治疗门脉高压食管静脉曲张出血之我见

治疗门脉高压食管静脉曲张出血之我见浙江医科大学附属二院（３１００１３）钱礼门脉高压症最严重的并发症是食管、胃底曲张静脉破裂出血．其治疗方法除内科之临时性止血外，基本上可分三种，各有其利弊得失：①门腔静脉分流术；希望通过术后门静脉压的下降，达到食管静脉...     

施他宁和硬化剂治疗门脉高压食管静脉曲张破裂出血

采用施他宁２５０μｇ静脉推注，再以２５０μｇ／ｈ连续静脉滴注，维持治疗门脉高压食管静脉曲张破裂大出血者１９例，结果：１２小时内出血停止者１６例，止血率８４．２％（１６／１９），３例仅有少量渗血，待出血基本控制后再注射硬化剂，胃及食管内潴留液很少，视野清晰，１９例全部完成硬化疗法，应用施他宁后食用静脉及门静脉宽度分别缩小３８．３％及３４．４５，均有显著差异（Ｐ〈０．０１），施他宁显著地减少胃液分泌和     

断流术联合分流术治疗门脉高压症(附22例报告)

食管静脉曲张破裂出血是门静脉高压症患者致命的并发症 ,其手术治疗时究竟是采用分流术还是断流术多年来一直颇有争议。既往多认为行断流术比较合理 ,但随着近年来对门静脉高压性胃病认识的逐渐加深 ,单纯行断流术的合理性受到质疑 ,提倡断流术联合分流术治疗门脉高压症的报道逐渐增多。本院 1 997年 1月～ 2 0 0 0年 1 2月共行脾腔分流或脾肾分流加食管下段胃底周围血管离断术治疗门脉高压症 2 2例 ,取得较为满意的近期效果 ,现报告如下。1　临床资料1 .1一般资料本组男 1 8例 ,女 4例 ,年龄 2 8- 5 4岁。术后均病理证实为肝炎后肝硬化 ,既…     

门静脉高压症合并十二指肠异位静脉曲张破裂出血一例

患者女 ,6 5岁。反复便血、头晕 1年余。查体 :重度贫血貌 ,腹部略膨隆 ,脾肋下 3ｃｍ。实验室检查 :血总蛋白5 5 1ｇ/Ｌ ,白蛋白 2 4 6ｇ/Ｌ ,球蛋白 30 5ｇ/Ｌ ,总胆红素 2 3 38μｍｏｌ/Ｌ ,直接胆红素 4 2 5 μｍｏｌ/Ｌ ,乙型肝炎病毒表面抗体(+)。血白细胞 1 85× 10 9/Ｌ ,血色素 19 8ｇ/Ｌ ,血小板 2 1×10 9/Ｌ ,凝血酶原时间 18 6ｓ,活化部分凝血活酶时间 32 7ｓ。Ｂ超提示肝脏弥漫性病变 ,脾静脉和门静脉未发现血栓 ,大量腹水。胃镜提示十二指肠降部中段有 4ｃｍ× 6ｃｍ片状粗大静脉团。经输血、止血 ,营养支持 ,保肝治疗 …     

门脉高压性胃病48例临床分析

本文对１０６例肝硬化门脉高压患者胃镜检查资料进行分析。结果门脉高压性胃病发生率４５．３％（４８例），其发生率与食道静脉曲张程度呈正相关。并探讨了门脉高压性胃病的发病机理、临床特点和诊治措施。     

结肠癌并区域性门静脉高压症出血死亡一例报告

患者男 ,6 4岁 ,以突发左上腹疼痛入院。经各项检查确诊结肠癌并肠梗阻 ,于 2 0 0 1年 3月手术治疗。术中见结肠脾区 7cm大小肿块 ,与脾门及胰尾粘连。病理检查 :结肠粘液腺癌 ,浸润肠壁全层 ;癌肿浆膜面局部与胰腺尾部粘连 ,未见癌组织侵及胰腺 ,无淋巴结转移。术后一般情况尚好 ;2 0 0 2年 3月后 ,反复出现三次黑便 ,每次 2 - 3d ,给予对症处理可缓解。胃镜检查示胃底静脉曲张。血常规、肝功能正常。大肠镜检查未见局部复发。B超和CT显示胰尾部可见 5cm× 5cm× 6cm的低弱回声区 ,轻度脾大。 2 0 0 2年 9月突然解大量柏油样便及呕吐鲜血…     

