乙肝肝硬化患者门静脉宽度与门静脉血栓形成的关系

背景门静脉血栓(portal vein thrombosis,PVT)的早期诊断仍是临床上一个难题,急需要发现可早期预测诊断的无创指标.目的探讨门静脉宽度与PVT形成之间的关系.方法收集418例乙肝肝硬化患者.根据是否发生PVT分为PVT组(n=66)和非PVT组(n=352)组.比较两组患者的一般资料差异,使用多因素Logistic回顾分析影响PVT发生的危险因素.通过受试者工作特征(receiver operating characteristic,ROC)曲线评估不同危险因素预测PVT的效能.结果与非PVT组患者相比,PVT组患者的Child-Pugh评分更高、Child-Pugh A级比例更低、血小板水平更高、D-二聚体水平更高、门静脉宽度更宽、门静脉血流更慢,上述差异均存在统计学意义(P<0.05).Logistic回归显示门静脉宽度(OR=3.941,P=0.001)、门静脉血流(OR=0.841,P=0.007)、血小板水平(OR=1.024,P=0.008)和D-二聚体水平(OR=2.383,P=0.000)是肝硬化患者发生PVT的独立危险因素.门静脉宽度诊断PVT的ROC曲线下面积最大为0.874,最佳诊断值为>12.5 mm,此时的预测敏感性和特异性分别为78%和82%.结论门静脉直径增加是肝硬化患者PVT发生的危险因素,对PVT诊断具有一定价值.     

Patent paraumbilical vein: hemodynamic importance in Mansoni's hepatosplenic portal hypertension (Study with ultrasonography Doppler

BACKGROUND: The hemodynamical effect of the collateral portosystemic circulation upon the portal system has not yet been fully understood. The US-Doppler made possible the non-invasive study of the portal system by evaluating the parameters: flow direction, diameter and flow velocity in it's vessels. AIMS: To study the paraumbilical vein as a collateral portosystemic pathway and identify patterns for appraising its hemodynamic importance to the portal system. METHOD: US-Doppler study of the portal system of 24 patients with Mansoni's hepatosplenic schistosomic portal hypertension, previous esophagic variceal bleeding and patent paraumbilical vein with hepatofugal flow. The diameter and the mean flow velocity were measured in the paraumbilical vein and so were the mean flow velocity in the portal vein, right and left portal branches. The Pearson test (linear correlation) was applied to the portal vein's mean flow velocity and the paraumbilical vein's diameter and mean flow velocity. The patients were divided in four groups: D1-paraumbilical vein with diameter < 0.68 cm (n = 14), D2-paraumbilical vein with diameter > or = 0.68 cm (n = 10), V1-paraumbilical vein with mean flow velocity < 18.41 cm/seg (n = 13) and V2-paraumbilical vein with mean flow velocity > or = 18.41 cm/seg (n = 11). The mean flow velocity in the portal vein, right and left portal branches of the four groups were compared. RESULTS: The paraumbilical vein diameter was 0.68 +/- 0.33 cm (range: 0.15-1.30 cm) and the mean flow velocity was 18.41 +/- 11.51 cm/seg (range: 5.73-38.20 cm/seg). The linear correlation between the portal vein's mean flow velocity/paraumbilical vein diameter and the paraumbilical vein's mean flow velocity showed r = 0.504 and r = 0.735, respectively. In the group D2 there was an increase in the mean flow velocity in the portal vein (17.80 +/- 3.42/22.30 +/- 7.67 cm/seg) and in the left portal branch (16.00 +/- 4.73/22.40 +/- 7.90 cm/seg). In the group V2 there was an increase in the mean flow velocity in the portal vein (16.31 +/- 3.49/21.96 +/- 5.89 cm/seg) and in the left portal branch (14.22 +/- 4.41/21.94 +/- 7.20 cm/seg). There was no change in the right portal branch (13.67 +/- 5.74/15.43 +/- 3.43 cm/seg). CONCLUSIONS: In portal hypertension due to hepatosplenic schistosomiasis, the patent paraumbilical vein, with hepatofugal flow, diameter > or = 0.68 cm and mean flow velocity > or = 18.41 cm/seg causes an increase of the mean flow velocity in the portal vein and left portal branch. The best US-Doppler parameter to appraise the paraumbilical vein influence upon the portal system is the mean flow velocity. The correlation between the increase in portal vein's mean flow velocity is stronger with the paraumbilical vein's mean flow velocity than with its diameter. The increase in the portal vein's and left portal branch's mean flow velocity may be understood as the paraumbilical vein's hemodynamic influence upon the portal system. An active portosystemic collateral pathway increases the mean flow velocity in the vein's segment proximal to its point of origin.     

