食管曲张静脉无创测压

食管曲张静脉压力测定是预测食管曲张静脉出血的最主要因素 ,食管曲张静脉的压力可在内镜下测定。 Palm er于195 1年首次报道静脉内测压 ,1982年瑞士学者 Monismann利用呼吸压力测定原理进行食管曲张静脉血管外测压。该方法不断改进 ,无创测压与直接穿刺测压的比较研究发现两者有极好的直线相关关系。目前 ,无创性食管曲张静脉测压研究仍处于实验室阶段 ,尚未获得公认 ,其原因在于难以消除血管壁张力对贴壁测压的影响     

A clinical predictor of varices and portal hypertensive gastropathy in patients with chronic liver disease

Background/Aims

The aim of this study was to identify the parameters that could noninvasively predict the presence of esophageal/gastric varices and portal hypertensive gastropathy (PHG) in patients with chronic liver disease (CLD), and to determine the accuracy of those parameters.

Methods

We retrospectively analyzed 232 patients with CLD who underwent both upper endoscopy and liver CT within an interval of 3 months. The multidimensional index (M-Index) for spleen volume was obtained from the multiplication of splenic length, width, and thickness, as measured by computer tomography.

Results

The multivariate analysis revealed that platelet, albumin, and M-Index were independently associated with the presence of varices and PHG. We combined three independent parameters, and developed a varices and portal hypertensive gastropathy (VAP) scoring system (=[platelet count (/mm³)×albumin (g/dL)]/[M-Index (cm³)]). The area under the receiver operating characteristic curve of the VAP score was 0.850 (95% confidence interval, 0.801-0.899). The VAP cut-off value of 861 had a sensitivity of 85.3%, a positive likelihood ratio of 3.17, and a negative predictive value of 86.4%. For predicting high-risk lesions for bleeding, with a cut-off value of 861 the sensitivity was 92.0%, the positive likelihood ratio was 2.20, and the negative predictive value was 96.4%.

Conclusions

The VAP score can predict the presence of varices and PHG in patients with CLD and may increase the cost-benefit of screening endoscopy in the clinical practice setting. A prospective validation study is necessary in the future.     

血清HBsAg水平与食管胃底静脉曲张破裂出血及child-pugh评分关系研究

目的 对乙肝后肝硬化食管胃底静脉曲张破裂出血及child-pugh评分与血清HBsAg水平的相关性进行分析研究.方法 将82例乙肝后肝硬化患者,根据食管胃底静脉曲张破裂出血情况,分为44例未出血组(未发生食管胃底静脉曲张破裂出血)和38例出血组(发生食管胃底静脉曲张破裂出血).另外根据child-puge分级情况,将患者分为26例child-pugh A级组、33例child-pugh B级组及23例child-pughC级组.分别对各亚组间HBsAg水平含量差异进行对比,并对HBsAg水平与食管胃底静脉曲张破裂出血及child-pugh评分的相关性进行分析.结果 出血组患者血清HBsAg水平含量明显高于未出血组(P＜0.05),而child-pugh C级组血清HBsAg水平含量最高(P＜0.05),child-pughA级组血清HBsAg水平含量最低(P＜0.05).同时血清HBsAg水平与食管胃底静脉曲张破裂出血及child-pugh评分与均存在显著的直线相关性(P＜0.05).结论 肝硬化患者血清HBsAg水平与食管胃底静脉曲张破裂出血及child-pugh评分存在密切的相关性.     

Ruptured duodenal varices arising from the main portal vein successfully treated with endoscopic injection sclerotherapy: a case report

Duodenal varices result from retroperitoneal portosystemic shunts that usually come from the pancreaticoduodenal vein and drain into the inferior vena cava. Because they are a rare but fatal cause of gastrointestinal bleeding, a prompt hemostatic intervention is mandatory. A 62-year-old man who had a history of excessive alcohol consumption presented with massive hematemesis and melena. Emergent endoscopy revealed ruptured varices with an adhering whitish fibrin clot on the postbulbar portion of the duodenum. Abdominal computed tomography demonstrated a cirrhotic liver with venous collaterals around the duodenum and extravasated contrast in the second and third portions. The collaterals originated from the main portal vein and drained via the right renal vein into the inferior vena cava. Endoscopic injection sclerotherapy with cyanoacrylate was successful in achieving hemostasis, and resulted in the near eradication of duodenal varices at a 6-month follow-up.     

