预防性套扎治疗重度食管静脉曲张63例分析

近年来,随着内镜设备、技术水平的不断提高,内镜下食管静脉曲张硬化剂注射疗法（ES）、内镜下食管静脉曲张套扎疗法（EVL）等方法凭借其近期疗效良好、降低出血及再出血发生率、显著提高生存率等优点,已逐渐成为治疗食管静脉曲张破裂出血的常用方法。但对于未发生过上消化道出血的重度食管静脉曲张患者,是否需要进行预防性套扎治疗尚存疑义。     

食管曲张静脉内镜套扎术31例护理体会

内镜下食管曲张静脉套扎术(EVL)是以内置弹性橡皮环结扎原理为基础,是安全有效、简单易操作的非手术预防和治疗食管静脉曲张破裂出血的实用方法。对肝炎后肝硬化并食管曲张静脉套扎31例患者术前、中、后的护理及配合工作进行分析。     

食管静脉曲张42例套扎后早期再出血的诱因分析及护理对策

食管静脉曲张破裂出血是肝硬化的严重并发症,死亡率高。内镜下食管静脉曲张套扎术（EVL）系经过结扎曲张静脉血管使套扎处组织缺血、坏死、脱落,静脉内血栓形成,血管闭塞,从而达到止血和预防出血的目的。因其简单、容易掌握、     

急诊内镜下套扎治疗肝硬化食管静脉曲张出血疗效观察

目的：探讨急诊内镜下套扎治疗肝硬化食管曲张静脉破裂出血的临床疗效。方法：对68例肝硬化食管静脉曲张出血的患者行急诊内镜下套扎治疗。结果：急诊止血成功率94．1％；止血成功后近期再出血5例，其中2例行2次套扎止血成功；2例止血失败，2例近期再出血患者行血管介入手术后止血成功；死亡3例。结论：急诊EVL是治疗肝硬化食管静脉曲张破裂出血的一种安全而有效方法。     

肝硬化套扎联合硬化序贯治疗的疗效评价

  目的 探讨套扎联合硬化序贯治疗对肝硬化食管静脉曲张的疗效。方法 选取医院2014-04至2017-04诊断为肝硬化并食管静脉曲张出血经过2次食管静脉曲张套扎治疗,食管静脉曲张内镜分级仍在中(G₂)、重(G₃)度的57例患者为研究对象,根据随机数字表法将受试者随机分为对照组(28例)和研究组(29例),研究组行套扎联合硬化序贯治疗,对照组继续行套扎序贯治疗。两组均在治疗后随访1年并复查胃镜,比较两组的序贯治疗次数、食管静脉曲张消除率、再出血发生率、并发症发生率。结果 研究组食管静脉硬化术序贯治疗次数(2.24±0.95)少于对照组食管静脉套扎术序贯治疗次数(3.29±1.27),两组比较有统计学差异(P＜0.05)。研究组静脉曲张消除率(89.66%)显著高于对照组(46.43%),再出血率(2.45%)低于对照组(14.29%),两组比较差异有统计学意义(P＜0.05)。两组并发症发生率比较差异无统计学意义(P＞0.05)。结论 套扎联合硬化序贯治疗可减少内镜下治疗次数,显著减少套扎术后残留的食管曲张静脉、延缓静脉曲张的复发,并发症风险无增加。     

内镜下套扎治疗食管静脉曲张破裂出血（附43例）

目的：探讨内镜下套扎治疗食管静脉曲张破裂出血的临床疗效。方法：对我院86例食管静脉曲张破裂出血患者分别给予内镜下套扎治疗与内科药物治疗,比较两组治疗疗效。结果：治疗组：止血成功率达90.7%,死亡率达4.7%,再出血率达11.6%。对照组则依次为69.8%、23.3%、32.6%。两组止血成功率、死亡率、再出血率的比较,均（P〈0.05）。结论：内镜套扎治疗食管静脉曲张破裂出血具有创伤小、止血迅速、临床疗效好,值得推广使用。     