Sonographic criteria for the diagnosis of hepatic involvement in hereditary hemorrhagic telangiectasia (HHT)

Hepatic involvement in hereditary hemorrhagic telangiectasia (HHT) is highly variable and may lead to severe clinical symptoms such as heart failure. This controlled, prospective study defined sonographic criteria for hepatic involvement in HHT. Color Doppler sonography and pulsed Doppler sonography were used to study 25 patients with HHT and liver involvement, 20 patients with HHT without liver involvement, 25 patients with cirrhosis, and 25 patients without liver disease. The diagnosis of hepatic manifestation was confirmed by computed tomography and/or angiography. Liver size, parenchymal changes of the liver, vessel diameters, and flow velocities of the portal vein and the hepatic artery were determined. Resistance index (RI) and pulsatility index (PI) were calculated. The diameter of the common hepatic artery was significantly dilated without overlap between HHT patients with liver involvement and the 3 control groups (mean 11.3 +/- 2.8 mm [HHT with liver involvement], 4.6 +/- 0.9 mm [HHT without liver involvement], 4.8 +/- 1.0 mm [cirrhosis], and 4.4 +/- 1.0 mm [healthy controls], P <.001). Doppler parameters of the proper hepatic artery differed significantly (all P <.001). In all patients with HHT and liver involvement, areas with intrahepatic hypervascularization caused by dilated intrahepatic arteries were observed in varying intensity. Cardiac output significantly correlated with the diameter of the common hepatic artery (r = 0.53, P =.007) and the portal vein (r = 0.42, P =.05). In conclusion, the diameter of the common hepatic artery (>7 mm) and intrahepatic hypervascularization are suitable sonographic diagnostic parameters of HHT with high sensitivity and specificity. Dilated diameters of the hepatic feeding vessels are indicators for systemic circulatory distress in these patients.     

术前CT/MRI检查指标对肝硬化脾切除术后门静脉血栓形成的预测价值

目的 观察术前CT/MRI检查门静脉系统指标预测肝硬化脾切除术后门静脉血栓形成（PVT）的价值。方法 2016年7月~2018年7月我院收治的87例乙型肝炎肝硬化脾切除术后患者接受CT和MRI检查,随访3个月,观察PVT发生率,采用多因素Logistic回归分析肝硬化脾切除术后PVT形成的独立影响因素。结果 在随访3个月末,在87例肝硬化脾切除术后患者发现PVT者46例（52.9%）,均为PVT Ⅰ级,门静脉附壁血栓45例（51.7%）,其中伴肠系膜上静脉附壁血栓14例（16.1%）;46例PVT组门静脉直径为（16.7±2.2） mm,显著大于41例非PVT组【（14.8±1.5） mm,P<0.05】,门静脉流速差为（8.4±5.5） cm/s,显著高于非PVT组【（6.1±3.6） cm/s,P<0.05】,脾容积为（1370.8±370.1） cm³,显著大于非PVT组【（1205.2±357.3） cm³,P<0.05】;多因素Logistic回归分析显示,门静脉直径（OR=0.869,95%CI=0.608~1.246）、门静脉流速差（OR=1.185,95%CI=1.079~1.317）和脾容积（OR=3.427,95%CI=2.215~5.302）均是肝硬化脾切除术后PVT形成的独立影响因素（P<0.05）。结论 术前CT/MRI检查指标可以预测肝硬化脾切除术后PVT形成,及时处理和预防将改善患者预后。     

Portal vein thrombosis after right hepatectomy: impact of portal vein resection and morphological changes of the portal vein