Prediction of large esophageal varices in cirrhotic patients using classification and regression tree analysis

OBJECTIVES:

Recent guidelines recommend that all cirrhotic patients should undergo endoscopic screening for esophageal varices. That identifying cirrhotic patients with esophageal varices by noninvasive predictors would allow for the restriction of the performance of endoscopy to patients with a high risk of having varices. This study aimed to develop a decision model based on classification and regression tree analysis for the prediction of large esophageal varices in cirrhotic patients.

METHODS:

309 cirrhotic patients (training sample, 187 patients; test sample 122 patients) were included. Within the training sample, the classification and regression tree analysis was used to identify predictors and prediction model of large esophageal varices. The prediction model was then further evaluated in the test sample and different Child‐Pugh classes.

RESULTS:

The prevalence of large esophageal varices in cirrhotic patients was 50.8%. A tree model that was consisted of spleen width, portal vein diameter and prothrombin time was developed by classification and regression tree analysis achieved a diagnostic accuracy of 84% for prediction of large esophageal varices. When reconstructed into two groups, the rate of varices was 83.2% for high‐risk group and 15.2% for low‐risk group. Accuracy of the tree model was maintained in the test sample and different Child‐Pugh classes.

CONCLUSIONS:

A decision tree model that consists of spleen width, portal vein diameter and prothrombin time may be useful for prediction of large esophageal varices in cirrhotic patients.     

An anatomical classification of the variations of the inferior phrenic vein

The majority of anatomical textbooks of gross anatomy offer very little information concerning the anatomy and distribution of the inferior phrenic vein (IPV). However, in the last decade, an increasing number of reports have arisen, with reference to the endoscopic embolization of esophageal and paraesophageal varices, as well as venous drainage of hepatocellular carcinomas (HCC). The IPV is one of the major sources of collateral venous drainage in portal hypertension and HCC. The aim of this study was to identify the origin and distribution of the IPVs (right and left), both in normal and (selective) pathological cases. We have examined 300 formalin-fixed adult cadavers, without any visible gastrointestinal disease, and 30 cadavers derived from patients with HCC. The right IPV drained into the following: the inferior vena cava (IVC) inferior to the diaphragm in 90%, the right hepatic vein in 8%, and the IVC superior to the diaphragm in 2%. The left IPV drained into the following: the IVC inferior to the diaphragm in 37%, the left suprarenal vein in 25%, the left renal vein in 15%, the left hepatic vein in 14%, and both the IVC and the left adrenal vein in 1% of the specimens. The IPVs possessed four notable tributaries: anterior, esophageal, lateral and medial. The right IPV served as one of the major extrahepatic draining veins for all 30 cases of HCC. These findings could have potential clinical implications in the transcatheter embolization of esophageal and paraesophageal varices, as well as in mobilizing the supradiaphragmatic segment of IVC.     

The diameter of the originating vein determines esophageal and gastric fundic varices in portal hypertension secondary to posthepatitic cirrhosis

OBJECTIVE:

The aim of this study was to determine whether and how the diameter of the vein that gives rise to the inflowing vein of the esophageal and gastric fundic varices secondary to posthepatitic cirrhosis, as measured with multidetector-row computed tomography, could predict the varices and their patterns.

METHODS:

A total of 106 patients with posthepatitic cirrhosis underwent multidetector-row computed tomography. Patients with and without esophageal and gastric fundic varices were enrolled in Group 1 and Group 2, respectively. Group 1 was composed of Subgroup A, consisting of patients with varices, and Subgroup B consisted of patients with varices in combination with portal vein-inferior vena cava shunts. The diameters of the originating veins of veins entering the varices were reviewed and statistically analyzed.

RESULTS:

The originating veins were the portal vein in 8% (6/75) of patients, the splenic vein in 65.3% (49/75) of patients, and both the portal and splenic veins in 26.7% (20/75) of patients. The splenic vein diameter in Group 1 was larger than that in Group 2, whereas no differences in portal vein diameters were found between groups. In Group 1, the splenic vein diameter in Subgroup A was larger than that in Subgroup B. A cut-off splenic vein diameter of 8.5 mm achieved a sensitivity of 83.3% and specificity of 58.1% for predicting the varices. For discrimination of the varices in combination with and without portal vein-inferior vena cava shunts, a cut-off diameter of 9.5 mm achieved a sensitivity of 66.7% and specificity of 60.0%.

CONCLUSION:

The diameter of the splenic vein can be used to predict esophageal and gastric fundic varices and their patterns.     

