Portal vein thrombosis: causes and treatment

Portal vein thrombosis (PVT) has a heterogeneous aetiology. Recently discovered thrombotic risk factors such as latent myeloproliferative disorders and prothrombotic genetic defects are important in the aetiology of PVT. At least one-third of the PVT patients exhibit a combination of thrombotic risk factors. Treatment with anticoagulant drugs has not proved beneficial for most PVT patients. Therapy with anticoagulants is only recommended in those with acute PVT, in those who recently underwent a portosystemic shunt procedure and in those with other thrombotic manifestations, particularly in case of proved hypercoagulability. Due to intact coagulation, oesophageal varices bleeding in patients with PVT has a better prognosis than in cirrhotics.     

Place of endoscopic variceal ligation for the prophylaxis of rebleeding from oesophageal varices. Prospective study about 102 cases

The aim of this study was to assess the efficacy and morbidity of endoscopic variceal ligation for the prophylaxis of rebleeding from oesophageal varices. This work is a prospective study including 102 patients having had at least one episode of variceal bleeding. The mean age is 52.5 years. Oesophageal varices were eradicated in 83.3% of cases after an average of 3.5 sessions. Recurrence of oesophageal varices after eradication was observed in 22% after an average follow-up of 7 months. 10 patients died before eradication of oesophageal varices from causes unrelated to the technique. The endoscopic variceal ligation is effective for eradication of oesophageal varices, with a low morbidity. This technique appears to be a method of choice in the prophylaxis of rebleeding from oesophageal varices.     

食管胃底静脉曲张内镜硬化剂治疗并发败血症危险因素分析

目的 比较食管胃底静脉曲张活动性出血和无活动性出血患者接受内镜硬化剂治疗后发生脓毒血症的差异,并分析危险因素,为临床治疗提供参考.方法 同顾性分析2005-2009年浙江中医药大学附属第六医院245例接受内镜检查或治疗的肝硬化患者的临床资料,并将患者分为3组:组Ⅰ患者有活动性出血接受内镜硬化剂治疗止血,共87例;组Ⅱ患者接受内镜硬化剂治疗预防出血,共74例;组Ⅲ患者为接受常规内镜检查明确有无静脉曲张或有曲张静脉而不需要硬化剂治疗共84例.在内镜治疗前、后行血病原菌培养.结果 组Ⅰ患者内镜检查治疗前17例(19.5%)血液病原菌培养阳性,硬化剂治疗后5例(5.7%)血病原菌培养阳性.病原菌分别为大肠埃希菌10株,肺炎克雷伯菌5株,棒状杆菌2株.组Ⅱ血液病原菌培养阳性0例,组Ⅲ1例,病原菌为表皮葡萄球菌.所有患者均无临床感染证据.结论 食管胃底静脉曲张无出血患者接受内镜检查治疗不会增加血液感染的危险.对此类患者没有必要预防性应用抗菌药物.相反,对于食管胃底静脉曲张出血接受内镜硬化剂治疗的患者则需要常规接受抗菌药物预防感染.     

内镜下套扎术联合硬化剂治疗肝硬化食管胃底静脉曲张的疗效分析

目的分析内镜下套扎术(EVL)联合硬化剂治疗肝硬化食管胃底静脉曲张的临床效果。方法将我院2011年至2013年期间收治的96例肝硬化食管胃底静脉曲张且曾破裂的患者分成对照组和实验组各48例。对照组采用EVL治疗,实验组采用EVL联合硬化剂治疗,分别于治疗后l个月、3个月及6个月复查内镜观察临床效果。结果治疗后1个月两组总有效率相比,差异无统计学意义(P>0.05);治疗后3个月及6个月实验组总有效率显著高于对照组,差异有统计学意义(均P<0.05)。结论内镜下套扎术联合硬化剂治疗肝硬化食管胃底静脉曲张疗效显著,可降低近期出血风险,值得临床广泛应用。     

