs of upper gastrointestinal (GI) bleeding. Double-contrast upper GI examinations revealed thickened, tortuous fundal folds in 6 patients and a lobulated fundal mass in 2. Thus, most patients with isolated gastric varices have portal hypertension rather than splenic vein obstruction as the underlying cause.     

Endoscopic gastrointestinal manifestations of liver disease

Esophageal and gastric varices are common manifestations of advanced chronic liver disease, but other endoscopic gastrointestinal manifestations of portal hypertension may occur. In the upper gastrointestinal tract, portal hypertensive gastropathy, particularly when severe, and gastric antral vascular ectasias are important alternative causes of gastrointestinal bleeding. Portal hypertensive enteropathy is an uncommon source of gastrointestinal bleeding, and its overall clinical significance remains unknown. In the lower gastrointestinal tract, portal hypertension may be associated with hemorrhoids, anorectal varices, and portal hypertensive colopathy, all of which are occasional causes of gastrointestinal bleeding.     

超声引导下经皮经肝门静脉行胃冠状静脉栓塞防治上消化道出血:2例报道并文献复习

食管胃底静脉曲张作为肝硬化患者门静脉高压的常见且最危险的并发症之一,程度严重时是发生上消化道出血的独立危险因素,其病死率高、进展快、易反复出血。目前食管胃底静脉曲张的治疗主要包括内镜下治疗、经颈静脉肝内门体分流术、外科手术、药物治疗等;此外,超声引导下经皮经肝门静脉实施胃冠状静脉栓塞防治这项新兴技术止血作用持久而更彻底,患者耐受更好。超声和数字减影血管造影多学科合作,可望在预防和治疗门脉高压食道胃底静脉曲张破裂的上消化道大出血发挥重要作用。      

内镜套扎联合部分脾栓塞术治疗门脉高压症及其对血流动力学的影响

目的 :探讨一种新的治疗门脉高压症的手术方法。方法 :对 41例合并食管静脉曲张和脾功能亢进的门脉高压症患者实施内镜套扎 -部分脾栓塞联合治疗 ,手术前后采用彩色多普勒超声检查门奇静脉侧支循环情况 ,与对照组进行对比研究。结果 :除 1例患者出现异位栓塞死亡 ,1例出现脾脓肿经开腹手术治疗得到治愈外 ,未发生其他严重并发症。联合术后患者食管曲张静脉得到根治 ,脾功能亢进缓解。手术后患者门静脉血流速度减慢 ,血流量减少 (P <0 .0 5) ,奇静脉血流量降低 (P <0 .0 1 ) ,胃左静脉血流速度减慢 (P <0 .0 5)。术后随访 2～ 2 4个月 ,未出现复发性出血。结论 :联合术能有效地治疗门脉高压症食管静脉曲张出血和脾功能亢进 ,减少了闭塞曲张静脉所需重复套扎次数及近期再出血 ,同时术后减少了门静脉血流速度 ,血流量 ,降低了套扎术后复发出血的风险 ,该方法操作简单 ,侵袭性小 ,尤其适应于肝功能较差 ,难以耐受分流及断流手术的门脉高压症患者。     

Comparison of barium swallow and left gastric angiography in the diagnosis of esophageal varices,with special reference to the management of variceal bleeding

Seventy-five patients with portal hypertension and esophageal varices were studied by means of barium swallow and selective left gastric angiography. The relative merits and limitations of these techniques in demonstrating the presence, extent, and severity of the varices are discussed, with reference to the selection of patients for prophylactic transection of the esophagus to prevent bleeding from the varices.     

Color Doppler Ultrasound in Portal Hypertension

Portal hypertension is one of the most important causes of morbidity and mortality in cirrhotic patients. A color Doppler evaluation of the left gastric vein (LGV) has proven utility in the prediction of esophageal varices and variceal bleeding in patients with portal hypertension. The purpose of this review is to discuss the ultrasound evaluation, imaging findings, and clinical application of Doppler ultrasound in the assessment of the LGV. Knowledge of the color Doppler technique and imaging findings of the LGV may help clinicians improve the monitoring of portal hypertension and predict patients with a high risk of esophageal varices.     