门静脉高压症患者血浆内源性硫化氢含量的变化和意义

目的:观察血浆内源性硫化氢(H2S)在门静脉高压症不同Child级别患者中的差异及其在门静脉高压症发病中的可能作用。方法:测定2007年9月～2007年12月在我院住院治疗的门静脉高压症患者(23例)和同期体检健康人群(25例)的血浆H2S水平、肝功能、门静脉管径,分析血浆H2S含量差异与门静脉高压症的关系。结果:门静脉高压症患者血浆H2S水平较健康人低;Child不同级别H2S含量存在明显差异,血浆H2S含量与门静脉管径具有负线性相关关系。结论:内源性H2S可能参与门静脉高压症的病理过程。     

内镜下食管胃静脉曲张精准断流术疗效观察

目的:观察内镜下食管胃静脉曲张精准断流术（ESVD）的疗效。 方法:选取2017年1月至2017年8月钦州市第一人民医院收治的门脉高压食管胃静脉曲张破裂出血患者80例为研究对象,依照患者入院顺序将其分成两组,每组40例。对照组给予内镜下套扎术治疗,观察组在内镜下实施ESVD术,记录两组手术一般情况及食管胃静脉曲张改善情况,并对比两组治疗后6个月内再出血率及并发症发生率。 结果:两组患者手术一般情况比较无显著差异（P>0.05）;观察组治疗有效率为85.00%,高于对照组的55.00%（P<0.05）;术后3、6个月观察组再出血率5.00%、10.00%,明显低于对照组的30.00%、40.00%（P<0.05）;术后6个月与对照组相比,观察组患者并发症发生率偏低,但无显著差异（P>0.05）。 结论:对门脉高压食管胃静脉曲张破裂出血患者在内镜下实施ESVD术后近期疗效较好,可促进患者恢复,远期疗效有待进一步观察。     

部分脾栓塞治疗肝硬化门脉高压并脾功能亢进

目的：探讨部分脾栓塞术的临床疗效。方法：采用Seldinger技术经股动脉穿刺置入导管至脾动脉，注入明胶海绵颗粒，栓塞脾动脉的部分小分支血管，治疗肝硬化门静脉高压并脾功能亢进患9例。结果：栓塞范围为30％～70％，术后患外周血象明显改善，上消化道再出血间期延长。无严重的并发症发生。结论：部分脾栓塞治疗肝硬化门脉高压并脾功能亢进是安全和有效的。     

The comparison of esophageal variceal ligation plus propranolol versus propranolol alone for the primary prophylaxis of esophageal variceal bleeding

Background/Aims

To investigate the efficacy and longterm outcome of esophageal variceal ligation (EVL) plus propranolol in comparison with propranolol alone for the primary prophylaxis of esophageal variceal bleeding.

Methods

A total of 504 patients were retrospectively enrolled in this study. 330 patients were in propranolol group (Gr1) and 174 patients were in EVL plus propranolol group (Gr2). The endpoints of this study were esophageal variceal bleeding and mortality. Association analyses were performed to evaluate bleeding and mortality between Gr1 and Gr2.

Results

EVL was more applied in patients with high risk, such as large-sized varices (F2 or F3) or positive red color signs. Total 38 patients had bleeds, 32 in Gr1 and 6 in Gr2. The cumulative probability of bleeding at 120 months was 13% in Gr1 versus 4% in Gr2 (P=0.04). The predictive factors of variceal bleeding were red color signs (OR 2.962, P=0.007) and the method of propranolol plus EVL (OR 0.160, P=0.000). 20 patients died in Gr1 and 12 in Gr2. Mortality rates are similar in the two groups compared, 6.7% in Gr1 and 6.9% in Gr2. The cumulative probability of mortality at 120 months was not significantly different in the two groups (7% in Gr1, 12% in Gr2, P=0.798). The prognostic factors for mortality were age over 50 (OR 5.496, P=0.002), Child-Pugh class B (OR 3.979, P=0.001), and Child-Pugh class C (OR 10.861, P=0.000).

Conclusions

EVL plus propranolol is more effective than propranolol alone in the prevention of the first variceal bleeding in patients with liver cirrhosis.     

内镜下套扎术联合药物治疗食管静脉曲张出血的近期疗效观察

目的探讨内镜下食管静脉曲张套扎术联合药物治疗肝硬化上消化道出血的近期疗效。方法回顾性分析2007年3月至2009年12月143例肝硬化患者行食管静脉曲张套扎术治疗的资料。结果食管静脉曲张套扎术术后联合普奈洛尔、抑酸剂、生长抑素等药物治疗,明显降低早期再出血、食管溃疡、门脉高压性胃病等发生率;肝功能C级患者再出血率明显高于A级及B级患者;肝硬化有脾切除加断流术史者与无脾切除加断流术患者比较,食管静脉曲张复发率低。结论食管静脉曲张套扎术术后联合药物治疗可降低食管静脉曲张复发、食管静脉曲张出血早期再发率,减少食管溃疡、门脉高压性胃病发生率。食管静脉曲张套扎术是治疗食管静脉曲张出血安全有效的方法,疗效确切,提高了患者生存率。     

