Prediction of the recurrence of esophageal varices based on portal vein pressure and oxygen tension in portal and peripheral blood.

In 27 variceal patients completely treated by ethanolamine oleate and polidocanol and followed for more than one year, the recurrence of varices was studied by measuring portal vein pressure and oxygen tension in the portal vein and peripheral arteries and veins before and after EIS. Frequent recurrence was observed in patients with increased PVP after EIS and lower or inverse PVO2-VO2 tension after EIS. The recurrence of varices after EIS may thus possibly be predicted based on portal vein pressure and PVO2-VO2 tension differences.     

Influence of the sclerosing of esophageal varices on portal pressure and azygos venous blood flow

Endoscopic sclerotherapy is widely employed for esophageal variceal hemorrhage. However it has side effects and can aggravate portal hypertension by suppression of portosystemic shunt. The purpose of the present investigation was to study the effect of variceal thrombosis on hepatic venous pressure gradient and azygos blood flow. Eight alcoholic cirrhotic patients with a first variceal hemorrhage were included. According to Child Pugh's classification, 4 patients were group A, 2 group B and 2 group C. At each session 40 to 60 ml of 1 p. 100 polidocanol were injected into the varices. A hemodynamic study was performed in each patient before and about one week after variceal obliteration (mean 3.3 procedures). Mean value of hepatic venous pressure gradient was 16.6 +/- 5.5 mm Hg and 17.0 +/- 3.8, respectively, before sclerotherapy and after eradication of varices; azygos blood flow 663 +/- 506 ml/mn before and 682 +/- 522 after; cardiac, output was 6.5 +/- 0.7 ml/min before and 6.5 +/- 0.8 after. None of these differences were significant. These results suggest that endoscopic sclerotherapy using polidocanol does not change hepatic venous pressure gradient and azygos blood flow, and does not lower blood flow through the gastroesophageal collaterals draining into the azygos vein. This is consistent with the hypothesis that thrombosis remains localized.     

肝硬化食道静脉曲张的门脉血流动力学改变及相关参数的研究分析

目的通过探讨乙肝肝硬化食道静脉曲张患者的门脉血流动力学改变,遴选敏感预测食道静脉曲张程度的相关彩色多普勒指标。方法肝硬化组80例,对照组30例,均经内镜检查,将食道静脉曲张程度分为轻、中、重度。彩色多普勒超声（CDFI）测定门静脉主干（PV）、脾静脉（SV）、肠系膜上静脉（SMV）及胃左静脉（LGV）四条静脉血管内径（D,cm）、平均血流速度（V,cm/min）,血流量（Q,ml/min）。结果 1.肝硬化组VPV、VSV、VSMV较对照组明显减低、VLGV的流速较对照组明显增快,DPV、DSV、DSMV、DLGV较对照组增宽,Qsv、Qpv、QLGV、QSMV均较对照组明显增多,肝硬化组Qsv/Qpv为54.5%,高于对照组的30.3%。2.随食道静脉曲张程度的加重,DPV逐渐增加、VPV逐渐下降、DLGV、VLGV、QLGV均明显增加,重度组均可见＂红色征＂,其中（＋＋）者为92.3%（36/39）。3.对照组LGV血流均呈向肝型,在肝硬化组中可见向肝、离肝、双向三种血流方向,肝硬化组中81.25%为离肝型血流,5%为双向型血流,13.75%为向肝型血流,其中重度组的离肝型血流比例高达94.9%。结论肝硬化门脉高压时PV、SV、SMV及LGV的血流动力学均有明显的改变,可作为判断食道静脉曲张程度的敏感、无创性诊断指标,其中LGV血流动力学指标在判断重度食道静脉曲张方面具有更重要的临床价值。     

Prediction of esophageal varices in cirrhosis by per-rectal portal scintigraphy

Portal circulation in patients with chronic liver disease was evaluated by per-rectal portal scintigraphy, and per-rectal portal shunt indices were calculated to estimate the extent of the portosystemic shunt. The purpose was to identify patients with cirrhosis at special risk of developing esophageal varices. The cumulative incidence of varices in 3 years of the study in patients whose shunt index was originally 20% or over, was significantly higher than that in patients whose shunt index was originally under 20%. The cumulative survival rate in 7 years of the study in patients whose shunt index was originally under 70% was significantly higher than that in patients whose shunt index was originally 70% or over. The information obtained by calculating the shunt index could be used by physicians in out-patient clinics when deciding the schedule with which to monitor patients using barium esophagogram or endoscopy, and choosing the examination method.     