Enteroscopic cyanoacrylate sclerotherapy of jejunal and gallbladder varices in a patient with portal hypertension

Bleeding from varices outside the gastroesophageal region is a rare, but regularly reported complication of portal hypertension. The treatment differs from the management of esophageal and gastric varices. We present here a report on the diagnosis and treatment of bleeding jejunal and gallbladder varices in a man with portal hypertension caused by chronic calcifying pancreatitis. The patient was suffering from recurrent, frequent, and massive gastrointestinal bleeding from varices at the anastomotic area of a cholecystojejunostomy. For diagnostic purposes, we carried out percutaneous Duplex ultrasonography and push enteroscopy with the Doppler technique. The treatment of varices in this area is traditionally surgical. This is the first report of enteroscopic sclerotherapy being successfully carried out using cyanoacrylate to treat hemorrhage from jejunal and gallbladder varices. No clinical signs of gastrointestinal bleeding were observed during a follow-up period of seven months.     

血清腹水清蛋白梯度与门静脉高压症食管胃底曲张静脉破裂出血的相关性研究

目的探讨血清腹水清蛋白梯度（SAAG）与门静脉高压症食管胃底静脉破裂出血的关系。方法对2009∽2011年冀中能源峰峰集团总医院门静脉高压症并发食管胃底静脉曲张破裂患者36例行选择性断流手术（观察组）,另选取同期40例食管胃底静脉曲张未出血患者作为对照组,2组患者的年龄、门静脉宽度、总胆红素、SAAG、部分凝血活酶时间（APTT）值进行比较,同时对出血手术患者SAAG和门静脉压力梯度（PPG）变化值行直线相关性分析。通过受试者工作特征（ROC）曲线确定血清SAAG对门静脉高压症食管胃底静脉破裂出血的预测值。结果观察组患者SAAG为（24.2±7.1）g/L,对照组患者SAAG为（15.2±6.0）g/L,2组比较差异有统计学意义（P〈0.05）。观察组患者SAAG与PPG变化值两者之间存在正相关（r=0.84,P〈0.01）,利用ROC曲线确定SAAG并预测门静脉高压症食管胃底静脉破裂出血的最佳诊断切点为18.3g/L,敏感度和特异度分别为95.1%和66.1%。结论血清SAAG是预测门静脉高压症食管胃底静脉破裂出血的良好指标。     

Intraperitoneal bleeding due to rupture of the left gastric vein (LGV) in a patient with liver cirrhosis: a case report

Intraperitoneal bleeding from ruptured ectopic varices is a rare and fatal complication in patients with portal hypertension. Although laparotomy with high mortality is performed, it is difficult to detect correct bleeding site and save the patient. This is probably the first case report of rupture from left gastric vein revealed by transjugular intrahepatic portosystemic shunt (TIPS). We propose the use of TIPS for diagnosing and treating intraperitoneal bleeding from ectopic varices.     

Repeated pancreatitis-induced splenic vein thrombosis leads to intractable gastric variceal bleeding: A case report and review

Gastric varices(GV) are one of the most common complications for patients with portal hypertension. Currently, histoacryl injection is recommended as the initial treatment for bleeding of GV, and this injection has been confirmed to be highly effective for most patients in many studies. However, this treatment might be ineffective for some types of GV, such as splenic vein thrombosis-related localized portal hypertension(also called left-sided, sinistral, or regional portal hypertension). Herein, we report a case of repeated pancreatitis-induced complete splenic vein thrombosis that led to intractable gastric variceal bleeding, which was treated by splenectomy. We present detailed radiological and pathological data and blood rheology analysis(the splenic artery- after a short gastric vein or stomach vein- gastric coronary vein- portal vein). The pathophysiology can be explained by the abnormal direction of blood flow in this patient. To our knowledge, this is the first reported case for which detailed patho-logy and blood rheology data are available.     

Variceal bleeding from an ileostomy stoma

Patients with portal hypertension due to cirrhosis commonly have bleeding from varices. In patients with a total colectomy, ileal varices can be a site of bleeding in cases of portal hypertension. Proper diagnosis requires studying the venous phase of the mesenteric arteriogram to show ileal varices, and carefully inspecting the mucocutaneous region of the ileal stoma for venous bleeding sites. Bleeding from ileal varices can be managed by either local control or portal vein decompression.     

