食管胃底静脉曲张出血的内镜防治进展

食管胃底静脉曲张出血(EGVB)是肝硬化的严重并发症,病死率高。内镜是目前治疗曲张静脉急性出血和预防再出血的最重要的手段,硬化剂注射、经内镜套扎、组织胶栓塞等内镜治疗方法自推广以来已有长足发展。现总结近年EGVB的相关内镜防治进展,就其操作方法的改进、制剂和方式的选择、不同内镜治疗方法联合内镜治疗与介入治疗联合以及超声内镜等现代手段在EGVB内镜治疗中的应用予以综述。     

预防食管胃静脉曲张破裂出血内镜治疗并发症的研究进展

食管胃静脉曲张破裂出血（esophageal and gas-tric varices bleeding, EGVB）是肝硬化门静脉高压症患者最严重的并发症,发病急,进展快,病死率高,是最主要的死因之一[1]。有效防治EGVB是改善患者预后的关键所在。随着内镜技术及设备的不断进步,内镜下治疗EGVB在控制出血和预防再出血方面疗效确切,成为处理急性静脉曲张出血的首选。目前内镜治疗 EGVB 主要包括硬化剂注射治疗（endoscopic variceal sclerotherapy, EVS）、套扎治疗（endoscopic variceal ligation, EVL）、组织黏合剂注射治疗、联合EVS和EVL治疗等。本文就食管静脉曲张破裂出血（esophageal varices bleeding, EVB）不同内镜治疗方法并发症的防治综述如下。     

肝硬化食管胃静脉曲张内镜下治疗后营养支持治疗的研究进展

食管胃静脉曲张破裂出血(EGVB)是肝硬化的主要并发症之一,起病急,病情危重,病死率达10％～30％.内镜下治疗是EGVB的主要治疗措施,其包括内镜下静脉曲张套扎术(EVL)、内镜下注射硬化剂治疗(EIS)及内镜下组织胶注射术(HI).EGVB内镜下治疗后的主要并发症之一是再次出血,影响再出血的原因较多,机体的营养状态...     

肝硬化食管胃底静脉曲张内镜防治进展

食管胃底静脉曲张出血(EGVB)是肝硬化严重的并发症之一,病情凶险,病死率高。内镜是目前预防与治疗曲张静脉破裂出血的重要手段。经内镜套扎治疗、硬化剂注射治疗、组织胶栓塞治疗等内镜治疗方法自推广以来已有很大发展。该文主要总结近年来EGVB的相关内镜防治进展,就其治疗原理、临床疗效观察、并发症、联合治疗、超声内镜引导下治疗等予以综述。     

食管胃静脉曲张出血的内镜诊疗进展

食管胃静脉曲张出血(EGVB)是肝硬化门脉高压症患者最凶险的并发症,死亡率高达50%。英国、美国在2000年、2005年相继提出EGVB的临床诊治规范或指南[1,2],我国目前还没有EGVB临床诊治规范,但由中华内科杂志编辑部特约国内13名专家,就目前研究进展及循证医学结果,于2006年6月提出了我国EGVB的诊治建议(草案)[3]。草案推荐对EGVB高危人群进行内镜检查以评估其静脉曲张的程度,采取预防措施。EGVB首次出血存活的患者如果不进行治疗再出血率达50～80%,内镜介入治疗可以显著降低其再出血率和病死率,是预防再出血的有效方法。内镜下介入治…     

食管胃底静脉曲张的内镜治疗

食管胃底静脉曲张出血（Esophageal and Gastric Varices Bleeding,EGVB）是各种原因所致门静脉高压患者常见的并发症和主要死因之一,其病情凶险,首次出血病死率为20％-40％,再出血发生率为50％-80％,病死率为30％～50％。到目前为止,除肝脏移植外尚无公认、高效的对因治疗方法。近年来随着内镜技术的不断发展,食管胃底静脉曲张的内镜下治疗得到了广泛应用,并收到一定效果。     

食管胃底静脉曲张破裂出血药物和内镜治疗进展

食管胃底静脉曲张破裂出血(EGVB)是肝硬化门静脉高压症最严重的并发症.肝硬化患者中有40%出现食管胃底静脉曲张,而有食管胃底静脉曲张的患者中约有50%～60%并发大出血,其突出特点为出血量较大、来势迅猛、病情凶险、病死率高达40%以上,如不及时治疗,患者可因急性大出血发生休克而导致严重后果.对EGVB的治疗一直以来是国内外治疗肝硬化门静脉高压症的主要目的和内容之一,其意义显得格外重要.目前,治疗方法多种.笔者现就目前药物及内镜治疗EGVB的方法以及在治疗上取得的一些进展综述如下.     

