Clinical response after transjugular intrahepatic portosystemic stent shunt insertion for refractory ascites in cirrhosis

Background: Transjugular intrahepatic portosystemic stent shunts (TIPSS) have been used successfully to reduce portal pressure in the context of variceal haemorrhage. Recent interest has focused on the possible use of TIPSS to manage refractory ascites.
Aim: To study the effect of TIPSS insertion in 18 patients with refractory ascites.
Results: Response rates were 33.3%, 50%, 33.3% and 26.7% at 1 week, 4 weeks, 3 months and 6 months, respectively. Overall mortality was 50% with a new or worsening encephalopathy rate also of 50%. Patients with lower serum bilirubin and serum creatinine prior to TIPSS insertion had greater response at 1 and 4 weeks, respectively. There was no improvement in either liver or renal function after TIPSS insertion by standard laboratory tests, although serum sodium increased in the responders after 1 month.
Conclusion: TIPSS improves refractory ascites in only a minority of patients, and is associated with high encephalopathy and mortality rates.     

经颈静脉肝内门体分流术治疗肝硬化并发上消化道出血的临床疗效

目的 探讨经颈静脉肝内门体分流术（TIPS）治疗肝硬化并发上消化道出血的临床疗效。方法 收集2012年3月—2017年3月我院接受治疗的肝硬化并发上消化道出血患者110例,对照组（35例）接受常规内科保守治疗,TIPS组（75例）在对照组治疗基础上联合TIPS治疗。对比TIPS组患者手术前后门静脉压力、门静脉内径、门静脉流速、血小板计数（PLT）、红细胞计数（RBC）、白蛋白（ALB）、总胆红素（TBIL）、丙氨酸转氨酶（ALT）、天冬氨酸转氨酶（AST）指标。随访并比较2组患者治疗后生存率、再出血率、生活质量情况。结果 75例行TIPS全部成功,技术成功率100%,围手术期无患者死亡,未出现心脏压塞、腹腔积血、胆汁瘘等严重并发症。与术前相比,TIPS术后门静脉压力、门静脉内径显著降低,门静脉流速明显加快（P＜0.05）。随访期间共有11例患者死亡,病死率14.7%,TIPS分流道3、6、12、24、36个月累积原发通畅率分别为95.6%、90.1%、85.7%、79.0%、74.2%。术后6个月时,PLT、RBC、ALB较术前改善（P＜0.05）,而TBIL、ALT、AST与术前差异无统计学意义（P > 0.05）。对照组3、6、12、24、36个月累积生存率为94.3%、91.3%、75.8%、71.0%、59.2%,TIPS组分别为98.7%、97.3%、95.7%、83.4%、70.6%,2组差异无统计学意义（Logrank χ2=2.743,P=0.098）。对照组3、6、12、24、36个月累积再出血率为5.7%、17.1%、23.5%、31.9%、43.2%,TIPS组分别为2.7%、4.0%、8.3%、14.4%、24.0%,2组差异具有统计学意义（Log-rank χ2=4.608,P=0.032）。与对照组比较,TIPS组术后6个月生活质量各项指标均明显改善,差异有统计学意义（P＜0.05）。结论 TIPS治疗肝硬化并发上消化道出血是安全、有效的,与保守治疗相比,TIPS可显著降低再出血率,并改善患者生存质量。     

TIPS 和 PTVE 治疗肝硬化食管胃底静脉曲张破裂出血的 临床效果比较

摘要： 目的 探讨经颈静脉肝内门体分流术 （TIPS） 和经皮经肝胃冠状静脉栓塞术 （PTVE） 对肝硬化食管胃底静 脉曲张破裂出血的疗效。方法 回顾性分析因肝硬化食管胃底静脉曲张破裂出血就诊并实施介入治疗的 61 例患 者资料, 其中 PTVE 组 42 例, TIPS 组 19 例。比较 2 组治疗成功率、 再出血率、 曲张静脉缓解情况、 肝性脑病发生率、 生存率及肝功能变化等。结果 2 组手术均成功, TIPS 组术后门静脉压力明显下降, PTVE 组的再出血率为 78.6%, 高于 TIPS 组的 63.2%, PTVE 组术后食管胃底静脉曲张缓解的有效率为 50.0%, 明显低于 TIPS 组的 89.5%（均 P＜ 0.05）; PTVE 组和 TIPS 组肝性脑病发生率分别为 14.3%和 26.3%, 2 年累积生存率分别为 95.2%和 89.5%, 差异均无 统计学意义; PTVE 组术后各时期肝功变化与术前差异无统计学意义; TIPS 组术后 1、 3 个月肝功能较术前及 PTVE 术后同一时期下降, 术后 6、 12 个月肝功能变化与术前及 PTVE 术后同一时期相比差异无统计学意义。结论 TIPS 治疗肝硬化食管胃底静脉曲张破裂出血手术安全, 再出血率低, 食管胃底静脉曲张好转快, 术后中远期对肝功能影 响较小, 是一种理想的介入治疗方法。     