食管胃底静脉曲张破裂出血内镜治疗联合经皮肝穿胃冠状静脉栓塞术疗效分析

目的：探讨内镜治疗（套扎、硬化剂及组织胶注射术）联合经皮经肝胃冠状静脉栓塞术治疗食管胃底曲张静脉破裂出血的中远期疗效。方法：共38例食管胃底静脉曲张破裂出血患者先行内镜检查及上腹部增强CT门脉重建。根据食管胃底曲张静脉严重程度采取内镜下套扎、硬化剂及组织胶注射术联合经皮经肝胃冠状静脉栓塞。结果：本组38例患者急诊止血10例,择期治疗28例。随访3～52个月,平均随访15个月,复发出血5例（13.1%）。结论：内镜治疗联合经皮经肝胃冠状静脉栓塞术治疗门脉高压消化道大出血是一种安全、可靠的治疗方法,能够显著降低再次出血发生。     

胃底静脉曲张内镜下治疗的临床观察

目的总结分析内镜下注射康派特凝胶治疗胃底静脉曲张的疗效及诊治经验。方法 2009年6月—2011年6月黑龙江省医院附属消化病医院对收治的28例经胃镜确诊的胃底静脉瘤患者行内镜下注射组织粘合剂α-氰丙烯酸正丁酯(北京康派特医用胶)注射治疗。结果 28例患者治疗均成功,无出血,术后随访6个月,再出血1例(3.6%)。结论内镜下注射康派特凝胶硬化治疗胃底静脉曲张疗效确切,是一种操作简便、可靠、安全的治疗方法,值得推广和应用。     

Schistosomal periportal fibrosis in Zimbabwe: use of ultrasound in patients with oesophageal varices

Ultrasound (U/S) imaging of liver was used in a prospective study of 62 consecutive patients with oesophageal varices in the central hospitals in Harare; 50 had haematemesis. U/S changes of Symmers's periportal fibrosis (PPF) were graded from mild (grade 1) to gross (grade 4). 46 patients (74%) had U/S features of PPF: 7 were grade 1, 7 grade 2, 29 grade 3, and 3 grade 4. Patients with PPF were more likely to have bled (P less than 0.05) and were less likely to have ascites (P less than 0.05) than those without PPF. Spleen or liver size or grade of varices did not correlate with the U/S grade of PPF. Rectal snips were positive for schistosome ova in 19 of 28 cases with PPF and 2 of 7 cases without PPF. Patients with PPF were more likely than those without PPF (P less than 0.005) or controls (P less than 0.0001) to have spent their childhood in an area of Zimbabwe with a high prevalence of Schistosoma mansoni. Schistosomal PPF appears to be a common cause of portal hypertension in Zimbabwe. It is strongly associated with childhood spent in areas of high S. mansoni prevalence.     

Role of minimally invasive interventions in the treatment of complications caused by recidive Klatskin tumors

BACKGROUND: The hilar cholangiocarcinoma grows slowly and gives metastases very rarely. The first prominent sign of this cancer is the jaundice. In spite of the small size of the tumour, oncologically radical resection is only feasible--owing to the anatomical position--in approximately 35-50% of the cases. This makes recidivity frequent. The recidive cancer involves the hilus of the liver, compresses the surrounding organs and develops different complications. METHODS: 37 patients underwent surgical resection in the 1st Surgical Department of Semmelweis University in the last ten years. Complete tumour-free surgical margins were found in only 48.6% of the cases. The mean follow-up was 23.2 (8-47) months. RESULTS: 9 patients were treated for complication caused by local recurrence. These were mechanical jaundice (9 cases), bleeding oesophageal varices (2 cases), gastric outlet obstruction (2 cases), liver abscess (3 cases) and pain caused by the infiltration of the coeliac ganglion (3 cases). Most part of the complication could be solved by minimal invasive therapy (percutane transhepatic endoprosthesis or drainage, endoscopic sclerotherapy, ultrasound-guided drainage, percutane blockade of the celiac ganglion). CONCLUSIONS: The fact that resected patients may survive several years as long as patients treated with endoprosthesis and irradiation only survive half a year, has brought a change in the way Klatskin cancer surgery is considered: resection of the tumour should be striven for--even by way of R1 resection. Therefore the risk of recurrence will increase. This is the first article in the literature, which has ever dealt with the complication caused by recidive cancer after resection of Klatskin tumour.     