肝硬化食管静脉曲张患者门静脉血栓形成的危险因素分析

目的旨在识别肝硬化食管静脉曲张患者中门静脉血栓(PVT)形成的独立危险因素,并建立一个预测PVT发生风险的列线图。方法回顾性分析2013年12月—2018年12月于山东大学附属省立医院就诊的283例肝硬化食管静脉曲张患者资料,根据影像学检查将其分为PVT组(n=119)和非PVT组(n=164)。计量资料两组间比较采用t检验或Mann-Whitney U检验,计数资料两组间比较采用χ2检验。利用多因素logistic回归分析筛选独立危险因素,基于多因素回归结果建立并检验列线图,应用C指数(C-index)、校准曲线评价其性能。结果单因素分析显示,PVT组在Child-Pugh分级(χ^2=9.388,P=0.009)、脾切除史(χ^2=26.805,P<0.001)、WBC(Z=-2.248,P=0.025)、PLT(Z=-3.323,P=0.001)、D-二聚体水平(Z=-6.236,P<0.001)及脾脏厚度(Z=-2.432,P=0.015)方面高于非PVT组,而TG水平低于非PVT组(Z=-4.150,P<0.001)。多因素分析显示,TG水平(OR=0.441,95%CI:0.190~0.889)、D-二聚体水平升高(OR=1.151,95%CI:1.041~1.272)、PT延长(OR=1.160,95%CI:1.025~1.313)、有脾切除史(OR=2.933,95%CI:l.164~7.389)是肝硬化食管静脉曲张患者PVT形成的独立风险因素。基于多因素回归结果,建立了列线图,其C指数值为0.745,校准曲线显示PVT发生的观测值和预测值之间有较好的一致性。结论TG水平降低、有脾切除史、D-二聚体水平升高、PT延长是肝硬化食管静脉曲张患者PVT形成的独立危险因素,基于此所建立的列线图,为临床医生评估PVT形成风险提供了一个定量、直观的工具。     

晚血门脉高压症门脉内径、门脉压及食管静脉曲张相关性分析

目的探讨晚期血吸虫病门脉高压症病人的门静脉内径、门静脉压及食管静脉曲张之间的相互关系、变化规律及其临床意义。方法对106例晚期血吸虫病门脉高压症病人在术前用B超和纤维胃镜分别检测门静脉主干内径和食管静脉曲张程度,在术中测定自由门静脉压力,测得结果进行统计学分析。结果门静脉内径与门静脉压间无相关关系(P＞0.1);但门静脉内径与食管静脉曲张之间存在正相关关系(P＜0.05);食管静脉曲张与门静脉压力之间也存在正相关关系(P＜0.01)。结论晚期血吸虫病门脉高压症病人的门静脉内径大小尚不能显示门静脉压高低,但食管静脉曲张程度既受着门静脉内径的扩大也受着门静脉压力的增高而加重。三者之间关系的阐明有助于临床上正确评估病程、判断预后和制定治疗方案。     

Large paraesophageal varices on endosonography predict recurrence of esophageal varices and rebleeding

BACKGROUND & AIMS: Recurrence of varices and rebleeding after endoscopic therapy is very common. Data on the prediction of recurrent varices after initial obliteration by endoscopic therapy are few. The aim of this study was to correlate the presence and the size of paraesophageal varices (PEVs) in patients after endoscopic variceal ligation with recurrent varices and rebleeding. METHODS: Forty patients who underwent endoscopic banding ligation for esophageal variceal bleeding were studied by endosonography within 4 weeks after obliteration of varices. PEVs were classified as none, small, or large (maximum diameter, > or =0.5 cm). Esophagoscopy and endosonography were then repeated every 6 months for up to 1 year. RESULTS: Two patients (5%) were not detected to have PEVs. Small and large PEVs were identified in 24 (60%) and 14 (35%) patients, respectively. During the follow-up period of 1-year, recurrent submucosal esophageal varices were detected in 24 patients, including 13 patients (93%) with large PEVs and 11 patients (46%) with no or small PEVs (P = 0.0019). Recurrent bleeding occurred in 6 patients (43%) with large PEVs and in 3 patients (12%) with small PEVs (P = 0.044). CONCLUSIONS: Patients with large PEVs have a higher risk of developing recurrent varices and rebleeding. (Gastroenterology 1997 Jun;112(6):1811-6)     

Blood flow and blood oxygen partial pressure of the azygos vein in portal hypertension evaluated by the catheter method