BackgroundRight hepatectomy occasionally requires portal vein resection (PVR) and causes postoperative portal vein thrombosis (PVT).MethodsA total of 247 patients who underwent right hepatectomy were evaluated using a three-dimensional analyzer to identify the morphologic changes in the portal vein (PV). The patients' characteristics were compared between the PVR group (n = 73) and non-PVR group (n = 174), and risk factors for PVT were investigated. The PVR group were subdivided into the wedge resection (WR) group (n = 38) and segmental resection (SR) group (n= 35).ResultsPostoperative PVT occurred in 20 patients (8.1%). Multivariate analyses in all patients revealed that postoperative left PV diameter/main PV diameter (L/M ratio) <0.56 (odds ratio [OR] 4.00, p = 0.009) and PVR (OR 3.31, p = 0.031) were significant risk factors for PVT. In 73 patients who underwent PVR, PVT occurred in 14 (19%) and WR (OR 11.5, p = 0.005) and L/M ratio <0.56 (OR 5.51, p = 0.016) were significant risk factors for PVT.ConclusionPVR was one of the significant risk factors for PVT after right hepatectomy. SR rather than WR may be recommended for preventing PVT.     

Preoperative predictors of portal vein thrombosis after splenectomy with periesophagogastric devascularization

AIM: To evaluate the predictive value of preoperative predictors for portal vein thrombosis (PVT) after splenectomy with periesophagogastric devascularization.METHODS: In this prospective study, 69 continuous patients with portal hypertension caused by hepatitis B cirrhosis underwent splenectomy with periesophagogastric devascularization in West China Hospital of Sichuan University from January 2007 to August 2010. The portal vein flow velocity and the diameter of portal vein were measured by Doppler sonography. The hepatic congestion index and the ratio of velocity and diameter were calculated before operation. The prothrombin time (PT) and platelet (PLT) levels were measured before and after operation. The patients’ spleens were weighed postoperatively.RESULTS: The diameter of portal vein was negatively correlated with the portal vein flow velocity (P < 0.05). Thirty-three cases (47.83%) suffered from postoperative PVT. There was no statistically significant difference in the Child-Pugh score, the spleen weights, the PT, or PLT levels between patients with PVT and without PVT. Receiver operating characteristic curves showed four variables (portal vein flow velocity, the ratio of velocity and diameter, hepatic congestion index and diameter of portal vein) could be used as preoperative predictors of postoperative portal vein thrombosis. The respective values of the area under the curve were 0.865, 0.893, 0.884 and 0.742, and the respective cut-off values (24.45 cm/s, 19.4333/s, 0.1138 cm/s^-1 and 13.5 mm) were of diagnostically efficient, generating sensitivity values of 87.9%, 93.9%, 87.9% and 81.8%, respectively, specificities of 75%, 77.8%, 86.1% and 63.9%, respectively.CONCLUSION: The ratio of velocity and diameter was the most accurate preoperative predictor of portal vein thrombosis after splenectomy with periesophagogastric devascularization in hepatitis B cirrhosis-related portal hypertension.     

脾切除联合贲门周围血管离断术治疗肝硬化门脉高压症患者预防门静脉血栓形成研究

目的 探讨脾切除联合贲门周围血管离断术治疗肝硬化门脉高压症患者门静脉血栓(PVT)的预测措施。方法 2017年1月～2019年3月我院肝胆外科诊治的肝硬化并发门脉高压症患者60例,均接受脾切除联合贲门周围血管离断术。术后将患者分成A组和B组。在B组,当出现抗凝指针时给予低分子肝素短期抗凝治疗。使用彩超检查门脉指标和诊断PVT形成。结果 术后,在B组30例患者中有20例(66.7%)接受了短期抗凝治疗;在术后3 w末,超声检查发现PVT患者15例(25.0%),其中A组11例(36.7%),显著高于B组的4例【(13.3%),P<0.05】;血栓形成组门静脉直径为(1.5±0.3)cm,与无血栓形成组比,无显著性差异【(1.4±0.2)cm,P>0.05】,门静脉血流流速为(12.3±1.4)cm/s,显著低于无血栓形成组【(14.5±1.7)cm/s,P＜0.05】;血栓形成组血清D-二聚体水平显著高于无血栓形成组(P＜0.05);血栓形成组外周血血小板计数为(142.6±58.9)×10⁹/L,显著高于无血栓形成组【(91.4±52.4)×10⁹/L,P＜0.05】。结论 在采取脾切除联合贲门周围血管离断术治疗肝硬化并发门脉高压症患者时,需警惕术后PVT的形成。对术后血小板计数急剧升高、血清D-二聚体显著升高和门脉血流减慢的患者应该及时给予抗凝治疗。     

