急诊经皮经肝食管胃底静脉栓塞治疗重度肝硬化消化道出血

目的　评价经皮经肝食管胃底静脉栓塞术在重度肝硬化患者急性食管胃底静脉曲张破裂出血中的应用价值。方法　 19例食管胃底静脉曲张破裂出血肝硬化患者 ,肝功能评价均为ChildC级 ,行急诊经皮经肝食管胃底静脉栓塞治疗。结果　 19例门脉穿刺及曲张静脉栓塞手术均获成功。 18例即刻止血成功 ;1例无效 ,行TIPSS治疗。 1～ 12个月随访期内 ,再出血 14例 ;死亡 15例 ;4例存活。严重合并症 1例 ,为腹腔内出血 ,行开腹探查。结论　对于ChildC级肝硬化食管胃底静脉曲张破裂出血患者 ,急诊条件下经皮经肝食管胃底静脉栓塞术止血效果肯定 ,当TIPSS禁忌时 ,可为首选治疗方法     

肝硬化患者胃肠动力学研究进展

肝硬化患者胃肠动力改变主要表现为食和运动功能下降，食管下降括约肌压力下降。其原因可能是受食管静脉曲张产生的机械因素影响及肝功能受损。胃排空延迟，主要原因为自主神经系统功能损害，胃肠激素代谢紊乱，可能与肝功能受损程度无关。小肠消化间期移行复合运动（ＭＭＣ）Ⅱ期延长，Ⅲ期缩短，使食物通过小肠时间延长。肝硬化门脉高压症合并食管静脉曲张破裂出血，硬化剂注射治疗后食管运动 弱，蠕动波数目减少，并诱发同时性收     

Use of carbon-11 methionine positron emission tomography to assess malignancy grade and predict survival in patients with lymphomas

The aim of this study was to investigate whether uptake of carbon-11 methionine (MET) is associated with histological grade of malignancy and survival in patients with newly diagnosed or recurrent lymphoma. Thirty-two patients with histologically confirmed lymphoma participated in the study. Twenty-six (81%) were studied before any therapy and six before treatment for recurrent disease. Twenty-eight patients had non-Hodgkin’s lymphoma and four had Hodgkin’s disease. An ECAT 931/08-12 positron emission tomography (PET) scanner was used for PET imaging. After the transmission scan, a median dose of 293 MBq of MET was injected intravenously and dynamic images were acquired for 40 min. The uptake of MET in tumour was measured as the standardized uptake value (SUV) and influx constant (K _i). The SUV formula was also adjusted to the predicted value of lean body mass (SUV_lean) and body surface area (SUV_BSA). The PET results were correlated with the clinical follow-up data. The median SUV in 32 malignant lesions was 6.6 (range, 1.9–12.4) and the median K _i was 0.116 min⁻¹ (range, 0.025–0.201, n=23). The median SUV was 7.0 (range, 5.4–12.4, n=9) in high, 6.2 (range, 1.9–10.4, n=11) in intermediate and 5.7 (range, 3.8–8.3, n=8) in low grade lymphomas. One intermediate grade lymphoma of the skin was visually negative (SUV 1.9). In Hodgkin’s disease the median SUV was 7.0 (range, 3.2–7.9, n=4). The median K _i value was 0.162 min⁻¹ (range, 0.147–0.197, n=7) in high, 0.099 (range, 0.025–0.152, n=10) in intermediate, and 0.078 (range, 0.056–0.152, n=4) in low grade lymphomas and 0.149 (range, 0.096–0.201, n=2) in Hodgkin’s disease. The difference between high and other grade non-Hodgkin’s lymphomas was significant when using K _i (P<0.001), but not with SUV, SUV_lean or SUV_BSA. The final outcome of the patients was not related to MET uptake. Lymphomas with a high K _i value tended to have a high S-phase fraction (r ²=0.46, P=0.043). It is concluded that MET PET is highly sensitive for the detection of untreated and recurrent lymphomas. Differentation of high grade lymphomas from lower malignancy grades seems to be possible if graphical analysis is applied to calculate K _i for MET. However, prediction of survival is not possible with MET PET. Received 5 March and in revised form 25 April 1998     

Follow-up of patients at low risk for hepatic malignancy with a characteristic hemangioma at US

