Risk and causes of gastroesophageal bleeding in patients with liver cirrhosis

BACKGROUND/AIM: Variceal bleeding is the most life-threating complication in liver cirrhosis. The aim of this study was to analyze the sources of gastroesophageal bleeding in patients with liver cirrhosis and to ascertain the risk factors of bleeding from esophageal varices. METHODS: This prospective study included 52 patients with liver cirrhosis and portal hypertension. Severity of liver dysfunction according to Child's classification, coagulation parameters, and endoscopic findings were analyzed. In patients with varices we analyzed the size, color, location of varices, and the presence of red signs. The varices were classified as small, medium and large. RESULTS: Esophageal varices were found in 76.9% of the patients. Isolated varices were present in 36.6%, and associated with other findings in 40.3%. Small varices were present in 10%, medium in 25% and large in 65% patients. Of them 55% had variceal bleeding. Variceal bleeding was present in 50% of the patients with medium and in 65.38% of the patients with large varices. There was no bleeding in the patients with small varices. Endoscopy revealed red signs before bleeding in 85% of the patients with large varices. There was a higher incidence of variceal bleeding in the Child's group B. There were no significant differences (p > 0.05) in the coagulation parameters in patients with and without variceal bleeding. Rebleeding was present in 86.36% of the patients. Most of them (52.63%) were rebleeding between 7 weeks and 12 months after the first episode of variceal bleeding. In the patients with the most severe hepatocellular dysfunction (Child's group C) the period between the first bleeding and rebleeding was the shortest (mean, 20.8 days). CONCLUSION: Our study revealed that esophageal varices are the most frequent sources of bleeding in the patients with liver cirrhosis. There is the association between the first bleeding and large varices and the red signs. Coagulation disorders and hepatic dysfunction were not related to the initial episode of variceal bleeding. The risk of early rebleeding was higher in the patients with severe hepatic dysfunction (Child's class C).     

CT测量脾脏指数预判肝硬化食管静脉曲张及出血的可能

目的探讨利用脾脏大小指数(sp len ic index,SI)来预测食管静脉曲张的程度及食管静脉破裂出血的可能性。方法肝硬化患者36例,均行内窥镜及CT检查。通过CT片测量脾脏大小计算SI,内窥镜观察食管静脉曲张的程度。结果(1)SI与食管静脉曲张程度之间呈显著正相关r=0.776P=0.001;(2)SI与肝硬化代偿及失代偿期之间有显著性差异(P=0.004);(3)SI与肝硬化有无出血之间亦有差异(P=0.029);(4)SI与肝硬化有无食管静脉曲张之间有差异(P=0.031);(5)SI与性别,年龄及肝硬化有无腹水之间无相关关系。当SI>940.42 cm3时,肝硬化患者有食管静脉曲张的可能性大。结论SI对预测高危食管静脉曲张有一定价值。SI值较大时提示有食管静脉曲张破裂出血的危险。     

肝硬化患者CT门静脉血管成像中门静脉侧支血管的表现

目的 分析肝硬化患者在16排螺旋CT门静脉血管成像(CTPV)上门静脉侧支血管的表现.方法 对36例经临床、肝功能和影像学检查诊断为肝硬化门静脉高压的患者行腹部CTPV检查,经图像后处理,获得门静脉系统及侧支血管三维重建图像.结果 CTPV可以直观地显示门静脉系统及整个门静脉侧支循环系统.36例病例中显示胃左静脉曲张29例(80.6%),食管下段静脉曲张18例(50.0%),胃短/W后静脉曲张15例(41.7%),食管旁静脉曲张9例(25.0%),胃-肾/脾-肾分流8例(22.2%),门静脉海绵样变7例(19.4%),脐静脉与腹壁静脉曲张6例(16.7%),椎旁静脉分流4例(11.1%).结论 CTPV能很好地显示肝硬化患者门脉高压侧支循环的开放部位、范围及严重程度,对判断病情、选择治疗方案及估计预后有重要的临床应用价值.     