Measurement of Intrahepatic Pressure as an Index of Hepatic Sinusoidal Pressure

Intrahepatic pressure was measured in 148 patients with liver disease (32 outpatients, 116 inpatients) and 13 controls with almost normal liver histology (inpatients), with a 23-gauge needle (inner diameter 0.38 mm). Intrahepatic pressure was significantly elevated in the group order of chronic active hepatitis without bridging necrosis (n = 17, 9.2 +/- 3.0 mm Hg), chronic active hepatitis with bridging necrosis (n = 24, 12.3 +/- 5.7), and posthepatitic liver cirrhosis (n = 65, 18.8 +/- 4.2), compared with controls (n = 13, 6.8 +/- 2.7), whereas it was not elevated in the group of idiopathic portal hypertension (n = 9, 7.8 +/- 2.5 mm Hg), acute hepatitis (n = 10, 8.4 +/- 2.6 mm Hg), and chronic persistent hepatitis (n = 23, 7.9 +/- 2.7 mm Hg), compared with controls. As complications, four patients had abdominal discomfort continuing for more than a day; however, patients were allowed to walk after they had rested on their beds for 30 min. In 37 patients (27 with cirrhosis, seven idiopathic portal hypertension, and three others), portal vein and/or hepatic vein catheterization was performed during the same procedure of intrahepatic pressure measurement. Intrahepatic pressure showed significant correlations with corrected wedged hepatic vein pressure (r = 0.91), portohepatic gradient (r = 0.69), wedged hepatic vein pressure (r = 0.79), and portal vein pressure (r = 0.68). Slopes were 0.97, 0.83, 0.66, and 0.65, respectively. In conclusion, intrahepatic pressure reflects hepatic sinusoidal pressure (corrected wedged hepatic vein pressure), and intrahepatic pressure starts to elevate at the stage of chronic active hepatitis.     

肝硬化脾切除术后门静脉系统血栓形成的危险因素分析*

目的 分析影响肝硬化患者脾切除术后门静脉系统血栓形成（PVT）的危险因素。方法 2015年1月~2018年6月我院收治的肝硬化患者94例,接受脾切除联合食管下段周围曲张血管离断术,使用彩色多普勒超声检查门静脉系统。采用多因素Logistic回归分析影响术后PVT形成的危险因素。结果 术后1个月随访,经彩色多普勒超声检查,发现PVT形成30例,未发生PVT患者64例;PVT组有腹水者为56.7%,显著高于无PVT组的32.8%（P<0.05）,脾脏厚度为（75.8±9.4） mm,显著大于无PVT组【（69.1±8.8） mm,P<0.05】,脾脏体积为（141.7±18.1） mm2,显著大于无PVT组【（126.8±17.2） mm2,P<0.05】,门静脉内径为（16.2±2.1） mm,显著大于无PVT组【（14.1±1.9） mm,P<0.05】,门静脉血流流速为（12.2±1.5） cm/s,显著慢于无PVT组【（14.6±1.6） cm/s,P<0.05】;应用低分子右旋糖苷或低分子肝素抗凝干预患者所占比例显著低于无PVT组（P<0.05）;Logistic回归分析显示,未应用抗凝治疗（OR=0.503,P=0.023）、门静脉流速减慢（OR=0.491,P=0.014）、脾脏体积增加（OR=1.872,P=0.044）和门静脉内径增宽（OR=1.982,P=0.021）是肝硬化脾切除术患者术后PVT形成的独立危险因素。结论 肝硬化脾切除术患者术后可能存在PVT形成,了解一些危险因素并给予积极的干预可能减少PVT形成的发生,使患者获益。     