PURPOSE: To determine the need for follow-up imaging in patients with a low risk of malignancy and with ultrasonographic (US) findings typical of hepatic hemangioma. MATERIALS AND METHODS: A computer search of US reports completed between 1991 and 1994 helped identify 383 patients whose reports contained the word "hemangioma." One hundred eleven patients were excluded because the lesion's appearance was atypical (n = 16) or because the patients had a high risk of malignancy (prior history or current evidence of extrahepatic malignancy or chronic hepatic disease [n = 95]). Fifty-nine patients were excluded because they were lost to follow-up (n = 41) or had clinical follow-up of less than 2 years (n = 18). The conditions of the remaining 213 patients with typical-appearing hemangiomas and a low risk of malignancy were analyzed. One hundred twenty-one patients underwent imaging follow-up or histopathologic confirmation. Ninety-two had clinical follow-up of more than 2 years (mean, 46 months). RESULTS: Of the 213 patients, four had benign lesions other than hemangiomas. One patient who subsequently developed a malignancy (neuroendocrine metastases from primary colonic carcinoma diagnosed 22 months after initial US) potentially had an early metastasis that was misdiagnosed as a hemangioma. CONCLUSION: On the basis of these results, the authors no longer recommend follow-up studies in their patients with a low risk of malignancy and a typical-appearing hemangioma at US.     

Prediction rule for characterization of hepatic lesions revealed on MR imaging: estimation of malignancy

OBJECTIVE: Our aims were to establish factors that are most predictive of hepatic lesion malignancy and to formulate a prediction rule. MATERIALS AND METHODS: A cross-sectional study of 227 abdominal MR imaging examinations revealed 85 lesions in 67 patients (29 men, 38 women; age range, 29-78 years; mean age, 51.4 years) who were being examined for primary malignancy (n = 42) or unknown lesion characterization (n = 25). All were referred for MR imaging after CT or sonography. Patient demographics (age, sex, history of malignancy), lesion size and morphology, quantitative T2 calculation, and pattern of enhancement on gadopentetate dimeglumine administration were evaluated for predictive ability. RESULTS: Thirty-two liver lesions were malignant (eight colon cancer, five breast cancer, four cervical cancer, three renal cancer, three lung cancer, and nine miscellaneous cancers), 53 were benign (37 hemangiomas, 15 cysts, and one focal nodular hyperplasia). Calculated T2 relaxation times (mean +/- standard deviation [SD]) were as follows: malignant tumors (91.72 +/- 21.9 msec), hemangiomas (136.1 +/- 26.3 msec), cysts (284.1 +/- 38.2 msec) (p < 0.001). Logistic regression analysis indicated that lesion size and sex and age of patient were not significant independent predictors (p > 0.05). However, the combination of a history of malignancy, T2 value, and gadopentetate dimeglumine-enhancement pattern allowed generation of a prediction rule with an area under the receiver operating characteristic curve of 0.95. The patient's weight, lesion morphology, and cell type of the primary malignancy did not provide additional predictive information (p > 0.2). CONCLUSION: We recommend using the combination of T2 quantification and patient history of malignancy before deciding to administer gadopentetate dimeglumine for optimal lesion characterization, especially for equivocal lesions with T2 values between 90 and 130 msec. These factors allowed the construction of a prediction rule for lesion characterization.     

肝硬化并发微小肝癌DSA的诊断价值

目的探讨DSA对肝硬化并发微小肝癌(MHCC)的诊断价值。方法340例肝硬化患者,腹部增强CT及B超检查未见肝脏占位病变,在经肝动脉自体骨髓干细胞移植术前行肝动脉DSA,多角度投照,对造影发现的MHCC用微导管行肝段TACE治疗。结果DSA检查诊断MHCC20例。病灶均为单发,直径0.4～1.0cm,DSA表现为肝动脉造影早期至中期出现边缘较清楚的结节状染色,染色持续时间15s以上。病灶分布在左叶2例,右叶18例。AFP阳性4例,阴性16例。TACE治疗1次11例,2次7例,3次2例。栓塞后均见病灶内碘油聚集。1例TACE治疗1次后手术切除,病理证实为肝细胞癌。结论DSA对肝硬化并发MHCC的检出能力优于常规增强CT及B超检查。     