Viral-induced cirrhosis: grading of severity using MR imaging.

OBJECTIVE: The purpose of this study was to determine whether MR imaging can be used to grade the severity of cirrhosis. MATERIALS AND METHODS: The MR examinations of 46 patients with cirrhosis were retrospectively reviewed independently by two radiologists and correlated with clinical severity assessed by Child-Pugh classification. MR imaging analysis by reviewers who were unaware of clinical status included comparison of volume indexes (computed as the product of three axis measurements) of the spleen and each segment of the liver, and changes in hepatic contour, iron or fat deposition, and presence of varices and collaterals. RESULTS: Volume index of the spleen and the presence of ascites and varices were significantly and positively correlated (p = .008, .002, .0001, respectively) with the clinical severity of cirrhosis (Child-Pugh classifications), and volume indexes of the posterior, medial, and lateral segments of the liver were significantly and inversely correlated (p = .001, .049, .041, respectively). On an MR scoring system based on four items (volume index of the spleen; volume index of posterior + medial + lateral segments; presence of ascites; and presence of varices and collaterals), averaged total MR scores were 2.5 +/- 0.3, 4.9 +/- 0.6, and 7.9 +/- 0.8 for Child-Pugh grades A, B, and C, respectively (p < .0001). The accuracy of MR scoring in distinguishing between clinical Child-Pugh grade A cirrhosis and further grades was 89%, the sensitivity was 93%, and the specificity was 82%. CONCLUSION: An MR scoring system can be used to grade the severity of cirrhosis.     

肝硬化肝内门—体循环交通的CT表现

目的：分析肝硬化门静脉高压肝内门-体循环交通的发生率及CT表现。材料与方法：复习连续100例肝硬化门静脉高压患者（合并或不合并肝癌）的增强CT扫描表现,统计各部位侧支循环的比例,并着重描述肝内门-体循环交通的CT表现。结果：肝内门-体循环交通4例（4%）,加上另外发现的2例,共6例,均为经肝左内叶门静脉左支脐静脉隐窝部至左内叶或左外叶实质内,再与副脐静脉交通的类型。交通静脉均走行于肝左内叶,其最大径可达2.2cm。5例合并存在其他部位侧支循环,包括食管粘膜下2例,食管和胃粘膜下、食管粘膜下的胃左、脾周和椎旁静脉曲线各1例。结论：肝内门-体循环交通虽不常见,但应引起重视,以提高肝内占位病变的鉴别诊断准确性及有助于提示临床医师注意肝性脑病的可能性。     

Percutaneous transhepatic portography. III. Relationships between portosystemic collaterals and portal pressure in cirrhosis.

The relationships among collateral veins, gastroesophageal varices, extrahepatic shunting, and free portal pressure were studied by percutaneous transhepatic portography in 57 patients with cirrhosis of the liver. The size of esophageal varices was related to the size of the coronary and short gastric veins and to the portal pressure. The size of gastric varices was related to cephalad collaterals from the spleen and splenic vein, but not to portal pressure. Portosystemic shunting was associated with collaterals in the lower abdomen, but not with varices or portal pressure.     

A noninvasive method for evaluating portal circulation by administration of Ti-201 per rectum

A new method for evaluating portal systemic circulation by administration of TI-201 per rectum was performed in 13 control subjects and in 65 patients with various liver diseases. In normal controls, the liver was visualized on the 0--5-min image whereas the images of other organs such as the heart, spleen, and lungs were very poor. In patients with liver cirrhosis associated with portal-systemic shunt, and in many other patients with hepatocellular damage, the liver was not so clearly visualized, whereas radioactivity in other organs, especially the heart, became evident. The heart-to-liver uptake ratio at 20 min after administration (H/L ratio) was significantly higher in liver cirrhosis than in normals and patients with chronic hepatitis (p less than 0.001). The patients with esophageal varices showed a significantly higher H/L ratio compared with that in cirrhotic patients without esophageal varices (p less than 0.001). The H/L ratio also showed a significant difference (p less than 0.01) between Stage 1 and Stage 3 esophageal varices. Since there were many other patients with hepatocellular damage who had high H/L ratios similar to those in liver cirrhosis, the effect that hepatocellular damage has on the liver uptake of TI-201 is also considered. Our present data suggest that this noninvasive method seems to be useful in evaluating portal-to-systemic shunting.     