内镜联合药物诊治肝硬化食管胃底静脉曲张破裂出血的疗效及再出血危险因素研究

目的：探讨肝硬化食管胃底静脉曲张破裂出血(EGVB)内镜联合药物诊治的效果及再出血危险因素。方法选取2011年1月至2015年7月期间在廉江市人民医院消化内科治疗的114例肝硬化EGVB患者作为研究对象。采用内镜下食管静脉曲张套扎术联合内镜下静脉曲张硬化注射术(EIS)治疗食管静脉曲张出血,采用组织黏胶内镜注射联合EIS治疗胃底静脉曲张出血,同时所有患者均给予生长抑素和心得安治疗。统计静脉曲张类型、疗效和并发症情况。根据止血成功后是否再出血把患者分为未出血组和再出血组,统计两组的再出血危险因素。采用行×列表χ2检验及其分割法和多因素Logistic回归分析等分析相关数据。结果所有患者均止血成功,止血成功率为100.00%。1型食管胃静脉曲张（GOVl）、2型食管胃静脉曲张(GOV2)、GOVl+GOV2的静脉曲张消失率分别为93.55%、66.67%、68.57%,其中GOVl的静脉曲张消失率明显高于其他两种类型,差异圴有统计学意义(P<0.05);GOVl、GOV2、GOVl+GOV2的静脉曲张复发率分别为9.68%、35.42%、37.14%,其中GOVl的静脉曲张复发率明显低于其他两种类型,差异圴有统计学意义(P<0.05);门静脉内径、Child-Pugh评分是再出血的独立危险因素,而白蛋白浓度和血钠浓度是保护因素。结论内镜联合药物诊治肝硬化EGVB的效果明确,其中以GOVl的疗效最为显著。影响肝硬化EGVB再出血的因素众多。     

急性食管胃底静脉曲张出血108例治疗体会

急性食管胃底静脉曲张破裂出血(esophageal gastric variceal bleeding,EGVB)是肝硬化门脉高压患者的严重并发症[1-2],因病因和出血部位特殊,临床上由EGVB导致的上消化道出血死亡率高达20%~40%[3-4]。近年来,随着内镜技术的进展,内镜下食管静脉曲张套扎术(endoscopic variceal liga-tion,EVL)和内镜下静脉曲张组织胶注射术在EGVB的防治中发挥重要作用。作者应用生长抑素     

门脉高压食管胃静脉曲张出血的治疗进展

肝硬化食管胃底静脉曲张(EGVB)是肝硬化的主要并发症之一,致死率高,也存在二次出血的风险。目前EGVB的治疗方式较多,但是尚未达成统一标准。非选择性β受体阻滞剂可以降低曲张静脉的出血率,但不能消除已经曲张的静脉。生长抑素可以减少内脏血流同时保护黏膜和促进止血。精氨酸加压素可通过减少胃食管血流达到止血目的,但可能出现内脏缺血。目前内镜下食管静脉曲张套扎、内镜食管静脉曲张硬化等是治疗肝硬化食管胃底静脉曲张破裂出血的首选方案。介入手术中经球囊闭塞下逆行静脉栓塞术(BRTO)主要用于有胃肾分流的静脉曲张患者,而经皮经肝胃冠状静脉栓塞术目前主要作为失去BRTO手术机会患者的补充治疗。手术治疗多用于内镜及介入治疗难以控制的肝硬化食管胃底静脉曲张破裂出血。     

内镜下套扎术与普萘洛尔预防肝硬化食管曲张静脉首次出血的对照研究

目的: 比较内镜下食管曲张静脉套扎术(endoscopic variceal ligation,EVL)与β受体阻滞剂普萘洛尔对预防首次食管曲张静脉出血的疗效及其安全性。方法: 选取食管静脉曲张的肝硬化病人168例,随机分成EVL组和普萘洛尔组,分别单独接受EVL和普萘洛尔治疗,比较其疗效和安全性。结果: 两组患者治疗前指标比较无明显差异,术后随访时间18~36个月。EVL组共有24例(28.6%)病人发生出血;普萘洛尔组有20例(23.9%)病人发生出血,两组差异无统计学意义(P>0.05)。总体病死率以及与出血相关的病死率无明显差异(分别21.4% vs 17.9%, 7.1% vs 6.0%, 均P>0.05),EVL组出现不良事件43例,其中3例危及生命;普萘洛尔组发生不良事件16例,两组差异无统计学意义(51.19% vs 19.05%,P<0.05)。结论: 普萘洛尔与EVL对预防首次食管曲张静脉出血的疗效无明显区别,但普萘洛尔引起的并发症要少于EVL。     