FibroScan技术判断乙型肝炎肝硬化患者食管静脉曲张程度的临床研究

目的 研究FibroScan对于乙型肝炎肝硬化患者食道静脉曲张程度的诊断效能.方法 人选乙型肝炎肝硬化患者158例,所有患者进行胃镜及FibroScan检测.对比不同食道静脉曲张程度患者FS值(FibroScan检测值)差异,绘制相应ROC曲线.结果 无食道静脉曲张患者、轻度食道静脉曲张患者、中度食道静脉曲张患者和重度食道静脉曲张患者的FS值分别是(21.7±9.9)kPa、(32.1±13.6) kPa、(42.3±20.0) kPa、(54.5 ±16.2) kPa.各组间比较差异有统计学意义(F值33.4,P＜0.001);组间两两比较,差异均有统计学意义(P均＜0.05).FS值判断是否存在静脉曲张、判断中重度静脉曲张和判断重度静脉曲张的ROC曲线下面积分别为0.798(95％ CI:73.1％～86.5％)、0.823(95％CI:74.5％～90.0％)和0.879(95％ CI:80.8％ ～ 95.0％),对应界值分别是23.3 kPa、31.5 kPa和34.6 kPa.结论 FibroScan检测可以用来判断乙型肝炎肝硬化患者食道静脉曲张程度.     

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。     

组织胶内镜注射联合套扎法治疗重度食管胃底静脉曲张

背景：作为国内临床常用的组织黏合剂,组织胶可瞬间产生聚合反应,具有生物组织固化速度快的优点,治疗食管胃底静脉曲张破裂出血具有很好的效果。 目的：探讨内镜下组织胶注射联合套扎法治疗重度食管胃底静脉曲张的近、远期临床疗效。 方法：纳入90例重度食管静脉曲张合并胃底静脉曲张患者,其中男64例,女26例,年龄22-75岁,在内镜下采用组织胶注射治疗胃静脉曲张,联合食管静脉曲张套扎治疗食管静脉曲张。治疗后2-4周内复查内镜,观察止血率、静脉曲张、曲张静脉直径、红色征、门静脉高压胃病情况等近期疗效和不良反应;曲张静脉消除后随访3-39个月,观察静脉曲张情况、组织胶排胶情况和局部增生状况、再出血、复发等中远期临床疗效及并发症。 结果与结论：①近期疗效：与治疗前比较,治疗后患者曲张静脉数目明显减少、红色征发生率降低、静脉高压性胃病好转(P均 < 0.01),但3例发生早期再出血。组织胶在治疗2周-3个月开始排出,未发生与组织胶注射治疗直接有关的食管狭窄、穿孔、严重感染、异位栓塞等并发症。②中远期疗效：静脉曲张复发9例,5例发生远期再出血。表明经内镜注射组织胶联合密集套扎法治疗重度食管胃底静脉曲张或(和)出血疗效确切,操作成功率高,止血效果好,并能有效预防远期再次出血,复发率低。中国组织工程研究杂志出版内容重点：生物材料;骨生物材料; 口腔生物材料; 纳米材料; 缓释材料; 材料相容性;组织工程全文链接：     

超声引导对经皮肝胃冠状静脉栓塞术的辅助作用

目的探讨超声引导对经皮肝胃冠状静脉栓塞术（PTVE）治疗肝硬化上消化道出血的辅助作用。方法52例经超声引导下PrrVE作为观察组,37例采用盲穿门静脉行PTVE作为对照组。比较2组患者穿刺成功率、穿刺时间（指确定穿刺点至导管置入时间）、栓塞效果及并发症发生率。结果观察组1次穿刺成功率（73．1％）显著高于对照组（43．2％）,P〈0．05具有统计学意义。观察组1次穿刺成功时间（2．3±0．6）min显著低于对照组（4．2±0．8）min,P〈0．05具有统计学意义。观察组栓塞成功率（100％）显著高于对照组（86．5％）,P〈0．05具有统计学意义。观察组并发症发生率低于对照组。结论超声引导对PTVE具有重要的辅助作用,能准确判断门静脉位置,增加了穿刺成功率,提高了穿刺速度。     

Clinical outcomes of balloon-occluded retrograde transvenous obliteration for the treatment of gastric variceal hemorrhage in Korean patients with liver cirrhosis: a retrospective multicenter study

Background/Aims

This study evaluated the clinical outcomes of balloon-occluded retrograde transvenous obliteration (BRTO) for the treatment of hemorrhage from gastric varices (GV) in Korean patients with liver cirrhosis (LC).