Balloon-occluded retrograde transvenous obliteration of gastric varices with gastrorenal shunt: long-term follow-up in 78 patients

OBJECTIVE: Our aim was to evaluate the long-term clinical results after balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices with spontaneous gastrorenal shunt. MATERIALS AND METHODS: A total of 78 patients with cirrhosis and with gastric varices, successfully treated by B-RTO, were enrolled in this study. Recurrence and bleeding of gastric varices and worsening of esophageal varices were endoscopically evaluated. Univariate and multivariate analyses were used to assess the prognostic factors for worsening of esophageal varices and survival. RESULTS: Recurrence of gastric varices was found in two patients; the 5-year recurrence rate was 2.7%. Bleeding of gastric varices occurred in only one patient after B-RTO; the 5-year bleeding rate was 1.5%. Worsening of esophageal varices was observed in 29 patients, and the worsening rates at 1, 3, and 5 years were 27%, 58%, and 66%, respectively. These esophageal varices were endoscopically treated to prevent rupture. Multivariate analysis showed the presence of esophageal varices before B-RTO was a prognostic factor for worsening (relative risk, 4.956). At a median follow-up of 700 days (range, 137-2,339 days), the survival rates at 1, 3, and 5 years were 93%, 76%, and 54%, respectively. The prognostic factors associated with survival were presence of hepatocellular carcinoma (relative risk, 24.342) and the Child-Pugh classification (relative risk, 5.780). CONCLUSION: B-RTO is an effective method for gastric varices with gastrorenal shunt and provides lower recurrence and bleeding rates. We believe that B-RTO can become a standard treatment for gastric varices with gastrorenal shunt, although treatment of worsened esophageal varices may be necessary after B-RTO.     

Discrimination of alcoholic from virus-induced cirrhosis on MR imaging

OBJECTIVE: The purpose of this study was to determine whether MR features help to differentiate virus-induced cirrhosis from alcoholic cirrhosis. MATERIALS AND METHODS: The MR examinations of 53 patients with cirrhosis (38 men and 15 women; age range, 28-73 years) caused by hepatitis B (n = 16), hepatitis C (n = 18), or alcohol abuse (n = 19) were retrospectively reviewed independently by two radiologists. The following MR features were assessed by each radiologist independently: volume indexes of the spleen and of each liver segment (based on 3-axis measurements), the nodularity of the surface, and the presence of regenerative nodules, ascites, iron or fat deposition, varices or collateral veins, the right posterior hepatic notch, and an expanded gallbladder fossa. RESULTS: The mean values of the volume index of the caudate lobe were significantly greater (p < 0.0001) in the group with alcoholic cirrhosis than those in the group with viral cirrhosis. The frequency of visualization of the right posterior hepatic notch in the patients with alcoholic cirrhosis was significantly greater (p < 0.05) than that in the patients with viral cirrhosis. The size of regenerative nodules of the liver in the patients with cirrhosis caused by hepatitis B was significantly greater (p < 0.02) than that in the patients with alcoholic cirrhosis. CONCLUSION: Enlargement of the caudate lobe and the presence of the right posterior hepatic notch on MR imaging are more frequent findings of alcoholic cirrhosis than of virus-induced cirrhosis.     

