Prediction of bleeding from esophageal and gastric varices in patients with liver cirrhosis]

A course of the disease was studied in 190 patients with hepatic cirrhosis and portal hypertension without bleeding as well as in 107 patients with bleeding from esophageal and gastric varices. The Wald's consecutive analysis with derivation of a summary diagnostic coefficient on the basis of 13 clinical signs was used. Effectiveness of the method was assessed by means of retrospective analysis of 150 case records and long-term results of treatment of 30 patients. The method permits to predict the development of gastroesophageal bleeding in 95.4% of cases.     

Liver transplantation in patients with liver cirrhosis and esophageal bleeding

BACKGROUND: Uncontrolled hemorrhage from esophageal varices is one of the most devastating complications of portal hypertension in patients with advanced cirrhosis. METHODS: Drug therapy, endoscopic therapy, transjugular intrahepatic portosystemic shunt (TIPS), or surgical shunts are used with increasing success in the prevention and treatment of bleeding. However, all these treatment modalities have limitations because they do not treat the liver cirrhosis itself. On the other hand, treatment modalities for variceal bleeding may influence the ease of the feasibility of the transplantation procedure. This is particularly the case for surgical treatments like portosystemic shunts and devascularization operations. For this reason these procedures should be avoided if possible. When positioned correctly, a TIPS provides an elegant way of treating portal hypertension without influencing the course of liver transplantation. Liver transplantation offers a treatment that cures both the portal hypertension and the liver disease. However, the use of this method of treatment is limited by the organ availability and by the organ allocation algorithm, resulting in considerable waiting time. CONCLUSION: In conclusion, esophageal bleeding should be noticed as an early warning factor, leading the hepatologist to consider liver transplantation and early listing of the patient.     

肝硬化食管静脉曲张出血的现代处理

20世纪40—80年代食管静脉曲张出血的病死率在30％～60％之间，主要治疗措施是气囊填塞、断流或分流手术。在过去的20年涌现了许多新的治疗方法，住院病死率也在稳定下降。据Saint-Autoine医院1980—2000年资料分析，1980年住院病死率为42．6％，1985年为29．9％，1990年为25％，1995年为16．2％，2000年为14．5％。肝功能A级患者病死率从9％（1980年）下降至0（2000年）；肝功能B级则从46％下降至0；C级病人从70％下降至32％。住院病人病死率在过去的20年里减少了3倍。这主要归功于处理的技术进步，其中包括：复苏技术、药物处理、内镜治疗、放射介入和肝移植的发展，特别是内镜治疗使静脉曲张出血治疗呈现了革命性改变。     

Hemodynamic study after devascularization procedure in patients with esophageal varices

The portal and systemic hemodynamics in 23 patients with esophageal varices caused by portal hypertension were studied by the thermodilution method with a thermodilution catheter. The patients had a mean age of 48.2 years and underwent splenectomy and devascularization with (17 cases) or without cardiectomy (six cases). The initial portal venous blood flow in all 23 patients was 0.99 +/- 0.31 L/min/m2, and this decreased significantly after splenectomy to 0.67 +/- 0.29 L/min/m2 in proportion to the resected spleen weight. The initial portal venous pressure was 36.5 +/- 6.8 cm H2O, and this decreased after splenectomy to 29.1 +/- 5.7 cm H2O but returned to the initial level after the devascularization procedure. Thus the portal hypertensive status was preserved in spite of the reduction in portal venous blood flow. There was no difference in the pattern of portal hemodynamic change between the patients who underwent cardiectomy and those who did not. In conclusion, it is indicated that the portal hemodynamic change after the devascularization procedure was not caused by cardiectomy but by the lack of splenic blood flow to the portal vein after splenectomy.     