内镜下组织黏合剂栓塞术治疗食管胃底静脉曲张出血的临床研究

目的比较内镜下套扎法及组织黏合剂注射法治疗肝硬化胃底静脉曲张的临床疗效。方法将154例肝硬化食管胃底静脉曲张患者随机分为内镜下套扎组(对照组)及组织黏合剂注射组(观察组),观察两组患者的再次出血发生率、曲张静脉改善有效率及并发症的发生率。结果两组患者手术均成功,均无严重的并发症发生。随访9个月,观察组3、6、9个月内再出血发生率明显低于对照组,而曲张静脉改善的有效率明显高于对照组,差异有统计学意义(P<0.05)。结论内镜下注射组织黏合剂能更加有效的预防再出血的发生,其临床疗效更为确切,可作为治疗食管胃底静脉曲张的首选方法。     

静脉曲张套扎联合部分脾栓塞治疗肝硬化食管静脉曲张出血的META分析

目的评价内镜下静脉曲张套扎（EVL）联合部分脾栓塞（PSE）治疗食管静脉曲张出血的临床疗效。方法检索PubMed、 EMBASE、 Web of Science、 The Cochrane Central Register of Controlled Trials、 Elesiver、全文数据库、中国科技期刊数据库（维普）、万方数字化期刊全文数据库、中国生物医学文献数据库等关于内镜下静脉曲张套扎联合部分脾栓塞治疗食管静脉曲张的疗效及安全性的随机对照试验（RCT）,使用Rev—Man5．2版软件对纳入的研究进行Meta分析。结果共7项RCT包含428例患者符合入选标准。Meta分析结果显示：（1）EVL联合PSE患者根治率高于EVL组（RR=1．55,95％CI：1．27～1．06,P〈0．0001）;EVL联合PSE患者再出血率较EVL组明显降低（RR=0．43,95％CI：0．26～0．72,P=0．001）;EVL联合PSE患者病死率与EVL组相比差异无统计学意义（RR=0．39,95％CI：0．12～1．26,P=0．12）。（2）EVL联合PSE患者血小板计数与EvL组相比明显增高（WMD=53．85,95％CI：45．72～61．98,P〈0．00001）。结论EvL联合PSE在临床疗效及改善血小板计数明显优于EVL,但由于相关的高质量研究文献数量有限及纳入的样本量较小,尚待高质量随机对照试验证实。     

影响经皮经肝食管胃曲张静脉组织胶栓塞术远期疗效因素分析

目的：探讨提高经皮经肝曲张静脉栓塞术（PTVE）治疗食管胃底静脉曲张出血远期疗效的相关因素。方法：192例肝硬化合并食管胃底静脉曲张出血的患者,经皮经肝穿刺向食管下段胃底部曲张静脉、食管下段周围静脉丛、胃底贲门周围静脉丛内注入永久性栓塞剂TH胶（a-氰基丙烯酸酯）。结果：192例患者中188例成功施行了PTVE,成功率达97．8％。168例患者随访期6～64月,根据注入的TH胶分布的范围,168例患者分为3种栓塞类型：食管-胃底型82例,胃底型67例,主干型19例,135例患者PTVE后同时施行部分脾动脉栓塞,42例随访中施行了内镜下套扎或硬化治疗。静脉曲张复发率15．5％（26／168）。胃食管栓塞组静脉曲张复发率明显低于胃底贲门型及冠状静脉主干型（P〈0．0001,log-rank test）。随访期间21例患者再出血,总出血率12．5％（21／168）。其中食管胃底型再出血率3．7％（3／82）;胃底型再出血率10．4％（7／67）;主干型再出血率58．1％（11／19）。联合内镜治疗者再出血为2．4％（1／42）,联合脾动脉栓塞组再出血8．9％（12／135）明显低于单纯PTVE治疗的27．3％（9／33）。结论：TH胶栓塞范围与远期疗效密切相关,联合部分脾动脉栓塞和内镜下套扎治疗能明显降低食管胃静脉曲张复发和再出血。     

内镜下食管静脉曲张及其出血治疗的护理体会

食管静脉曲张破裂出血是肝硬化病人的主要并发症和致死原因,内镜下食管静脉曲张套扎术是目前预防和治疗食管静脉曲张破裂出血的有效方法之一,预防和治疗肝硬化食管静脉曲张出血是降低死亡率的关键,而内镜下套扎治疗已经代替了硬化疗法成为现在急性静脉曲张出血的最普遍的治疗方法。近年来,我院消化内镜中心用六连发套扎器对该类患者进行了治疗和护理,取得了良好的疗效,现报告如下。     