Value of portal hemodynamics and hypersplenism in cirrhosis staging

AIM: To determine the correlation between portal hemodynamics and spleen function among different grades of cirrhosis and verify its significance in cirrhosis staging. METHODS: The portal and splenic vein hemodynamics and spleen size were investigated by ultrasonography in consecutive 38 cirrhotic patients with cirrhosis (Child's grades A to C) and 20 normal controls. The differences were compared in portal vein diameter and flow velocity between patients with and without ascites and between patients with mild and severe esophageal varices. The correlation between peripheral blood cell counts and Child's grades was also determined. RESULTS: The portal flow velocity and volume were significantly lower in patients with Child's C (12.25±1.67 cm/s vs 788.59±234 mm/min, respectively) cirrhosis compared to controls (19.55±3.28 cm/s vs 1254.03±410 mm/min, respectively) and those with Child's A (18.5±3.02 cm/s vs 1358.48±384 mm/min, respectively) and Child's B (16.0±3.89 cm/s vs 1142.23±390 mm/min, respectively) cirrhosis. Patients with ascites had much lower portal flow velocity and volume (13.0±1.72 cm/s vs1078±533 mm/min) than those without ascites (18.6±2.60 cm/s vs1394±354 mm/min). There was no statistical difference between patients with mild and severe esophageal varices. The portal vein diameter was not significantly different among the above groups. There were significant differences in splenic vein diameter, flow velocity and white blood cell count, but not in spleen size, red blood cell and platelet counts among the various grades of cirrhosis. The spleen size was negatively correlated with red blood cell and platelet counts (r= -0.620 and r= -0.8.34, respectively). CONCLUSION: An optimal system that includes parameters representing the portal hemodynamics and spleen function should be proposed for cirrhosis staging.     

Study of portal vein thrombosis in patients with idiopathic portal hypertension in Japan.

BACKGROUND/AIMS: The aim of this study was to elucidate the incidence and clinical manifestations of portal vein thrombosis (PVT) in patients with idiopathic portal hypertension (IPH) in Japan during long-term follow-up. PATIENTS AND METHODS: Twenty-two patients with IPH were examined for PVT by sonography during a follow-up of 12+/-6 years. Clinical manifestations and patient outcome related to PVT were studied. Seventy patients with liver cirrhosis were examined by sonography as an incidence control of thrombosis. RESULTS: Nine IPH patients had portal thrombosis (9/22, 41%), a higher incidence than in liver cirrhosis patients (7/70, 10%). Those with thrombosis showed ascites, marked hypersplenism, and low serum albumin. Four patients with thrombosis died. Patients without thrombosis showed less clinical problems after long-term follow-up. Plasma antithrombin III and protein C activity decreased in almost half of the patients. However, there were no differences in these parameters between patients with and without thrombosis. CONCLUSIONS: In Japan, IPH patients had a high incidence of portal thrombosis, a significant factor for poor prognosis. Whether the management of PVT contributes to an improvement of a clinical course of IPH or not should be clarified in further study.     

晚期血吸虫病门脉高压症术后门静脉血栓形成的危险因素分析

目的探讨晚期血吸虫病门脉高压症脾切除贲门周围血管离断术后门静脉血栓(PVT)形成的危险因素。方法收集2004年8月至2014年3月期间本院外科收治的211例晚期血吸虫病门静脉高压症患者的临床资料,对可能影响术后PVT形成的因素进行单因素分析和Logistic回归分析。结果 211例患者中,59例术后PVT形成,发生率为27.96%(59/211)。单因素分析显示术前上消化道出血史、门静脉直径、脾静脉直径、食管静脉曲张程度、腹水、门脉高压性胃病、胃底静脉曲张、血氨水平是患者术后PVT形成的影响因素。Logistic回归分析显示门静脉直径增宽(OR=1.763,P=0.000)和门脉高压性胃病(OR=1.089,P=0.037)是患者术后PVT形成的独立危险因素。结论晚期血吸虫病门脉高压症术后PVT形成的发生率较高,门静脉直径增宽和门脉高压性胃病是PVT形成的独立危险因素。     