肝硬化食管静脉曲张无创性预测指标的探讨

目的 回顾性分析外周血血小板计数与脾脏长径比值对不同病因肝硬化合并食管静脉曲张的预测作用.方法 收集我院肝硬化住院病例共107例,其中乙肝肝硬化59例,酒精性肝硬化32例,原发性胆汁性肝硬化16例;有食管静脉曲张73例,无食管静脉曲张者34例.记录外周血血小板计数、B超下脾脏最长径值、血清白蛋白、转氨酶及凝血酶原时间等各项指标.应用Ginanni等研究发现的909作为血小板计数与脾脏长径比值阈值进行评估分析. 结果 有食管静脉曲张的患者与无食管静脉曲张患者的凝血酶原时间[(13.0±1.5)s比(15.7±3.1)s]、脾脏长径值[(128±23)mm比(148±41)mm]、白蛋白[(36.0±5.4)g/L比(31.0±2.6)g/L]、血小板计数[(9±6)×109/L比(5±3)×109/L]、血小板计数和脾脏长径比值[(760±529)比(438±317)]相比差异均有统计学意义.909作为血小板计数与脾脏长径比值阈值适合于国人,其预测食管静脉曲张存在的敏感性达到91.8%,特异性为71.3%.结论血小板计数/脾脏长径比值可以作为非侵入性方法进行食管静脉曲张存在的评估,且909可以作为阈值对我国肝硬化人群是否合并食管静脉衄张进行预测.     

The portal circulatory characteristics of patients with esophageal and gastric varices in liver cirrhosis

It was established while examination of 166 patients with hepatic cirrhosis and the portal hypertension syndrome that the varicose esophageal veins are supplied with the blood from left and right gastric veins, and varicose veins of stomach--mainly from short and posterior gastric veins. The regularities of the portal hemodynamics change while the gastric veins varicosity occurrence were revealed: the hepatic portal perfusion lowering and the collateral hepato-fugal blood flow strengthening.     

Transcatheter embolization therapy of esophageal varices and hypersplenism with liver cirrhosis

Transcatheter variceal embolization (PTO, TIO) has been performed in 71 cases and splenic artery embolization (SAE) in 22 cases (15 PTO-SAE combination and 7 SAE alone). Results for varices of PTO combined with SAE were better than with PTO alone. Furthermore PTO combined with SAE was found to be reliable even for long term control of bleeding, the longest follow up being almost over 3 years during which time we have had no case of rebleeding. Improvement of Child's criteria was seen to be better in SAE cases (52.4%) than in splenectomized cases (12.5%) and PTO alone (17.4%). Hepaplastin test and level of cholinesterase were used to assess liver function, before and after treatment. It was found that SAE cases improved considerably, in contrast to the splenectomized and control cases which showed little or no improvement. Thus to increase durability for long term control of bleeding and general condition, PTO should be combined with SAE. Furthermore, it is suggested that this combined embolization therapy should be used for nonsurgical treatment of esophageal varices and hypersplenism with liver cirrhosis.     

肝硬化食管胃底静脉曲张破裂出血的综合治疗

食道胃底静脉曲张破裂出血是肝硬化的严重致死性并发症之一。门脉压力增高与食道胃底曲张静脉破损是其发生的必备条件及主要风险因素,其临床治疗方法涉及药物、内镜、介入、手术及肝移植,优势各异。笔者从门静脉压力、曲张静脉破损及肝功能损害等风险因素控制的角度,分析评估了目前其各种临床治疗方法的临床效果及作用机制。控制单一风险因素的治疗方法的临床效果往往有限,而对多种风险因素进行联合控制的综合治疗方案具有较好的临床疗效。内镜结合脾动脉主干栓塞的联合治疗方案具备优于其它治疗方案的理论优势。     

剪切波弹性成像测量脾脏硬度评估肝硬化食管静脉曲张

肝硬化并发食管静脉曲张(EV)破裂出血具有较高复发率和致死率。通过超声剪切波弹性成像测量肝脏和脾脏硬度可无创检测EV并评估其严重程度。本文对超声剪切波弹性成像技术测量脾脏硬度评估肝硬化EV的应用进展进行综述。     

Portal hemodynamics, collateral venous circulation and encephalopathy in patients with esophageal and gastric varices in liver cirrhosis

Complex hemodynamic investigations were conducted in 166 patients with liver cirrhosis and syndrome of portal hypertension. It was established that gastric varicose veins (VV) in 40% of observations are connected with v. renalis sin. by means of gastrorenal shunts (GRS), esophageal VV in 16.9% of observations--with v. renalis sin. Gastric VV frequently are connected with large GRS. More the GRS diameter, the more pronounced lowering of volemic blood flow in portal vein occurs. While gastric VV presence the volemic blood flow value in portal vein significantly lesser than while isolated esophageal VV. Encephalopathy occurs more frequently in patients with GRS, flowing into v. renalis sin. than in patients while other collateral blood flow ways present. Reverse dependence was revealed between GRS diameter and the degree of portal vein pressure lowering.