MDCTP对肝硬化门脉高压侧支循环血管的显示价值

目的:评价16排螺旋CT门静脉血管成像(MDCTP)技术在显示肝硬化门脉高压侧支循环血管方面的应用价值。方法:对38例临床诊断肝硬化门脉高压的患者行上腹部MDCTP检查。采用MIP、MPR、VR等三维重组技术进行图像后处理,获得门静脉系统及侧支循环血管图像。结果:38例中显示食管胃底粘膜下静脉曲张31例,食管旁静脉曲张10例;胃左静脉曲张29例,胃短静脉曲张26例;脐静脉与腹壁静脉曲张7例;脾-肾或胃-肾分流6例;腹膜后分流2例。结论:MDCTP能显示肝硬化患者门-体侧支循环开放部位、范围及程度,有重要的临床应用价值。     

胃左静脉MSCTA预测肝硬化门静脉高压食管胃底静脉曲张破裂岀血的价值

目的探讨胃左静脉多层螺旋CT血管造影(MSCTA)预测肝硬化门静脉高压食管胃底静脉曲张破裂岀血的临床应用价值。资料与方法应用16层螺旋CT对74例肝硬化门静脉高压症患者和200名正常对照者行上腹部增强扫描,采用多平面重组(MPR)、最大密度投影(MIP)对胃左静脉进行血管重组,观察胃左静脉和食管胃底静脉曲张情况,并测量胃左静脉最大内径进行统计学分析。结果总体肝硬化门静脉高压组胃左静脉最大内径与正常对照组比较明显增宽(P=0.00),肝硬化门静脉高压出血组、未出血组胃左静脉最大内径与正常对照组比较均显著增宽,差异具有统计学意义(P<0.05)。以胃左静脉最大内径7.0 mm为判断岀血的标准,其敏感性、特异性、准确性分别为61.5%、77.1%、71.6%。结论 MSCTA可以清晰显示胃左静脉和食管胃底静脉曲张情况;胃左静脉增宽是肝硬化门静脉高压食管胃底静脉曲张破裂出血的一个危险因素,胃左静脉内径的测量对食管胃底静脉曲张破裂岀血具有一定的预测价值。     

门静脉高压侧支循环的螺旋CT表现

探讨肝硬化门脉高压侧支循环的螺旋ＣＴ表现。材料与方法,搜索肝硬化门脉高压患者５２例,其中２３例采用３ｍｍ薄层容积扫描,重建层厚１．５ｍｍ,并进行ＭＩＰ管重建。结果螺旋ＣＴ显示脐周静脉曲张１２例,胆囊周围静脉曲张８例,脾肾静脉侧支开放９例,腹膜后静脉曲线１０例,食管静脉曲张２４例,     

对照内镜评价三维动态增强MR血管成像诊断食管胃静脉曲张的临床价值

目的 探讨3D动态增强MRA(3D DCE MRA)诊断食管胃静脉曲张的临床价值.方法 回顾性分析2003年4月至2008年6月期间本院同时行3D DCE MRA和内镜检查的153例门静脉高压患者,将所有患者分为出血组和无出血组,对3D DCE MRA图像进行减影后处理,采用MIP和薄层(thin-MIP)方法3D重组,测量3D DCE MRA图像中食管壁内和壁外曲张静脉、胃黏膜下和胃周曲张静脉的最小、最大以及平均直径,对照内镜结果,采用Spearman秩相关分析研究3D DCE MRA与内镜结果的相关性,并采用X~2检验比较出血组和无出血组食管壁外及胃周曲张静脉的出现率.结果 出血组食管静脉重度曲张59例,中度曲张6例,轻度曲张5例,无出血组食管静脉重度曲张32例,中度曲张4例,轻度曲张5例;出血组胃静脉重度曲张28例,中度曲张34例,轻度曲张16例,无出血组胃静脉重度曲张7例,中度曲张12例,轻度曲张9例.减影后的MIP图像能够总体显示食管胃曲张静脉,thin-MIP重组图像能够鉴别食管壁内和壁外曲张静脉以及胃黏膜下和胃周曲张静脉.3D DCE MRA测得食管胃曲张静脉的直径与内镜分级呈相关性,r值为0.544～0.878(P＜0.01).食管静脉重度曲张组91例,在出血组(59例)和无出血组(32例)出现食管壁外静脉分别为27例(27/59)和24例(24/32),差异有统计学意义(X~2=7.199,P＜0.01);胃静脉重度曲张组35例,在出血组(28例)和无出血组(7例)出现胃周静脉的分别为22例(22/28)和4例(4/7),差异无统计学意义(P=0.340).结论 3D DCE MRA可全面显示食管胃曲张静脉,对食管和胃静脉曲张的评价与内镜结果呈正相关,食管壁外静脉的出现可能降低重度食管静脉曲张破裂出血的危险性.     