To evaluate the clinical significance of blood flow in the azygos vein and the oxygen partial pressure in azygos venous blood in portal hypertension, we examined 25 patients with liver cirrhosis, 4 with chronic hepatitis, 4 with idiopathic portal hypertension (IPH) and 16 controls by the continuous thermodilution method and azygos venous blood sampling. The azygos venous flow was significantly higher in the patients with chronic liver diseases than in the controls. There was a significant correlation between azygos venous flow and hepatic venous pressure gradient. In the patients with liver cirrhosis, about one half of the azygos venous flow was assumed to represent upward collateral flow, as the azygos venous flow was 3.4% of cardiac output in the controls, 6.3% in the liver cirrhosis patients, and 5.1% in the IPH patients. Oxygen partial pressure in azygos venous blood was higher in patients with portal hypertension, especially in the IPH patients, which indicates that part of splenic flow drains into the azygos vein.     

Experimental prehepatic portal hypertension and esophageal varices in the rabbit

Prehepatic portal hypertension was induced in rabbits by constricting the vein, creating a pressure approximately 100% higher than the preoperative value. Angiographic, endoscopic, and pressure studies confirmed the portal hypertension to be decompressed, with shunting of blood through esophageal varices. Small periportal collaterals were insufficient to prevent the esophageal shunting. The esophageal varices developed within 4 weeks and were a consistent finding throughout the observation period. No relation between the extent of portal hypertension and the size of the varices was found.     

Left gastric vein hemodynamics and variceal recurrence in patients undergoing prophylactic endoscopic ligation of high-risk esophageal varices

BACKGROUND: Early recurrence of esophageal varices remains problematic after endoscopic variceal ligation. To evaluate the efficacy of prophylactic endoscopic ligation for esophageal varices at high risk for bleeding, the relationship between left gastric vein hemodynamics and variceal recurrence was investigated. METHODS: Thirty-five patients with cirrhosis underwent endoscopic variceal ligation. Angiography was performed in all patients before treatment and after eradication of varices to study left gastric vein hemodynamics. RESULTS: Before treatment, 12 patients had hepatopetal flow in the left gastric vein (type I), 17 had hepatofugal flow (type II), and 6 had hepatofugal flow with an extra-esophageal shunt (type III). In type I and III patients, the direction of blood flow in the left gastric vein did not change after eradication of varices. Type II patients showed bi-directional flow in the left gastric vein after treatment. Varices recurred in all but one type II patient and in one type I patient during follow-up (mean 36.7 months). The 2-year recurrence-free rate was higher in type I patients (p = 0.0001) and type III patients (p = 0.0002) than in type II patients. CONCLUSIONS: Prophylactic ligation seems to be a safe and useful procedure, especially in patients with type I or III hemodynamics in the left gastric vein before treatment.     

Double-blind investigation of the effects of propranolol and placebo on the pressure of esophageal varices in patients with portal hypertension

This study was aimed at investigating the effects of propranolol on esophageal variceal pressure in patients with portal hypertension. Variceal pressure was measured at endoscopy using a miniature pressure-sensitive gauge in 20 patients with portal hypertension. Measurements were obtained under baseline conditions and 20 min after double-blind administration of propranolol (0.15 mg/kg; n = 10) or an identical amount of placebo (normal saline, 0.3 ml/kg; n = 10). Under baseline conditions, variceal pressure was similar in propranolol and placebo groups (14.1 +/- 5 mm Hg vs. 14.9 +/- 6.6 mm Hg, respectively; not significant). Placebo had no significant effect on variceal pressure (baseline = 14.9 +/- 6.6 mm Hg; placebo = 15.5 +/- 6.6 mm Hg; not significant), and values after placebo administration were closely correlated with baseline values (r = 0.98; y = 1.1 + 0.97 x; p less than 0.0001). In contrast, propranolol caused a significant decrease in the pressure of esophageal varices (from 14.1 +/- 5 mm Hg to 11.3 +/- 4.4 mm Hg; p less than 0.0002). No significant changes in the size of esophageal varices were observed after propranolol or placebo administration. This study shows (a) the endoscopic pressure-gauge technique has a low variability and may be used to assess acute drug-induced changes in variceal pressure; and (b) propranolol causes significant decreases in variceal pressure in patients with portal hypertension and esophageal varices.     

Drug therapy of esophageal varices hemorrhage in portal hypertension

The author discusses the etiopathogenesis of portal hypertension and possibilities how to influence it during treatment of acute haemorrhage from varicosities and how to implement primary and secondary prevention. In treatment of acute haemorrhage the author recommends terlipresin, 1 mg every 4 hours. In primary and in particular in secondary prevention he emphasizes the necessity of early administration of beta-blockers.     