脾动脉栓塞术治疗门脉高压食管静脉曲张出血

目的：更合理选择治疗门脉高压食管静脉曲线出血的方法。方法：采用脾动脉栓塞术２０例（第１组）、生长抑素８肽（善得定）静脉滴注２５例（第２组）和垂体后叶素静脉滴注２２例（第３组）治疗门脉高压食管静脉曲张出血（ＥＶＢ）进行疗效对比。结果：第１、２、３组的即时止血率和１月内再出血率分别为９５％、９６．０％、４０．９％和１０．０％、４８．０％、５０％。好时止血率第１组明显优于第３组（Ｐ〈０．０１），而与第２     

门静脉高压食管静脉曲张出血吻合器断流止血的体会

3年来我院对13例食道静脉曲张出血患者采用消化道管状吻合器断流止血，止血快，彻底，疗效良好。本组病例男性11例，女性2例，年龄在20～40岁者9例，41～60岁以上者4例。术后再出血2例，首次出血4例，两次以上出血7例。估计术前出血总量2000～3000ml。诊断为结节性肝硬变，充血性睥肿大，食道静脉曲张。     

肝移植治疗肝硬化门静脉高压症的临床疗效

目的 探讨肝移植治疗肝硬化门静脉高压症的临床疗效.方法 回顾性分析2000年1月至2012年1月北京大学人民医院收治的181例肝硬化门静脉高压症患者的临床资料.肝移植手术适应证为反复发作上消化道大出血,经内、外科和介入治疗无效,或合并肝功能失代偿的门静脉高压症患者.根据患者情况选择行经典原位肝移植或背驼式肝移植.术中于移植肝植入前后分别经胃网膜右血管置入套管针,连接测压管测压.观察手术前后门静脉压力变化情况,术后并发症的发生情况.术后通过肝移植随访中心定期随访,并根据具体指标调整用药,随访时间截至2012年12月,监测患者食管静脉曲张再出血及生存情况.Kaplan-Meier法计算生存率,计量资料采用（x）±s表示,均值比较采用t检验.结果 181例患者中,65例行经典原位肝移植,116例行背驮式肝移植.手术时间为（485±97） min,术中出血量为（4 380±1 993） mL,无肝期时间为（56±24） min.157例患者留置T管,24例患者未留置T管.102例患者术中经胃网膜右静脉测量了肝移植前后的门静脉压力,术前门静脉压力为（32±11）cmH2O（1 cmH2O =0.098 kPa）,术后门静脉压力为（21±6）cmH20,手术前后门静脉压力比较,差异有统计学意义（t=2.412,P＜0.05）.肝移植术后严重感染23例、急性肾衰竭20例、严重腹腔内出血6例、血管相关并发症5例和移植物原发无功能2例.181例患者均获得随访,随访时间为6 ～131个月.138例患者术后1年复查内镜或行上消化道造影检查,112例曲张静脉完全消失,其余26例较术前明显减轻,总改善率为85.71％（138/161）.术后1年内4例患者出现了上消化道再出血,再出血率为3.70％（4/108）,其中3例经止血药物或内镜治疗后得到缓解,1例死于再次出血导致的肝衰竭.随访患者术后1个月、1年及5年生存率分别为86.8％、84.9％、77.4％.23例死亡患者中,15例死于MODS,5例死?     

The use of sclerotherapy for the management of oesophageal varices in portal hypertension

Summary Although sclerotherapy is currently the most widely used treatment for the management of both acute variceal bleeding and the long-term management of patients with varices, its definitive role in the treatment of these patients has yet to be finally proven. Sclerotherapy appears to be the most effective treatment for the majority of patients with acute variceal bleeding. Failures require either a shunt or a transection and/or devascularisation procedure. Current evidence favours simple staple gun transection or a shunt (either a portacaval shunt or a side-to-side narrow diameter polytetrafluoroethylene graft between the portal vein and vena cava). In long-term management of patients after a variceal bleed the currently favoured treatment is repeated sclerotherapy. However, failures should be identified early. We define failures as patients who present with varices that are either difficult to eradicate by sclerotherapy or who have repeated life-threatening variceal bleeds during the course of repeated injection sclerotherapy. Such patients should have either a portal-to-systemic shunt or a transection and devascularisation operation. Further controlled trials are required to define the specific indications for the individual forms of therapy. Prophylactic treatment for varices that have not yet bled is unjustified at present. Based on a presentation to the International Congress on Surgical Endoscopy, Ultrasound, and Interventional Techniques, Berlin 1988     