肝硬化食管静脉曲张出血胃镜下套扎治疗的疗效

目的探讨肝硬化食管静脉曲张出血胃镜下套扎临床疗效。方法回顾性分析204例肝硬化食管静脉曲张破裂出血病例,根据治疗方法分为三腔二囊管组（三腔管组）81例和曲张静脉套扎组（套扎组）123例,比较两组止血成功率、病死率、住院时间、并发症发生率、生存时间等。结果套扎组72h止血成功率100％高于三腔管组的84．0％（x^2=21．084,P〈0．01）;套扎组无死亡患者,三腔管组死亡6例（x^2=9．387,P〈0．01）;套扎组住院时间显著少于三腔管组;套扎组并发症为18．7％显著少于三腔管组的63．0％（x^2=41．394,P〈0．01）;术后2W复查,套扎组中度为60．0％（x^2=8．499,P〈0．01）及重度食管静脉曲张的66．2％（x^2=5．343,P〈0．05）均显著低于三腔管组。套扎组上消化道出血复发1次（x^2=30．997,P〈0．01）及2次以上比例显著低于三腔管组（x^2=19．088,P〈0．01）;12个月内病死率显著低于三腔管组（x^2=21．113,P〈0．01）;4年累计生存率（86．6％）显著高于三腔管组（22．3％）。结论肝硬化食管静脉曲张破裂出血套扎成功率高、并发症少、复发率低,是一种有效的治疗方法。     

Risk and causes of gastroesophageal bleeding in patients with liver cirrhosis

BACKGROUND/AIM: Variceal bleeding is the most life-threating complication in liver cirrhosis. The aim of this study was to analyze the sources of gastroesophageal bleeding in patients with liver cirrhosis and to ascertain the risk factors of bleeding from esophageal varices. METHODS: This prospective study included 52 patients with liver cirrhosis and portal hypertension. Severity of liver dysfunction according to Child's classification, coagulation parameters, and endoscopic findings were analyzed. In patients with varices we analyzed the size, color, location of varices, and the presence of red signs. The varices were classified as small, medium and large. RESULTS: Esophageal varices were found in 76.9% of the patients. Isolated varices were present in 36.6%, and associated with other findings in 40.3%. Small varices were present in 10%, medium in 25% and large in 65% patients. Of them 55% had variceal bleeding. Variceal bleeding was present in 50% of the patients with medium and in 65.38% of the patients with large varices. There was no bleeding in the patients with small varices. Endoscopy revealed red signs before bleeding in 85% of the patients with large varices. There was a higher incidence of variceal bleeding in the Child's group B. There were no significant differences (p > 0.05) in the coagulation parameters in patients with and without variceal bleeding. Rebleeding was present in 86.36% of the patients. Most of them (52.63%) were rebleeding between 7 weeks and 12 months after the first episode of variceal bleeding. In the patients with the most severe hepatocellular dysfunction (Child's group C) the period between the first bleeding and rebleeding was the shortest (mean, 20.8 days). CONCLUSION: Our study revealed that esophageal varices are the most frequent sources of bleeding in the patients with liver cirrhosis. There is the association between the first bleeding and large varices and the red signs. Coagulation disorders and hepatic dysfunction were not related to the initial episode of variceal bleeding. The risk of early rebleeding was higher in the patients with severe hepatic dysfunction (Child's class C).     