Congenital hepatic fibrosis in children. Report of 9 cases and review of the literature

Congenital hepatic fibrosis is a recessive autosomic disease with two major risks: gastrointestinal haemorrhage caused by portal hypertension and cholangitis related to bacterial infection of dilated intrahepatic bile ducts.. The aim of our study is to define epidemiological features, the presenting symptoms, the diagnosis, the evolution and the management of this disease. Between January 1990 and December 2000, we reported the cases of nine children with this disease at children hospital of Tunis. Three were male and six female. The mild age was three years and six months. Consanguinity was present in five cases and similar cases were found in six cases.The FHC was revealed by portal hypertension in five cases, angiocholitis in one case and by portal hypertension and angiocholitis in three cases. Liver biopsy was done in seven children. Ultrasound examination of the liver and kidney revealed caroli syndrome in five cases and polykystose renal in two cases The intravenous pyelography was performed in four cases showing precalicial canalicular ectasia in four cases. Eosophageal endoscopy had shown oesophageal varices in six patients. The follow up had shown that three patients had gastrointestinal bleeding, three had angiocholitis. One patient died with multivisceral failure. The treatment of acute bleeding has needed blood transfusion in four cases. Primary prevention of bleeding was done by endoscopic sclerosis alone in one case and associated to betablokers in two cases. Secondary prevention of varices bleeding was done by sclerotherapic in two cases, by beta blokers alone in one case and by betablokers associated to elastic ligation of oesophageal varices in one case.     

急诊内镜下套扎对肝硬化食管静脉曲张出血的治疗

目的:探讨急诊内镜下套扎对肝硬化食管静脉曲张出血的止血效果及安全性。方法:对138例肝硬化食管静脉曲张出血患者在急诊状态下紧急内镜套扎,观察止血效果。结果:急诊止血成功率94.71%,术中无并发症发生,近期再出血5例,且4例经再次内镜套扎止血成功。结论:急诊内镜套扎对肝硬化食管静脉曲张出血的治疗是一种安全有效的止血方法。     

食管静脉曲张破裂大出血急诊硬化治疗的体会

目的探讨食管静脉曲张破裂大出血时急诊硬化治疗的临床效果。方法56例大出血患者行急诊食管静脉内注射5%鱼肝油酸钠,共71例次,其中11例次活动性大出血在改良三腔管牵引下内镜硬化治疗(EIS),7例次经再次EIS时出血停止。结果首次EIS能明确出血部位51例(91.1%)。急诊止血率为92.1%,并发症4例,发生率7.1%,EIS中并发大出血引起死亡1例。结论急诊EIS是救治致死性食管静脉曲张大出血一种有效办法,改良三腔管牵引下行EIS,安全、操作方便,适用于基层医院。     

Bleeding colonic varices controlled by propranolol

A 64-year-old man with hepatic cirrhosis developed severe haemorrhage from oesophageal varices. He underwent a course of sclerotherapy injections which successfully obliterated the oesophageal varices and prevented further oesophageal bleeding. He later developed serious bleeding from a site in the region of the ascending colon; angiography and radionuclide imaging suggested that varices were present in that region. Therapy with oral propranolol was effective in preventing any recurrence of gastrointestinal bleeding.     

How to insert a Sengstaken-Blakemore tube

The Sengstaken-Blakemore (SB) tube is a valuable tool in the emergency treatment of patients with bleeding oesophageal varices. However, as its use may be associated with a number of serious complications it should be used judiciously and inserted with care. Once bleeding has been controlled with an SB tube, definitive treatment for the bleeding varices should be urgently considered.     

