肝硬化患者门静脉高压性胃病发病因素的研究

背景：门静脉高压性胃病是肝硬化患者上消化道出血的原因之一．但其发病机制目前尚不完全清楚。目的：探讨肝硬化患者门静脉高压性胃病的发生与肝硬化分级、食管胃底静脉曲张程度、腹水量和胃肠激素血管活性肠肽（VIP）水平的关系。方法：45例肝硬化患者行胃镜检查观察食管胃底静脉曲张程度和胃黏膜改变．行腹部B超检查观察腹水量，同时检测血清白蛋白、总胆红素、胆碱酯酶、凝血酶原时间等肝功能指标和血浆VIP水平。结果：Child—Pugh A、B、C级肝硬化患者、不同程度食管胃底静脉曲张患者以及不同程度腹水患者之间的门静脉高压性胃病发生率均无显著差异（P〉0．05）。但肝硬化伴门静脉高压性胃病患者的血浆VIP水平较无门静脉高压性胃病者显著升高（P〈0．001）。结论：门静脉高压是门静脉高压性胃病的必要条件，而其他因素．如血浆VIP水平与门静脉高压性胃病的发生也有一定关系。     

肝硬化门静脉高压症合并食管胃底静脉曲张破裂出血的急救处理

目的：探讨肝硬化门静脉高压症合并食管胃底静脉曲张破裂出血急诊抢救治疗的临床经验并评估其疗效。方法回顾性分析2005年1月至2012年12月浙江省湖州市南浔区人民医院收治的11例肝硬化门静脉高压症合并食管胃底静脉曲张破裂出血患者的临床资料。结果11例患者上消化道出血24 h内止血比例为9／11,全部11例患者上消化道出血72 h内出血停止。但其中1例患者于治疗后第7天再出血,因拒绝再次三腔二囊管止血而死亡;1例患者上消化道出血后13 d死于肝功能衰竭。治疗总有效率为82％（9／11）,死亡率为18％（2／11）。结论采取内科措施控制出血,将紧急手术转为择期手术,可提高肝硬化门静脉高压症合并食管胃底静脉曲张破裂出血急诊抢救治疗的成功率。     

彩色多普勒超声判断侧支循环形成在门静脉高压症临床分型及术式选择中的意义

目的探讨彩色多普勒超声判断肝硬化门静脉高压症（PHT）侧支循环形成情况在PHT临床分型及术式选择中的意义。方法对40例不同Child分级PHT患者（有食管胃底静脉曲张者28例），应用彩色多普勒超声检测门静脉血流方向及侧支循环形成情况。结果40例中向肝血流者30例（75％）,双向血流者6例（15％），离肝血流者4例（10％）。自发性侧支循环形成27例（67．5％）。Child A、B、C级侧支循环形成比例分别为11／20、6／8、10／12。差异无显著性（P〉0．05）。食管胃底静脉曲张组侧支循环形成率为78．6％（22／28）。无静脉曲张组侧支循环形成率为41．7％（5／12），二者之间差异有显著性（P〈0．05）。结论彩色多普勒超声是观察肝门静脉血流量的良好方法，根据其判断侧支循环形成情况对PHT的临床分型和根据其分型选择不同手术方式具有重要意义。     

小探头超声用于胃底静脉曲张诊断及判断组织粘合剂疗效的初步评价

目的 与常规内镜下肉眼判断比较,评价小探头超声检查在诊断胃底静脉曲张及评价内镜下组织粘合剂治疗疗效中的临床价值。方法 １０例临床诊断为肝硬化的患者于内镜治疗前先行胃底腔内小探头超声检查,随后对诊断存在胃底静脉曲张的患者行内镜下组织粘合剂治疗,而后即刻再行小探头超声检查以观察其疗效。结果 常规内镜下肉眼判断与小探头超声检查对胃底静脉曲张的诊断准确率分别为７０％（７／１０）和１００％（１０／１０）;后     

超声下胃左静脉指标在肝硬化食管静脉曲张破裂出血预测中的应用

目的：评价超声下胃左静脉指标测量在肝硬化食管胃底静脉破裂出血预测中的应用价值。方法对80例肝硬化门静脉高压患者（出血组34例,未出血组46例）和35例健康志愿者（对照组）行彩色多普勒超声检查,观察胃左静脉以及食管胃底静脉曲张情况,计算胃左静脉最大内径及胃左静脉分流指数。结果与对照组比较,门脉高压患者胃左静脉最大内径增宽,其中出血组胃左静脉最大内径大于未出血组及对照组（P＜0．01）。以胃左静脉最大内径6．5 mm为出血预测标准,预测出血的特异性、敏感性和准确性分别为78．3％、73．5％、76．3％。胃左静脉分流指数截断值定于0．13时,预测出血的特异性、敏感性和准确性分别为82．5％、76．3％、69．8％。结论超声检查测量胃左静脉最大内径及胃左静脉分流指数有助于预测肝硬化食管胃底静脉破裂出血。     