消化内镜联合四联疗法对胃溃疡伴活动性出血的疗效观察及再出血原因分析

目的观察消化内镜联合四联疗法对胃溃疡伴活动性出血的治疗效果,并分析其再出血的相关危险因素。方法选取2016年9月至2018年9月焦作煤业集团有限责任公司中央医院消化科收治的88例胃溃疡伴活动性出血患者作为研究对象,并按照随机数表法将其随机分为观察组与对照组,每组44例,观察组患者采用消化内镜联合四联疗法治疗,对照组患者单纯采用四联疗法治疗,对比两组患者的临床疗效,观察两组患者治疗后再出血的发生情况,并分析再出血的相关危险因素。结果治疗2周后,观察组患者的临床疗效明显优于对照组(Mann-Whitney U=708.500,Z=-2.380,P=0.017);经多因素Logistic回归分析发现,血红蛋白含量低、溃疡为A1期及未联合消化内镜治疗是患者再出血的独立危险因素(OR=1.792、1.165、1.879,P=0.015、0.022,0.031)。结论胃溃疡伴活动性出血患者应用消化内镜联合四联疗法治疗,可有效提高治疗效果,降低再出血发生率,且患者血红蛋白含量低及溃疡为A1期也是胃溃疡伴活动性出血患者再出血的独立危险因素,应加以重视。     

组织胶注射治疗胃底静脉曲张破裂出血安全性及疗效分析

目的探讨内镜下组织胶注射急诊治疗门静脉高压导致胃静脉曲张破裂出血的安全性及疗效。方法 64例门静脉高压胃底静脉曲张急性出血患者行内镜下组织胶注射治疗,观察分析即时止血率、曲张清除率、并发症及其影响因素。结果即时止血率为100%（65/65）,术中、术后均无严重并发症出现。术后6个月曲张静脉完全消失率为30.8%（20/65）,基本消失率为41.5%（27/65）,部分消失率为26.2%（17/65）,无效率为1.5%（1/65）。GEV1与IGV1型患者疗效显著优于GEV2型（P〈0.05）。结论经内镜下注射组织胶急诊治疗门静脉高压胃底静脉曲张破裂出血止血效果好,再出血发生率低,疗效确切。     

TIPSS加断流术治疗门静脉高压症的疗效观察

目的　研究TIPSS加断流术治疗门静脉高压症的临床疗效。方法　对 6 0例门静脉高压症伴食管静脉曲张破裂出血患者采用TIPSS加断流术治疗。治疗时伴有中度腹水 41例 ,重度腹水 8例 ,按Child Pugh分级标准肝功能为A级 11例 ,B级 37例 ,C级 12例 ,上消化道钡餐检查示食管静脉中、重度静脉曲张。治疗分两步进行 ,首先行TIPSS治疗 ,2周后再行断流术。结果　TIPSS术后无近期分流道阻塞、再出血和死亡 ,食管静脉曲张显著减轻。 1～ 5年随访 ,肝内分流道阻塞率、出血复发率和病死率分别为 11.9%、3.5 %和 7.0 %。结论　TIPSS加断流术是一种疗效确切的治疗门脉高压症的方法。     

TIPS for prevention of recurrent bleeding in patients with cirrhosis: meta-analysis of randomized clinical trials.

PURPOSE: To compare the effects of transjugular intrahepatic portosystemic shunt (TIPS) creation with those of endoscopic treatment with or without propranolol administration (i.e, conventional treatment) on recurrent bleeding, encephalopathy, and mortality by using meta-analysis of 11 published randomized clinical trials. MATERIALS AND METHODS: Data from 11 relevant studies were retrieved by means of computerized and manual search. The combinability of the studies was assessed in terms of clinical and statistical criteria. Data were extracted on the basis of the intention-to-treat principle, and treatment effects were measured as risk differences between TIPS creation and conventional treatment. Pooled estimates were computed according to a random-effects model. RESULTS: A total of 750 patients were included in 11 trials. No significant heterogeneity was found for any of the outcomes. Pooled risk differences were recurrent bleeding, -31% (95% CI, -39%, -23%); encephalopathy, +16% (95% CI, +10%, +22%); death due to all causes, +2% (95% CI, -4%, +9%); and death due to bleeding, -5% (95% CI, -11%, +6%). Clinically important complications occurred in 22% of patients and were associated with both treatments. TIPS dysfunction occurred in 55% of patients. CONCLUSION: TIPS creation markedly reduces risk of rebleeding but increases risk of encephalopathy without affecting survival. Therefore, TIPS creation may not be the best first-choice therapy for prevention of recurrent variceal bleeding. Criteria for selection of candidates for TIPS creation should be assessed in future prospective studies.