Liver metastases, a rare cause of portal hypertension and stoma bleeding. Brief review of literature

INTRODUCTIONPortal hypertension is an unusual complication of liver metastases, which is frequently occurring in malignant disease. Portal hypertension may cause oesophageal varices and also stoma varices (colostomy and ileostomy). Oesophageal varices and bleeding from these varices have been frequently reported in literature. Stomal varices have also been reported in literature mostly associated with liver cirrhosis. These stomal varices lead to the massive bleeding causing morbidity and mortality.Portal hypertension is a pathological increase in portal pressure gradient (the difference between pressure in the portal and inferior vena cava veins). It is either due to an increase in portal blood flow or an increase in vascular resistance or combination of both. In liver cirrhosis, the primary factor leading to portal hypertension is increase in portal blood flow resistance and later on development of increased portal blood flow. It has been postulated that in liver metastasis the increase in portal flow resistance occurs at any site within portal venous system as a consequence of mechanical architectural disturbance.PRESENTATION OF CASEWe report a case of a 64 year old gentleman who developed portal hypertension due to secondary metastases from colorectal cancer. He subsequently developed bleeding varices in his end colostomy.DISCUSSIONWe believe that the combination of extensive metastases and chemotherapy induced portal hypertension in our patient.CONCLUSIONOur case and other literature review highlight that the recurrent bleeding stoma associated with colorectal cancer should be investigated for portal hypertension.     

门肝分流术治疗猪肝硬化门脉高压症

目的 观察肝侧门静脉-肝总动脉侧端分流术和侧侧分流术(统称门肝分流术)对猪肝硬化门脉高压症动物模型的治疗效果.方法 对照组和实验组(即肝硬化门脉高压模型组)实验猪各15头分别行门肝分流术,观察门静脉血入肝及降压的过程.结果 对照组和实验组门肝分流术前门静脉压力分别为(20.51±0.74) cm H2O(1 cm H2O=0.098 kPa)和(30.82±2.53)cm H2O(P＜0.05);术后30 d分别为(19.75±0.84) cm H2O和(20.84±1.36) cm H2O(P＞0.05).对照组和实验组门静脉与肝总动脉的压力差术前分别为(7.20±0.34) cm H2O和(17.34±0.62) cm H2O(P＜0.05);术后30 d分别为(6.40±0.21) cm H2O和(7.84±1.32) cm H2O(P＞0.05).分流后术中脾静脉注射亚甲蓝肝脏染色良好.术后观察30 d无肝坏死及肝性脑病发生,脾肿大恢复正常.门肝分流术对肝功能的影响较大,对其他血生化代谢指标影响较小.结论 门肝分流术后虽然门静脉血入肝通道发生变更,但门脉血流动力学并未受到显著影响,反而建立了新的平衡机制来维持门脉血流动力学的稳定,达到门脉降压效果.门肝分流术后肝功能恢复所需时间较长,且需进一步治疗.     

Gastrectomy in combination with a distal splenorenal shunt in a patient with gastric cancer and portal hypertension: report of a case

We describe the case of a patient with gastric cancer complicated by portal hypertension due to liver cirrhosis. Endoscopy showed esophageal varices in the lower third of the esophagus and a superficially depressed lesion in the middle third of the stomach, while a biopsy suggested signet-ring cell carcinoma. Laboratory data showed pancytopenia, the indocyanine green fraction after 15 min was 29%, and the symptoms corresponded to the Child B criteria. A preoperative arteriogram revealed a remarkably dilated left gastric vein and the development of collateral pathways. We performed a distal subtotal gastrectomy with a reconstruction by the Billroth I method combined with a distal splenorenal shunt (DSRS) and a splenopancreatic disconnection (SPD). The endoscopic findings of the esophageal varices 15 months after surgery showed only a few white veins and the red color sign had disappeared. Now 7 years have passed since surgery, the risk of variceal hemorrhage has disappeared, and the patient is ambulatory and well. These results seems to be attributable to the long-term maintenance of the shunt selectivity and good portal hemodynamics. In patients with gastric cancer complicated with esophageal and/or gastric varices, it is recommended that DSRS with SPD be performed after a reconstruction using the Billroth I method. Received: July 11, 2001 / Accepted: January 8, 2002     