Correlations between colonic wall thickening in patients with virally induced cirrhosis on CT and clinical status

PURPOSE: The purpose of this work was to determine the frequency and CT imaging spectrum of colonic wall thickening and correlate these with the clinical severity of virally induced cirrhosis. METHOD: Fifty-nine patients were identified with virally induced cirrhosis and no other causes of colonic wall thickening. The abdominal CT scans of these patients were retrospectively reviewed by two radiologists to determine the presence of colonic wall thickening from the ascending colon to the descending colon, to assess the segmental distribution, and to correlate these findings with the clinical status assessed by Child-Pugh classification, presence of ascites, splenic volume index, varices score, and serum albumin levels. RESULTS: Colonic wall thickening was identified in 18 (31%) patients. The frequency of the affected distribution of colonic wall thickening was as follows: ascending colon in 17 (29%) patients, transverse colon in 11 (19%) patients, and descending colon in 7 patients (12%). The ascending colon was the most common site of colonic wall thickening (p < 0.001). Ten (17%) patients had multisegmental distributions. Colonic wall thickening had a statistically significant association with Child-Pugh grades A, B, and C (p < 0.0001), presence of ascites (p < 0.0004), splenic volume index (p = 0.0026), varices score (p < 0.0001), and serum albumin levels (p = 0.0364). The segmental distribution of wall thickening significantly correlated with Child-Pugh grades A, B, and C (p = 0.0005), presence of ascites (p < 0.001), varices score (p < 0.0001), serum albumin levels (p < 0.0001), and splenic volume index (p = 0.0135). CONCLUSION: Colonic wall thickening occurs commonly in patients with virally induced cirrhosis. The presence and number of colonic wall thickening were correlated with the grading of the severity of cirrhosis.     

肝硬化门静脉高压侧枝血管的多层螺旋CT表现

目的用多层螺旋CT(MSCT)统计、分析肝硬化门静脉高压患者的侧枝循环表现。方法收集203例肝硬化门静脉高压患者MSCT上腹部检查的完整资料。结果共发现门静脉侧枝或异常血管612处:食管下段静脉曲张175处,食管旁静脉曲张49处(其中伴假肿瘤征13处),胃底静脉曲张119处,胃冠状静脉曲张105处,胃肾静脉分流34处,脾肾静脉分流15处,椎旁静脉丛曲张16处,脐静脉再通48处,副脐静脉再通22处,脐静脉、副脐静脉同时再通4处,腹壁静脉丛曲张呈蛇头征12处,门静脉海绵样变8处,门静脉右后支瘤样扩张并与下腔静脉分流4处,胃左静脉直接入肝与门静脉左支相连1处。结论MSCT可较好地显示各类门静脉高压侧枝,了解这些异常表现有助于作出正确诊断,避免误诊,对临床选择治疗方法有重要的意义。     