双剂量奥曲肽对肝硬化门脉高压症断流术后患者血流动力学的影响

目的研究双剂量奥曲肽对肝硬化门脉高压症断流术后患者门脉压力、肝脏血流动力学影响。方法肝硬化门脉高压症断流术患者26例,随机分两组,术后24h开始用奥曲肽。A组12例,奥曲肽50μg／h;B组14例,奥曲肽25μg／h;胃网膜右静脉插管至门静脉主干,动态测定门脉压力;彩色超声多普勒测定门脉直径（PV）、门脉最大血流速度（PFVmax）、门脉平均血流速度（PFVmean）、肝动脉最大血流速度（HAVmax）、肝动脉最小血流速度（HAVmin）;计算门脉血流量参数（PFI）、肝动脉血流量参数（HAFI）。结果断流术后,两组患者门脉压力平均降幅15．4％,PFI降低（P〈0．05）;HAVmax、HAVmin、HAFI增加（P〈0．05）。用奥曲肽72h后,两组PFI、PFVmax、PFVmean降低（P〈0．05）;用药5min门脉压力降低,24h达高峰,门脉压力平均降幅20．6％。A组停药后48h内,门脉压力未见回升,平均降幅23．1％;B组停药后2h门脉压力有回升趋势,平均降幅11．6％;停药后24h、48h两组患者门脉压力比较差异有统计学意义（P〈0．01）。Logistic分析发现,PV、PFVmax、PFVmean、HAVmax、HAVmin与门脉压力无独立相关性。结论肝硬化门脉高压症患者行断流术后,门脉压力降低。双剂量奥曲肽均能明显降低门脉压力;停药后48h内,奥曲肽50μg／h组门脉压力未见回升。提示,临床用奥曲肽50μg/h对防止静脉曲张再出血更合理。     

Portalsystemic hemodynamic changes in chronic severe hepatitis B： An ultrasonographic study

AIM： To evaluate portalsystemic hemodynamic changes in chronic severe hepatitis B.
METHODS： Hemodynamic parameters included portal vein diameter （PVD）, portal vein peak velocity （PVPV）, portal vein volume （PW）, spleen length （SPL）, spleen vein diameter （SPVD）, spleen vein volume （SPW） and umbilical vein recanalization. They were measured by Color Doppler ultrasonography in 36 patients with chronic severe hepatitis B, compared with 51 normal controls, 61 patients with chronic hepatitis B, 46 patients with compensable cirrhosis, and 36 patients with decompensable cirrhosis.
RESULTS： In the group of chronic severe hepatitis B, PVD （12.38 ± 1.23 mm） was significantly different from the normal control, compensable cirrhosis and decompensable cirrhosis groups （P = 0.000-0.026）, but not significantly different from the chronic hepatitis group. PVPV （16.15 ± 3.82 cm/s） dropped more significantly in the chronic severe hepatitis B group than the normal control, chronic hepatitis B and compensable cirrhosis groups （P = 0.000-0.011）. PW （667.53 ± 192.83 mL/min） dropped significantly as compared with the four comparison groups （P = 0.000-0.004）. SPL （120.42 ± 18.36 mm） and SPVD （7.52 ± 1.52 mm） were longer in the normal control and chronic hepatitis B groups （P = 0.000-0.009）, yet they were significantly shorter than those in the decompensable cirrhosis group （P = 0.000）. SPW （242.51 ± 137.70 mL/min） was also lower than the decompensable cirrhosis group （P = 0.000）. The umbilical vein recanalization rate （75%） was higher than the chronic hepatitis B and compensable cirrhosis groups. In the course of progression from chronic hepatitis to decompensable cirrhosis, PVD, SPL and SPVD gradually increased and showed significant differences between every two groups （P = 0.000-0.002）.
CONCLUSION： Patients with chronic severe hepatitis B have a tendency to develop acute portal hypertension, resulting in significantly reduced portal vein     