Bucrylate treatment of bleeding gastric varices: 12 years' experience

BACKGROUND AND STUDY AIMS: For several years now there has been an increasingly widespread use of a tissue adhesive in the treatment of bleeding gastric varices to achieve rapid, safe control of hemostasis and prevent rebleeding. In this study we report on our experience with the use of Bucrylate (Hystoacryl) for the treatment of gastric varices over a period of more than a decade. PATIENTS AND METHODS: Since 1988, 174 cirrhotic patients with actively bleeding gastric varices have been admitted to our department, where they received emergency treatment with injections of Bucrylate. Any associated nonbleeding esophageal varices were subjected to traditional sclerotherapy in combination with the Bucrylate treatment. The gastric varices were subdivided into four distinct groups according to the method advocated by Sarin in 1989. The patients underwent weekly sclerotherapy sessions until their varices were eradicated, and the follow-up with a mean of 36 months (range 9-90 months) consisted of endoscopy at 3, 6, and 12 months during the first year and then yearly checks to confirm obliteration of the varices. RESULTS: The hemostasis (97.1%), early rebleeding (15.5%), and hospital mortality (19.5%) rates of the patients with bleeding gastric varices, treated with the tissue adhesive, were very similar to those of patients treated for esophageal varices over the same period (98.1%, 13.0%, and 16.4%, respectively). The most frequent cause of death at 30 days was liver failure (76% of cases), followed by hemorrhagic shock (8.8%), and other less frequent causes. Sclerotherapy achieved obliteration rate for gastric varices (70-75%) similar to that for esophageal varices in those patients with portal hypertension due to intrahepatic block (alcoholic and posthepatitis cirrhosis), but a rate of only 32% in the group of patients with prehepatic block (splenoportomesenteric thrombosis), where surgery proved more effective (69%). The medium- and long-term survival rates depended on the stability of the patients' liver conditions, on rapid, effective control of variceal hemostasis, and on complete, lasting obliteration of the gastric varices. CONCLUSIONS: The use of Bucrylate in emergency sclerotherapy achieved results in bleeding gastric varices on a par with those obtained in esophageal varices in cases of alcoholic and posthepatitis cirrhosis. The group of patients with portal hypertension due to prehepatic block (splenoportal thrombosis) showed no benefit from sclerotherapy in terms of obliteration of gastric varices, but benefited from elective surgery. The choice of the obliterating treatment indicated may be facilitated by classifying gastric varices into distinct groups on the basis of anatomicotopographic criteria.     

胰源性区域性门脉高压CT成像的临床应用价值

目的探讨胰源性区域性门静脉高压的CT门静脉成像的临床应用价值。方法前瞻性选择70例胃镜提示胃底静脉曲张的患者,进行CT增强扫描及后处理,分析其中28例胰源性门静脉高压患者的CT表现。结果在28例胰源性门静脉高压患者中,显示GEV扩张24例,CGV扩张21例,SGV扩张23例,发生胃肾分流4例,图像重建后可以清楚显示各血管的走行及曲张程度。结论CT门静脉成像可以连续的显示血管走行及其毗邻关系,多角度显示侧支循环血管,有助于指导术前分析和评估,对胰源性区域性门静脉高压具有重要临床诊断价值。     

Coil-assisted retrograde transvenous obliteration for gastric varices in a Chinese case

Gastric varices are a major complication of portal hypertension in patients with liver cirrhosis and are associated with more massive bleeding events and higher mortality rate. Transjugular intrahepatic portosystemic shunt (TIPS) and balloon-occluded retrograde transvenous obliteration (BRTO) have been well documented as effective therapies for portal hypertensive gastric variceal bleeding. In China, TIPS are well accepted but BRTO is not well recieved due to the increase risk of complications associated with traditional BRTO. However, modified-BRTO, known as coil-assisted and plug-assisted retrograde transvenous obliteration (CARTO and PARTO, respectively), is receiving increased attention due to devoid of BRTO’s shortcomings. No CARTO case from China has been reported in literature thus far. Here, we present a Chinese case of CARTO to treat gastric varices bleeding.     