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目的 探讨经皮穿肝及穿脾治疗门静脉高压胃食管曲张静脉破裂出血的可行性和疗效。方法 对19例病人行经皮穿肝胃冠状静脉栓塞术,对12例病人行经皮穿脾胃冠状静脉栓塞术。结果 所有病人手术成功。随访3－26个月,再出血3例,其中6个月内再出血1例;死亡6例,其中1例死亡原因为上消化道出血,5例为肝功能衰竭。结论 该手术是治疗门静脉高压胃底食管曲张静脉破裂出血的有效方法。对于肝占位病变及门静脉癌全等不宜行经皮穿肝门静脉插管的病人,经皮穿脾门静脉插管可作为一种安全的替代方法。     

肝硬化门静脉高压脾切除后免疫功能状况

目的 探讨肝硬化门脉高压病人行脾切除后对机体免疫功能的影响。方法 测定正常人、肝硬化病人、肝硬化门脉高压行脾切除贲门周围血管离断术和行脾切除脾肾静脉分流加断流术后病人的外周血中ＩｇＡ,ｉＧｇ,ＩｇＧ,ＣＤ３,ＣＤ４,ＣＤ８,ＮＫ细胞。结果ＩｇＡ,ＩｇＡ在４组间均无明显差异。ＩｇＧ与正常组比较,肝硬化组、断流手术组、联合手术组均明显升高（Ｐ〈０．０５,Ｐ〈０．０１）,但在后３组间无明显差异。ＣＤ３     

儿童食管静脉曲张出血内镜下硬化剂注射治疗

目的 探讨儿童食管静脉曲张的治疗方法。方法 对３年中收治的６例患儿行内镜下硬化剂注射治疗。结果 ６例患儿４例经２次注射,２例经３次注射出血控制,近期止血率１００％。结论ＥＳ治疗儿童食管静脉出血应被视为首选疗法。     

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目的 探讨应用吻合器经腹行食管下段部分切除再吻合治疗门静脉高压食管胃底静脉曲张出血的疗效。方法 回顾分析了自1995年10月至2001年11月行贲门周围血管离断术加用吻合器作食管下段部分切除再吻合48例(切除组)的疗效，并与20例同期仅行周围血管离断术(单纯组)的疗效进行比较，分别观察食管曲张的消除率、再出血率、手术死亡率、吻合口狭窄以及吻合口瘘的发生率。结果平均随访20个月。单纯组再出血率为25％(5／20)，切除组无再发出血。食管静脉曲张的治愈率切除组为100％，而单纯组为50．0％(10／20)。吻合狭窄发生率切除组为4．1％(2／48)，单纯组为0。两组均未发生吻合口瘘。结论 应用吻合器行食管下段切除再吻合术是安全的，可使断离更为彻底，降低复发，从而进一步提高周围血管离断术的疗效。     

胃肠恶性肿瘤伴肝硬化门静脉高压症的外科治疗

目的总结肝硬化门静脉高压症合并胃肠肿瘤患者围手术期处理经验。方法对2000年1月至2005年7月收治的23例(17例胃肿瘤及6例结肠肿瘤)合并肝硬化门静脉高压症行手术治疗的胃肠肿瘤患者资料进行回顾性分析研究。结果本组23例患者,治愈17例,死亡6例,死因为MODS5例,急性肺栓塞1例,病死率为26.1%。死亡病例与肝功能分级有明显关系,ChildA级死亡1例(12.5%),B级死亡2例(22.2%),C级死亡3例(50%)。发生吻合口漏1例,胰尾血管出血1例,未发生残胃缺血。结论对合并有门静脉高压症的胃肠肿瘤患者,正确掌握其手术适应证和时机,加强围手术期处理,以降低病死率和并发症发生率。