肝硬化并发门静脉血栓危险因素的Logistic回归分析

目的 探讨肝硬化并发门静脉血栓(PVT)形成的危险因素。方法 2012年3月~2016年12月收治444例肝硬化患者,其中并发PVT者44例,无PVT者400例。收集并对比两组患者的临床资料。采用t检验或x²检验进行危险因素的单因素分析,采用非条件多因素Logistic回归模型进行独立危险因素分析。结果 单因素分析显示,PVT组与无PVT组患者在Child-Pugh评分（7.65±2.01对6.90±1.85）、血红蛋白（HB）、血小板（PLT）、D-二聚体、纤维蛋白原降解产物（FDP）、白蛋白、门静脉内径、脾脏长径、脾脏厚径、门静脉流速和糖尿病发生率方面比较差异均具有统计学意义（均P<0.05）;多因素Logistic回归分析结果显示:门静脉内径（OR=1.258,95%CI 1.035~1.616,P=0.009）、D-二聚体（OR=3.915,95%CI 2.243~5.796,P=0.000）和糖尿病（OR=4.189,95%CI 2.067~6.231,P=0.000）是肝硬化并发PVT形成的独立危险因素。结论 影响肝硬化并发PVT发生的因素众多,其中血D-二聚体水平升高、门静脉内径增宽和伴有糖尿病是其独立危险因素,应给予充分的重视。     

Doppler hemodynamic study in portal hypertension and hepatic encephalopathy

BACKGROUND/AIMS: The aim of our study was to evaluate and compare the differences in the parameters of portal hypertension in two groups of patients with liver cirrhosis, with and without hepatic encephalopathy (HE). METHODOLOGY: 30 patients with liver cirrhosis, 17 (56.7%) of them with HE, were investigated by clinical, neurological, laboratory, endoscopic methods and with color Doppler ultrasonography (CDU) at the Institute for Digestive Diseases, Clinical Center of Serbia, Beograde. RESULTS: Significant correlation was found between the diameters of the right liver lobe and the portal vein (p=0.01), and also between the diameters of the spleen and splenic vein (p=0.0002), in both groups of patients. Mean portal vein diameter significantly increases (p=0.01) in patients with HE (14.87 +/- 1.86mm), compared to those without HE (13.2 +/- 2.31mm), while mean splenic vein diameter was not significantly different in the two groups. In patients with ascites, CDU showed significantly lower (p=0.03) portal flow velocity (11.87 +/- 6.25cm/ sec), compared to those without ascites (14.33 +/- 4.41cm/sec). Splenic flow velocity was not significantly different (16.00 +/- 6.60cm/sec with ascites and 14.61 +/- 5.29cm/sec without ascites). In patients with HE, portal flow velocity was significantly lower (9.00 +/- 5.41cm/sec) compared to those without HE (14.0 +/- 7.03cm/sec) (p=0.04). Mean splenic flow velocity was significantly lower (p=0.03) in patients with HE (12.60 +/- 4.16cm/sec), compared to those without HE (17.77 +/- 5.91cm/sec). Portal flow velocity shows linear decrease, related to the increase of the liver damage (Child-Pugh score), while splenic velocity was not related to this parameter. CONCLUSIONS: Ultrasonographic parameters of portal hypertension show significant correlation between the diameters of liver/portal vein and spleen/splenic vein. Portal hemodynamic parameter (blood flow velocity) is significantly related to the stages of liver damage, presence of ascites and HE, while splenic hemodynamics is specific and not directly related to these parameters.     

Portal vein thrombosis: etiology, diagnostic strategy, therapy and management

Myeloproliferative disorder, liver cirrhosis with portal hypertension, deficiency of natural anticoagulant proteins, gene mutation and hepatocellular carcinoma are the most frequent causes of portal vein thrombosis (PVT). Higher accuracy of the diagnostic methods is the reason why today the cause of PVT can be found more frequently. With imaging methods, PVT with or without cavernous transformation can be diagnosed. Fresh thrombus can be undetected in sonography due to the low echogenity but can be recognized in color Doppler sonography, especially with contrast-enhancing agent. Contrast-enhanced 3D MR angiography allows a comparable accuracy in the detection of PVT as digital subtraction angiography. Therapeutical options of PVT consist of mechanical recanalization of the portal vein, local fibrinolysis with or without placement of transjugular intrahepatic portosystemic stent shunt (TIPS), combination of mechanical recanalization and local fibrinolysis, systemic thrombolytic therapy, anticoagulation alone and surgical thrombectomy. Once PVT is found in sonography, Doppler sonography may be performed in order to distinguish benign from malignant thrombus. If further information is needed, MR angiography or contrast enhanced CT is the next step. If these tests are unsatisfactory, digital subtraction angiography should be performed. Until the early nineties, shunt surgery was recommended in patients with PVT who bled despite endoscopic treatment. Today, in symptomatic noncavernomatous PVT, recanalization with local methods is recommended. Additional implantation of TIPS should be performed when the patient is cirrhotic. In recent PVT in non-cirrhotic patients anticoagulation alone is recommended. It is expected that in old PVT anticoagulation can prevent further extension of the thrombus.     