多排螺旋CT血管成像技术对肝硬化门脉高压侧支循环血管的显示价值

目的探讨多排螺旋CT(MDCT)显示肝硬化门脉高压症侧支循环血管的诊断价值. 方法对肝硬化门脉高压患者23例,使用16排螺旋CT机行上腹部增强CT扫描,采用MPR、MIP、VRT等三维重建技术进行图像后处理,获得门静脉系统血管图像以显示开放的侧支循环血管. 结果显示食管胃底黏膜下静脉曲张20例,食管旁静脉曲张7例;胃左静脉曲张18 例,胃短静脉曲张16例;奇静脉、半奇静脉曲张8例;脐旁静脉与腹壁静脉曲张9例;脾肾、胃肾之间分流7例;腹膜后分流11例.结论 MDCT门静脉系统血管成像技术能良好地显示肝硬化门脉高压侧支循环血管,具有重要临床应用价值.     

肝硬化食管胃静脉曲张的内镜治疗

肝硬化食管胃静脉曲张出血是危及生命的门脉高压并发症。食管静脉曲张一级预防策略为非选择性β受体阻滞剂（non selective beta blockers,NSBBs）或内镜下静脉曲张套扎术（endoscopic variceal ligation,EVL）,急性出血时首选EVL,其二级预防推荐NSBBs联合EVL。胃静脉曲张出血中,食管胃静脉曲张1型（gastroesophageal varices type 1,GOV1）应用EVL,食管胃静脉曲张2型（gastroesophageal varices type 2,GOV2）和孤立胃静脉曲张（isolated gastric varices,IGV）推荐内镜下组织胶注射术。预防胃静脉曲张再出血方面,内镜下组织胶注射术和经颈静脉肝内门体分流术（transjugular intrahepatic portosystemic shunt,TIPS）可应用于GOV2型和IGV,EVL、NSBBs或内镜下组织胶注射术可应用于GOV1型。胃静脉曲张一级预防可选用NSBBs或内镜下组织胶注射术。     

内镜套扎联合部分脾动脉栓塞术治疗门静脉性上消化道急性出血的研究

目的　探讨急诊内镜套扎联合部分脾动脉栓塞术治疗门静脉高压并发上消化道急性出血的疗效。方法　对 4 8例门静脉高压并食管胃底静脉曲张破裂急性出血患者行急诊内镜下曲张静脉套扎术(EVL) ,联合部分脾动脉栓塞术 (PSE) ,观察近期止血效果和远期再出血发生率及外周血细胞等变化。结果　EVL PSE联合术近期止血效果显著 (10 0 % ) ,食管胃底曲张静脉消失率达 6 8.75 % (33/48) ;无手术死亡 ,无严重并发症 ,远期再出血率 6 .2 5 % (3/48) ,外周血白细胞及血小板均较术前明显回升 (P <0 .0 5 )。结论　联合术能有效地救治门静脉高压并食管胃底静脉曲张破裂急性出血 ,减少单纯内镜下套扎治疗的次数和复发再出血的风险。该法创伤小 ,安全有效。     

Isolated varices of the gastric fundus--endoscopic diagnosis and surgical treatment.

Isolated gastric varices in patients with portal hypertension are a relatively rare source of bleeding into the gastrointestinal tract. Endoscopy is a very valuable method of diagnosis in such cases. The authors report their own observation of gastric varices, well documented with the endoscopic technique before and after surgery. Varices of the gastric fundus are always an indication to surgical management. On the basis of their own experiences made with 5 patients, the authors recommend a direct intervention in form of an extragastric suture or resection of the convolution of the varicose veins, in selected patients simultaneously complete with a portasystemic shunt.     

EUS for portal hypertension: a comprehensive and critical appraisal of clinical and experimental indications

Endoscopic ultrasonography (EUS) has significantly improved our understanding of the complex vascular structural changes that occur in portal hypertension and their clinical and prognostic significance. EUS in combination with color Doppler technique enables us to study the hemodynamic changes in the portal venous system noninvasively, and to determine objectively the effect of different pharmacological agents on portal hypertension. EUS has also found some role in the treatment and follow up of esophageal and gastric varices. It may play a clinical role in the diagnosis of gastric, duodenal, and rectal varices. Recently reported EUS-based devices that measure variceal wall tension and intravariceal pressure noninvasively could have an impact on the identification of patients at high risk of variceal bleeding with the aim of initiating prophylactic treatment, and in the assessment of patients' responses to drug therapy of portal hypertension. EUS is occasionally very helpful in the clinical management of portal hypertension. It is an interesting and important research tool for many experimental indications that are not routinely applied in clinical practice at this time.