经皮经肝TH胶栓塞治疗胃静脉曲张的疗效分析

目的观察经皮经肝组织胶粘合剂（TH胶）栓塞治疗胃静脉曲张的临床疗效。方法经皮经肝TH胶栓塞治疗胃静脉曲张30例,术后定期复查胃镜及CT门静脉成像,观察TH胶在血管内的分布范围、血管栓塞程度及静脉曲张消失情况。结果30例患者静脉曲张治疗有效率100％。21例患者随访11—33个月,平均27．9个月,静脉曲张复发率14．29％（3／21）;术后门脉高压性胃病17例80．95％（17／21）;再出血率9．52％（2／21）,均为门脉高压性胃病出血。术后CT平扫及门静脉血管成像检查显示,TH胶在胃底周围静脉、胃壁的穿支静脉及其他供血静脉内栓塞良好,TH胶持久沉积,未出现栓塞血管再通及明显新的侧枝形成。结论经皮经肝TH胶栓塞术可使胃曲张静脉及其供血静脉长期闭塞,是治疗胃曲张静脉的有效方法。     

肝硬化门静脉高压彩超测量临床意义探讨

本文用彩色多普勒超声（彩超）对20例正常人、42例肝硬化门静脉高压症（PHT）患者进行血流动力学观察。材料与方法一、仪器美国ACUSON－128型彩超，探头频率3．SMHZ，取样g积Zm”“二、对象20例正常对照，平均年龄436土14．13岁。实验组42例，平均48．24i12．27岁。肝炎后肝硬化41例，酒精性肝硬化1例，伴胃底食管静脉曲张33例，痔静脉曲张1例，上消化道出血19例37次．肝功能分级：ChildA级9例，B级23例，C级10例，合并肝癌5例。三、方法实验组1周内无急性出血史，排除药物等因素对门静脉系统血流动力学影响．检查前禁食禁水6～8小…     

内镜超声检查评价胃底静脉曲张栓塞术

目的 探讨小探头超声检查评价胃底静脉曲张栓塞术的临床价值。方法 将肝硬化伴有内镜确诊及可疑胃底静脉曲张患者分为两组，超声组109例（其中急性活动性出血患者67例）中内镜确诊78例，31例可疑胃底静脉曲张小探头超声检查确诊21例，对该组99例确诊患者行组织黏合剂（Histoacryl）栓塞治疗，术后即行超声检查，发现栓塞不完全者再次予以治疗；对照组76例（其中急性活动性出血患者62例），均为内镜诊断明确者，行组织黏合剂栓塞治疗。3个月后两组均采用小探头超声复查，以超声所见评价疗效。结果 两组急诊止血率均为100％；超声组3周内无再出血患者，对照组早期再出血率为11．8％（9／76），两组之间差异有非常显著意义（P〈0．01）；术后3个月小探头超声随访，超声组中胃底静脉曲张消失率为97．0％（96／99），对照组为76．3％（58／76）。两组之间差异亦有非常显著意义（P〈0．01）。结论 小探头超声检查评价胃底静脉曲栓塞术具有较高的价值。     

经内镜栓塞术联合套扎术治疗食管胃底静脉曲张出血的疗效观察

目的探讨胃底静脉曲张栓塞术联合内镜下食管静脉曲张套扎术（EVL）治疗肝硬化上消化道出血的疗效。方法经急诊胃镜检查发现活动性胃底静脉曲张出血合并Ⅱ°以上食管静脉曲张且排除其他病因的上消化道出血患者共156例,分为治疗组和对照组,治疗组胃底静脉曲张组织粘合剂栓塞同时食管静脉EVL治疗;对照组胃底静脉曲张组织粘合剂栓塞治疗2个月后行食管静脉EVL。结果两组均未发生与治疗相关的并发症。止血成功率治疗组为96．3％（77／80）,对照组为97．4％（74／76）,（P〉0．05）;近期再出血率治疗组为6．4％（5／78）,对照组为21．3％（16／75）,两组差异有统计学意义（P〈0．05）;两组患者随访6个月,再出血率分别为13．0％（9／69）、25．4％（17／67）,差异有统计学性意义（P〈0．05）。胃底静脉曲张改善总有效率治疗组和对照组分别为61．6％、59．1％,食管曲张静脉改善总有效率为74．0％、67．9％,差异均无统计学意义。结论胃底静脉曲张栓塞联合EVL是治疗肝硬化胃底静脉曲张出血并食管静脉曲张的安全有效方法,同时联合治疗更能降低再出血率。     