Portal vein blood flow measurements using pulsed Doppler and electromagnetic flowmetry in dogs: a comparative study

Comparative measurements of portal vein blood flow were performed at laparatomy in anesthetized dogs using either a pulsed Doppler echo system or electromagnetic flowmeters. Three hundred four simultaneous determinations were obtained under baseline conditions and during vasopressin and glucagon infusions. In each dog, serial triplicate measurements were taken within 10 min of each other. In all the cases, flow changes induced by vasoactive drugs followed the same direction regardless of the method used. Portal vein blood flow as measured by electromagnetic flowmetry ranged from 85 to 1570 ml/min. Portal vein blood flow values obtained with Doppler and electromagnetic flowmeters were not significantly different (609 +/- 335 vs. 600 +/- 370 ml/min; p = NS) and were highly correlated (r = 0.918, p less than 0.001). The difference between values obtained by the two techniques was -3 +/- 159 ml/min or -1.0% +/- 21.2% (mean +/- SD). This difference was not influenced by the portal vein diameter but increased slightly as a function of the angle of insonation. When considering the mean of triplicate measurements, we also found a highly significant correlation between data obtained by the two techniques (r = 0.934, p less than 0.001; n = 63). The mean difference was 11 ml/min, but limits of agreement between these methods were -267 and +239 ml/min. This relative discrepancy was explained by a coefficient of variation higher in Doppler measurements than in electromagnetic measurements (10.9% vs. 5.9%). These data demonstrate that under our experimental conditions, Doppler flowmetry is probably not an ideal method to measure absolute portal vein blood flow values, and that more sophisticated equipment is needed to improve its reproducibility and accuracy. In humans, however, this method might be a useful tool to assess the direction of portal flow changes in the same individual.     

肝硬化患者门静脉血栓形成危险因素的Logistic回归分析

目的研究肝硬化患者门静脉血栓（PVT）形成的相关危险因素。方法回顾性分析我院消化内科2007—2008年确诊的肝硬化患者80例,其中19例肝硬化PVT患者作为血栓组,61例肝硬化非血栓患者作为对照组,收集相关临床资料,对可能影响PVT形成的因素进行单因素分析和Logistic回归模型分析。结果Logistic回归模型分析结果显示,血浆D-二聚体、门静脉宽度（MPV）、血小板（PLT）是肝硬化患者PVT形成的独立危险因素（P值分别为0.003、0.012、0.036）。结论肝硬化患者应注意监测血浆D-二聚体、门静脉宽度、血小板等指标,以便早期预防和发现PVT的形成。     

脾切除术与TIPS术治疗肝硬化患者门静脉血栓发生率比较*

目的 比较脾切除术与经颈静脉肝内门腔静脉内支架分流术(TIPS)治疗肝硬化患者门静脉血栓(PVT)发生率的差异。方法 2017年1月～2018年12月兰州大学第一医院诊治的肝硬化并发脾功能亢进症患者96例,其中接受脾切除者45例,接受TIPS术治疗者51例。术后随访12个月,使用腹部超声或CT或CTA检查诊断PVT。应用Kaplan-Meier法计算PVT累计发生率。结果 在术后1个月、3个月、6个月和12个月,脾切除术组PVT累计发生率分别为40.0%、46.7%、48.9%和48.9%,显著高于TIPS术组(分别为7.8%、9.8%、15.7%和21.6%,P<0.05);在接受脾切除术患者,基线指标比较发现PVT组门静脉主干直径显著大于非PVT组,差异具有统计学意义(P<0.05);在TIPS术后1年,发生PVT患者11例(21.6%)。基线指标比较,未发现发生与未发生PVT组各指标具有统计学差异(P>0.05)。结论 在肝硬化并发脾功能亢进症患者,接受脾切除术后PVT累计发生率显著高于TIPS术。因此,术前应认真评估病情,严格掌握适应证,择优选择手术方法,并积极给予防治处理。