The use of transjugular intrahepatic portosystemic stent shunt (TIPS) in the management of portal hypertensive bleeding

Acute esophageal variceal hemorrhage is a terrible complication of portal hypertension and. rebleeding is very common in survivors of acute variceal bleeding. Traditional medical management options include the use of vasoconstrictor, balloon tamponade, and endoscopic therapy. Though endoscopic therapy has achieved successful hemostasis in the majority of acute variceal bleeding episodes, the outcome is usually dismal when such therapy fails. Transjugular intrahepatic portosystemic stent shunt (TIPS) was invented to decompress portal hypertension, but is now widely used in Western countries to treat patients with refractory variceal hemorrhage or refractory ascites. By contrast, TIPS has not been commonly used in Asia. In this article, I have reviewed the role of TIPS in the management of portal hypertensive bleeding, which will hopefully be useful for clinicians facing variceal bleeding that is not amenable to endoscopic therapies.     

生长抑素联合内镜套扎术治疗食管静脉曲张破裂出血的疗效观察

目的：观察生长抑素联合内镜套扎术对食管静脉曲张破裂出血的治疗效果。方法：将60例患者随机分为生长抑素组和垂体后叶素组,内镜治疗前分别给予生长抑素或垂体后叶素,然后行内镜套扎治疗。观察两组的止血率、再出血率和不良反应发生率。结果：生长抑素组与垂体后叶素组相比,止血率明显提高,再出血率和不良作用明显下降,治疗效果明显优于后者（P〈0．05）。结论：生长抑素联合内镜套扎术可以明显提高食管静脉曲张破裂出血的治疗效果和安全性。     

内镜下食道静脉曲张破裂出血连续套扎治疗临床疗效观察

目的：探讨采用内镜下连续套扎治疗肝硬化食道静脉曲张的临床疗效。方法：对43例肝硬化食道静脉曲张破裂出血的住院患者采用内镜下套扎治疗,并观察其疗效、并发症和近期再出血率。结果：食道静脉曲张破裂出血患者的急诊止血率为100％,并发症2．3％,早期再出血4．7％。结论：内镜下套扎治疗是食道静脉曲张破裂出血止血的一种有效方法。     

Embolization combined with endoscopic variceal ligation for the treatment of esophagogastric variceal bleeding in patients with cirrhosis

Background Esophagogastric variceal bleeding caused by cirrhosis is a kind of emergent condition in the clinic. This study was conducted to explore the therapeutic effect and superiority of embolization of gastric fundus vadces combined with endoscopic variceal ligation （EVL） of esophageal varices for the treatment of patients with esophagogastric variceal bleeding caused by cirrhosis. Methods Totally 172 patients were diagnosed by endoscopic examination within 24 hours of hospitalization with active gastric fundus variceal bleeding and grade II above esophageal varices caused by cirrhosis. Other causes leading to upper digestive tract bleeding were excluded. Patients were randomly divided into a control group （n=82） and a therapy group （n=-90） following a random number table method. For the former, embolization for gastric fundus varices was performed, then an EVL for esophageal varices was performed 2 months later. For the therapy group, embolization for gastric fundus varices and EVL for esophageal varices were performed at the same time. Results The rate of emergency hemostasis in the therapy group was 100.0%, higher than that in the control group （87.8%, P〈0.05）. The rate of early rebleeding in the therapy group was 6.7% while the rate in the control group was 23.6% （P〈0.05）. No complications related to treatment occurred in both groups. Conclusion Embolization for gastric fundus varices combined with EVL for esophageal varices is a safe and effective method for the treatment of patients with esophagogastric variceal bleeding caused by cirrhosis.     