Retrograde transvenous obliteration of gastric varices

PURPOSE: To evaluate the clinical efficacy, techniques, and complications associated with balloon-occluded retrograde transvenous obliteration of gastric varices. MATERIALS AND METHODS: Between December 1994 and November 1997, balloon-occluded retrograde transvenous obliteration was performed on 20 patients with gastric varices in danger of rupture and with gastrorenal shunts; three patients also had hepatic encephalopathy. The sclerosant was injected into the gastric varices during balloon occlusion. The degree of progression of the gastric varices and of collateral veins was classified into five grades, with grade 1 being least progression and grade 5 most progression; collateral veins that had developed were treated with embolization. Follow-up consisted of fiberoptic endoscopy and computed tomography. RESULTS: Technical success was achieved in all patients. Occlusion of collateral veins was essential for the occlusion of gastric varices with a grade greater than grade 2. The clinical symptoms of hepatic encephalopathy in the three patients improved remarkably. Follow-up endoscopy 3 months after the procedure revealed the disappearance of gastric varices in 15 patients and reduced variceal size in five. During the follow-up period, 19 patients had no recurrence of gastric varices; three patients had aggravation of the esophageal varices. CONCLUSION: Balloon-occluded retrograde transvenous obliteration is a feasible alternative to a transjugular intrahepatic portosystemic shunt for patients with large gastrorenal shunts or hepatic encephalopathy (or both).     

Evaluation of portosystemic collaterals by SPECT imaging after endoscopic variceal sclerotherapy: usefulness for predicting recurrence.

Bleeding from esophageal varices is a major cause of morbidity and mortality in cirrhotic patients. Identification of patients at high risk for bleeding is particularly important. The aim of this study was to determine whether detection of portosystemic collaterals by SPECT could predict the outcome of endoscopic injection sclerotherapy of esophageal varices and be useful for selecting appropriate therapy. METHODS: Sixty-two patients with liver cirrhosis who were considered at high risk of bleeding were treated with endoscopic injection sclerotherapy. Endoscopy was performed every 3 mo after therapy or until bleeding occurred. Before and within 2 wk after therapy, tomographic images of intra-abdominal blood pool were constructed by SPECT. RESULTS: Before therapy, the following portosystemic collateral routes were observed: coronary veins in 53 (85.5%) of 62 patients, short gastric veins in 8 patients (12.9%), splenorenal shunts in 10 patients (16.1%), and paraumbilical veins in 6 patients (9.7%). Patients positive for imaging of coronary veins were divided into 3 groups on the basis of changes in images after therapy: complete responders (n = 17), whose coronary vein images disappeared completely; partial responders (n = 18), whose images became smaller; and nonresponders (n = 18), whose images did not change significantly before or after therapy. The rates of recurrence after endoscopic injection sclerotherapy until 6 mo in complete responders (4/17, 23.5%) and partial responders (7/18, 38.9%) were significantly less (P < 0.05) than that in nonresponders (11/13, 84.6%). The rate of recurrence of esophageal varices until 6 mo in nonresponders treated with additional submucosal injection sclerotherapy (1/5, 20.0%) was significantly less (P < 0.05) than that in nonresponders without additional submucosal injection sclerotherapy (11/13, 84.6%). CONCLUSION: Abdominal blood-pool SPECT, a noninvasive method, is useful for evaluating the therapeutic effectiveness of endoscopic sclerotherapy, for predicting the recurrence of varices, and for selecting appropriate management after sclerotherapy.     

Dynamic liver scanning in cirrhosis

Dynamic hepatic scintigraphy was performed in 49 patients with established cirrhosis, using intravenous 99Tcm-pertechnetate and 99Tcm-sulphur colloid in a prospective study of its predictive value. There was a close correlation between the hepatic perfusion index (reflecting the ratio of arterial to total hepatic blood flow) obtained with pertechnetate (HPI-P) and with sulphur colloid (HPI-C) (r = 0.775; p less than 0.0001), and both indices correlated with disease severity (HPI-P p less than 0.0001; HPI-C p less than 0.01). HPI-P was significantly increased in patients who died, in patients with varices and in those with hepatic encephalopathy. HPI-C was significantly increased in patients with varices, in patients with hepatic encephalopathy and in those who had bled from varices. Neither HPI-P nor HPI-C was able accurately to predict the development of complications during the follow-up period. The trapping index (TI), reflecting a combination of hepatic extraction efficiency, degree of intrahepatic shunting and extrahepatic extraction of colloid, was significantly impaired in patients who died and in those with ascites, varices and/or variceal bleeding, but not in patients with hepatic encephalopathy. The trapping index correlated with disease severity, as did the computer-derived spleen-liver ratio (S-L ratio). Neither TI nor S-L ratio was able to predict the development of complications. The clearance rate constant of colloid from peripheral blood, the uptake rate constants for liver and spleen, and splenic volume were all found to be unhelpful as indicators of disease severity or as predictors of complications. While perfusion indices derived by dynamic hepatic scintigraphy reflect the severity of the underlying liver disease, their determination on a single occasion appears to offer no benefit in predicting the likelihood of major complications.     