肝硬化患者食管静脉曲张及曲张程度的早期诊断方法分析

目的 对乙肝后肝硬化门脉高压症患者胃镜、B超、血液检验等进行分析，探讨这些检查在肝硬化门脉高压症患者食管静脉曲张诊断中的意义。方法 148例乙肝后肝硬化患者（合并或无门脉高压者）进行电子胃镜、腹部B超、血液检验，观察食管胃底静脉曲张的情况，测量门静脉主干内径、脾静脉内径及脾脏长径之间的差异，并分析这些指标与食管静脉曲张的关系。结果 食管静脉曲张发生率为61％，食管静脉曲张程度越重，伴胃底静脉曲张比例越高；随食管静脉曲张程度不同，门静脉主干内径、脾静脉主干内径及脾脏长径之间存在差异。血小板记数、脾脏长径、血小板记数／脾脏长径、Child—Pugh分级在合并有食管静脉曲张与未合并食管静脉曲张两组中存在明显差异。多因素分析发现，血小板记数／脾脏长径指数与食管静脉曲张的发生密切相关，独立性强。结论 门静脉主十内径、脾静脉内径、脾脏厚度可为判断门静脉高压提供参考，综合上述3点并结合胃镜检查结果可较准确判断有无食管静脉曲张及程度；血小板记数／脾脏长径指数能够较为准确地预测肝硬化门脉高压症食管静脉曲张的发生。     

门静脉高压患者胃静脉曲张的内镜识别和分类

背景：肝硬化门静脉高压的出血原因中，食管和（或）胃静脉曲张破裂出血最为常见。胃静脉曲张的发生率较食管静脉曲张低，但再出血率高，出血量大，死亡率亦较高。尽管如此，胃静脉曲张在临床诊治过程中未受到应有的重视。目的：根据内镜下对食管和胃静脉曲张的识别和分类，了解食管和胃静脉曲张的比例。方法：根据Sarin分类，在内镜直视下将114例门静脉高压患者分为单纯食管静脉曲张、胃食管静脉曲张1型（GOV1型）、胃食管静脉曲张2型（GOV2型）、孤立性胃静脉曲张1型（IGV1型）和孤立性胃静脉曲张2型（IGV2型）五种类型。结果：本组患者中单纯食管静脉曲张42例（36．8％），GOV1型40例（35．1％），GOV2型20例（17．5％），IGV1型12例（10．5％），未见IGV2型。结论：半数门静脉高压患者存在胃静脉曲张，临床工作中仅处理食管静脉曲张是很片面的。须努力开展组织黏合剂、球囊闭塞下逆行经静脉栓塞术（B．RTO）或外科分流等治疗：对有条件的患者应鼓励开展肝移植治疗。     

Is there ileopathy in portal hypertension?

BACKGROUND AND AIMS: Portal hypertensive gastropathy and colopathy are well described endoscopic abnormalities in patients with portal hypertension. Endoscopic abnormalities in the ileum in patients with portal hypertension have not been well described. The aim of the present study was to evaluate endoscopic abnormalities in the ileum of patients with portal hypertension. METHODS: Patients with portal hypertension of various etiologies were included in the study. Upper gastrointestinal endoscopy was performed to record esophageal varices, gastric varices and portal hypertensive gastropathy. Colonoscopy with retrograde intubation of the ileum was performed and the presence of colorectal varices, colopathy and mucosal findings in the ileum were noted. RESULTS: Forty-one patients (age 16-80 years, 33 men) were studied. Esophageal varices were present in all. Portal hypertensive gastropathy was present in 27/41 (66%) patients. Rectal varices were noted in 22/41 (54%) patients and 17/41 (42%) patients had features suggestive of colopathy. Ileum could be intubated in 38 patients (93%). Endoscopic abnormalities in the ileum were noted in 13/38 (34%) patients. Ileopathy as evident by endoscopic mucosal abnormalities was observed in 10/38 (26%) patients. Ileal varices were present in 8/38 (21%) patients. Three of these had ileal varices alone while the remaining five patients also had associated ileopathy The presence of ileopathy was significantly associated with the presence of portal hypertensive gastropathy and colopathy but not with esophageal, gastric or rectal varices. CONCLUSIONS: Ileopathy occurs in one-third of patients with portal hypertension and is significantly associated with the presence of portal hypertensive gastropathy and colopathy.     