Peripheral benzodiazepine receptors in the brain of cirrhosis patients with manifest hepatic encephalopathy

Purpose It has been suggested that ammonia-induced enhancement of peripheral benzodiazepine receptors (PBRs) in the brain is involved in the development of hepatic encephalopathy (HE). This hypothesis is based on animal experiments and studies of post-mortem human brains using radiolabelled PK11195, a specific ligand for PBR, but to our knowledge has not been tested in living patients. The aim of the present study was to test this hypothesis by measuring the number of cerebral PBRs in specific brain regions in cirrhotic patients with an acute episode of clinically manifest HE and healthy subjects using dynamic ¹¹C-PK11195 brain PET. Methods Eight cirrhotic patients with an acute episode of clinically manifest HE (mean arterial ammonia 81 μmol/l) and five healthy subjects (22 μmol/l) underwent dynamic ¹¹C-PK11195 and ¹⁵O-H₂O PET, co-registered with MR images. Brain regions (putamen, cerebellum, cortex and thalamus) were delineated on co-registered ¹⁵O-H₂ ¹⁵O and MR images and copied to the dynamic ¹⁵O-H₂O and ¹¹C-PK11195 images. Regional cerebral blood flow (CBF) (¹⁵O-H₂O scan) and the volume of distribution of PK11195 (¹¹C-PK11195 scan) were calculated by kinetic analysis. Results There were regional differences in the CBF, with lowest values in the cortex and highest values in the putamen in both groups of subjects (p<0.05), but no significant differences between the groups. There were no significant differences in the volume of distribution of PK11195 (V _d) between regions or between the two groups of subjects. Mean values of V _d ranged from 1.0 to 1.1 in both groups of subjects. Conclusion The results do not confirm the hypothesis of an increased number of PBRs in patients with HE.     

高压氧对肝硬变患者肝储备功能的影响(论著)

目的：观察高压氧（ＨＢＯ）对肝硬变患者肝储备功能的影响。方法：将３８例肝硬变患者按肝功能Ｐｕｇｈ等分级方法［１］分为肝功能良好组（ｎ＝１８）和损害组（ｎ＝２０）。于ＨＢＯ治疗前及治疗后６、１２天进行口服葡萄糖耐量试验（计算服糖后１２０、６０分钟血糖浓度比值即ＯＧＴＴＲ１２０／６０），检测血清前白蛋白（ＰＡ）、白／球蛋白比值（Ａ／Ｇ）、总胆红素（ＴＢｉ）、凝血酶原时间（ＰＴ）及靛青绿１５分钟潴留率（ＩＣＧＲ１５），根据以上检查结果判断ＨＢＯ治疗对肝储备功能的影响。结果：ＨＢＯ可明显提高Ａ／Ｇ值及ＰＡ水平，降低ＯＧＴＴＲ１２０／６０、ＴＢｉ及ＩＣＧＲ１５，对ＰＴ亦有明显改善及控制作用。结论：ＨＢＯ可提高肝硬变患者肝储备功能，是肝硬变患者术前准备的有助方法     

Multidetector computed tomography for preoperative assessment of hepatic vasculature and prediction of splenic artery steal syndrome in patients with liver cirrhosis before transplantation

The purpose of this study was to evaluate the accuracy of MDCT for preoperative assessment of hepatic vascular anatomy and the identification of liver-transplantation (OLT) patients at risk of developing subsequent splenic artery steal syndrome (SASS). A total of 145 patients with liver cirrhosis who had undergone OLT and had pre-operative three-phase MDCT (4- to 64-rows) within 100 days before OLT were enrolled retrospectively. MDCT and 3Ds were reviewed by two independent blinded observers (O1/O2). Pre-operative imaging findings were correlated with intra-operative results; findings indicative for SASS were correlated with clinical data and DSA. Among all 145 patients, 16 patients (11%) showed accessory hepatic arteries (accuracy O1/O2, 97%; with 3Ds, 100%); 32 (22%) patients had replaced hepatic arteries (accuracy O1, 97%; O2, 95%; with 3Ds, 100%; κ?=?0.87 and 0.89, P?<?0.001). Among 119 patients, 12 patients developed SASS after OLT. The logistic regression model revealed the spleen volume (P?=?0.0105) as a predictive factor of SASS. With spleen volumes ≥829 ml, an accuracy of 75% for prediction of SASS was obtained. MDCT with three-dimensional post-processing (3Ds) was highly accurate for pre-operative hepatic vessel evaluation in patients before OLT. In addition, spleen volume was a predictive factor for developing SASS after OLT.     