食管静脉曲张破裂大出血急诊硬化治疗的体会

目的探讨食管静脉曲张破裂大出血时急诊硬化治疗的,临床效果。方法56例大出血患者行急诊食管静脉内注射5％鱼肝油酸钠,共71例次,其中11例次活动性大出血在改良三腔管牵引下内镜硬化治疗（EIS）,7例次经再次EIS时出血停止。结果首次EIS能明确出血部位51例（91,1％）。急诊止血率为92．1％,并发症4例,发生率7．1％,EIS中并发大出血引起死亡1例。结论急诊EIS是救治致死性食管静脉曲张大出血一种有效办法,改良三腔管牵引下行EIS,安全、操作方便,适用于基层医院。     

The sixth Carlos E. Rubio Memorial Lecture. Prevention and treatment of variceal hemorrhage

The medical treatment of portal hypertension has experienced a marked progress in the past decade due to the introduction of effective portal hypotensive therapy. This has been possible because of the better understanding of the pathophysiological mechanisms leading to portal hypertension. A major step forward was the introduction of beta-blockers for the prevention of bleeding and rebleeding from gastroesophageal varices. Effective therapy requires the reduction of the hepatic venous pressure gradient (HVPG) to 12 mmHg or below, or at least by 20% of baseline values. Unfortunately, this is only achieved in 1/3 to 1/2 of patients. Combination therapy, associating isosorbide-5-mononitrate and propranolol or nadolol administration enhances the reduction in portal pressure and increases the number of patients in whom HVPG decreases by more than 20% of baseline values and below 12 mmHg. Randomized clinical trials (RCT's) do support the concept that combination therapy is more effective than propranolol or nadolol alone, significantly better than sclerotherapy, and probably than endoscopic banding ligation. Therapy may be complemented by the association of spironolactone. The main inconvenience of pharmacological therapy is that there is no non-invasive method available to detect non-responders to treatment. Failures of drug therapy should be managed endoscopically. Failures of endoscopic treatment require 'rescue' by means of TIPS or shunt surgery. Patients with advanced liver failure should be considered for orthotopic liver transplantation, and put into a waiting list if eligible. In the treatment of acute variceal bleeding pharmacological therapy offer the unique advantage of allowing to provide specific therapy immediately after arrival to hospital, or even during transferral to hospital by ambulance, since it does not require sophisticated equipment and highly qualified medical staff. Vasopressin has been abandoned because of its toxicity, although this can be reduced by the combined administration of transdermal nitroglycerin. Terlipressin has longer effects and is more effective and safer than vasopressin alone or in combination with nitroglycerin. It has proved to be effective and to decrease mortality from bleeding in double-blind studies. RCT's have shown that this drug is as effective and safer than emergency sclerotherapy. Therapy should be maintained for five days to prevent early rebleeding. Somatostatin is probably as effective as terlipressin. Octreotide is probably useful after endoscopic therapy but can not be recommended as first line treatment. Endoscopic injection sclerotherapy and endoscopic banding ligation are very effective, but require well trained medical staff. There is an increasing trend for initiating therapy with a pharmacological agent, followed by semi-emergency endoscopic therapy as soon as a well trained endoscopist is available (within 12-24 hours), while maintaining drug therapy for 5 days. Failures of medical therapy may be treated by a second session of endoscopic treatment, but if this fails TIPS of emergency surgery should be done. In high-risk situations, such as bleeding from gastric varices or in patients with advanced liver failure, the decision for TIPS or surgery should be done earlier, after failure of the initial treatment.     

Chronic splenomegaly in Nairobi, Kenya. II. Portal hypertension

Eighty-five patients with chronic splenomegaly and proven oesophageal varices were studied at Kenyatta National Hospital, Nairobi. The major defined groups were hepatosplenic schistosomiasis (24%), cirrhosis (20%) and portal vein occlusion (11%). Hyper-reactive malarial splenomegaly (tropical splenomegaly syndrome) was considered as the cause of oesophageal varices in only one patient. In 26% of cases liver biopsy was non-diagnostic and the extrahepatic portal vein was demonstrated radiologically to be patent. Such patients were thought to be suffering from idiopathic portal hypertension, not previously described elsewhere in Africa. Hepatitis B surface antigen was detected in 12% of controls and in 58% of patients with cirrhosis (p less than 0.001). Some serological marker of previous hepatitis B virus infection was present in 92% of patients with cirrhosis and in 79% of controls. Kamba patients from Machakos and Kitui Districts were significantly more prevalent than expected among these 85 cases of portal hypertension.     