Unusual sites of upper gastrointestinal variceal bleeding

When patients with portal hypertension bleed from varices, these are most commonly located in the esophagus and gastric fundus. However, varices can develop anywhere in the upper or lower gastrointestinal tract. Oftentimes if an active upper gastrointestinal bleeding site is not evident at the time of endoscopy, bleeding is attributed to any esophageal or gastric varices that are present. This supposition may not always be true as illustrated in the two patients presented here. Likewise, the absence of esophagogastric varices in a patient with portal hypertension does not preclude the presence of varices elsewhere. Endoscopic examination of the second and third portion of the duodenum can sometimes be helpful in accurately locating the bleeding site.     

肝硬化门静脉高压患者胃镜与B超表现相关性研究

目的 通过对肝炎肝硬化门静脉高压患者胃镜、B超检测结果行相关性分析，为临床判断肝硬化程度、早期预防并发症提供参考。方法 选择肝炎肝硬化门静脉高压患者192例，根据食管静脉曲张程度分为轻、中、重度3组。比较胃底静脉曲张在各组中发生比例，并测量门静脉主干宽度、脾静脉宽度、脾脏厚度，研究其与食管静脉曲张程度相关性。结果 3组患者胃底静脉曲张发生比例存在显著差异，食管静脉曲张程度越重，伴胃底静脉曲张比例越高；随食管静脉曲张程度不同，门静脉主干内径、脾静脉内径及脾脏厚度之间存在差异，脾脏厚度与脾静脉内径之间存在直线相关关系。结论 门静脉主干内径、脾静脉内径、脾脏厚度可为判断门静脉高压提供参考，综合上述3点并结合胃镜检查结果可较准确判断有无食管静脉曲张及程度。     

Nodules in antrum after variceal eradication a new finding in patients with portal hypertension

Portal hypertension is known to cause esophageal varices, gastric varices and portal hypertensive gastropathy (PHG). The prevalence of gastric varices and PHG is known to increase after eradication of esophageal varices. PHG includes the presence of a mucosal mosaic pattern, cherry red spots, and/or black-brown spots and gastric vascular ectasia (GAVE). Patients with portal hypertension in whom esophageal varices were eradicated were on follow up endoscopy for detection of recurrence of esophageal varices. Their status of PHG was assessed and patients antral nodules were enrolled. Twenty patients with antral nodules were identified over one year. Fifteen out of 20 patients had cirrhosis as etiology of portal hypertension, three had non-cirrhotic portal hypertension and two had extra-hepatic portal vein thrombosis. GAVE was seen more commonly (n=8, 40%) in patients with PHG with nodules. PHG with antral nodules is a novel endoscopic finding present both in cirrhotic and non-cirrhotic portal hypertension with unknown pathogenesis, and is seen more commonly in patients with eradicated varices who are on long-term follow up.     

螺旋CT门静脉造影对门脉高压侧支循环的研究

目的探讨多排螺旋CT门静脉造影(CT portal venography,CTPV)显示肝硬化门脉高压侧支循环血管的临床应用价值。方法对92例肝硬化门脉高压的患者分别进行CT门脉造影,获得门脉侧支循环血管的清晰图像,测量门静脉主干和胃左静脉直径,将胃镜与CT门静脉造影两种技术进行比较。结果应用CT门静脉造影能清晰显示和测量门脉侧支循环的血管。CT门静脉造影与胃镜两种方法对食管和胃底曲张静脉的显示能力具有一致性,Kappa值分别为0.502和0.478。结论应用多排螺旋CT门静脉造影能很好显示和测量门体间侧支循环血管。联合应用多排螺旋CT门静脉造影与胃镜两种方法,对于肝硬化门静脉高压患者的诊断、病情判断和估计预后有帮助。     

Successful endoscopic sclerotherapy for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol

Two patients with liver cirrhosis and portal hyper-tension related to hepatitis infection were admitted to Shanghai Ruijin Hospital due to recurrent melena and hematemesis. Isolated gastric varices were observed in the gastric fundus during the retroflexion of gastroscope. We carried out endoscopic sclerotherapy successfully for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol, which disappeared dramatically several months after two courses of sclerotherapy for each patient. No complication and clinical signs of gastrointestinal re-bleeding were observed during the 6-mo endoscopic follow-up. CT portal angiography （CTPA） has been widely used in the assessment of variceal treatment and improves the results of endoscopic injection therapy.