胃镜下聚桂醇注射联合套扎术治疗食管胃底静脉曲张的临床观察

目的探讨胃镜下聚桂醇注射联合套扎术治疗肝硬化食管胃底静脉曲张(EGV)的疗效和安全性。方法2016年1月至2018年1月,西安高新医院消化内科连续收治的肝硬化EGV患者作为研究对象,采用随机数字表法分为单纯套扎组和硬化联合套扎组,每组50例。单纯套扎组仅行胃镜下静脉曲张套扎术治疗,硬化联合套扎组术中行胃镜下静脉曲张套扎术治疗前先完成聚桂醇注射治疗。主要对比分析2组门静脉血流动力学测定结果,术后7 d、3个月、6个月的疗效评估结果,术后并发症发生情况。结果单纯套扎组和硬化联合套扎组术后门静脉血流速度[(23.87±2.57)cm/s比(26.52±2.71)cm/s,t=5.017,P<0.001]、血流量[(781.45±80.55)mL/min比(877.45±90.42)mL/min,t=5.606,P<0.001]比较差异均有统计学意义,且2组均明显高于术前(P均<0.05)。2组术后7 d治疗有效率分别为96%(48/50)和100%(50/50)(χ2=2.041,P=0.153),术后3个月分别为84%(42/50)和96%(48/50)(χ2=4.000,P=0.046),术后6个月分别为76%(38/50)和92%(46/50)(χ2=4.762,P=0.029)。2组术后并发症总体发生率分别为14%(7/50)和20%(10/50)(χ2=0.638,P=0.424)。结论胃镜下聚桂醇注射联合套扎术治疗肝硬化EGV安全有效,较胃镜下静脉曲张套扎术优势在于患者门静脉血流动力学改善更明显、疗效更稳定。     

Endoscopic ligature of esophageal varices in the treatment of portal hypertension

Endoscopic ligation (EBL) has shown to have greater effectiveness and minor number of adverse side effects than sclerotherapy in the treatment of esophageal varices. The introduction of multiband devices that allow 5-10 bands positioning in a single session, has obtained to simplify the technique execution, avoiding the use of overtube and inherent complications. EBL sessions are carried out every 2 weeks until eradicate the varices, which is obtained in around 90% of the patients after 2-4 sessions. In agreement with the present evidence, non-selective betablockers are the first therapeutic election in primary prophylaxis of hemorrhage by esophageal varices, whereas EBL would have to reserve for patients with betablockers intolerance or contraindications. Combined treatment with betablockers and isosorbide-5-mononitrate, with EBL is probably a good therapeutic option for the secondary prophylaxis of hemorrhage by varices. EBL effectiveness can be increased if it is combined with betablockers. Patients who have contraindications for betablockers treatment or present hemorrhage while receiving prophylaxis with them, must be treated with endoscopic ligation. EBL in combination with vasoactive pharmacological treatment is the election treatment of acute hemorrhage by esophageal varices; nevertheless varices sclerotherapy can be made if the execution of EBL is technically difficult.     

Portal hemodynamics in patients with gastric varices. A study in 230 patients with esophageal and/or gastric varices using portal vein catheterization

The hemodynamic features of gastric varices are not well documented. The purpose of this study was to investigate the nature of hepatofugal collateral veins, their origins, the direction of blood flow in the major veins and collateral veins, and portal venous pressure. To this end, 230 patients, mostly cirrhotic, who had esophageal or gastric varices, or both, demonstrated by endoscopy were investigated by portal vein catheterization. The findings were correlated with endoscopically assessed degrees of varices. Gastric varices were seen in 57% of the patients with varices due to portal hypertension. In most of the patients with advanced gastric varices, esophageal varices were minimal or absent. When patients with gastric varices were compared with those having predominantly esophageal varices, it was found that advanced gastric varices were more frequently supplied by the short and posterior gastric veins, they were almost always associated with large gastrorenal shunts, and portal venous pressure in patients with large gastric varices was lower. Chronic portal systemic encephalopathy was more common in patients with large gastric varices due to hepatofugal flow of superior mesenteric venous blood in the splenic vein than in patients with predominantly esophageal varices. Thus, the hemodynamics in patients with large gastric varices are distinctly different from those in patients with mainly esophageal varices, and such differences seem to account for the differing incidence of chronic encephalopathy and variceal bleeding.