Management of the patient with hemorrhaging esophageal varices

Bleeding from esophageal varices remains a difficult clinical problem, carrying a high likelihood both of rebleeding and of mortality. The initial approach requires adequate but not overly vigorous volume replacement with blood and other fluids. Once the patient is resuscitated, upper gastrointestinal endoscopy should be performed to establish the source of bleeding. Both endoscopic variceal sclerotherapy and balloon tamponade appear to be effective in achieving temporary control of acute ongoing hemorrhage from esophageal varices. The value of intravenous vasopressin remains controversial. Rebleeding can be prevented in most patients by shunt surgery. However, surgery carries both considerable early morbidity and mortality (related mainly to the severity of the underlying liver disease) and substantial longer-term morbidity and mortality from hepatic encephalopathy and liver failure. The role of pharmacologic agents (eg, propranolol) intended to prevent variceal hemorrhage by reducing portal pressure remains to be established. At present, we recommend use of endoscopic variceal sclerotherapy for the control of active variceal bleeding, with employment of balloon tamponade and intravenous vasopressin if sclerotherapy is successful. Emergency shunt surgery should be reserved only for those patients whose bleeding cannot be controlled by these other means. For prevention of rebleeding in Child class C patients, we attempt to obliterate the varices by repeated endoscopic sclerotherapy. Patients who have two to three episodes of rebleeding despite this approach are considered for shunt surgery. For better-risk patients who do not have ascites, which is difficult to control, we are currently recommending a distal splenorenal shunt. Alternatively, repeated endoscopic variceal sclerotherapy is used for these better-risk patients (Child class A or B) in some centers, with shunt surgery reserved for patients who continue to rebleed. Which approach to preventing rebleeding in the better-risk patient is more effective, as well as the role of pharmacologic therapy with propranolol or other agents, remains to be settled by well-controlled randomized clinical trials.     

急诊胃镜下组织胶治疗胃底静脉曲张破裂出血的疗效观察

目的探讨急诊胃镜注射组织胶治疗肝硬化合并胃底静脉曲张破裂出血的疗效。方法选取2010年9月至2012年3月由北京军区总医院肝病治疗中心收治的57例肝硬化合并胃底静脉曲张破裂出血患者作为研究对象,所有患者均在出血后24 h内接受胃镜下注射组织胶治疗。57例患者共接受76点组织胶注射,累计注射组织胶109 mL。结果①76点组织胶注射均取得成功,成功率为100%。②57例患者均为活动性出血,注射组织胶后均即时止血,随访期间未发现再出血病例。24例患者复查了胃镜,10例患者胃底曲张静脉明显缩小,14例患者胃底曲张静脉未见明显变化。近期死亡3例,病死率为5.3%,死亡原因均为肝性脑病。③所有患者术后均未出现明显不良反应,14例患者出现低热,9例患者出现上腹饱胀不适感。结论急诊胃镜注射组织胶治疗肝硬化合并胃底静脉曲张破裂出血的疗效确切,具有止血效果好、止血速度快、再出血发生率低、不良反应较轻等优点。     

部分脾动脉栓塞术联合食管静脉曲张套扎术用于肝硬化食管静脉曲张出血的二级预防临床效果

目的:评价部分脾动脉栓塞术(partial splenic artery embolization,PSE)联合内镜下食管静脉曲张套扎术(endoscopic variceal ligation,EVL)用于肝硬化食管静脉曲张出血的二级预防的临床效果。方法:回顾我院2012年6月至2013年5月诊断肝硬化食管静脉曲张破裂出血78例患者,比较PSE联合EVL和单纯EVL食管静脉曲张根治率、复发率、再出血率、血白细胞、血小板、脾静脉直径、门静脉直径。结果:联合治疗在食管静脉曲张根治率、晚期再出血率显著低于单纯套扎,但在食管静脉曲张复发率和早期再出血率没有差异。联合治疗明显改善患者外周血白细胞、血小板数量,提高患者免疫力和止血能力,有统计学意义(P<0.05)。虽然联合治疗缩小门静脉直径、脾静脉直径,但没有统计学意义(P>0.05)。结论:PSE联合EVL治疗食管静脉中远期疗效较单纯EVL更佳,有更高的根治率、白细胞及血小板,更低的晚期再出血率。     

内镜套扎治疗肝硬化食管静脉曲张破裂出血疗效分析

目的观察分析内镜套扎治疗肝硬化食管静脉曲张破裂出血（EVB）的疗效。方法选取74例肝硬化食管静脉曲张破裂出血的患者,皆选择在内镜下行套扎术治疗,观察效果。结果 74例患者结扎后成功止血69例,术后出现反复便血3例。术后并发症31例;严重并发症6例;严重胸骨后痛有1例。结论内镜套扎治疗肝硬化食管静脉曲张破裂出血的疗效理想,术后并发症少。