Outcome of hypovascular hepatic nodules with positive uptake of gadoxetic acid in patients with cirrhosis

Objectives

To evaluate the longitudinal risk to patients with cirrhosis of hypervascular hepatocellular carcinoma (HCC) developing from hypovascular hepatic nodules that show positive uptake of gadoxetic acid (hyperintensity) on hepatocyte phase images.

Methods

In 69 patients, we evaluated findings from serial follow-up examinations of 633 hepatic nodules that appeared hypovascular and hyperintense on initial gadoxetic acid-enhanced magnetic resonance imaging (EOB-MRI) until the nodules demonstrated hypervascularity and were diagnosed as hypervascular HCC. Cox analyses were performed to identify risk factors for the development of hypervascular HCCs from the nodules.

Results

The median follow-up was 663 days (range, 110 to 1215 days). Hypervascular HCCs developed in six of the 633 nodules (0.9 %) in five of the 69 patients. The only independent risk factor, the nodule’s initial maximum diameter of 10 mm or larger, demonstrated a hazard ratio of 1.25. The one-year risk of hypervascular HCC developing from a nodule was 0.44 %. The risk was significantly higher for nodules of larger diameter (1.31 %) than those smaller than 10 mm (0.10 %, p?<?0.01).

Conclusions

Hypervascular HCC rarely develops from hypovascular, hyperintense hepatic nodules. We observed low risk even for nodules of 10 mm and larger diameter at initial examination.

Key Points

? Hypervascularization was rare on follow-up examination of hypovascular, hyperintense nodules ? The risk of hypervascularization in a nodule increased with large size ? Hypovascular, hyperintense nodules require neither treatment nor more intense follow-up

     

Hepatic perfusion changes in patients with cirrhosis indices of hepatic arterial blood flow.

PURPOSE: This study used radionuclide angiography to evaluate semiquantitatively the hepatic arterial blood flow changes associated with cirrhosis. METHODS: The parameters of net arterial hepatic perfusion were estimated by analysis of first-pass flow studies in 11 control participants and in 15 patients with cirrhosis (Child-Pugh classification B-C). Hepatic, renal, and splenic time-activity curves were generated, normalized per pixel, and corrected for background. The rate of hepatic arterial blood flow was compared with the reference kidney and spleen perfusion using the hepatorenal and hepatolienal perfusion indices, respectively. These indices were defined as: PI = area under hepatic curve limited by time of the renal (splenic) curve peak/area under renal (splenic) curve to its peak RESULTS: The values of both these perfusion indices are significantly greater in the patients with cirrhosis than in controls (hepatorenal perfusion index, P < 0.01; hepatolienal perfusion index, P < 0.05). The values of the hepatic perfusion index (the ratio of the arterial to the total liver blood flow), which were also calculated, were elevated in the patients with cirrhosis (P < 0.01). CONCLUSIONS: The results confirm that the net hepatic arterial blood flow is increased in patients with cirrhosis. Radionuclide angiography accompanied by calculation of arterial perfusion indices may provide semiquantitative parameters of net hepatic arterial blood flow.     

内科治疗对肝硬化患者血清胃动素,肽YY,IgG和铁蛋白的影响

目的 :研究内科治疗对肝硬化患者血清胃动素 (MTL) ,肽YY(PYY) ,IgG和铁蛋白 (FRT)的影响。方法 :临床确诊的肝硬化患者 78例 ,按病因分为乙型肝炎后 (HbsAg阳性 ) 61例 ,丙型肝炎后 (HCV抗体阳性 ) 5例 ,酒精性 4例和原因不明 8例 ;Child分级为A级 2 3例 ,B级 39例和C级 1 6例。并选 2 7例无肝胆胰及内分泌疾病者作对照。结果 :与对照比较 ,肝硬化患者血清MTL ,PYY ,IgG和FRT均明显升高 (P <0 .0 1 ) ,且与肝功能损伤程度有关。经内科治疗 4周后 (n =70 )血清MTL ,PYY和IgG均有下降 (P <0 .0 5) ,而FRT下降不明显 (P >0 .0 5)。结论 :本组肝硬化患者血清MTL ,PYY ,IgG和FRT有明显升高 ,经内科治疗可改善     