临床药师参与经颈静脉肝内门体静脉分流术后使用华法林致消化道出血药物治疗1例

临床药师从制定止血方案、抗凝药物选择等方面对1例经颈静脉肝内门体静脉分流术后使用华法林抗凝致消化道出血的患者进行了药学监护,为临床合理用药提供了建议,避免了潜在的治疗风险。临床药师直接深入临床,与医师共同制定最优的药物治疗方案,解决治疗中的用药问题。     

利伐沙班与低分子肝素对经颈静脉肝内门体分流术后患者的抗凝疗效比较

目的比较利伐沙班和低分子肝素对门静脉血栓患者经颈静脉肝内门体分流术(TIPS)后的抗凝疗效。方法门静脉血栓栓塞TIPS术后患者40例,分为低分子肝素组和利伐沙班组。低分子肝素组23例,术后次日开始给予低分子肝素4 100 IU,皮下注射,q12h;利伐沙班组17例,术后次日开始给予利伐沙班10 mg,口服,qd;均连用5 d。监测术后第1、3、7、10、14日血小板计数(PLT)、凝血酶原时间(PT)和活化部分凝血活酶时间(APTT)水平的变化,观察两组术后3个月内门静脉血栓(PVT)和不良反应的发生情况。结果术后3个月内低分子肝素组发生PVT 1例,利伐沙班组1例,PVT复发率组间无显著差异(P>0.05)。两组术后第1、3、7、10、14日PLT、PT和APTT值比较均无显著差异(P>0.05)。低分子肝素组1例患者于术后第3周并发肠系膜静脉广泛血栓形成,食管静脉曲张破裂大出血抢救无效死亡;利伐沙班组无死亡病例。两组均有轻度肝性脑病发生,未见腹腔出血、胆道出血等不良反应的发生。结论门静脉血栓患者行TIPS术后,给予利伐沙班或低分子肝素抗凝疗效相当。     

Bradykinin does not contribute to peripheral vascular tone in patients with cirrhosis and ascites

Bradykinin is an endothelium-dependent vasodilator and inflammatory mediator. The aim of the present study was to examine the effects of bradykinin on peripheral vascular tone in patients with cirrhosis and ascites. Forearm blood flow was measured using venous occlusion plethysmography in 8 patients with biopsy-proven alcohol-induced cirrhosis, ascites, and portal hypertension, and 8 age- and sex-matched healthy controls. On 1 occasion, subjects received an intrabrachial infusion of the selective bradykinin antagonist B9340 (1.5-13.5 nmol/min) followed by a control vasoconstrictor norepinephrine (60-540 pmol/min), and on another occasion bradykinin (100-900 pmol/min) followed by the endothelium-independent vasodilator, sodium nitroprusside (SNP, 2-8 microg/min). Bradykinin and SNP caused a dose-dependent vasodilatation (P < 0.001 for both) that did not differ between the 2 groups. Although norepinephrine caused a similar dose-dependent vasoconstriction in both groups (P < 0.001), B9340 had no effect on forearm blood flow in either group (at 13.5 nmol/min in patients; -5%, 95% CI -13-3). Bradykinin does not provide a major contribution to the maintenance of peripheral vascular tone in patients with cirrhosis and ascites. Our findings also suggest that, in contrast to cardiovascular disease, patients with liver cirrhosis do not have marked endothelial dysfunction.     

The monoethylglycinexylidide test does not impair psychometric performance in patients with chronic hepatitis or cirrhosis

Lidocaine (LID) is an aminoethylamide used in hepatology to perform the monoethylglycinexylidide (MEGX) test for the evaluation of liver function in patients with cirrhosis (CIR) or chronic hepatitis (CH). The authors evaluated whether the MEGX test changes psychometric performance in patients with chronic liver disease and, in particular, whether it might trigger subclinical portosystemic encephalopathy in patients with CIR. Thirty patients with CIR and 20 patients with CH were studied. They underwent a standard-dose MEGX test, before and after which a psychometric test was administered and blood pressure, heart rate, and adverse effects were recorded. The MEGX test did not modify psychometric performance. Mean arterial blood pressure and heart rate did not change at the end of the MEGX test in either patients with CH or CIR. Adverse effects were present in 66% of all patients during lidocaine injection and lasted up to 3 minutes afterwards. They were more frequent in patients with CH than in patients with CIR (85% vs 53%). No relationship was found between adverse effects and lidocaine dosage, nor between adverse effects and MEGX or lidocaine concentration at 15 minutes. Standard-dose MEGX test does not worsen or trigger portosystemic encephalopathy in CIR. Adverse effects were frequent but mild.