Ligation of oropharyngeal mucosa: a rare complication of ligation of esophageal varices. Two case reports

The eradication of oesophageal varices by binding became the best traitment for the bleeding by rupture of the verices. She tends to substitute the sclerosis because of her fast delay of eradication and her fewer complications and gravity. The incidence of complications after the binding vary between 3.3 and 11%. The most frequent complication is the appearance of oesophageal ulcers that sometimes causes bleeding. A dysphagia can happen within a few hours after the binding. Infections are rare. We report two cases of pharyngeal mucosae binding occurring during the binding of the varices.     

胃粘膜低级别上皮内瘤变随访研究

目的探讨胃粘膜低级别上皮内瘤变自然转归及其影响因素。方法收集2005—2010年合肥市第二人民医院内镜中心经病理诊断为低级别上皮内瘤变410例患者的临床病理资料进行回顾性分析,并随访其中63例患者的内镜形态学、病理学及血清学幽门螺旋杆菌细胞毒素相关基因蛋白A（Hp—CagA）结果。结果胃粘膜低级别上皮内瘤变的内镜表现形态各异,缺乏特异性。随着年龄的增加,胃低级别上皮内瘤变的比例也逐渐增加。位于贲门胃底的低级别上皮内瘤变中960岁患者占64．3％（36／56）,高于其他部位（均有P〈0．05）。63例患者中6例发生进展,其中4例癌变,癌变率6．3％（4／63）。病灶〉15mm、凹陷性病变、伴有不典型增生性肠化、Hp-CagA阳性是影响胃粘膜低级别上皮内瘤变转归的因素（均有P〈0．05）。结论胃粘膜低级别上皮内瘤变患者具有一定癌变潜力,不同患者应区别对待。胃镜随访有利于发现早期胃癌。     

Baveno指标在门静脉高压出血风险筛查中的研究进展及其在晚期血吸虫病中的应用前景分析

门静脉高压是危害中国700多万肝硬化病人临床预后的最主要原因,食管胃底静脉曲张破裂出血是其最常见的致死性并发症,所以建立与完善门静脉高压出血风险监测和管理制度,尤为迫切。Baveno共识是国际上最具权威的门静脉高压症临床诊断指南,其所提供的Baveno指标(肝静脉压力梯度、肝硬度测定值、血小板计数以及内镜检查)对门静脉高压和静脉曲张出血的筛查和检测都有着重要的临床指导意义。本研究通过对Baveno指标在门静脉高压出血风险筛查中的研究与应用进展进行综述,以期能够更好地了解各个指标的优缺点及目前该领域的研究现状,为优化、开发更加有效的筛查方法与指标提供参考,特别是为晚期血吸虫病人门静脉高压出血风险筛查提供依据。     

Revision needed of follow-up policy for Barrett's esophagus

The frequency of adenocarcinomas at the oesophagocardial junction is increasing and, if symptomatic, the patients chances of cure are bleak. Given the association of Barrett's oesophagus (Barrett's oesophagus; denoting metaplasia of the oesophageal squamous cell lining to gastric-type mucosa) and oesophageal adenocarcinoma, it is plausible that establishing the presence of Barrett's oesophagus will subsequently enable two preventive strategies: primary, i.e. the treatment and eradication of Barrett's oesophagus, and secondary, the early diagnosis of (pre)malignancy during periodic endoscopic follow-up. Given the frequent occurrence of Barrett's oesophagus and the rarity of oesophageal adenocarcinoma there is a clear risk of overdiagnosis and overtreatment. Most studies on the effect of regular follow-up are uncontrolled and barely give any indication of a favourable outcome. Only a minority of patients with Barrett's oesophagus ought to have periodic endoscopic checkups: those with dysplasia or with one or more of the known risk factors (especially male gender, specialised type Barrett's oesophagus and long segment Barrett's oesophagus). Those patients must be healthy enough beforehand to undergo surgical treatment if necessary. The amount of quantity or quality of life that may be gained from this approach has yet to be established.