Neural mechanism of cognitive control impairment in patients with hepatic cirrhosis: a functional magnetic resonance imaging study

BACKGROUND: Many studies have claimed the existence of attention alterations in cirrhotic patients without overt hepatic encephalopathy (HE). No functional magnetic resonance imaging (fMRI) study in this respect has been published. PURPOSE: To investigate the neural basis of cognitive control deficiency in cirrhotic patients using fMRI. MATERIAL AND METHODS: 14 patients with hepatic cirrhosis and 14 healthy volunteers were included in the study. A modified Stroop task with Chinese characters was used as the target stimulus, and block-design fMRI was used to acquire resource data, including four stimulus blocks and five control blocks, each presented alternatively. Image analysis was performed using statistical parametric mapping 99. After fMRI examinations were complete, behavior tests of Stroop interference were performed for all subjects. Overall reaction time and error numbers were recorded. RESULTS: Both healthy volunteers and patients with hepatic cirrhosis had Stroop interference effects. Patients with hepatic cirrhosis had more errors and longer reaction time in performing an incongruous color-naming task than healthy volunteers (P<0.001); there was no significant difference in performing an incongruous word-reading task (P = 0.066). Compared with controls, patients with hepatic cirrhosis had greater activation of the bilateral prefrontal cortex and parietal cortex when performing the incongruous word-reading task. With increased conflict, activation of the anterior cingulate cortex (ACC), bilateral prefrontal cortex (PFC), parietal lobe, and temporal fusiform gyrus (TFG) was decreased when patients with hepatic cirrhosis performed the incongruous color-naming task. CONCLUSION: This study demonstrates that patients with hepatic cirrhostic have cognitive control deficiency. The abnormal brain network of the ACC-PFC-parietal lobe-TFG is the neural basis of cognitive control impairment in cirrhotic patients.     

选择性血管加压素V2受体拮抗剂治疗肝硬化腹水的Meta分析

目的 评价选择性血管加压素V2受体拮抗剂治疗肝硬化腹水的疗效及安全性.方法 检索PubMed、EMBASE、Web of Science、The Cochrane Central Register of Controlled Trials、中国期刊全文数据库、中国科技期刊数据库(维普)、万方数字化期刊全文数据库等关于选择性血管加压素V2受体拈抗剂治疗肝硬化腹水疗效及安全性的随机对照试验(RCT),使用RevMan5.0版软件对纳入的研究进行Meta分析.结果 共9项RCT包含1884例患者符合入选标准.Meta分析结果显示:①治疗组患者体重降低幅度明显大于安慰剂组(WMD=-1.98kg,95％CI:-3.24～-0.72kg,P=0.002);治疗组患者血清钠升高幅度明显大于安慰剂组(WMD=3.74mmol/L,95％CI:0.91～6.58mmol/L,P=0.01);治疗组患者腹水恶化的比例较安慰剂组明显降低(RR=0.51,95％CI:0.34～0.77,P=0.001).②治疗组患者尿量增加幅度明显大于安慰剂组(WMD=1437.65ml,95％CI:649.01～2226.30ml,P=0.0004);治疗组患者血肌酐与安慰剂组相比差异无统计学意义(WMD=-3.49μmol/L,95％CI:-12.54～5.56μmol/L,P=0.45).③治疗组患者心率、收缩压、舒张压和病死率与安慰剂组相比差异无统计学意义(P＞0.05);治疗组其他不良反应发生率(P=0.003)高于安慰剂组;治疗组死亡率与安慰剂组相比差异无统计学意义(P=0.49).结论 选择性血管加压素B2受体拮抗剂可以改善肝硬化腹水和稀释性低钠血症,并且对心脏和肾脏无明显影响,不良反应相对较少,可能成为肝硬化腹水治疗的一种新选择.