影响经皮经肝食管胃曲张静脉组织胶栓塞术远期疗效因素分析

目的：探讨提高经皮经肝曲张静脉栓塞术（PTVE）治疗食管胃底静脉曲张出血远期疗效的相关因素。方法：192例肝硬化合并食管胃底静脉曲张出血的患者,经皮经肝穿刺向食管下段胃底部曲张静脉、食管下段周围静脉丛、胃底贲门周围静脉丛内注入永久性栓塞剂TH胶（a-氰基丙烯酸酯）。结果：192例患者中188例成功施行了PTVE,成功率达97．8％。168例患者随访期6～64月,根据注入的TH胶分布的范围,168例患者分为3种栓塞类型：食管-胃底型82例,胃底型67例,主干型19例,135例患者PTVE后同时施行部分脾动脉栓塞,42例随访中施行了内镜下套扎或硬化治疗。静脉曲张复发率15．5％（26／168）。胃食管栓塞组静脉曲张复发率明显低于胃底贲门型及冠状静脉主干型（P〈0．0001,log-rank test）。随访期间21例患者再出血,总出血率12．5％（21／168）。其中食管胃底型再出血率3．7％（3／82）;胃底型再出血率10．4％（7／67）;主干型再出血率58．1％（11／19）。联合内镜治疗者再出血为2．4％（1／42）,联合脾动脉栓塞组再出血8．9％（12／135）明显低于单纯PTVE治疗的27．3％（9／33）。结论：TH胶栓塞范围与远期疗效密切相关,联合部分脾动脉栓塞和内镜下套扎治疗能明显降低食管胃静脉曲张复发和再出血。     

Renovascular impedance and esophageal varices in patients with Child-Pugh class A cirrhosis

PURPOSE: To evaluate the frequency of increased renovascular impedance and its relationship with the presence of esophageal varices in patients with Child-Pugh class A cirrhosis without ascites. MATERIALS AND METHODS: The intraparenchymal renal resistive index (RI) (reference value, <0.7) and portal congestive index (ie, the ratio between the portal cross-sectional area and mean flow velocity; reference value, <0.07) were measured by using duplex Doppler ultrasonography in 50 consecutive patients. The frequency of varices was assessed endoscopically. The data were analyzed with the Fisher exact test. RESULTS: The renal RI was consistent with increased impedance (ie, >0.7) in 18 (36%) patients and was normal in 32 (64%). The proportion of patients with varices was significantly higher in the former group: 14 (78%) versus 10 (31%) (P =.002). In detection of the presence of varices, the renal RI was uniformly better than the portal congestive index in terms of sensitivity (58% vs. 48%), specificity (84% vs 54%), and positive (3.60 vs 1.04) and negative (0.50 vs. 0.96) likelihood ratios. RI determination improved the ability to exclude the presence of varices from a basal pretest probability of 52% (26 of 50 patients) to a final one of 69% (22 of 32 patients) and that of predicting the presence of varices from 48% (24 of 50 patients) to 78% (14 of 18 patients). CONCLUSION: A substantial proportion of patients with Child-Pugh class A cirrhosis without ascites have increased renovascular impedance; this significantly correlates with the presence of varices.