Methods

We retrospectively analyzed data from 183 LC patients who underwent BRTO for GV bleeding in 6 university-based hospitals between January 2001 and December 2010.

Results

Of the 183 enrolled patients, 49 patients had Child-Pugh (CP) class A LC, 105 had CP class B, and 30 had CP class C at the time of BRTO. BRTO was successfully performed in 177 patients (96.7%). Procedure-related complications (e.g., pulmonary thromboembolism and renal infarction) occurred in eight patients (4.4%). Among 151 patients who underwent follow-up examinations of GV, 79 patients (52.3%) achieved eradication of GV, and 110 patients (72.8%) exhibited marked shrinkage of the treated GV to grade 0 or I. Meanwhile, new-appearance or aggravation of esophageal varices (EV) occurred in 54 out of 136 patients who underwent follow-up endoscopy (41.2%). During the 36.0±29.2 months (mean±SD) of follow-up, 39 patients rebled (hemorrhage from GV in 7, EV in 18, nonvariceal origin in 4, and unknown in 10 patients). The estimated 3-year rebleeding-free rate was 74.8%, and multivariate analysis showed that CP class C was associated with rebleeding (odds ratio, 2.404; 95% confidence-interval, 1.013-5.704; P=0.047).

Conclusions

BRTO can be performed safely and effectively for the treatment of GV bleeding. However, aggravation of EV or bleeding from EV is not uncommon after BRTO; thus, periodic endoscopy to follow-up of EV with or without prophylactic treatment might be necessary in LC patients undergoing BRTO.     

门静脉内皮细胞损伤与门静脉高压症相互关系的研究

采用Masson三色染色法,辅以形态学观察,研究肝硬变病人(n=30)肝内外门静脉的内皮细胞变化。发现血管内皮细胞有明显损伤,伴血栓形成及管壁结构改建。提示血管内皮细胞损伤与门静脉高压症有密切关系。     

髓过氧化物酶(MPO)在妊高征发病中的作用

目的本文旨在探讨髓过氧化物酶在妊高征发病中的作用。方法采用分光光度计比色法检测胎盘组织中中性粒细胞髓过氧化物酶(MPO)活性。结果重度妊高征组胎盘组织MPO含量显著高于中度妊高征组(P<0.05);重度妊高征组胎盘组织MPO含量显著高于正常组(P<0.05);中度妊高征组胎盘组织MPO含量与正常组相比较没有显著性差异(P>0.05)。结论重度妊高征妇女胎盘组织髓过氧化物酶含量较正常孕妇相比增高,差异有显著性,支持妊高征发病的中性粒细胞活化导致的内皮细胞损伤学说。     

Contractile profile of esophageal and gastric fundus strips in experimental doxorubicin-induced esophageal atresia

Esophageal atresia (EA) is characterized by esophageal and gastric motility changessecondary to developmental and postsurgical damage. This study evaluated thein vitro contractile profile of the distal esophagus and gastricfundus in an experimental model of EA induced by doxorubicin (DOXO). Wistar pregnantrats received DOXO 2.2 mg/kg on the 8th and 9th gestational days. On day 21.5,fetuses were collected, sacrificed, and divided into groups: control, DOXO without EA(DOXO-EA), and DOXO with EA (DOXO+EA). Strips from the distal esophagus and gastricfundus were mounted on a wire myograph and isolated organ-bath system, respectively,and subjected to increasing concentrations of carbamylcholine chloride (carbachol,CCh). The isolated esophagus was also stimulated with increasing concentrations ofKCl. In esophagus, the concentration-effect curves were reduced in response to CCh inthe DOXO+EA and DOXO-EA groups compared to the control group (P<0.05). The maximumeffect values (E_max) for DOXO+EA and DOXO-EA were significantly lower thancontrol (P<0.05), but the half-maximal effective concentration (EC₅₀)values were not significantly different when the three groups were compared(P>0.05). In response to KCl, the distal esophagus samples in the three groupswere not statistically different with regard to E_max or EC₅₀values (P>0.05). No significant difference was noted for EC₅₀ orE_max values in fundic strips stimulated with CCh (P>0.05). Inconclusion, exposure of dams to DOXO during gestation inhibited the contractilebehavior of esophageal strips from offspring in response to CCh but not KCl,regardless of EA induction. The gastric fundus of DOXO-exposed offspring did not havealtered contractile responsiveness to cholinergic stimulation.